Transcripts For CSPAN2 CMS Administrator Nominee Seema Verma Testifies At Confirmation Hearing 20170313

The committee will come to order. Id like to welcome everyone to this morning steering and today were going to consider the nomination of seema verma to serve as administrator of the centers for medicare and medicaid services. Welcome, ms. Verma, to the we are so happy to have you here and your family as well. I appreciate your willingness to lead this key agency at this critical time. I see that your family has joined you here today to lend support. I extend a warm welcome to all of them and to you as well. Cms is the Worlds Largest health insurer, covering over onethird of the u. S. Population through medicare and medicaid alone. It has a budget of over one trillion dollars and it processes over 1. 2 billion claims a year for Services Provided to some of our nations most vulnerable citizens. Ms. Verma, having dealt with cms extensively in your capacity as a consultant to numerous state Medicaid Programs, you know full well the challenges the agency deals with on daily basis. I suspect you also know that the job youve been nominated for is a thankless one, fraught with numerous challenges. The good news is that there are opportunities in those challenges and i believe you are the right person for the job and that you will make the most of those opportunities to improve our healthcare system. The failings of obamacare are urgent and must be addressed in short order. Over the past six years, we have watched as the system created under obamacare has led to increased costs, higher taxes, fewer choices, reduced competition, and more strains on our economy. Under obamacare, Health Insurance premiums are up by an average of 25 this year alone. Under obamacare, americans, including millions of middleclass americans, have been hit with a trillion dollars in new taxes. And under obamacare major insurers are no longer offering coverage on exchanges, and earlier this week, we learned that another Major Carrier will exit the market in 2018. As Congress Works to change course with regard to our ailing healthcare system, cms will play a major role in determining our success. I applaud the step the agency took yesterday under the leadership of hhs secretary price with its proposed rule to help stabilize the individual insurance markets, but there is much more work to be done and i am confident that, if you are confirmed, you will be a valuable voice in driving change. Id like to talk specifically about medicaid for a moment. The Medicaid Program was designed to be a safety net for the most vulnerable americans. As such, i understand and value the moral and social responsibilities the federal government has in ensuring Health Care Coverage for our most needy citizens. I am committed to working with states and other stakeholders, as i think everyone on this committee is, and the American Public to improve the quality and ensure the longevity of the Medicaid Program. But we must also acknowledge that the Medicaid Program is three times larger, both in terms of enrollment and expenditures, than it was just 20 years ago. Additionally, the Medicaid Expansion under obamacare exacerbated pressures on the program at a time when many states were already facing difficult choices about which benefits and populations to serve. As a result, we have a responsibility to consider alternative funding arrangements that could help to preserve this important program. We also need to consider various reform proposals that can improve the way medicaid operates. Ms. Verma, we will need your assistance in both of these efforts, and your experience in this particular area should serve you well. On the subject of ms. Vermas experience, i want to note for the committee that she has been credited as the Creative Force behind the healthy indiana plan, the states medicaid alternative. This Program Provides access and Quality Health care to its enrollees, while ensuring that they are engaged in their care decisions. The Program Continues to evolve while hitting key metrics and, overall, enrollees are very satisfied with their experience. While we may hear criticisms of this program from the other side of the dais here today, we should note that hhs and cms leaders under the Obama Administration repeatedly approved the waiver necessary to make this program a reality. Ms. Verma has assisted a number of other state Medicaid Programs as well. Her efforts all have the same focus, getting needed, highquality care to engaged patients in a fiscally responsible way. This is exactly the mindset we need in a cms administrator. Now, ms. Verma, as if the challenges associated with medicaid are not enough to keep you busy as cms administrator, you will also be tasked with helping to ensure the longevity and solvency of the Medicare Trust fund, which is projected to go bankrupt in 2028. That already come down from 2032 i believe. All told, between now and 2030, 76 million baby boomers will become eligible for medicare. Even factoring in deaths over that period, the program will grow from approximately 47 million beneficiaries today to roughly 80 million in 2030. Maintaining the solvency of the Medicare Program while continuing to provide care to an ever expanding beneficiary base is going to require creative solutions. It will not be easy. But we cant put it off forever, and the longer we wait, the worse it will get. Now that ive had a chance to discuss the challenges facing cms and some of ms. Vermas qualifications, i want to speak more generally about recent events. Weve gone through a pretty rough patch recently on this committee, particularly as weve dealt with President Trumps nominations. I dont want to rehash the details of the past few weeks, but i will say that i hope that recent developments do not become the new normal for our committee. As ive said before, im going to do all i can to restore and maintain the customs and traditions of this committee, which has always operated with assumptions of bipartisanship, comity, and good faith. With regard to considering nominations, that means a robust and fair vetting process, a rigorous discussion among committee members, and a vote in an executive session. On that note, maybe the icy treatment of nominees is starting to thaw today, at least i hope it is. One tradition that has been absent here this session has been the introduction, on many occasions, of nominees by senators of both parties from the nominees home states, especially in cases when the nominee and the home state senator have a relationship. Im pleased to say that the senior senator from indiana is reaffirming that tradition by appearing here today. And so is our other senator from indiana. I thank the senator for taking the time to appear today and introduce their constituent. Ill give him a chance to do so in just a few minutes. With that, i look forward to ms. Verma sharing her vision and views here today. I also look forward to what i hope will be a full and Fair Committee process that allows us to process this nomination and report it to the full senate in short order. I will now at this time recognize my cochairman on this committee, senator wyden, for his Opening Statement. Thank you very much, mr. Cha, ms. Verma and your colleagues from indiana. I just thought it was worth noting that the hoosier basketball tradition, ms. Verma, looks like you brought close to two squads of basketball players, and we welcome you and your family today. Its obvious that the health care post were going to discuss today is not exactly dinnertable conversation in much of america, but the fact is it is one of the most consequential positions in government. The agencies responsible for the health care of over 100 million americans who count on medicare and medicaid. It plays a key role in implementing the Affordable Care act. Thats why cms needs experienced and qualified people for the job. People who know the ins and outs of the whole system, medicare, medicaid, and private insurance. The agency needs a strong and experienced authority, and this is particularly true now when it does appear that some of my colleagues on capitol hill, meaning and administration, are looking to make radical changes in American Health care. In my view, many of these proposals would take the country back to the days when health care was mostly for the healthy and the wealthy. So were going to start with a promise of medicare. Which has always been a promise of guaranteed benefits. That makes up more than half of the agencies spending, about 2 billion a day. With more seniors entering the program each year, theres an awful lot to do to protect, and in my view, update the medicare guarantee for this century. That means addressing the high cost of prescription drugs. It means making the program work better for those with chronic illnesses, like Heart Disease and cancer. Thats a majority of the medicare spending today. It will take bipartisan support is intact, senator grassley privatizing medicare is the wrong direction in my view. Its important here today how your view differ from some of the policymakers who are advocating those kinds of approaches literally be interested in turning the program into a voucher system. Additionally, if confirmed your play a key role in fomenting the medicare physician payment reforms. Its essential that may be implemented as intended by the congress because we want to start moving health care from paying for volume to paying for value. Also the agency implements rules of the road in the private insurance market. And today many of those rules amount to bedrock values for Health Insurance in the country. It means not discriminate against those with a preexisting condition no matter what. It means setting the bar for what type of medical Care Insurance companies have to cover. And it means letting young people stay on their parents policy until 26. Unfortunately, just yesterday the agency released a proposed rule that in my view goes in the opposite direction. From where i sit, the message from yesterdays rule is Insurance Companies are back in charge, and patients are going to take a backseat to the open Enrollment Period, for example, was cut in half from three months to six weeks. If somebody drop coverage during the year for any reason, Insurance Companies could collect back premiums before an individual could get Health Insurance again. And Insurance Companies would have free reign to offer less generous coverage at the same or higher cost. This again sounds to me like its going back to yesteryear when Health Care System really did work for the healthy and wealthy. The administration has been saying the best is yet to come. The evidence seems to me to suggest otherwise. The president could have taken steps to create course to build on bipartisan basis, but instead issued an executive order on the day he was sworn in that is obviously now creating market uncertainty and anxiety. You dont have to look much further than humanities decision in the last day or so. We want to hear from you about how youre going to implement this program that millions of americans count on and how youre going to do it, even though we have republicans here who want to unravel the law. In short, i want to see us get beyond what is come to be known as repeal and run. Repeal and run goes beyond disrupting the individual market. It would also in the Medicaid Expansion that brought millions of low income, vulnerable americans into the Health Care System. This is an area obviously where you have extensive experience. I want to discuss some of the tradeoffs associated with those efforts, and i am particularly concerned about the possibility as ive been informed that somebody making barely 12,000 a year would get locked out of Health Coverage for no less than six months because they couldnt pay for health care due to it upcoming check, for example, or an emergency car repair. Theres been independent evaluation indicating that 2500 people were bumped from coverage due to situations like this. Ive also seen in the same report that more than 20,000 persons were pushed into a more expensive, less cover hints of medicaid plan because they couldnt navigate the system ass less comprehensive that you will put in place. I want to wrap up with just two last points, mr. Chairman, tier one with respect to taking these ideas on a nationwide tour. Im not there yet. I say that respectfully. Well hear more about the program and your support with respect to the states. We touched on in the office. We authored section 1332 of the Affordable Care act saying that states can do better. States have an idea better coverage, lower cost. God bless them, were all for it but we cant use 1332 or any other provision for the states to do worse. One last issue i want to touch on deals with ms. Vermas work. As i understand it you had a Consulting Firm. You all were awarded more than 8. 3 billion in contracts directly by the state to advise the state, and that was while you all were managing the programs. In fact, you would architect. At the same time as has been told me you contracted with at least five other companies that provided hundreds of millions of dollars of the services and products to these programs, hb enterprises, milliman, maximus, Health Management associates, roche diagnostic. And in at least two of these firms hp and hma, the terms of the state contracts appear to have had you in effect overseeing work that the firms performed. Now, george w. Bush had an ethics lawyer, a fellow named richard painter, wasnt exactly a liberal guy, and he said yesterday that this arrangement, and i will quote him, clearly should not happen and is definitely improper. He in effect said you on both sides of the deal, helping manage States Health programs while being paid by vendors to the same programs. He said that was a conflict of interest. I want to hear you respond to his assertion. We are going to want to know more about your work for companies that do business with the state and one of the questions will be if you are the cms administrator, if youre confirmed what you recuse yourself from decisions that affect the companies who were your client we will look forward to your testimony with the two indiana senator. Yorunning with the right crowd, and thank you, mr. Chair. Thank you, senator. Im please to head over my normal witness introduction to a pair of our distinguished colleagues that both senators from the Hoosier State will introduce ms. Verma and a testament to her work and to her as a person. I asked that the Senior Center from indiana mr. Donnelly start the introduction of internet over to senator young. Senator donnelly, you go ahead, proceed. Thank you, mr. Chairman. Chairman hatch, Ranking Member wyden, members of the committee, thank you for inviting her today. It is a pleasure to be here with my friend and colleague, senator todd young, to recognize this important accomplishment of a fellow hoosier. As you know any kind of president nominates an individual for a leadership position in our government, it is an honor and reflection of the tremendous trust and respect he has in that person. For this reason im pleased to be here today to help recognize ms. Seema verma for her nomination to be the next administrator of the centers for medicare and medicaid services, cms, and introduce her to this committee for your consideration. Ive always felt a personal belief that we accomplish more when we Work Together. In indiana we call that hoosier commonsense. In working collaboratively to help hoosiers get access to Quality Health care, is something ms. Verma and i have had the opportunity to do together. As many of you all are already aware, ms. Verma has played a central role in crafting medicaid policy in many states, including our own. In indiana she worked with governor daniels and then governor pence as well as other state and federal partners to take advantage of opportunities made possible by the Affordable Care act to expand medicaid through the healthy indiana plan can also know as hip. Today hip 2. 0 has helped to lower our states uninsured rate, improve Health Care Outcomes and has played a Critical Role in combating the opioid abuse and heroin use epidemics. Hundreds of thousands of hoosiers currently have Health Insurance through hip 2. 0 and the program is an example of what is possible when we Work Together. As ive shared with ms. Verma, and i will share with you, i am deeply concerned about the future of health care in our country as well as the rhetoric surrounding the current debate. I firmly believe that maintaining access to critical programs like medicaid and medicare and building upon the progress of the aca is fundamental to both the physical and Financial Wellbeing of thousands of americans across our country. It is my sincere hope that this administration, working with this committee and others, will approach medicare and medicaid with a thoughtful and pragmatic consideration, these critical programs deserve. I have watched ms. Verma take this commonsense hoosier approach and hope she uses of this opportunity today to share with you her vision for how she can Work Together with all of the members of this committee and congress as a whole to expand access to Quality Health care, and protect and build on the progress weve made over the last several years. With that, chairman hatch, Ranking Member wyden, members of the committee, thank you for allowing me to introduce ms. Verma. To ms. Verma and her family, congratulations on this tremendous honor. I look forward to ms. Vermas testimony and i think the committee for your hard work and your consideration of ms. Verma for this very important position. Thank you very much, senator. Thank you, chairman hatch, Ranking Member wyden, and members of the committee. It truly is an honor to be with you to introduce a fellow hoosier, seema verma, to be administrator for cms. President trump simply could not have made a better choice in selecting seema verma to lead what is argued with the most office within hhs. An office that comes the Health Care Needs of over 100 million americans with a budget of almost 1 trillion. In her 20 year career as an innovator in the health care sector, shes worked extensively with a variety of stakeholders from both sides of the aisle to deliver better access to health care. As president , ceo and founder of svc, she helped several states to redesign their archaic medicaid systems, including in my home state of indiana. Seema revolutionize the Medicaid Program as architect of the healthy indiana plan which we know as hip pickets the nations first consumer directed Medicaid Program. She transformed a complex, rigid medicaid system into one where hoosiers are back in control of their Health Care Needs. Since 2007, hip has achieved impressive results. Hoosiers are more likely to seek Preventative Care, take a prescription medication, and seek primary Care Services at their physicians offices, not the emergency room. Her innovative ideas working and its now an important proof of concept that medicaid had a more efficient than a one size fits all approach. She accomplished this with the support and buying from people, again, on both sides of the aisle. And all levels of the process. By putting the mission about politics, she demonstrated a willingness to work with anyone, anyone who was willing to do the same. She worked with the democrats indiana statehouse. She worked with the Obama Administration to find Common Ground on how to best provide Quality Health care to hundreds of thousands of low income hoosiers. And it worked. As cms administrator, seema will have the ability to use her extensive experience to help other states achieve what we have in indiana, Better Health outcomes for our most vulnerable. I look forward to working with you. I thank you, sir. Thanks to both of you senators. Such a real honor for the committee to both of you, come and i know ms. Verma really appreciates it. We know you are busy so we will let you go. Ms. Verma, we will now turn to you for your comments and your feelings on this nomination, and then we will turn to questions from the senators up here. Good morning chairman hatch and Ranking Member wyden. I appreciate and am grateful for your consideration of the nomination by President Trump to be the administrator for the centers for medicare and medicaid services, and i thank you for the time that many of you spent with me in advance of the hearing and i appreciate hearing about your priorities low income mothers to improve birth outcomes i fought for coverage, pretty or health care access, and for improving the qut of care and have continued to fight for these issues for the past 20 years. But im deeply concerned about the state of ash Health Care System as theres frustration all around. Many americans are not getting the care that they need, and we have a long way with to go in i dont having Health Status of americans. Doctors are increasingly frustrated by the number of costly and time consuming burdens. Health care continues to grow more and more expensive in the the American People are tired of partisan politicses. They just want their Health Care System to be fixed. And i know this not simply because ive worked in health care but because out of intimately it affected my own personal life. My mother is a Breast Cancer survivor due to early diagnosis and treatment, and a few years back, my neighbor aidan was diagnosed with a stage four neuroblaysmoma a large tumor growing since he was maybe born and wrapped all around his kidney he went through keep chairperson, radiation, stem cell treatment and surgeries all experimental. This may aidan will celebrate his 12th birthday. And both my mom and aidan are testaments to the grace of god and the ingenuity of the American Health care system. This is why people travel from all across the world to get care in the United States. I want to be part of the solution making sure that the Health Care System works for all americans. So that families leak my own and aidans have the care that they need. I want to be able to look my children in the eye and tell them that i did my part to serve my country and to have a voice for people that dont often have one. This is a formidable challenge that i am no stranger to achieving success under difficult circumstances. My father left his entire family to immigrate to the United States touring the 1960s and pursued four degrees while working to earn money. On my mothers side my grandmother was married at age of 17 with no more than a fifth grade education. But my mother went on to be the first woman in her family to finish a masters degree. My parents made a lot of sacrifices along the way to provide me with the opportunities that they didnt have. And taught me the value of hard work and determination. Im extremely humbled as a firstgeneration american to be sitting before this committee after being nominated by the president of the United States. It is a testament to the fact that the American Dream is very much alive for those willing to work for it. And it is my dream and my passion to work on the frontlines of health care to improve our system. Throughout my career, i have brought people together from all sides of the political spectrum to forge solutions that worked for everyone. One of my proud arest moments in my career was watching the and Legislature Pass the healthy indiana plan which was a program for the uninsured with a bipartisan vote. It is a one trillion agency and covers over 100 Million People. Many of whom among nations most vulnerable citizens providing high quality Accessible Health care for these americans isnt just a luxury but necessary and matter of life and death. Should i be confirmed . I will work with cms teams to ensure that the prals are focused on achieving positive Health Outcomes and improve the health of the people that we serve. To achieve this goal, i will work towards policy that itser or patient centered approaches that increase competition, quality, and access while driving down costs. Patients and their doctors should be making decisions about their health care, not the federal government. We must find creative ways to empower people to take ownership for their health. We should support doctors and providing high quality care it their patients and ensuring that cmss rules and regulations dont drive doctors and providers from serving the people beneficiaries. If confirmed i will towards the programs to address changing needs of the people they serve, leveraging innovation and technology to drive better care. I will ensure that efforts around preventing fraud and abuse are a priority because we can knot afford to waste a single taxpayer dollar but usher in new era of leadership to drive Better Outcomes. If i have the honor of being confirmed, i will carry this vision along with my strong beliefs in open communication, collaboration, and bipartisanship. I will work with you. Be response of to your inquiry, concerns, and value your counsel. I thank you for the consideration of my nomination. Thank you so much. We really appreciate your willingness to serve, and i look forward to to getting you through this process. Let me just answer obligatory questions to give you first is there anything youre aware of in your background that might have conflict of interest to do the tax cuts which youve been nominated . With the consulted with the office of ethics and have indicated in areas where i thought would be an issue and ill be recusing myself of matters that would present potential conflict. Well, thank you. Do you know of any person or any reason personal or otherwise that would it shall that would in any way prevent you from fully honoring the duty of offices which youve been nominated . I do. Do you agree without reservation to respond to think reasonable, any reasonable inquiry see here. Getting these pages apart. [inaudible conversations] any reasonable summon to appear and testify before any for any duly constituted committee of the congress if you are confirmed . I do not. Youre willing to do that . I am willing to do that. Okay. Finally, do you mit to provide a prompt response in writing to any questions addressed to you by any senator on this had committee . I do. Well, thank you. Let me now get into some just questions, i know youre aware of the historic bipartisan medicare and reauthorization act, that i had a lot to do with in 2015 called macra law got rid of the dreaded sgr formula and made improvements to how medicare pays physicians. Im pleased that our work on the implementation that these changes helicopters to be bipartisan. Both in how republicans and democrats in the congress have worked together an how congress had worked with the Obama Administration thft, in fact, the Obama Administration gain physician and other stakeholders through the initial implementation phase. Now strikes me that this process of consultation early and often should be the rule and not the exception. What is your view on how to how to engage stakeholders to approve to arrive at the best policy decisions and other cms programs . Thank you senator. I applaud Congress Efforts to pass macra an step forward to providing more stability to providers but move us to Better Outcomes. In terms of stakeholders i think the most important thing that we can do is engage with stakeholders as quickly as possible on the front end and all the way through the process. Understanding stakeholder perspective and what folks are going through on the front end. What their challenges are, and as were developing policies and programs to have that open communication, i think is helpful towards any successful implementation it is not just a one time thing or front end but all the way through the process. Even after the programs established it is always important to have that dialogue with stakeholders because they can tell you whats working and what is not working and when you think of new ideas and youre thinking about implementing them, they can help you figure out whether it is going to work or not. I know ive had that experience in my career and ive always found it very help hadful in integral part of success. As the baby boomer generation ages, number of persons age 65 and olds nor the United States is expected to dramatically increase, with an increase in demand for a Long Term Service and support, notably medicaid is primary payer of these services what changes any should be made to meet increase and demand ensuring that fiscal sustainability of the Medicaid Program . I think medicaid is a very important program. Its been the safety net for so many vulnerable citizens. When i think about Medicaid Program, i think about some of the individuals that ive met. One person in particular, i think about is the quadriplegic on a breathing machine, and he requires 24 hourcare. I think about the mother of a disabled child and this is the face of a Medicaid Program. And so as we think about Medicaid Program and where we are today, i think that we can do better. We have a challenge of making sure that were providing better care for these individuals but the program isnt working as well as it can. Theres very intractable program that is inflexible. States is are in a situation where theyre having to go become and forth doing reames of paperwork trying to get approvals from the federal government, and at the end of the day are we achieving the outcomes that we want to achieve . As i think about the Medicaid Program i thinks theres an opportunity to make that program work better. So that were focusing on improving outcomes for the individuals that are served by the program. All right, in 2014 i working closely senator and leaders from the house and committee to act a of bipartisan by camera law called the improving medicare lets see here, proving medicare care for transforms or impact. Impact act served as critical Building Block to achieve medicare close to kid quality measurement and payment reform. Specifically the impact act requires that that the requires the collection of standardized data to have medicare not only compare quality across the can kid settings but also improve hospital and a discharge planning. Now, our goal is to produce data driven evidence that congress can use to debate best ways to align medicare opposed to kid payments that improve Patient Outcome and save taxpayer dollars. And our intention is to ensure that were able to do this type of this type of thing. Want to ensure that beneficiaries are receiving post to kid Care Services in the right setting at the right time. Now, will you commit to working with me and members of congress on this committee and the Community Provider on implementation of the impact act . It would be my pleasure to work with the committee, stakeholders anyone else that was interested to make that program a success. Well thank you and turn to senator white. Thank you very much, and thank you for your testimony. I want to start with the comment you made that you were committed to coverage, of course, is what this is all about. Unfortunately when ive seen since the beginning of the year has been basically about rolling back coverage. And in fact, congressman rice fastened your seat and refused to commit to making sure that no one would be worse off in terms of coverage. Now, the president said in his campaign ill quote, were going to have insurance for everybody. The American People are going to have great health care, much less accident pensive and much better thats what had the president said. Yesterday cms did the contact opposite first to come out of the agency, the agency that you would like to head after price was confirmed meant less coverage, higher premiums, and more out of pocket costs for working families. How would you square what President Trump said in the campaign with what cms did yesterday . In terms of the rule that you speak of, i have not been involved in the development of that rule out of respect for the committee and from the nomination process ive not been involved in that and havent been with cms i cant speak to that. But i can tell you that im committed to coverage and been fighting on this issue for 20 year answer to do that if im confirmed. But i just read you quotes and its not like, you know, atomic secrets or classified materials. What the president said is very different than what cms did yesterday and you read newspapers youre a very informed fern talking cutting the Enrollment Period im looking at the headlines can the then rollment period in half which really is going to limit or ability to get the very people we need most. The younger, healthier people. So one more try. How would you square the president said with what happened yesterday . I think the president and i are both chitted committed to coverage. I have not had an opportunity to review that. But again i think the president and i both agree that we heed to fight for coverage and make sure that all americans have access to affordable, highQuality Health care. What troubles me about yesterday is once again Insurance Companies are coming first and patients come later. Tell me one thing you would change to put patients first . One thing that i would do is, i think, whats very important is that patients be in charge of that you are health their healte to drive decision about their health care that they get to make the choices about what kind of Health Care Plan works well for them. I think its important that our patients have access to quality coverage to the doctors to their choice of doctors, and their choice of plan. Could you get us a specific on that because thats been admirable philosophy, but i still dont know, yesterday was good for Insurance Companies. And it was bad for patients. Id like to have a specific example and well keep the record, you know, open of something you would do to put patients first and i respect the fact that youve articulated a philosophy but i really want to know a specific about what you do to put patients first. Lets move on with respect to another area of responsibility youll have and thats prescription trugs in medicare because we all know that these prescription costs are just clobbering, you know, families and seniors, federal government, and whole variety of stakeholders that youll refer to as the administrator of the agency youre going to have an opportunity to address this problem. President has been vocal on it. Again, give me a specific change to Medicare Part d that you would suggest to bring costs down. Well i think that the issue drug pricing is something that all americans are concerned about and the president is concerned about about that as well. People want to make sure that when they need the drugs when theyre going through an illness they think about my mom, my neighbor aidan when they need drugs that they need, they want to know that they have access to that and it is affordable and all concerned about that specific issue. Part d i think has been a good program are and it has expanded access to medications for people that didnt have it before and i think that structure of the program in terms of how it put Senior Citizens in charge of their health care they can go on aen played finder go onis line. J my time is up and i got welts on my back to show for it. I asked you for a specific change going forward, that you would do to help seniors and others hold down their costs. As you know theres discussion of making changes so that medicare could garbage is will one specific you can give me . The reason that the medicare question is so important is not only does this effect older people so dramatically, but your experience is on medicaid side and i respect this people have different experiences. So i very much would like to hear a specific on this key medicare issue that you would actually be for. I would be for policies that continue to put Senior Citizens in charge of their health care. That puts them in the drivers seat of making decisions that work best for them to figure out what plan covers medications that nay need. What plan is affordable to them. And allows them to make the decisions about their health care and that gives them access to the medications that nay need that doesnt limit that in any way. And that is affordable to them. My time has expired i still didnt get a specific example. I happen to be for a host of things on transparency, on negotiation, on trying to make sure that we squeeze more cost savings out of the middle members of the jury im going to hold the record home but ive asked you for specifics in two areas putting patients first and how you would hold down cost of part d and respectfully i didnt get the specific hold the record open for it. I think senator grassley youre going to call out names on your side or [inaudible conversations] next that didnt take much time. [laughter] so what im going to talk to you about is things that have happened in the past. And hopefully coming from an administration that wants to drain the swamp, i think i would changes to be made under your leadership in this agency. And i would suggest that you probably cant do anything about this suggestion that im going to give you to respond to the last question on my colleague but if you would push doing away with pay for delay programs between dog and generics i think it would go a long ways to helping get drugs cheaper. Cms has told me that it does not have much authority to do anything about some frauds committed against programs even those even if those actions are in cmss own words quote unquote a clear violation of the laws. And [laughter] common sense tells me that if theres a clear violation laws cms can do something about that. If thats the fair attitude there i ask you to see whether the past interpretation is right by checking that interpretation. But in a january 28th letter to me about the medicare drug rebate program, cms said it could tell a manufacture when drugs is misclassified and then quote end quote attempt to reach an agreement in other words after the money has been stolen from the taxpayers, take some trouble to get it back if you can reach an agreement. But there are a lot of tools that the government has to fight fraud. And the most effective one we have is a claim act since 1987 when i got that law in place, the department of justice has used the false claims act to recover more than 33 and 9 billion dollars just lost from just a Health Care Fraud alone. But cooperation between Health Care Justice and administrators is important and seems that cms could have at least picked up the phone and girch the department of justice a headsup when these manufactures refused to cooperate and properly classify their drugs. So Pretty Simple question and might even be calling this softball question. But it is pretty important to me would you commit to proactively cooperating with the department of justice in fraud cases and to fully supporting the use of the false claims act to combat fraud on Government Health care programs . I will absolutely do that and i applaud your effort and has been an integral proponent of recovering dollars when theres fraud so i thank you for your service and your work on that. Yeah, next question in had the fall of 2016, and in january of 2017, i sent several letterso cms regarding steps it took to hold accountable for misclassifying epipen as generic under prebeat program, c has publicly state has had it, expressly advised that the pen for purple of the Medicaid Drug Rebate Program was incorrect, however, cms has failed to fully respond to my oversight request and refuses to provide records of communication with myland and not clear as to what the authority has to do with to correct drug misclassifications. Because of epipens misclassification that government and states are hold millions of dollarses from milan, congress and American People hold answers. So in if confirmed would you commit to fully responding to my oversight request and providing the request of records of communication beyond milan and cms i hope thats a short s. That is a short yes. In light of epipen misclassification and potentially other drugs that have been misclassified under medicaid what steps will you take to ensure that drugs are properly classified under medicaid . I think what happened with the milan pen and epipen issue is very disturbing. The idea that perhaps Medicaid Programs which are struggling to pay for those programs, that they could have potentially received rebates is disturbing to me so if im confirmed i would like to review the processes in place there in materials of the classification and brands and generic to make sure that type of thing doesnt happen again. I want those communications from cms i hope you can get them for me. J ill be happy to work request you on that senator. Thank you very much. Welcome to you and your family. First thing, many, many questions i have, but first regarding medicare do you believe that Medicare Program ares should negotiate the best price for seniors on medicare . I think that we need to do everything that we can do to make drugs her affordable for seniors. And im thankful that we have the Part D Programs that are performing that negotiation on the behalf of seniors. Do you believe we could get a better price if medicare was negotiating as va does as other private entities do to get the best price for seniors. I think that competition is the key to getting good price ares i think that yes or no on negotiations . I dont think thats a simple yes or no answer because i think there are many ways to achieve that goal and goal is to make sure were getting affordable prices for seniors if we look at the part d Prime Minister and way theyve negotiated this, we know when theres a lot of competition the price goes down. So i think we have to figure out ways and im happy to work with you on that how to increase competitiveness and support Part D Program. But i like about the Part D Program is that it puts seniors in charge of making the decisions about the the drugs that they need. Using the plan finder tool, go in there, this can put the medications that they need and then stop because i dont have a lot of time. So under the repeal of the Affordable Care act, actually seniors would begin to pay more because the gap in coverage for those who have to lose a lot of medicine would appear again. So weve closed that, no gap for seniors. And that would reopen. Do you support that . Part of the repeal . I think that its as a ive said before i think it is important to get seniors most affordable drug prices do you support returning to ga and coverage for seniors under Medicare Part d . Seniors access to affordable medications and medications that they need that they choose. Okay. Let me ask now about follow up a little bit more on yesterdays decision is railroad are aing cms. One of the things that they decided to do yesterday was to cut for people to be able to get insurance from three months to six weeks. Dow support that . I havent had a chance. To review that rule i was not involved in the development of that. Does that seem like a good idea . Im sorry does it seem leak a good idea from your standpoint . I want to review implication of that. I was not as i want respect for this process, i have not been to hhs and cms and have not been involved in the development of that rule. So i would look forward to reviewing that and happy to report back to you after ive had had a chance to review that. L when we look at another really important set of provisions in the Affordable Care act is something that i call patient protections where everybody with insurance doesnt matter who it is has more ability right now to get the care that theyre paying for through their insurance if not just a decision of the Insurance Company. So there are a number of Different Things that folks now count on and one is having an essential set of basic health Care Services. That are defined so that when Insurance Companies are getting Everybody Knows theres a basic set of services that the woman youll get Maternity Care, that Mental Health will be covered the same as physical health or or Substance Abuse services so on. So theres a basic set of services. Dow support having that as a basic set of essential services in our Health Care System . I support americans being in charge of their health care. I support americans being able to decide what benefit package works best for them. I think it is hard to know what works for one person might not work for another person and i think its important that people be able to make decisions that work best for them and their families. As a mother of two children, you know in a family i know what had were looking for but what im looking for might not work better for another family so i support americans being in control of their health care, and making the decisions that work best for them and their families. Do you believe that women should have to pay more to get prenatal care and basic Maternity Care as a coverage as a writer, as an extra coverage . You know, im the a woman so i certainly support women having access to the care that they need. I have two children of my own and ive appreciated bank service should women be paying more for health care because were women . I think that women should be able to make the decisions that work best for them. But if the decision is made by the Insurance Company, as to what to charge, how do we headache that decision is this prior to Affordable Care act ive said about 70 of the Insurance Companies and the private market place didnt cover basic Maternity Care and basically look at women as being preexisting conditions being a woman. Different kinds of Health Services that we need werent provided or viewed as essential services thats changed now where women have what are basic services for us covered as a basic services where we dont have to pay extra as a rider in order to get basic care. And so im just asking do you think that makes sense . You know, obviously, i dont to see women being discriminated against. Im a woman and i appreciate that. But i also think that women have to make the decisions that work begs for them and their had family. Some women height want maternity coverage and some women might not want it or choose it and feel like they need that. So i think its u up to women to make the decision that work best for them and their families. Thank you. Thank you mr. Chairman. As you can imagine were now having two votes, so theres nobody here to question so i think what ill do is recess for about 15 minutes. Sorry to interrupt like this but thats so in light of the u. S. Senator and we sure appreciate you and appreciate your patience and appreciate i appreciate the way youre answering these questions. [inaudible conversations] and your with expertise really comes through. So with that ill just recess for about 15 minutes so if i can get the second vote and be right back. [silence] recess and return to senate. [inaudible conversations] welt thank you mr. Chairman an congratulations on your nomination and thank you for being Courtesy Call to my office we had a very, very good discussion you have a very impressive record with regard to medicaid, more especially pushing for greater innovation and flexibility in the program. I must say your Opening Statement was not only relevant right on point. But inspiring as well. Thank you for that. I think i would speak for all members of the committee. We need to make a copy of her statement available mr. Chairman and virtually every member maybe them on it. I agree with that and bring this back together. Okay. As cochair of the Senate Health Care Congress in particularly concerned on how regulation is coming out of your agency work or often do not work for our small providers we talked about that and im also interested in how we harness payment and delivery models that are better tailored to their communities and their needs given low volume of patient and medicare patients i know youre very familiar with that with their work in indiana. How do we work to include our small and rule providers call improvement programs without disadvantaging them due u to the unique populations they serve . Secondly, would rural relevant quality measures or different data thresholds be more appropriate to encouraging participation and certain valuebased purchasing and or pay Performance Program . Thank you for your question senator . Rural Health Providers have unique and challenging often only providers in their communities that are providing services and so when people come to them, theyre dealing with a variety of Different Health issues. Its not just preventive kir and primary Specialty Care and dont always have access to services. The challenge for them is that even attracting work force and finding providers to cool out to those regions is a challenge and it is difficult. Because they have those multiple challenges, it is difficult for them when there are lots of rules and regulations coming down from the federal government. As a Small Business owner and working with small physician offices, you sort of understand that it is tiflt sometimes when theyre on the frontlines and theyre trying to manage such very complex situations to also deal with rules and regulations difficult. That being said, we want to assure is that all americans have access to high Quality Health care. But i think we have to be very careful with our rule providers to make sure were not putting durable burdens on them that actually you know, impact accessibility to care or quality to care so i think when it coming to rule providers we food to support them through the process and we need to make sure they have the appropriate Technical Assistance to get to where they need to be, and understanding that, you know, understanding that the demands that they have on their time might impact their ability to implement those regulations. I really appreciate that. We have i think we have 83 probably more today critical access hospitals, and i know you have the same situation in indiana. Thank you for your statement. As a member of both the health and finance committee as many of my colleagues are, we often see a disconnect between new and e exciting therapies that are proved bit fda and Reimbursement Policies policies from cms and for example last year only one, one bioseminar was approved bit fda and guidance documents were still outstanding cms proposed and finalized a payment policy that could stieflt innovation in this area. How would you anticipate working with the fda to ensure cms is developing best payment policies for patient and providerses in the taxpayer . Well, i think collaboration and a coordination is critical within a hss and ill appreciate secretary price in his leadership there. Careful coordination and collaboration between similar agencies and sister agencies is important. I think being on the front end and discussing with them, understanding understanding what their intentions are what is coming down the pipeline making sure that cms is prepared to and coordinated with any efforts that fda has. I must tell you that, and in health care has talking to many of my hospital administrators, and the rural providers in charge of cms, the term used a lot in the past has been its a mess. I know youre going to fix what. But there is a cmss senator for Consumer Information in insurance oversight societal thats the new acronym i was not aware of that. I thought i knew most of them has responsibility for governing and Health Care Act marketplace. What do you see it pointing under your leadership . If im confirmed as administrator my job is to implement the law to playing a role with the current law, and so i would look to congress and its efforts around addressing the Affordable Care act and my assessment of the role will depend on how congress decides what to do with the Affordable Care act. And so i make that decision based on the ultimate outcome of congresss decisions around the Affordable Care act. I must say mr. Chairman that im impressed with your statement. I know that we have several senators talk about unraveling of obamacare. We had a entire Insurance Company lead the market. We have another one describing it as a death spiral. I think we need to see a rescue team to make sure that is still there and build new bridges. But i think thats about that would be my taking on that. Thank you so much for your testimony and thank you for the leadership and i know youre going to bring to cms. Thank you, senator. Well thank you, senator. Well were waiting for other questioners let me just ask a question. One of the issues that is focused on over the past three year is large back log of medicare appeal for performing by this contractors. But statement improper payments pose a real threat to the financial well being of the Medicaid Programs, so what are your views on how do balance a need for Robust Program and integrity and also claims accuracy with me with the need toen sure timely payment and providers without causing so i think thats a very important question. Fraud and abuse if im confirmed would be a top priority thats what i call, you know, should be lowhanging fruit as we look at the Medicare Program assuring its sustainability over the longterm and given the Medicare Trustees report the not future medicare and running out money t some point we cant afford to waste a single taxpayer dollar. So if i think of fraud and abuse especially with with Fraud Prevention is looking to have efforts really be on the front end. Not waiting to do a pay and then chase. But really on the front end addressing fraud and so as were developing programs to make sure that were putting those procedures and policies in place, so that we can identify fraud and abuse on the front end. I think that issue that you raise in terms of back log and burden that it puts on providers is something that concerns me. We want to make sure with cmss policies that we arent preventing providerrings for participating in the program and being active in this. And the back log and things like that have really made it difficult for provider where is theyre not getting paid for these types of issues so i think it is a balance we have to strike with being aggressive on fraud and abuse but not potentializing focusing our penalty efforts on bad players without penalizing a providers that are trying to do the right thing. Well thank you is that states are increasingly moving programs into a manage care Delivery System with managed care now representing almost 40 of federal medicaid spending. Now, in the last year, the cms released updated framework for medicaid manage care, what if any changes do you believe are port to federal and state oversight of medicaid manage care . I think that managed kir has been had an important opportunity for states that gives them the ability to set a capitation rate with providers and hold the manage care Company Accountable for meeting that financial dmantd also an opportunity to set to identify goals and outcome and hold Companies Accountable for the care and jots comes that they serve. But that they provide, in terms was Regulatory Framework and managed care role, i think that we we probably need to move to an era where were Holding States accountable for outcomes. But having states having to go through pages and pages of regulation, my question would be for for that regulation is, what does it do to improving Health Outcomes for the individual . And im all about wanting to make sure that were being appropriate with our health care dlears dollars and managing effect iively but when we look at regulation is that regulation helping states improve Health Outcomes . States will spend millions of dollars implementing that particular regulation. And i think we have to ask ourselves, what will we achieve . So i think there are some, some important developments within the manage care regulation, but if im confirmed i want to take a look at that to make sure were not burdening states with the additional regulations. Okay, let me ask you this, your written statement providerrings struggling to deal with administrative burdens while we need providers to be accountable, for the care they provide, and the associated government spending, it is crucial to minimize the regulatory requirements to take time away from treating patients. Now weve heard concerns regarding the very specific requirements that are a part of medicare and Medicaid Electronic Health record that of the medicare, medicaid, medicare and Medicaid Electronic Health record incentive program. We also hear that many other requirements are unneeded or outdated. How do you think cms is have task of reducing unnecessary regulation . I think one of the places to start is by talking to doctors and having open communication and collaboration with physicians. If im confirmed that would be a priority for me to touch base with our providers and understand the issues that are getting in the way of them being able to provide high quality care to the patients that they serve. I would want to identify the types of regulations and a provisions that are that are asking providers perhaps to consider maybe not participating if in the programs. I think starting with that open communication, and dialogue and working with them to understand what their concerns are. Thank you. I think i turned senator wyden for any questions he has. Thank you, thank you very much. Mr. Chairman, and again im just trying to get a sense of how you would approach some of these things is why i ask apropo what cms did one specific example about putting patients first same thing with respect to, you know, Medicare Part d, with this committee is a chairman touched on colleagues touched on. Both feel members feel very strongly about rural practices and rural patients and we feel very strongly about making sure that we get macra right and when im home this oregon i get asked about who key parts of the new Payment System a lot. I get asked about Virtual Group and nominal risk and people say hey, whats this going to mean for the small and rural practice . Now, obviously, you know this is not dinner table conversation, you know, either. But for the doctors in rural small practices, they say this is really going to tell us about whether were going to get to succeed in this brave new world of of Payment Systems. So tell me a little bit about how you as administrator would look at Something Like this. I mean, senator has also been concerned about the Virtual Groups. How would you go about structuring and implementing these Virtual Groups . I think that you know, i think so small providers rural in terms of macra a challenge for them and worthy goal but we have to be supportive of them through the process of implementing it, this terms of providers taking rsk and especially smaller providerses i think that thats a thats a larger mountain to climb i think theyre going to be reare reluctant to take risk when theyre starting out many small providerring rural dont have financial reserve that Bigger Health systems have, and you know, in terms of putting them on the hook when we think about outcome and Health Outcome and Holding Accountable for outcome all of that depends on patient, and i think thinking about strategy about how we can engage patients to be a part of that equation, so that they have a same investment they have some investment to work with their providers to achieving outcomes but in terms of smaller and rural providers taking on risk i think thats a formidable challenge. And on vir Virtual Groups what is your tick on say the most important thing to make them work . Well, i think we have to continue to work with them, to understand what their specific concerns are and rye to address it. But i think at the end of the day, those are going to be challenges that were going to have to work through with them. You know, what i have found is listening to folks, understanding what their concerns are and trying to see to best of our ability if we can try to address those concerns. And what about the whole question about no, maam nominal risk and i want to keep this open ended enough so i want to hear had about you know paragraph 3 you know line 2. I just want to get a general sense of how you would approach it. Because this is what rural physicians and patients are going to talk to me about. Im going to have town Hall Meetings in a couple of days so how about no, nominal risk . This is the challenge here. I dont know that rural providers and small providers want to take risk at all. And i think that, you know, when were designing these rams, we have to keep in mind their specific needs. Taking on risk, you know, is something that Insurance Companies have done some of the larger Health Care Systems syste done. If we lock at aco models we know very few large Health Care Systems are comfortable so some may or may not want to do that. So does that mean when i listen to that, it sounds to me a little bit like ms. Verma wants to keep the service. [inaudible conversations] i think the service there are definitely some concerns with that service that is volume over quality and outcome so im not suggesting that that works better. I think that there is something to be said and i support efforts to increase coordination of care. And to hold providers accountable for outcomes. I think, though, in terms of theres also Holding Providers accountable for outcomes and it is another thing altogether this have them accepting risk. So lets do this like we did the other two questions. I would like in writing because this is so important for rural practices, rural providers, i would like just even one specific that you would pursue to try to address these issues the reason im asking is because it is a big list theres no question about that. Theres no question that trying to keep a rural practice open is a big lift but these are questions that providers are going to ask me. Theyre going to see me and say ron youre on this committee and deal with these issues. How is government going to go about doing it in so i ill have one additional question later mr. Chairperson. But the matter of the specific respect to patients first to Insurance Companies first as we heard yesterday and pharmaceutical question where i would like a written answer, and i think given the fact that these matters are moving on a fast track, were going to need to have your answers certainly within the next three days or so. Okay. I have one additional question later mr. Chair. Ask it now we have a couple of more question on the vote thats the reason this is second. We both have to go dont we . Mr. Chairman if youre willing i have one additional question i assume youll want to make a closing statement at the end and i would like to too and we have senatorrings coming back so i think [inaudible conversations] okay. Well come back. We have ten minutes before the vote here. Inch well come back. Well let me use a little bit of this ten minutes to ask is another question. Theres great provider interest in participating in various medicare projects that change the way payment is made to incentivize providers change the way that they deliver care. Now many of these alternative payment arrangements are run through the senate for medicare and others are conducted independent of it such as the good portion of the Accountable Care organizations program. Now while all of these programs involve some type of formal e evaluation theres understandably great interest in knowing what works and what does not as soon as possible. Now what is your view to testing different medicare approaches and how to best assess the result. Make a couple of things. One, first of all i would say that i support efforts around innovation it is important that were always trying to climb the highest mountain. And that were never satisfied with where we are. Always trying to figure out how to do better. How to get better quality care. Better Health Outcomes, improve delivery services. And so innovation is important. But as were looking at testing new ideas i think that process has to make sure of a couple of things. We needs to make sure were not forcing and not mandating individuals to participate in a experiment or some type of a trial theyre, theres not consent around but i think thats very important so i would say that first off. In terms of e valings. E valings is an important component, obviously, thats why were doing it to understand whether that can be transferred to whether it can be used for a Larger Population or for policy of a program. So evaluation is a critical opponent of that and set up on the front end needs to be, you know, on a before the evaluation goes full scale i think it should be done on a small population or on small frame first before it is expanded but that evaluation needs to be done on front end all the way throughout the process. I think as it is expanded or before it is expanded thoses should be shared with stakeholders and i hope with members of congress and there should be discussion about that before that becomes formal policy. Well, thank you. Let me just ask one more question while were wait for some of the senators to get become and then i have to go vote again. Seniors have a choice whether to roll in traditional government run Medicare Service program or in an alternative private insurance option called Medicare Advantage. According to cms, approximately 18. 5 million 30 beneficiaries estimated to sign up for Health Care Advantage plan. Now generally Medicare Advantage plans offer extra benefits such as dental, vision, hearing, and wellness or require smaller copayments or deductibles than traditional medicare, and seniors pay a higher monthly premium to get these extra benefits. But also theyre financed through plan savings. Traditional medicare does not limit patient out of pocket spending for part a and part b services. Causing some seniors to buy supplemental Medicare Coverage called metagap. Insurance, people who do not have retire coverage or who cannot afford supplemental insurance find Medicare Advantage plans are for extra benefits that traditional medicare does not cover and protects them higher than expected out of pocket spengtd spending. I had a lot to do with Medicare Advantage by the way so ill tell you that in advance. Can you commit to working with this committee and congress to preserve and strengthen this successful Medicare Advantage program . I can and it would be my pleasure to work with you on that. I think that Medicare Part Medicare Advantage has been a Great Program for seniors. And i like about it that it is offering choice rs if seniors. They have the ability to figure out again, just like in part d what plan works begs for them and the fact that it provides them the opportunity to have additional benefits, vision, and dental services, i think it is very important in the fact that it providing more choices for seniors is a appropriate proponent. Soy notice that the senator will pass, and doctor cassidy is here so im going to call on him next and then [inaudible conversations] bye. Thank you for being here. I dont think im going to be age able to get become and continue on until we get this hearing over. Seems to have had an effect upon us. Can you just comment the nature of the structure of getting folks Health Savings accounts requiring things on their part, what i did vote for expense as well as for outcomes . Thank you for your question. Its always a pleasure to talk about the healthy indiana plan. I appreciate the opportunity. The healthy indiana plant is about empowering individuals to take ownership for their help we believe in the potential of every individual to make decisions about their healthcare im going to interrupt you occasionally. Theres some that say Health Savings accounts even pre funded are not appropriate for those who are low income suggesting the lack the sophistication with which to handle that. But youre suggesting that the healthy indiana plan, i assume was what, 130 the speed is it starts at the very lowest level of the poverty spectrum, so people at 0 of people who dont have income spirit they were enrolled as well . They were enrolled in a plane. Just because individuals are poor doesnt mean they are not capable of making decisions. It doesnt mean they dont want to be able to have choices and that they shouldnt have those choices. They are capable of making decisions about their health care. Just because someone is poor doesnt mean they shouldnt have choices and not capable of making decisions that work best for them. [inaudible] its my understanding, in other states when it was an expansion, [inaudible] i think you doubted outcomes improved, id like the National Bureau of Economic Research which found outcomes did not improve. Spivak so the healthy indiana plan what weve seen is the individuals that were actively engage in making contributions to the Health Savings account hd Better Outcomes. They had more primary care, more Preventative Care. They had lower er use. They were more satisfied with their care and we also showed that they had better adherence to the drug regiments that their doctors prescribe. So all across the board. [inaudible] you ended up with two different populations, that the bill that contributed reflected something [inaudible] did you find that to be the case . What we found is that the individuals that were making contributions toward their care were sick or individuals. They had more complex illnesses and yet when they were making contributions toward their care they had Better Health outcomes than individuals that were healthier to start with. Really . So the folks who were sick or theoretically less disposable income, they cant work as much, nonetheless Better Healthcare more is reflected in the contribution that there was a positive correlation between thats correct. Better drug adherence, more Preventative Care. These were not my small margins i would add. When we look at primary care and their Preventative Care of these are margins by about 20 for primary care and Preventative Care. So they were significant differences for individuals. What it shows us is that we can empower individuals to take ownership for the help and the people just because they dont have income doesnt mean that they are not capable and that they dont want to have choices. We believe in the dignity at the potential for individuals to make decisions. Theyre happy to do that and get Better Outcomes. The key factor in academic literature they speak of the activate patient. Thats the critical factor. To what degree does the patient engaged as a partner in health, what degree does she participate both related to each other but that turns up against a positive outcome, lower cost. Thats exactly what weve seen. Even with the healthy indiana plan, if we compare that plan to other states weve been able to do it, cost less. We been able to reduce the number of uninsured in our state at higher levels and other states that have run more Traditional Program spirit we done it at a lower cost, have Better Outcomes or reduce the number of uninsured spirit inevitably i is a federal role n this. So is it possible you could reduce the federal role to zero and a plan such as yours still be viable in a state with a high poverty rate . In indiana negotiating the healthy indiana plan and being able to achieve the waivers, this is something governor daniels asked the federal government, and we use the healthy indiana plan for the Medicaid Expansion . He asked this before the Supreme Court decision which made it optional. And it took us, so he wrote that first letter in 2010, and it took the federal government almost five years to make a decision about whether this program could work. So i think that something we need to look at or that i would Hope Congress would want to work on because that type of back and forth again, theres federal dollars that are essential as well. Exactly. Thank you. I yield back. Senator nelson. Good morning. I enjoyed talking to you on the telephone. Do you support during the Medicare Program into a voucher system . I support the Medicaid Program, or Medicare Program being there for seniors. People are making contributions into the program. So with that include the voucher system . I think that, i dont support that. I think what he do support is giving choices to seniors and making sure that program is in place. What weve seen its efforts, a lot of concern about the future of excuse me for interrupting. I didnt understand. The fellow who is now the secretary of hhs had taken a position as congressman, supporting the voucher system. Turning medicare into a voucher system. Do you support that . So let me back up with my answer here and tried to explain this a little bit more. You know, i think what ive seen in terms of different types of options that are being discussed around medicare, those are born out of individuals that want to make sure that that program is around. I want to make sure the program is rent for my kids. And so what we know from the Trustees Report so to make sure it will be around you are saying that you would consider alternatives . I think that, im not supportive of that. I think that we need, but i think its important that we look for ways of making sure that the program is sustainable for the future. Let me give you one of the alternatives. One of the alternatives is to increase the age from 65 to 67. Do you support that . You know, i think ultimately what direction that we go into his app to congress. As the administrator of cms my job would be to carry out whatever congress decides the best course of action for the Medicare Program, and i would hope that we work towards making the program more sustainable so that it does exist for future generations and that its a program that provides highquality care, accessible care, and gives so you dont think you should be involved in policy . You said leave it up to congress. I think its the role of the cms administrative use to carry out the laws that are created by congress. Let me ask you, theres another availability that seniors enjoy, which is the donut hole was closed, which means that seniors in florida spend about 1000 less out of their pockets by drugs being reimbursed through medicare. So in the Medicare Prescription Drug program, now i know that you just had a question close to this, but what i need to know is, do you support the provisions in the aca that close that coverage gap to make prescription drugs more affordable, or closing the donut hole, yes or no . I support efforts to make the availability of medications affordable and accessible for seniors. I like to make sure that they have choices about the medications that they need, at that that coverage is affordable to them. So i support efforts. In terms of let me, im running out of time. Im just trying to get clear your thinking on this. So if a senior, since you support making drugs affordable to seniors, but if a senior had to pay 100 a thousand or more dollars out of their pocket per year for their drugs com, isnt something that you would support . Ultimately what happens with the donut hole is really up to congress and how we move forward on this. As the role of the administrator my job would be to implement the policy or the legislation that is developed by congress. So back to the policy by congress. Heres one you may be able to answer. How about, as you know on dual eligibles, the federal government gets a discount from the Drug Companies for the dual eligibles that are eligible as medicaid until they get to 65, then they get their drugs from medicare. But then there is a discount. Would you support requiring drug manufacturers to pay drug rebates to medicare for the dual eligibles . As i said before i support efforts to make drugs more affordable to seniors, and i think this is an issue that were all concerned about. The president is concerned about as well, that we need to make it more affordable. I would look forward to working with congress on strategies that can help it be more affordable while maintaining accessibility and ensuring that our seniors have access to the drugs that they need. Im sorry that you have the constraints put on you so that you cant answer these questions forthrightly, and those are the questions that i can tell you Senior Citizens are begging to hear the answers. Because if you had approached this as candidate trump had, saying he was going to protect medicare and Social Security and not have any cats, your answers would be different, and they would be clear. But youve chosen to go the route that you have and im sorry that you had those kind of constraints. Thank you, mr. Chairman. Thank you, senator nelson. For benefit of a member of the committee, the order remains of those who havent asked questions is isaacson, brown, held her and scott and thats the order we will go in, and less someone who comes in who is still on the list. Ill take my time. First of all, i make a statement, you had to, in less you want to, but words are strange thing sometimes. I can be used to denote what you want the ultimate goal to be. In the Veterans Administration, and im the chairman of the Veterans Affairs committee, three years ago republicans and democrats joined together to create what was done as the Choice Program to try and expedite veterans Getting Services and to maximize the use of the va and the private sector. In the first year of that program, there were 2 million more appointments filled to the va than the Previous Year and all those were access to the private sector gave veterans better access. The veteran had the choice to use the private sector and the Veterans Administration to do. I think thats a good example of where choice made a difference, deliver healthcare, didnt change the cost, made accessibility that am in the program worked better. Choice is not a bad word. Choice can be a good word and congress did that three years ago in august and its been a good program. Are you coming with that program . Im not the money with the program but i do believe, i agree with you that choice is critical. When theres choices and competition and we got folks that are trying to attract our beneficiaries to the system. So choice and competition are very important to driving better quality and outcomes and a lowercost. In georgia we have 1. 9 million georgians on medicaid. 1. 3 million of those 1. 9 million our children. Half of the children born in my state are born with medicaid benefits. Are you committed as we go through the reforms and enhancements and improvements of the program to make sure we keep children foremost in her mind for coverage . Absolutely. As a mother i certainly understand the importance of health care for children and one of the things im reminded of him may work with the Medicaid Program and with the chip program, i remember hearing a story about a woman and it was after the chip program had been passed, but she talked about how she had a child, infant, probably one or two years old, and she had gone to the doctor and her child had an ear infection. And the doctor gave her a prescription for a simple antibiotic to treat the infection. She went home that night and she had a choice to make, if she fillefelt the prescription she wouldnt have enough money to pay for meals for the whole family and so she made the painful decision of not making filling the prescription and feeding her family for the whole week. And what happened to fetch out is that because of his untreated infection, he ended up losing his hearing and going deaf. Im always reminded of that story and that child now needs lots of Different Services to help him through. Thats something that couldve been prevented. So its very important that children have access to highquality services. Its really important so that we dont have situations like that. Thank you for your answer. Are you to move with the cures bill that passed . I am. Senator warner and i had one of the provisions in the bill which is important to us on Home Healthcare provider for reimbursement for dual medical equipment under part b on Home Healthcare and Home Infusion and Home Healthcare through medicare. Its something want to make sure because under the aca Home Healthcare was almost totally removed. Having had personal experiences i know Home Healthcare is the best environment and the least cost to the government. I hope you will look closely at that 21st cures, century cures to see to it they didnt but it. I be happy to work with you on that. I agree, i think the cares act and i applaud congress to come together on a bipartisan basis to pass that law anything is going to every tremendous impact on the healthcare of americans. I i appreciate your efforts on that and would be happy to work with it. And lastly just a quick of windows in a stable state legislation, the biggest thing we thought was frau brought in medicare and medicaid and that still a problem today. I am very familiar with, from the business i was in, the verification of eligibility is important to make sure you have minimal fraud and minimal waste. Are you committed to using to te commercial Resources Available in the private sector to verify eligibility where that is important . I am absolutely committed to that. Thank you very much. Senator brown, uncharted type senator menendez slipped and so he will be one at ahead of you. Senator menendez. Thank you, mr. Chairman. Ms. Verma, congratulations on your nomination. One of the successes of the Affordable Care act was establishing of a nationwide benefit standard called essential health packages, benefits package one of my amendments to the law which was adopted by this committee was to ensure that coverage for behavioral Health Services like therapies for children with autism are available in every plan purchased through the marketplace. Thats to ensure a child in georgia or indiana or new jersey as equal coverage and equal access to the care that they need. Ive heard from countless families about the anxiety they have over losing access to critical Autism Services through a change in the essential Health Benefits that allows Insurance Companies to deny coverage, which is especially acute in states that lack of state based requirement. Do you agree i child access to insurance that covers a condition like autism should not be based on what state they live in . I appreciate your question. My husband is a child psychiatrist so he deals with those issues on a day in and day out basis so i certainly understand the concerns. I have been advised by the office of government ethics not to dissipate on issues regarding participate, because my husband is a psychiatrist and it could impact his practice spirit autism is not then Mental Health issue. Autism is an illness that were still trying to develop the essence of its cause. But at the end of the day, i use it by way of example. Are you suggesting that you cannot tell the committee a simple answer to the question that it shouldnt matter where you live in the nation, that in fact, you should have access to the same coverage as any other child . I think all americans should have access to the healthCare Services that they need. However in the issue that theyre asking me to, i been advised by the office of government ethics not to participate on matters that, because of our relationship, my husband practice, to not did they define to you the list of things that fall under this category . He does treat each other with autism so that asked not to engage on matters that involve his practice. Pretty amazing to me. Let me ask you this. As you know congress had to act on it packet of medicare expenditures extended. Which do you consider to be your top priority . I have not reviewed that particular regulation but would be happy to do that if im confirmed and work with you on that. Well, let me just say, medicare is a big part of what cms deals with. And i wouldve thought that in preparation for this and you would have a sense of these are extenders that are almost on an annual basis or i annual basis, biannual it is the heart of giving us a sense of what you as the potential administrator would be advocating as it relates to medicare. Your role as cms administrator is more than just executing simply the laws of the country which, certainly you would hear but it is also a policy development, heavy position, that the president and the secretary of health and human services, and the congress relies on when drafting laws that ultimately would have impact in your parameter. So you have no idea as to which one you consider the most significant . At this point i would want to review that before i gave you my opinion on that particular area. Let me ask you this. During our meeting in my Office Referred several times to socalled ablebodied beneficiaries as we were speaking about medicaid. Do you believe that low income and workingclass individuals who gained access to medicaid, thanks to the Affordable Care act expansion, should be eligible for medicaid . I think that i think thats a simple yes or no because my time is limited. Do you believe that they should have access to Medicaid Eligibility . I think that all americans should have access to highQuality Health Care Services spirit thats not an answer here you are nonresponsive and ask about medicaid specific spirit when i think about the Medicaid Program i think about almost into different parts. Theres a part of the Medicaid Program that serves the aged and the blind and the disabled. But very different population then somebody ablebodied individuals. But at the end of the day all americans should have access to highquality affordable Health Care Coverage spirit well, i would just simply say, unresponsive to my questions. I cant vote for someone to be the administered at one of the most significant agencies that affects the health care of people in the country if i cannot glean from you in an open hearing under oath what your answers are to these questions. I have no answers, and so its a very difficult, very difficult. I have not reflected libyan against the president nominee. I voted for soul of the budget got to give me more than that. I hope your responses to written questions will be more enlightening for me. Thank you. Congratulations on your nomination. To quit a great discussion about innovation in the Pacific Northwest and someone to follow up on that. To my colleagues point, theres been a lot of discussion about block granting medicaid or are you in favor of that . Yeah, i think come when i think about the Medicaid Program i will say that the Medicaid Program as a status quo is not acceptable. I think that we can do a lot better for the many people that depend on this program. Were talking about disabled individuals, quadriplegics, people that are developmentally disabled, mentally disabled. We can do a better job than what we have today in the program. We know we are not delivering great Health Outcomes. Theres been study after study that shows even people who dont have medicaid have better Health Care Outcomes. Do you think there is problems with block granting . When i look at this i think we need to think about how we can make this program work better. The status quo is not acceptab acceptable. This is that United States of america and we can do better are vulnerable populations. We can all states accountable for producing Better Outcomes. So are you endorsing block granting . I am endorsing the program being changed to make it work better for the citizens that rely on it. See youre not endorsing block granting . Undefined understand, because this is the debate as you as far as im concerned, and then a sample of our colleagues probably those in the house are very adamant about this. Undefined understand where you are on that question, whether you either are for it or against it or have concerns about or endorse it. This is spectrums and give you a little more room than my colleague you gave your speed i appreciate that, thank you. What isil is a program working better, whether block grant or per capita cap, there are many ways we can get there. At the end of the day the program is a working as it should. When you have one state spending 4000, another state spending 15,000 for the same population and can wish of the outcomes are better . Can we show that individual had accessible to highquality care . What we know going on on the state level is that, in terms of accessibility, onethird of doctors are not taking medicaid patients. That means for disabled person that when they are sick, they call the doctor and some of the doctors want to take them and the doctors that are taking them are having to wait for a long period of time to get care. I think we can do better for these people and i support efforts to get us there. I would say this. This whole notion that decapitated block grant we know what the results of those programs have been. We have numbers here that resulted in 37 cut. If you just extrapolated that out, and lets you assume you have these states who would step up and cover those populations, my colleague was talking only about the increase in population, the increase in population is whats driving the cost. So coming up with a better strategy for the population like rebalancing that i had a chance to talk to you about, way more costeffective in our state. We saved 2. 5 billion by taking people out of nursing home care and putting them in communitybased care. Trying to cap a date or say will block grant it ends up if he just said to my state, the state didnt come up with any more funds, if you apply the same 37 , you would be cutting over 100,000 people in king county or cutting 43,000 people in spokane, or i calculate the numbers again just an extrapolation of what that 37 reduction, that of the block granting program have received over the last 15 years, it would be like having a Million People in ohio off the medicaid and less estate came up with more money. So my point about this is, i hope you will be much of an advocate for the innovation in medicaid, instead of trying to nickel and dime for people on a copayment or administered a cost, come up with a strategy like rebalancing that gives people real opportunities to do with his population, save costs and keep people and a Better Healthy situation. Thats why i have great grave concerns about this notion of block granting medicaid or decapitation as you mentioned. I agree with you. This is what it should be about innovation but was going on today is that we have a very inflexible system. When states are trying to do Creative Things and i agree in terms of rebalancing incentives and giving medicaid beneficiaries the option of being served in the committee, thats something we should support and two. The way this system is set up is that states have to go to the federal government for any routine changes can be sent to want to do something innovative and creative. They can take years to get a waiver done. We need to create a Medicaid Program to allow states to be innovative and love that flexibility so that they can focus on producing Better Outcomes for individuals. I strongly do not want to see anyone not give Health Services. Were talking about the most disabled and Vulnerable People in our population. We can do better. We should be able to deliver Better Outcomes for these individuals and hold states accountable for accessibility and highquality coverage. This isnt about taking people off the program. This should be about improving outcomes. We will have many more chances. I hope you will remember innovate dont cap a date. Thank you, mr. Chairman. Senator cardin. Thank you, mr. Chairman. What follow up on senator cantwell point because i think the essence of her comments are absolutely accurate. Welcome. You are a product of my state of maryland in education and were very proud of your a cop judgment. Its nice have your family here, and i want to talk about Minority Health and Health Disparities in this country. Part of the Affordable Care act was to put a focus on that. We have a national institute. Theres a good reason. Historically minorities have been discriminated against in our healthcare system. We look at health care results in diabetes, Heart Disease, hiv aids, infant mortality and of indicators and we know we have a problem. Weve been making progress on that problem and thats what i want to refer to senator cantwell is point about resources. Resources are important and i wish every policy decision we make in this committee and we make in congress and made at the white house was driven by what is the right policy results. But far too often its driven by the budget numbers. Thats the reality. Thats what we deal with. Senator cantwell is point is if you move to a block grant the Medicaid Program, the odds are its going to be to fill up a budget number, not fill a policy driven objective. And who is vulnerable . The most Vulnerable People in our society. In maryland almost 70 of the medicaid population are from communities of color. Thats in my state of maryland, 70 . So when we expanded the opportunities for medicaid under the Affordable Care act it made a big difference. You may be smart with the greater big health center, prince georges county. You are familiar with that community. Ive been visiting that center for many years. They are now able to provide Mental Health services and pediatric dental services, and giving access to care in a Vulnerable Community because of the expansion of medicaid. If we were to go to a program that is innovative by doesnt have the resources to implement implement Vulnerable People are going to get hurt. I just want to get your understanding as to the importance of resources. We are not going to improve our Health Care System by telling people of means that they cant spend money on healthcare. They can get the healthcare that they need. Its the vulnerable population that is going to be challenged. As tough as budgets are here, budgets in annapolis and other states around the nation are even tougher. Medicaid is such a large part of the state budget that when you say we will innovate but we need to invest to innovate, they dont have the money to invest to innovate. Then you have to look at, lets eliminate dental or essential benefits that senator menendez was talking about. So tell me how youre going to advocate for the poor, how you will advocate for those who are challenged and our system. I dont know all of the answers of the indian assistant. You and i had a chance to talk about it. I applaud you for looking for innovation in your state, but i know some interpreted to mean that those copayments and some had to pay, they dont have the resources to pay and then if they dont they get put into a system where there denied certain benefits that they desperately need. Im interested as to how you see this system being fair for those who are vulnerable. First of all i would say i have fought for coverage for Better Outcomes, for vulnerable populations my entire career starting with individuals with hiv aids, working with low income mothers to improve birth outcomes, the issues you raise run Minority Health are near and dear to my heart. Im a minority and understand that are different. Different cultural norms that impact the type of care, health care is delivered on the types of advice that we give the individuals that are minorities. I certainly understand that. You talked about the healthy indiana plan and making sure people of resources for their healthcare. We looked at and healthy indiana plan was all about choices. We believe in the individual dignity and the empowerment of individuals to make their choices about their healthcare. What we found is when we gave people those choices, they make good choices and they had Better Health outcomes. We saw emergency room usage go down. We saw individuals having more primary care and more thats what we are saying under the expansion of medicaid in the state of maryland. Many more people insured. We are seeing much greater, less use of emergency room care, much more preventive healthcare because we now have more people in the medicaid system, about 250,000 more in our state. So yes the expansion of thirdparty coverage is critically important but the quality of coverage is critically important. If you dont have preventive care, if you dont have pediatric dental, you know what happened. We know what happened in our own state in 2007 with the tragic death. I appreciate were looking for innovation but if you dont have the basic coverage, if you dont have the ability to provide essential services, its the vulnerable who are going to suffer. I do want to see the vulnerable suffer. Like i said id been working on that particular issue my entire career, dundas on the local level creating programs in Marion County for uninsured individuals and addenda on the state level. And if confirmed i will continue that fight spirit i thank you. Thank you, mr. Chairman spirit senator brown. Finally made it. Thank you, mr. Chairman. Thank you for your leaders to serve as nice as you again and thanks for coming to my office and speaking. I was a little disturbed with senator nelsons, the question about medicare eligibility age. 67 or even 70 as your future boss has both sponsored legislation on at least 67 and he was not wanting to tell the committee that he changed his mind or was opposed to it. And on voucherizing, privatizing medicare i was concerned when he said its up to congress. Of course it is but i would hope that you would come asking this as a question but i would hope you would look at cms as a platform to tell your boss and your ultimate boss the present who said he would do that and then he nominate congressman price but i hope you would stand up against us two things because they are devastating to workingclass americans. A couple questions. First question is simple. Governor kasich recently named a new director for the department of medicaid, governor kasich as you know extended medicaid in ohio, 700,000 plus people now have medicaid coverage. Ohios former medicaid director had an excellent relationship with cms. My question is, i would like to ensure the positive relationship and i like to ask you to commit to sitting down in person with the director and perhaps if she chooses and you choose a group of medicaid administrators around the country to discuss my state and their states priorities and concerns when it comes to the Medicaid Program. Id like to ask you to do that in the first few month on the job speaking that would be my pleasure. I feel strongly about working with states and an open relationship and partnership. Thank you. During our meeting you spoke glowingly about ship and what its done. In 2010 when congress improved chip by streamlining enrollment processes and increase outreach efforts and other things we now have 95 of children in america with affordable Health Insurance. Whats not to love about that . Secretary price mentioned in this hearing that he would support an eight year extension of chip of the current chip program. Its important that when we upgraded chip in 2010 and streamline it so its a clean law now and easily understood. Do you agree with secretary price that congress should act quickly to pass an eightyear extension cords do you agree that should be a a major extensn of the current chip program to provide certainties for families and state budgets . Please give me a yes or no. I support the reauthorization of the chip program and agree with congressman price that we need to do this to the fullest extent possible and i look for to working with congress on that. Do you agree to eight years that he suggested . I support the reauthorization as long as possible. Okay. Eight years would be possible. I know its congress but, i mean, what you dont even want to know or dont understand is your recommendation to this congress, you can say its up to congress of course ultimate the laws are but your recommendation to congress, if you end secretary price would say we want eight years extension and you would also say we want a a clean extension, not a rollback but what we had in 2010, with the present law is n is not that would really, really matter. I think you get every democrat, most republicans and that would take that off the table, take the uncertainty out of all these programs that would just kind of limp along extending it a year or two or three or five at a time. I ask you again, will you recommend eight years and will you recommend a clean chip extension . I will recommend and support the reauthorization of the childrens Health Insurance program for as long as possible. I think its very critical that children have access to highquality services. You and i talked about this in your office about my experience with this, so i support children having access to health it is more important to me if you wouldve suggesting yes but i appreciate the answer. Beginning march 8, hospitals will be required to give moon notices to applicable Medicare Beneficiaries as required under the notice act which congress im sure youre where past just last year. If confirmed as administrator will you commit to aggressively enforcing those notice requirements for hospitals, yes or no . If im confirmed, as cms of ministry is my job to follow the law and to implement the programs as designed by congress. Okay. The moon notice is important First Step Towards getting beneficiaries Additional Information but it doesnt fix the issue of observer status, the underlying threeday stay requirement. Hospitals are increasingly turning for Medicare Beneficiaries as outpatients under observation steps as opposed to admitting them as inpatients. While as inpatient patients, while the classification of hospital stay doesnt affect the level of care to the beneficiary receives come at a significant repercussions for the threeday requirement and for Medicare Coverage. The support changes to the threeday stay requirement . That something i would want to review and would look for to working with you on that. Do you have opinions of the threeday stint on . I would want review review that in more detail. Do you know what it is . I do know what it is but a like to review that and at this point, and be happy to work with you on that. Secretary price who apparently knows more about the observation status issue raised during his confirmation hearing. He specifically mentioned hed like to work on improving this rule. I assumed would work with him on that. So can you give me any thoughts on what you do at cms to improve the threeday requirement . I think we need to work with provided on this. I know theres been some issues there in terms of Skilled Nursing facility and the impact of the rule on patients ability to get in with that. So i would want to review that are carefully and be happy to give you my comments. That was less than satisfactory. I appreciate the effort. Its a huge operation status, huge concern for beneficiaries across my state and we get calls as im sure in indiana, some your counterparts were doing medicare got calls, but i know senator cardin, nelson and others have and work on this issue for years. I hope we can work on it. Thank you. Thank you, mr. Chairman. Senator heller, i apologize but send it as soon slipped in. Thank you, mr. Chairman. I hate it when that happens. My apologies. Ms. Verma, thank you for being here. Welcome and thank you for your willingness to serve. I know this event touched on already but i wanted to followup, because when the macro final rule was released last november i was concerned about a decision to delay implementation of Virtual Groups. Then acting administrator slavitt indicated details are being worked out and cms was soliciting feedback from physicians. The rule stated the limitation would not come until 2018. Being from south dakota ike and continues to consumer that we roll out new Payment Systems in rural areas. What you make it a priority of yours to ensure that Virtual Groups are time and effectively implemented . I would be happy to do that and happy to work with you on that issue. How do you plan on engaging with those rural and sole practitioners to ensure that this is about option that they can take advantage of . I think that the rural providers confront your providers, are in a very unique situation. When we are thinking about policies we need to engage with them on the front end to understand what their concerns are before policies are rolled out. To make sure were understanding the impact on them. Things that work well in an urban community dont necessarily work well i think sometimes living in dc we dont have that understanding. Anytime i think we have a policy we need to work with rural providers, with front to provide on the front and to understand what their concerns are and what the potential impact would be. And then once something is after we need to make sure that we have that continued collaboration and communication so that our problems and issues that we can address them in a timely way so that we are not impacting patient care and there were always, a commitment to providing highquality care and access speed im glad to hear you say that. Additionally, the gao had recently released a report, a fact it was in december that lists the hurdles a small and rural practices may face when trying to participate in the new payment models. As cms moves away from feeforservice and toward rewarding quality, i want to ensure that rural providers in my state will be able to participate in new and innovative methods that increase quality and reduce costs. Aside from the previously mentioned Virtual Groups, the last question, how would you go about ensuring that small and rural providers have access to these programs . I think its critical we make sure in rural areas, frontier communities, that we have a high Quality Healthcare. It goes back to collaborating with them. These programs i think have enormous promise to deliver highquality care and move us in a different direction. We need to work with his providers on the front end to make sure they can handle these new regulations and rules. What i find is that in the Rural Communities and frontier communities, they are stressed in providing care. They have a lot of enormous burdens and we need to be careful that rules and regulations dont prohibit them from providing highquality care whecare. When youre out on the front lines youre trying to provide care, and having to do with a lot of rules and regulations can be difficult. So we need to be supportive of them by providing Technical Assistance, making sure we are available for communication and supportive of him throughout the process of implementation. Id like to return quickly to one other issue and thats to the Meaningful Use Program for Electronic Health records. Given the program somewhat rocky track record, what do you believe is the future of the Meaningful Use Program at this point . I think that Electronic Health records i think have enormous promise. I think its helpful for physicians in terms of proms come in from the doing data and evaluation that has been a rocky start. Ive gone to the Doctors Office and even seen signs in the waiting room that says were going to be delayed or is going to take a while because were still getting used to Electronic Health records. Ive been in the room with my doctor where there staring at the computer instead of looking at me as i tell them about my healthcare issues. We need to make sure that its working and working for providers and patients interoperability if were going to Electronic Health records then we should make sure that it fulfills its promise so if somebody goes to the emergency room, even if they were in a different hospital or different provider system at the doctors can pull up the information and that they have those tools about what medications the person is on. We need to make sure it is full fill its promise and not being more burdensome. I think theres a lot of potential there in terms of prompts. I hear physicians like the ability, when they are talking to a patient being able to say what pharmacy do like and dimitri sent that script. Theres a lot of value so we need to make sure its also the full its promise and is giving us the things it supposed to do so when you go short to an emergency room you have all that information. Sometimes with, short on some of those things. That something went think we need to continue efforts around that. Final point. I look forward to working with you. I mentioned in our discussion, meeting, better coordination between the Indian Health Service Account cms and thats an issue with that lots of issues, problems with in my state of south dakota and hope we can make a lot of headway. Thank you and thank you, mr. Chairman. Senator heller. Mr. Chairman, thank you spent your time has arrived. Terrific terrific. Ms. Verma, congratulations to you and your whole family was there behind you. Your kids are very patient. I know sean is getting a little fidgety so maybe we need to hurry up a little bit. Glad youre here and glad of them is here also. 20 of the states population in nevada is on medicaid. Another 15 of the population is on medicare. We discussed in my office how important it was for you to strengthen and protect these programs and a critical that was from nevada. I want to do and i appreciate the conversation that we did that in my office. And like everybody else i assume on this committee that everybody is strong support of medicare. I share that. I will say also that i have not supported and will not support legislation that does weaken medicare. So before i get started, mr. Chairman, im not quite sure who is playing mr. Chairman at this point. Id like to submit for the record a letter that i received from the speaker of the house in the Nevada Legislature and also majority leader. I ask secretary price if you would without objection it would be made a part of the record. Thank you. Lets go to a couple of questions. I want to maintain the conversation weve been having on medicaid, if you dont mind. As youre probably aware nevada is one of 32 states that chose to expand eligibility for the Medicare Program. Numbers, since the expansion, nevada Medicaid Enrollment increased from 350,000, to over 600,000. As of july 2016 Medicaid Enrollment in nevada is over 200,000 people greater than what was projected before the expansion. Ive had numerous conversations with the governor. Ive had conversation with state employees. Ive had conversation with state employees. Our state legislature, our hospitals that are seriously concerned about moving this program to a block grant. They are concerned they will not have the appropriate funding to cover cleared all 600,000 nevadans that join the program and that are on medicaid. Their concern they do not have the staff to implement such significant changes. They are also concerned with a parttime legislature, the state will not have the time needed to establish drastically different Medicaid Programs. I guess my question to you is whether or not you are sympathetic to these concerns for this block grant States Companies expanded block grant states like nevada . And you understand those concerns . I absolutely understand those concerns. Ive worked with states for almost 20 years never understand the concerns. I understand the state budget. I understand the stakes have expand the state that have been expanded. In terms of the Medicaid Program, for me the opportunity is about improving Health Outcomes. Were talking about a very vulnerable population. These are individuals that come into safety net. They dont have another place to turn, if you disable, a quadriplegic, if youre paralyzed medicaid is program. But what we have today doesnt work well. We know that studies after study showed that the outcomes are not great. We know that states are spent different amounts money, 4001 state, 12,000 in another state. Do we know we are getting Better Outcomes . To ask individuals about their care tax i think the conversations were having should all be around improving Health Outcomes and trying to do a better job. I do want to be about hurting states. Thats why come from. Thats what i understand. Ive worked with governors and understand that whether our engines of state budget and is not a whole lot of extra money. I think this is about giving states, putting states in a leadership role so they can manage their programs better. I think when states are closer to the people that they serve, then the federal government may have a better understanding of what can work in their state. Then the federal government. I think we heard from some of the senators today about rural areas, for example. They have special challenges, front to areas. Some the things that are coming down from washington in terms of a onesizefitsall approach doesnt always work. The new state should have the flexibility to design a program that works better for the people that they are serving and they are better positioned to make those decisions that we are in dc. I think this is an opportunity to create flexibility so that they are not having to go to the federal government every time to want to make a simple and routine change. What weve seen in the Medicaid Program is that because its so inflexible, theres not a whole lot you can do in designing a program. So what states to often when times are tough is they cant provide a rates. In 2012 with over 44 states either freeze or cut provider rates and that has an impact on access to care. They are doing that now because i dont care about the people that they serve it is because the program is so inflexible. I think an opportunity to give states more flexibility is an opportunity to improve Health Outcomes for individuals. Is it fair to say youre pushing a block grant approach . I am pushing an approach that improves the Medicaid Program because i dont think the status quo is acceptable. I think we can do better for disabled people and the people that are very vulnerable and that are dependent on this program. I think we can do better improving outcomes and making sure individuals are not receiving healthcare in the emergency room and that their health is actually improving speed of my time is up. Our block grant on the table or off the table . I think anything should be on the timber can approve Health Outcomes for the third vulnerable population. Its my understanding block grants are on the table. You know, i think block grants, per capita capsicum anything we can do to help improve outcomes and create a level of accountability for states, i think we should export all of those actions and i look for to working with congress on this. Thank you. Senator scott. Were excited about your opportunity that lies before you i am the cochair of the caucus and every valentines day have a chance to go to the Childrens Hospital at the medical University South carolina and hang out with some of the kids who been hospitalized several times a year, often times for or chronic conditions that consistently resurfaces as a matter fact the Sickle Cell Disease has accounted for someonsomearound 246,596 emergem visits as a principal diagnosis in 2014. The lady behind me, jordan, is a student at my alma mater ayes hh school shipment in and out of the hospital as a youngster, 15 years old, a number of times. Having an opportunity to see the challenges that so many families face and the necessity of medicaid is their primary provider brings a lot of questions. One of the i would love to get your input on is what are your thoughts about innovative things cms can do to reduce readmissions, decrease cost for providers and payers and improve care for those with sickle cell and similar chronic conditions . I think one of the things that we can do is that, anybody on the Medicaid Program, they are in a vulnerable situation, whether its being age blind disabled or having a disease specific condition. They are completely dependent on this program. And as listed in my Opening Statement sometimes its a matter of life and death for these individuals. They have no place to turn. So we need to ensure that we have the best possible program, better quality, Better Outcomes. I think those decisions and the ability to do that should come at the state level, and the state has a better understanding of the Delivery System and the citizens they serve. They are in a better position to make those decisions. In terms of readmissions and really focusing on outcomes. I think on the federal level its important to establish what are the expectations of the program . What are we going to hold states accountable for . Should be quality and accessibility. Have you found working with the state of indiana there are a couple of things that you thought worked really well on the state level that you would like to see on the National Level . First i would say that every state is different. I know. As a worked with states and i might be known for the healthy indiana plan and people say do the healthy indiana plan nationally, every state has different opinion. Ive never actually had a state that wanted the healthy indiana plan in entirety. They looked at it, took that, think they like about it and applied it and they designed their own programs. So i think thats all we need to have a program thats flexible and allows states to do what works best for them. Is that that most of us consider the 50 states the laboratories of our democracy were good things happen. Without having question a National Model where we thicken the best ideas from the state is an important part of your responsibility moving forward. I know that you consult with a number of states including South Carolina for programs like the pay for success financing models were medicaid basically pays for performance, which i think is a fantastic model. What do you see as a future of the pay for Success Model in medicaid and what is the appropriate role for cms in that process . The concepts around the program are critical. Instead of micromanaging the process, i think we need to sort of, we need to say definitively here are the outcomes were driving towards. I think right now what we are doing is managing the process, not Holding States accountable. In terms of South Carolina, one of their innovative things that theyve done there is the application of the Nurse Family Partnership for low income families or low income firsttime mothers. Having that Home Visit Program i think is an idea, an excellent idea. But again that program had a lot of thought. It took many, many many months to get the program approved through cms and thats a great example of how the state has its idea, innovative, proven in other communities and to be able to do that on a readily basis without having to go through that long process of approvals, i think thats an idea and the importance of having state flexibility. Thank you mr. Chairman spirit thank you, senator. Senator enzi. Thank you, mr. Chairman. First of all i want to thank yu for the opportunity i had to meet with you before. I do want to ask unanimous consent the statement i have could be put in the record. Without objection. We do have an outstanding nominee before us that has had a good life outside of washington, and she doesnt need to be subject to personal attacks or a similar partisan discord. I really get the stressed the way these hearings go where we try to push for things in actual legislation that ought to be reviewed, ever again reminded that she gets to make good suggestions. We cant to pass some fine laws, sometimes, id read about you. You have it just studied medicaid and medicare and other health situations. Youve actually been handson. Youve done things. You actually helped states to make the process work better. You have a track record, and its very impressive. I think around here that makes you overqualified, unfortunate unfortunately. You havent been cutting people off of medicaid and medicare. You have experience thats worked at the state level. You and i talked about frontier and rural, and thats been emphasized here again because we have several states represented better frontier and rural wyoming has the lowest population in the nation and weve also had a devastating Economic Hardship because of the last administration didnt like energy. We are the energy state, and so our state has had to make some very tough decisions. A year ago the legislature, biannual budget income had to cut 8 . When the session finished they found out that wasnt enough. So the governor had to cut 8 . Now theyre into the second year and when they came back they found revenues are down so much i have to cut another 8 . That presents a lot of problems, not just in the healthcare area, but across the board in education particularly is being devastated by that. But they are working through it and they will get it. When i met with you i also talked about medicares Competitive Bidding program and we talked about some of the unique challenges of rural and frontier states. I want to know if you be willing to continue to have a dialogue about how to Competitive Bidding process can ensure that people actually get what they think theyre getting and what we think that we are buying. In your view is it going to be important for cms to look avoiding putting in place the onesizefitsall programs . Or frontier provider on the front end and having that discussion so were not having problems later on down the line, and if we are having issues, we need to be responsive to that, because we want to make sure we are not impacting beneficiary impact and seniors and other folks always have high quality care and that they have accessibility. We dont want to see that our policies and our programs are actually preventing providers or were losing providers or that they dont want to see medicare or medicaid beneficiaries anymore. Be very careful with policies so were not pushing providers out of the system, but actually attracting providers to the program. When we attract providers to the program, were giving our seniors, medicaid beneficiaries, were giving them more choices. And when they have choices, thats whats going to drive quality in the system and, hopefully, lowerrer costs. Again, youve demonstrated what you talk about. Youre not just talking about something that you studied in a book or that you wrote a ph. D. Paper on. As you know, dualeligible individuals are a complex and expensive patient population. It affects both medicare and medicaid, so are you committed to working at the federal level and with states at the state level to address the mounting financial concerns about the dualeligible population . I think we, we must address that issue. I mean, as we have an aging baby boomer population and more and more folks coming into the Medicaid Program and Medicare Program, were going to these to have closer collaboration and make sure that we have the incentives in place to manage that program well and to assure that we are providing comprehensive, coordinated, quality care to those individuals. I think its difficult and confusing for them when theyre on two different programs, and we need to make sure that Program Works well for those beneficiaries. Thank you. And thank you for your outstanding presentation and your family has to be really impressed, as am i, with your capability of answering and your vast knowledge. Thank you. Thank you, senator. Thank you, senator. The Ranking Member would like to and a question or two, and then well wrap it up. Thank you, mr. Chairman. I do have a couple questions and a quick wrapup, but let me also say that i very much appreciate how this hearing has been handled by you. Youve made it clear that senators get to ask the questions that are important, and thats the best bipartisan tradition of the finance committee. Thank you. As we move to wrap up, i just want to make that clear. I have two questions for you that remain, ms. Verma. One stems from this horrible tragedy you described where the family was forced to choose between food, putting food on their table or paying for a prescription to treat a childs ear infection. And the family, as you stated in a horrible account, chose food, and the child lost their hearing permanently. What ive been told about the healthy indiana plan that you designed, the you had an individual if you had an individual who was making barely 12,000, had the same kind of choice and chose not to pay their premium, they would be cut off from coverage for six months. So that individual would not get treatment for an ear infection or another, or other such condition. Is that correct . This is what ive been told, and i would just like you to tell me if the thats correct or not. The healthy indiana plan is about empowering individuals to take ownership all due respect, is that correct . Because we looked at the figures with respect to poverty. And as i understood it at 12,000, that person would be cut off. Is that right . The way the healthy indiana plan works is that people that are above the poverty level, above 100 of the poverty level, make contributions into their Health Savings account. They make those contributions into their savings account, they get monthly statements so they can see how that money is being spent. If they complete their preventive Health Care Systems, then they have the ability to roll over that amount thats in there, in their savings account, to offset their contributions. If they havent completed their preventive services, they can still roll over because that contribution that theyre making is theirs, and they own that. In terms of what you indicated, if somebody doesnt make a contribution into their account or chooses not to make that contribution, just like it is in the Affordable Care act, just like it is in the exchanges, in the exchanges as for the same population individuals make contributions, they have 30 days to make that contribution, and if they dont, theyre terminated from coverage, and they cant reenter until the open Enrollment Period. That is the exact same coverage, that is the exact same policy. In fact, the policy that we have in the healthy indiana whoa, whoa, whoa. Gives people 60 days theres a three month grace period in the aca. There is a 30day period where they continue your Health Coverage. But after that they suspend payment. So the individual actually does not have payment for their health Care Services. And then they cant reenter the program until a special Enrollment Period. With the healthy indiana plan, they actually have a 60day grace period, and then they can before theyre terminated from the program. Im going to ask this in writing, but weve reviewed this, and if they make 12,000, theyre terminated. And im going to ask you that in writing. Let me go on to the ethics question. This was reported in the Indianapolis Star, i guess thats the big paper in your state, that while you were running the state of indianas Medicaid Program, you and your Consulting Firm were paid millions of dollars by companies that did business with the state including hewlettpackard and milliman and maximus and Health Management associates. And these companies provided financial and actuarial, administrative and Management Services to indiana medicaid. So the question became the indiana ethics regulations on conflicts of interest do not technically apply to you because you were a contractor and not a state employee. But my question deals with, essentially, basic Ethics Principles because it is hard to see how its okay to basically orchestrate the States Health care programs and then get paid by the contractors the state hires to carry out those very programs. So let us set aside indiana law. We understand that, i understand that those indiana rules do not technically apply to you because you are a contractor. But how is this not a conflict because you are setting, in effect, on both sides of the negotiating table . Let me start by saying that i hold honesty and integrity and adherence to a high ethical standard as part of my personal philosophy. Thats for me. I demand that of my employees, and i set that example for my own children. In terms of the issues that you raise in indiana, we sought an ethics opinion, so we sought counsel on this to make sure there were no issues. On a practical level, on a daytoday level, we werent negotiating for hp, and what we were doing for hp was helping hp develop communication materials for when they were putting out system changes so that people understood what those changes were. So we were helping them with communications materials. What we were doing for the state was around policy and helping them develop programs. And so there was not overlap. When there was, when there was the potential or when we were working on programs, we would recuse ourselves. So we were never in a position where we were negotiating on behalf of hp or any other contractor with the state that we had a relationship with. We were transparent, the state knew about our relationships. I think that they issued a statement indicating on, in a response to the p Indianapolis Star article that they were aware of our relationship. We disclosed that relationship. And on a practical, daytoday level, we didnt engage in anything that would put us, you know, put us in a situation. We were supervising their work, negotiating their contracts, and we made that very transparent on the front end. So if there was ever an issue, you know, ive been in meetings where we were talking about contractors, talking about implementing a program, and when it came to a vendor that we had a relationship with, i would recuse myself. I would get up and leave the meeting so that there was never any issue. And i think the state has spoken on this. And the work that we have done with hp and these other vendors has extended over three separate governors and over six secretaries of health. So the recentlyousted head of the state agency administering your contract told this paper, the star, that you once attempted to negotiate with state officials on behalf of hewlettpackard while being paid by the state. So lets do, lets do this, because obviously there are differences of opinion. My concern was it wasnt just one company. It wasnt just hewlettpackard, but it was these wide array of companies that i listed, milliman, maximus, and a wide variety of services. And my concern is its very clear that indiana ethics rules dont apply to you in a technical sense, because you were a contractor. No dispute about that. But it sure looks to me like you were on both sides of the table as a lot of money was being decided. And i think that really leads me to my last kind of point for today, ms. Verma. Youve been asked a lot of questions, and my own sense, and ive listened carefully to my colleagues. These were not gotcha questions. These were questions that were appropriate given the fact that, if confirmed, youre going to head an agency thats involved with a trillion dollars of spending in health care of 100 Million People or thereabouts. And i think these questions were designed to get a sense of how you would approach them. And i felt very strongly i enjoyed our conversation. I decided im going to try to give you as much real estate as i could in getting a sense of how you would approach it. Thats why i asked the question about pharmaceutical prices which is huge and so important to people. And i said im going to ask ms. Verma to give me one example, just one example of what she would do if confirmed in this position. And we didnt get it in that area and in the rural area and in a variety of others. So the chairman will take us through the rules for getting the questions for the record, but im going to be reviewing those questions and responses very carefully. Because when im troubled about today is for questions that i thought were appropriate for a job like this. A trillion dollars worth of spending. Were not really getting much of a sense of how youd approach it. And i think that this committee needs answers, i think the public needs answers, and ill look at your written questions very carefully and look forward to talking with you further. Thank you, mr. Chairman. Thank you, senator. I want to thank ms. Verma for appearing here today. This hearing is an important part of our, of our committee vetting process, and i must say that, not surprisingly, you, ms. Verma, have acquitted yourself very well. I look forward to ms. Verma being reported out of the committee and being confirmed by the senate. And my goal is for this to all happen expeditiously. It is critical that we, that we get a strong, skilled leader in as cms administrator. It is essential to our efforts for collectively addressing our nations Many Health Care challenges. Our current add administer orer who is not confirmed, but he had all kinds of conflicts, but we allowed him to go forward. Hes a very bright guy who has a lot on the ball. Finish and here you are, somebody who really has proven to be a tremendous leader in health care not just in indiana, but as an example to the rest of the states. And all i can say is youll be a strong, skilled leader as cms administrator. Now, its essential for our efforts for collectively addressing our nations Many Health Care challenges that we get you there. Oh, senator portman, do you still have some questions . [laughter] i didnt notice you came in. Im not very noticeable, i guess, mr. Chairman. I apologize, mr. Chairman. Ive been here twice listening dutifully, and ive had separate hearings going on at the same exact time, so ive been bouncing back and forth, but i would like the opportunity to ask my questions. Ive not had an opportunity to do that yet. Then go ahead. Proceed. Thank you, and i apologize for your patience mostly, ms. Verma, who have been very patient. Ive been watching them. Amazing at their age. My kids never could have done that. So i heard a lot of the back and forth be earlier, and let me just go to some of these issues. First of all, i like what youre saying about patients taking more responsibility for their own health and how do you have a Health Care System that encourages that. I think we talked about innovation earlier. Part of the innovation has to do with that. We want people to lead healthier, stronger lives, and part of that is providing that incentive within our Health Care System. We talked about leveraging technology and innovation. I like that, and many of us in our states are doing some things that are innovative. As you know, the state of ohio has an Innovative Health care director who i know youve worked with before. And a lot of this is about taking the existing dollars and using them more effectively to create better care. And i think thats a great opportunity, frankly, in a Health Care System thats in need of more innovation. And the Technology Part can be exciting. It can also be very expensive, so it has to be dealt with appropriately. You said more state flexibility, and later you talked about Holding States accountable for Health Outcomes. So looking not at the input as much and the volume, but looking at the output and the quality. I think thats something where youre going to find a lot of agreement on both sides of the aisle here. You also a made the comment with regard to medicaid that it sometimes can take years to get a waiver. And i have to say its worse than that. Sometimes you cant get a waiver. And as you know because you were involved in putting together ohios waiver, we were not able to get a waiver to be able to give the state the flexibility that they wanted to be able to provide more innovation, better quality care, more Holistic Care focusing more on prevention and wellness and getting people into the Health Care System not just when they have an emergency, but to have a Better Health outcome by having primary care physicians and so on. And thats something that concerns me, that its not just about it takes too much time often to go through this process, but literally we cant get these waivers sometimes. And the Obama Administration, hhs rejected the ohio application. The healthy indiana plan was accepted, and you were very involved not just in developing that, but in implementing that. So if you could just speak briefly about whats the best thing about the healthy indiana plan . Is it some of these characteristicses i talked about earlier or others, and how could that be taken nationally . Then i want to talk to you about Medicaid Expansion specifically. I think what its done is it gives dignity to individuals, it empowers them, it recognizes their potential to fulfill their dreams. We dont assume just because somebodys poor that they dont want choices about their health care, they dont deserve choices, that they dont want to be involved, that theyre not capable of making decisions. And what we have found is that when we do that, when we create a situation, they are actually more engaged in their health care, and their engagement leads to Better Outcomes. It leads to lower emergency room, more primary care, more preventive care, higherrer satisfaction and better drug adherence. Okay. So thats what i want to hear, because thats what we should all hope for, that people have access to Affordable Care and that the results are, you know, Better Health outcomes because they are taking more responsibility for their own health and have the ability to do that, including access to primary care. So heres our situation this ohio. We have about 200,000 people who get coverage through the exchange, 212,000 as of yesterday. But we have over 700,000 people in Medicaid Expansion. So when people talk about the Affordable Care act in ohio, they talk about it in terms of some of the mandates on Small Businesses, some of the issues, obviously, that have resulted in higher costs to provide health care, the higher premiums, weve gone up 91 in the individual market the last four years, people just cant afford it. But theres a lot of focus in here in washington on the exchanges which are important in ohio but, frankly, in ohio whats more important for us is those over 700,000 people who are in expanded medicaid. And, again, youve talked a lot about this today and what you might support, not support in terms of how do you get more authority and responsibility back to the states. So thats my question for you. I am very concerned that we not move forward too quickly with the replacement and leave those people behind. Im also very supportive of a better system including much more state flexibility along the lines of what governor kasich wanted with his waiver request that was rejected. So help me to understand how we can insure that we do provide coverage to these people particularly in my state, you know . The prescription drug, heroin, now fentanyl issue is huge, and the treatment thats provided to people in ohio is often now through Medicaid Expansion. And we want people to get into this treatment. Again, that provides them Better Health outcomes in every respect. So talk to me just briefly about that. I know you dont have much time thanks to me being at the end here, but how can we be sure we can get a good, flexible plan to cover those people even under a better way than Medicaid Expansion . Well, i think that, first of all, i support coverage, and the individuals that are being served through medicaid, through the exchange, i support people having coverage for the issues that you raise. People are facing Substance Abuse, opioid addiction, theyre going to need help, and we need to address that issue. But if we look at what the Affordable Care act has done, and people talk about coverage, well, coverage doesnt necessarily translate to access to care. You know, i was in the nod with an uber driver and asking him about his coverage, and he said hed gotten coverage through the exchangeses through the Affordable Care act, but he said i cant do anything with it because my deductibles 6,000. And, you know, i cant get to the doctor. I still cant afford it. And be i think, you know, thats a great story of coverage doesnt necessarily translate into access. And so, you know, as we move to a different system, i think those are things that we need to keep in mind whether thats through the Medicaid Program or through another coverage vehicle, then we need to make sure we are providing high quality care and also provide accessible care. Thank you. And we look forward to continuing that conversation, and i know im over time, but i do think this is going to be the key issue for us in ohio, how do we insure in that transition we provide that coverage. Thank you, mr. Chairman. Thank you, senator. Ms. Verma, youve been very patient and very intelligently have answered these questions of my colleagues, and so i the committees has received several letters in support of ms. Vermas nomination that i ask be added to the record without objection. And finally, i would ask that any written questions for the record be submitted by 5 p. M. Tomorrow, february 17th, 2017. With that, with that, we want to thank you for being here, thank you for your answers, thank you for your patience, and well adjourn this hearing. Thanks so much. Thank you, senator. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] the u. S. Senate continues working today on President Trumps nominees. Theyll debate the nomination of Health Care Consultant sue ma verma, who you just saw, to head the centers for medicare and medicaid services. Shed be in charge of more than a trillion dollars in federal spending on the Health Care Agencies as well as the childrens Health Insurance program and the insurance marketplaces created by the 2010 health care law. Senators are expected to vote on the confirmation at 5 30 eastern, and well have live coverage here on cspan2. A couple of other nominations are awaiting senate floor action. Former senator dan coats for National Intelligence directer and attorney David Friedman for u. S. Ambassador to israel. Tonight on the communicators, michael powell, president and ceo of ncta, the internet and television association, talks about major issues facing the industry and what we might see from the new fcc chair, ajit pai. Mr. Powell is interviewed by lydia beyoud with bloomberg bna. Can you speak more specifically about those opportunities and what this change in leadership from tom wheeler to ajit pai as chairman, what does that mean to you and your industry . Chairman pai is very coax focused on the concept of light touch, the understanding that this market moves at breakneck speed. Theres a huge amount of futility to some of these regulatory proceedings. By the time theyre over, this market has shifted radically, that businesses dont have the luxury of sitting on decisions for six months and eight months and a year before they have to make decisions. And i think the new commission is committed to that kind of speed of action. Watch the communicators tonight at eight eastern on cspan2. In case you missed it, here