Transcripts For CSPAN3 HHS Secretary Sylvia Burwell Testimony On The Fiscal Year 2017 Budget 20160212

The ebola and zyka virus. Stressing the need to prevent the viruses from becoming a problem. Secretary burwell also presented the president s hhs 2017 budget request, calling for 82. 8 billion in discretionary spending. This is just over 2 hours. It is my distinct privilege to introduce secretary burwell. It would appear that senator widen, grassley, grapo, the indomitable senator schumer are not here, they have conflicts. None intended, and im going to ask unanimous consent that the statements by the distinguished senator from oregon, Ranking Member mr. Wyden and our distinguished chairman mr. Hatch be inserted into the record at this point, without objection. Our witness today isle th and huchlage Services Second burwell. Shes been leading the department of health and Human Services since june of 2014. She has a long history of Public Sector service including her previous position under president obama. In the clinton administration, she served as the Deputy Director of omb, the chief of staff to the treasury secretary and staff director at the National Economic council. She has not served as the secretary of agriculture however. She has private sector experience, including serving as the president of the walmart foundation. Before that, as the president of the Global Development program at the bill and Melinda Gates foundation. She received her degree from Harvard University and a bachelors degree from Oxford University where she was a rose scholar. Thank you for being here today we would invite you to please proceed with your five minute opening statement. We have inserted the statements by the Ranking Member and the chairman for the record. We will proceed with questions following the secretarys statement please proceed. Thank you, senator roberts and members of the committee. I want to thank you for the opportunity to present the president s budget. As many of you all know, i believe we have common interests and share Common Ground. And the last legislative session, this committee embraced that view of bipartisanship and leadership when it took historic steps to pass the medicare authorization act of 2015. I want to thank that committee for the leadership, a very important piece of legislation for a number of reasons. The budget before you today is the final budget for this administration and my final budget. The budget makes critical investments to protect the health and well being of the American People. It helps ensure that we can do our job to keep people safe and health healthy, accelerates our progress, and expands and strengthens our Health Care System. It helps us continue to be responsible stewards of the taxpayers dollars. For hhs, the budget proposes 82 billion. Our request recognizes the constraints on our budget environment. And includes targeted reforms to medicare, medicaid as well as other programs. Over the next 10 years, these programs would result in savings of 419 billion. It invests in the safety and health of all americans. We work to stop the spread of the zika virus. The administration is requesting 1. 8 billion in emergency funding. We appreciate congresss consideration of this important and timely request. As we implement the essential strategies to fight this virus. I know the recognize in opiod misuse affects americans. Every day, 78 people die from opiod overdose deaths. Too many of our nations children and adults with diagnosable Mental Health disorders dont receive the treatment they need. This budget proposes 780 million to fry to close that gap. Research shows early interventions can set the course for a childs success. Thats why we propose expanding and extending the Home Visiting program to support the childs growth. We must relentlessly push forward the frontiers of science and medicine. This budget includes the president s cancer initiative. Each 1 drop in cancer deaths saves our economy approximately 500 billion. Not to mention the comfort and security it brings to families across the country. Today were entering a new era in medical science, including 45 million for the administrations brain initiative. We can continue that progress. For the americans to benefit from these breakthroughs in medical science. We need to ensure that all americans have access to quality Affordable Care. The Affordable Care act has helped us make historic progress. Today more than 90 of americans have health coverage, the first time in the nations history that this has been true. The budget seeks to build on that progress by improving the quality of care that patients receive, spending our Health Care Dollars more wisely. By advancing and improving the way we pay doctors, coordinate care, we are building a better, smarter, healthier system. I want to thank the employees of hhs who in the past year have helped in the Ebola Outbreak in west africa, and have helped millions of americans enroll in health coverage, and done the quiet day to day work that makes our nation healthier and stronger. Im honored to be a part of that team im personally committed to working closely with you and your staff to find Common Ground and deliver impact for the American People. With that, id be happy to take your questions. Thank you. Thank you very much for your statement madam secretary. You recently stated that you believe we have more work to do with the Affordable Health care act the marketplace is stable. Im going to take the opportunity to remind you that one of the five insurers offering coverage in the marketplace from my home state of kansas left the exchange this year, and that insurer provided coverage for nearly half of all kansas residents last year. When we hear stories like this, when we say we have assured stability. It becomes a problem i think the data of your own department shows the premiums will increase 16 this year in kansas thats an increase thats causing a great concern. So with insurers already pulling out of the marketplace, im troubled that cms is taking steps to increase government control of the plans available in the exchanges and ultimately reduce Consumer Choice through the new notice of benefit and payment parameters. The notice claims that an excessive number of Health Care Plan options my question is, does cms believe there are too many planned choices available on the exchanges . I cant imagine you would say anything else but no . With regard to the question of the stability in the marketplace, the marketplace this year most of the folks that came into the marketplace, 9 out of 10 had an ability to be in a market where there are three or more issuers, thats where we believe competition occurs. I believe we need to continue to take steps to further stabilize and make sure the market stays stable with regard to the payment notice, i think you know were in the middle of that and will be completing that payment notice. Our objectives arent about limiting choices for the consumer, instead, making it easier for the consumer to make choices. A number of steps we took this year in open enrollment are about that. We created tools in the marketplace this year, you could search plans and understand if the providers that you were looking for are a part of that. The other part of that is create a tool thats called the total cost tool. Its a tool that allows you to figure out your deductibles and premiums for the year. We can continue to promote stability in the market and make sure there is Consumer Choice, not to limit it. I appreciate that. The acting administrator recently introduced the rural health council. I know that you havent had time to get up to speed on all the details, but i would appreciate any more information you can provide to the committee after this hearing opinion im very much interested in how you see this new effort functioning. The distinguished senator franken is the co chairman of the Royal Health Care caucus. We i need to know or we would like to know how this new council will coordinate with or utilize the work already done by the hhs Rural Health Task force and the National Advisory committee on rural health and Human Services. We have a lot of folks interested. There may be some duplications and i hope we can pull that together. With regard to the council. The council that acting administrator slav ago has pulled together is in response to topics we discussed in this committee. Any regulation that was coming through to cms to me, there were questions about Rural America i would ask every time, and i think what we are now doing is formalizing a process by which those analytics are important for us to understand, because i believe rural markets and urban markets in our country are different. It is formalizing a process that we have been doing informally over the past year, in terms of that rule making, well be happy to work, i think you hear its an issue of interest wed like to work. Make sure we consider the right things as we answer these questions about Rural America. Always good to see you, and thank you for your work on the budget. The implementation of the basic health plan, which now some states have taken up, i want to get your commitment that youll continue to implement those plans across america. My understanding with new york, its already targeting lower premiums and plans of that are better drivers of driving down cost in the marketplace, so definitely want to get your commitment on that. I think you know in the time ive been here, weve engaged in a number of these and now with new york and minnesota we look forward to other states coming forward with proo posals that do a number of things. It has to meet the basics to ensure the number of people that have access would have access. If needs to meet the requirements of Health Benefits already. At the same time, we know these plans are about access, but theyre also about states coming to approaches that are doing Delivery System reform. We look forward to working with states as they come forward with their plans. I think its very telling when you look at this model. Clearly were talking about the lower income population that was always hard to serve in general. That is to get them on an affordable plan, maybe because their employer didnt offer it or didnt have market leverage. To look at new york of low monthly premiums of only 20. Its quite astounding to see we can provide great coverage for a huge population, as ive always been a fan, focused more on managed care which also drives down the cost as well. I look forward to your commitment to working with other states on that. As the administration looks at internal payment models. How are we making sure were moving ahead, particularly for low medicare rate states like washington, that wants to see the improvements and wants not to be penalized but to reward it for that. How are we making sure that were transitioning off of fee for service and on to this payment model in rapid fashion. A number of things were doing. Last year in january, we committed as an administration that we would transfer 30 by the end of 2016 of our payments in medicare, the payments based on value, not volume. That and by 2018 it would be 50 of the payments. We are on track to meet that goal for this year, its important were a large portion of the dollars, its important because of the signal sent to market. Whether thats private players or medicaids where that happens. Rewarding those who are making advances in quality and affordability. We also with our Accountable Care organizations. We took the feedback we have received and in the next round of those, we have put forward changes that hopefully will protect and reward those who are already leading in the space. On graduate medical education, theres something that you guys have entailed on setting the standards for emerging needs in health care as it relates to medical education. What are those standards going to entail. What were trying to do . We want to make sure the monies that are for graduate medicare are targeted toward those in the medicare population. We want to ensure were focusing on primary care, where we know we need more services as well as the issue of specialties where we do not have enough people. What were going to try to do is create standards that target the money and guide it to places where it serves the population its supposed to. But b, its target to the places where we have shortages. The problem that we have, that we need to focus on is that given a state criteria, were not you can be in seattle and be well served but be in spokane and have a shortage, we need to focus on the fact that even within a state, you can have great geographic differences and what youre doing to serve graduate medical education. So its a priority for us to have that graduate medical education in spokane. Our colleagues here have to understand that while there is a cap on medicaid expenses right now in puerto rico, if tens of thousands of people come to the United States, theres no cap on that so we are just digging a deeper hole in our budget by not fixing the problem in puerto rico. Thank you much ill let my colleague get to that when he addresses it. [ inaudible ] the need to be objective on the analysis and we thank you for that. As you know cbo recently came out with an estimate that said that in 10 years of without addressing mandatory spending in other issues, the mandatory interests will consume 99 of all federal revenues. Obviously thats unsustainable. You and i have been together in rooms talking about budget issues. When you were o b director, we werent able to reach an accommodation, either going big, so i decided if we couldnt do that, i would go small. Every week i would go to the senate floor and talk about waste, fraud and abuse. One of the issues that im going to be talking about today is the igs report regarding improper payments through cms. Its my understanding that the Inspector General listed 25 implemented recommendations for improvement and protecting taxpayers dollars. With cms. Cms said it wants to address this, but its short on resources. This is a catch 22, theres an estimate that cms could save 1. 76 billion if it had followed the installation of improving automated claims and a number of other things. My question is youre asking for more resources. Just like to bring this to your attention. There are ways to free up money for absolutely necessary functions for cms. And some of these recommendations if for all of these recommendations, if theyre implemented can help with that process. So i wanted to bring that to your attention. Id like to get your response to that in terms of the ability to go forward in these recommendations implemented. We agree, and i thousand you probably know the 71 statistic. For every one dollar we believe we can save 7. Last year together with the justice department, we had the largest takedown we have had in the fraud area. It was over 700 million in one takedown. We believe we need finances to change and do some of that automation. We asked for some of those resources i think you may have had an opportunity to speak with administrator slavitt. Fraud is a very important part that i think we can go at and go aggressi aggressively, with data getting ahead of it. The other part we need to consider is, with improper payments, theres fraud and that whole category that people arent providing the right information. As we tightened requirements, in order to do things like requiring paperwork before payment, so we get in front of it. We see greater numbers of people not getting the right payment. Thats a place where the resources are important many. Giving your experiences, i know this is something in your wheel house. As secretary of hhs and overseeing cms. Youre exactly the right person, in the right place to get this done we wish you success in getting these things implemented here, it can free up funds for programs that may be waiting for those funds. Absolutely, and thats why were hopeful our budget request. That particular part of the budget request, results in greater savings. The 71 number is what weve seen on the average of the last three years. Thank you. I have 40 seconds left which i yield back in the interest of a vote coming up. Whos next . Thank you, mr. Chairman. I will only ask one question on this round given colleagues being here. Were very pleased the secretary is it here, secretary burwell in my view gives Public Service a good name. We are glad that she is here. The issue of opiod abuse is widespread across the country. Its of particular concern to oregon i think colleagues know that ive opened an investigation into potential conflicts of interest between opiod manufacturers and the pain industry. The concern here is, the manufacturers may be trying to influence opiod prescribing practices and will have more to say on that in the days ahead. Now oregon has been among the states with the highest nonmedical use of prescription pain relievers. One in 15 people who take prescription painkillers for nonmedical purposes are going to try heroin within 10 years. Nationally, Health Care Providers write prescriptions for every adult american to have a bottle of pills. Many studies and experts found that physicians are inadequately trained on pain management. This past week i sent a letter to the cdc director to offer my support for the cdcs Draft Guidelines for prescribing opiods for chronic pain. Set aside for purposes of this morning the question of the investigation into potential conflicts of interest. We will talk more about that in the future for purposes of this morning, what does hhs plan to do to ensure that opiods are prescribed more appropriately, and what does it plan to do to reduce the number of people using prescription pain relievers for nonmedical purposes . When i came to hhs in june of 2014, this was one of the priorities i chose, because im from the state of west virginia, where i think many of you know the problem is acute. In neighboring states and all over the country, colorado and pennsylvania too. Across the country p. We put together a three part strategy. It was three parts with number one being the issue you just touched on. And that is prescribing. Prescribing is how this starts, its how it starts in terms of the prescription medication. So many people that do heroin, it is after they have done Prescription Drugs. In colorado, i met a young woman who said after three months, heroin was cheaper, easier to get and a better high. We see that, and she started with her wisdom teeth being pulled and taking the drugs. Medical assisted treatment, this is the approach that i think theres broad participate support, at the state level with governors, sheriffs in terms of making sure were getting the treatment for the people. Right now in our states across the country we have so many people who are already addicted. Thats what the vast majority of the monies that we have in our proposal do. Its important to note that is money that will go to states and communities. It will go through samsa and hursa. The majority of the dollars are to get out so we can do medication assisted treatment. The third part of the strategy is naloxon, many people overdose, you all know the numbers as i mentioned in my testimony, 78 people a day in the country are dying. That overdose can be prevented from being a death by applying naloxon, sometimes called narcan. Some of the monies are about making sure we get access to that drug, to the First Respond responders, we recently saw organizations like cvs and wall greens working to make this an over the counter drug in certain states. Thank you, mr. Chairman. Nice to have you here. I appreciate having to discuss these issues with you. I wanted to raise concerns weve had about the great plains area. The reports coming out of there have been unacceptable. Unfortunately there has been a failure to deliver on the promises to Fix Health Care services in this area. In 2014 i was formed that a contractor was in place to strengthen the link between external oversight and the Effective Development of patient care processes. Report after report it covers the same issues. The administration seems to continuously fail. I would like to know from you what the administration has done to make meaningful reforms to the system and to ensure that patients receive the quality care patients deserve. I share your concerns in terms of the progress that has not been made that needs to be made. There are a number of changes we are taking right now in terms of trying to get a different result from where we are i think it was important when cms said we didnt have safety and quality issues, we acted upon that to protect the health and well being of the folks. In the region itself we actually have changed the leadership in the region. We are supporting that by sending some of our Public Health Commission Core officers who work on quality issues to supplement the ihs folks on the ground. At the department itself in terms of making sure that were doing quality and management changes, i think its both about meeting the quality standards, but management and culture that we need to make some changes in we have lettered a deputy who has come from the field to work on the quality issues and brought in mary smith as another deputy to work on the Management Issues i think you saw in the hearing you were in, i specifically asked the acting deputy to actually put together an Interagency Group within the department of health and Human Services that met yesterday, to see and set specific goals what have we can achieve during our time. Thank you, well look forward to continuing to follow up on those issues. I wanted to change gears for just a moment and ask about this is more forward looking, i hope. On how we can make reforms at the ihs. Id like to follow up on an issue i aggressed with the officials last year. When would the administration finalize physician and nonhospital based services under the referred care program. I understand from the Budget Proposal that this regulation is awaiting approval at omb and im encouraged by what were hearing about the progress, im interested when you believe this regulation will be posted. Additionally, would like to know how the administration plans to conduct its consultation with the nine tribes in south dakota. With regard to the specific regulation youre speaking of yes, its generally a 90 day process, the comments come back to us and the question is how extensive those are in terms of the timing, its at a late stage of a regulatory process and its one that is a priority for us. Were hopeful that soon we will get it out. I think its also related to the issue you know. Because your state and your governor had been an important part as has alaska of changing the way we do some other payment issues that arent a part of that regulation, but i think are important to the Payment System of how we provide health care. Were working on something that doesnt require the same process in terms of the payment i think you knee were changing some of the matching rates. I appreciate that and would encourage you to push omb and to be able to move forward with the finalization of that regulation. Ive written you in the past regarding one area of improvement which is the electronic mechanisms used to exchange information. In the purchased and referred care claims are still being mailed back and forth. The administration is considering a move to electronic claim payments and would be interested in an update if thats something the administration believes is feasible. With regard to the specifics of where that one is, id like to get back to you on it. With the emphasis in our Delivery System one of the anchors of the strategy there is electronic Health Benefits and data information. And the ability to move that more quickly so we improve quality. And we improve affordable. It fits overall, where specifically is it at this moment, ill need to get back. Under the aca, 17. 6 Million People now have health care. Louisiana is expected to expand medicaid in their legislative session. Thats another 400,000 people. Thats 18 million. The republican governor states that have refused to expand medicaid and will eventually is another 4 million. So 18 million plus 4 million is 22 million. 22 Million People will have health care out of an eligible population that did not have health care of 34 million. Thats two thirds. Thats to use the lexicon of today. Thats a huge success. I dont think that that story is really understood how successful the aca is. If you wonder where i got the 34 million. Im taking 34 million was the population that didnt have health care, and im subjecting the those that are here illegally, 11 million, to get 34. 22 out of 34 million will have health care. Thats a success. I want you all to chronicle that story. When we think about the issue of the success, its aroundal forwardability. As you reflect on the access point. Were now at a place where over 90 of americans have insurance in the country. That is a very big change from where we are. Additional folks are in medicaid from 2013 until now. And we know that in the marketplace, that 17. 6 as well as other numbers in terms of that reduction. The other thing i think is important to reflect. People have Health Insurance through that as well. All those things are coming together to put that downward pressure, i dont think we can forget other things like preexisting conditions. So Many Americans, people who have cancer, asthma, thats been an important change that many people think is very beneficial as well as Preventative Care and conditions. That gets a little bit to senator cantwell. Puerto rico, the mosquito that is in puerto rico that has spread a long of ding fever is the same mosquito that carries the zika virus. Where its having these tragic results is on pregnant women with children that are deformed. Puerto rico needs help. And lo and behold if puerto rican pregnant women are being exposed and they have this tragic result of these births thats going to be an additional expense upon the Health Care System to take care of these babies. I know you put 250 million in your budget to curb what is expected to be in puerto rico this outbreak of zika. You want to comment about this . With regard to the zika virus. The plan we have in place is about preventing further damage. What we know is that on the island of puerto rico, this mosquito is a dominant presence. Its a mosquito that will sometimes bite four humans in one feeding. It spreads the disease quickly. 80 of the people arent symptomatic, you dont necessarily know if you have had it. The importance of getting resources to puerto rico in terms of pregnant women taking care and protecting and us doing mosquito control. And its not just for puerto rico, puerto rico is the place where we expect that we will see the most and we have had mosquito transmission already. In the continental u. S. In states like florida and texas. Were also concerned because this mosquito is prevalent as well, and want to make sure were putting the resources against preventing as much spread as we can of the zika virus. Thank you, mr. Chairman. I wanted to continue along the lines senator nelson was talking about as you know, the cdcs decision of vector born diseases in ft. Collins, colorado has been on the front line of studying. Your opening presentation has proposed 18. 8 billion to resummoned to the zika virus. Can you give us more detail how you plan to spend that money. Because the issue of testing for zika is something that is occurring with the cdc, in terms of ft. Collins, thats where a lot of the testing is occurring. Its a part of what that money is about, is making sure that states will have the capacity to test. For any woman who has gone to mexico, and know the estimates are 450,000 pregnant women travel to these regions where zika is. If they come back, they wont necessarily know, because 80 of people dont know you have the disease. You most likely will be tested and we recommend youre tested. If youve gone to this region. A lot of the money is about making sure that the states are going to have that testing capability. Senator grassley and i introduced the ace kids act. Our bill now has 30 co sponsors. It would improve care for children with cancer, con genital heart disease. Approximately two thirds of the 3 million children are covered by medicaid. These children in california estimate 6 of medicaid enrollees and nearly 40 of medicaid costs for kids. Our bill would create a National Framework of world Class Providers and hospitals in the Medicaid Program that would coordinate care across state lines. I know hhs is working within certain states to test these types of models. Senator grassley and i are working with our finance committee to try to pass the bill. I am bringing it to your attention. Were going to need assistance in your team to pass this into law. Is this something you would be willing to prioritize . Yes, we want to work with the authorities, we have to do some of the things we can do that are ideas and concepts and we want to work with you on ensuring we can do all the work we can to make sure these kinds of children are cared for. If we could coordinate it, with that, mr. Chairman, ill yield back, i know theres a vote. Were going to go to senator portman i apologize, i will be back. Senator portland will take over. And my staff am say whos next. Thank you, madam secretary for reaching out before this hearing and seeking council, except to say that we have differences on this budget. I agree with what will the senator said. Id love to work with you on the reduced cost. You and i talked about some of these fiscal challenges we faced. I want to talk about something i like on the budget. Thats the work on opiod addiction. Its at epidemic levels in my state and around the country. Were losing lives every single day. We have over the last three year s, over a dozen meetings up here from experts around the country who have tried to bring in the best people to figure out, how do you get at this problem . You and i have talked about, and you reached out to me, and i appreciate that over the last several years on this issue. This just passed the Judiciary Committee. That doesnt happen around here so i want to thank you for whats in the budget. What you put in the budget provides more funding for treatment. It provides funding to look at the effectiveness of treatment programs. Some work better than others. And some that i visited in ohio have incredible results thats important at the federal level, i know you have a personal interest for it. Senator white house is the other co author of this. We have over 120 groups around the country that have supported us on this, the attorneys generals, i think 38 of them now endorse the bill. The groups represent the people who work in the trenches every day in the states i know that the white house has said generally good things. We understand there has to be funded. The funding we got in at year end will help. I wonder if you had any thoughts on cara you can share with us today. First thank you for your leadership. Its important to the progress we can make. You have been a strong leader and appreciate our conversations about these issues as well. It aligns with the strategy in this hearing. Im hopeful. I think you know i have 11 months. The idea that we can put in place the things ill start to see the results of our efforts, its going to take longer. The idea we can put in as many as possible of the things i think we need to do, and the support for medication assisted treatment. We look forward to continuing to work with you on it many glad to hear about the vote. I obviously wasnt here, soy did not know. We are encouraged by the vote and the amount of support were getting from around the country. It would help us to get it through the process without. Were going to see it, people offer amendments to try to kill it. Its never been about politics. Weve been working on this for years. We kept it nonpartisan. You would be pleased to sign it, to start this new strategy for our government to play a Better Partnership role to address what is a crisis in our communities. Theres other legislation that senator toumy and myself have introduced. Its called the stopping medication abuse and helping seniors act. This helps us save lives that patients on medicare are doctor shopping. Getting pain medications from multiple doctors, multiple pharmacies. We know these programs work. And the plans, medicare is prohibited from using this important tool. As was commented by cms in terms of our ability to do it, you know it would come statue tore illy. I think the one concern we want to make sure is that we dont make access too hard. Pain is an important issue. In terms of the issuance. So i think we agree we can do a much better job, which is what the objective of the bill is, in terms of controlling this access to these drugs in terms of providers and pharmacies. I want to make sure we do it in a way that doesnt inhibit access for those that need it. Look forward to working with you on that as well. Thank you, mr. Chairman. Thank you, mr. Chairman. We have rotating chairmanships today. Thank you for your service to our country. I think you do an outstanding job. As you know, Congress Passed the autism care act in august of 2014, which i wrote to continue the research, the intervention. The support programs that existed under the old namedqm÷ combating autism act. And while the cares act contains requirements that hhs conduct research into key areas impacting the Autism Community, chief among them is a report focused on young adults and youth with autism who are transitioning out of School Based Support Services into the larger community. According to the cdc data one in 68 children nationally and one in 45 in my home state of new jersey are identified with an Autism Spectrum Disorder. Early diagnosis has come a long way to support these children, unfortunately youth and adults dont have the same access to support and services after they leave the school. The happenstance of the date on the calendar changes their lives dramatically. After the laws passage, i convened a roundtable discussion with key Autism Community leaders in new jersey. This issue of aging out and transitioning to Community Based services was something that was consistently mentioned as an area in dire need of attention. Which is exactly why i mandated this report. A comprehensive understanding of not only what services are currently available but what we need to do to ensure that every individual with an Autism Spectrum Disorder can succeed into adulthood. The report is due to congress this upcoming august, two years after autism cares act was signed into law. Can you provide us with an update on the progress of the report and confirm that it will be completed by the statutory deadline . So first, thank you for your leadership in this space because its important to helping us in the work we do. We are working in terms of this report and i will get back in terms of the specific question you are asking on august exactly and come back to you. I am concerned, because i understand, my understanding may be wrong, that this has not even been started. So if thats the case, i dont know how we make the august deadline but i hope im wrong and you will give me better news than that. If not, then i would like to get a sense, i would like to give it a sense of urgency. Now, i know many of my colleagues have talked about the Opioid Epidemic and of course, it deserves that attention. Last year in new jersey, heroin deaths in our state are up 160 since 2010 and we suffered more than 1,200 overdose related deaths. So this is really an epidemic. Now, i recently held a listening session with key Addiction Treatment stake holders in new jersey to address this growing crisis and to a person, the issue that came up most frequently, there are many, but the one that came up across the spectrum as the most substantial barrier to Addiction Treatment was the limitation on a providers ability to conduct medication assisted treatment. As you may know these limitations cap a providers ability to treat at most 100 patients. Now, with the number of people seeking treatment far outpacing the number of providers who can help, it seems to me that this is an outdated limitation and tying providers hands and limiting treatment to those who need it the most. I would certainly like to see a broader provider universe but when something is an epidemic, you need to figure out that maybe an artificial cap at one time is now not the reality of the moment. So while i appreciate the administrations bold request for additional funds in this area and intend to be as supportive vigorously of it as i can, what can we do to increase the access to medication assisted treatment and what further efforts can the department take under its current authorities . I think that specifically in the case of the specific drug in terms of the medication and that specific type of medication assisted treatment and right now, we are actually in the middle of changing our regulations and proposals and using as much of our Administrative Authority as possible to change that. Thats something i would expect to happen this year. With the drug as senator portman indicated, it is a place where the questions of diversion of it and use are the things we want to make sure. I think we believe we can expand those caps and move those numbers without creating that problem but thats what were working on right now, using our administrative authorities. I would also reflect that as part of the budget in the budget, theres a proposal to actually expand the ability for trained people in correct settings. In other words, making sure that beyond physicians might be able to use it, meeting certain criteria. There are two fronts were working on. One is within the budget, the other is administrative action we are taking. I would appreciate if your staff would keep us abreast of how that administrative function is moving. Finally, i just want to mention, if i may, mr. Chairman, i know my colleagues have brought it up, but i hope that your department will do everything you can to take the administrative steps that are possible within your wherewithal on the Health Care Crisis in puerto rico. This is really i listen to the stories from people on the island and i listen to their families in new jersey and it is getting way out of hand. There are other issues that they have in terms of their finances, but this is an issue that is of increasing concern and i hope that you will see what administrative powers you have to help the people, the 3. 5 million american citizens who just happen to live in puerto rico. So we are very focused and we are very focused in terms of the Administration Administrative actions we can take. We have taken a number of those in the medicare space. I think as you know, the medicaid space is where large dollars and large amounts of care are very important and its on unequal footing. Im sure this committee spent time yesterday with my colleague, secretary lew, on important legislation that needs to occur in his area, but i would be remiss if i did not emphasize the importance of some of the help and what we are trying to do is make sure that americans in puerto rico have equitable care in terms of medicare and the rates. Thats what the proposal is in the budget. At the same time, we will do everything we can from an administrative perspective. I also think the issue that was just raised about zika is particularly important. When one thinks about the cost that senator nelson was mentioning, cdc estimates that for children who are born with some of these severe birth defects depending on the severity, the cost is 1 million to 10 million per child. So making sure that we are doing everything we can right now to help and assist and support puerto rico in eventing cases of zika in pregnant women that could in turn lead to additional issues are a place thats a priority focus. I think you probably heard i have spoken to that in the past several days in terms of the urgency of the need. Of the financial assistance. I appreciate your answers. We are ready and willing to do whatever we can from this side of the capitol to be helpful in your efforts there. Thank you. Thank you, mr. Chairman. Secretary burwell, thank you. Let me say in public what i told you in private two days ago on the phone. I want to tell you how much i appreciate your accessibility, your willingness to work to solve problems. Appreciate everything you have done for us in georgia. Thank you very much. You are on the Moon Shot Task force for cancer cures, is that correct . I am. I have a homework assignment for you. The Surgeon General in 2014 said skin cancer was the Fastest Growing killer of all cancers and melanoma the Fastest Growing of the skin cancers. As one who survived two melanomas in my life, i took that on as a call to action and started investigating what was happening at fda. And found out there was a 13 year backlog of ingredients that had been submitted to fda for approval in sunscreen that had been delayed in terms of the processing of their approval. So we passed the sunscreen innovation act out of the Health Education labor and pension committee, passed it on the floor, passed by the house and signed bay the president. 14 months later, none of those ingredients have been approved yet. Nothing has moved forward. So as one to quote the president , hes asked you to identify and address any unnecessary regulatory barriers and consider ways to expedite administrative reforms. Would you please make the first item on your agenda the sunscreen innovation act and getting those backlogged sun screen additives approved . With regard to the issuing, we have had time and since last year, i have spent time on this issue. One of the things in terms of those ingredients is we actually need the data and information from the actual manufacturing companies. I think you know we are working with them, being very clear about here is what we would need to meet the standard of approval. And that is part of what the act did in terms of the new act is making sure that we meet the standards. The sunscreens and i think everyone knows, now we put them on every day because we know and what you said is a true thing, on our children, our 8 and 6yearold, every day in the summer those sunscreens are going on. The question of what that sunscreen does in terms of absorption in the skin and whether it causes other issues, thats what we want to just make sure. We just want to get to a base level of safety, we have been very clear, we heard you when you talked to us last year about this issue, and we are trying to work with the companies to be very clear about this is the data we need. For us, saying that it was approved in another place, can we just see the data, the aun lit particulars that make sure we know what we are putting on children is safe. This is one we will continue to work on. We want to make progress on it, too. We are trying to work with industry. To make sure that we are being clear, that we make it as simple as possible to get the information we need to make sure its safe. I will do a favor for you. If you get me the information i need to call them to tell them to expedite getting submitted to you what you need, i will do that if, i have just been handed this so i take no responsibility for the accuracy of this, but i have great staff, it says fda has moved the goalpost and is now requiring a new test that no one has ever heard of. I will check on what that is and if you will check on that, too, we will see if we can get the barrier removed. I think its important to get these done as fast as possible. On the zika virus, i know tom frieden and i talked lft welast week. The estimated request is 1. 8 billion, is that correct . Thats correct. 1. 48 for hhs. In another hearing i was part of, i heard there was money left in the ebola fund that had not been spent yet and somebody suggested using some of that to go towards zika until we can get the bill towards the congress on zika. That would be fine but please do one thing for me. There were private hospitals that assisted the administration in responding to the ebola. We are told they would be reimbursed for their costs if they responded. Be sure they are reimbursed before you spend that on something else. Yes, sir, senator, one of the things we want to make sure is that we finish the job on ebola. Thats a very important thing for us to do. We know that just this last week, a new case has occurred so even when we had declared it clean, a new case and the good news is, they were swabbing dead bodies to continue watching for it and thats how we found it, were able to do the Contact Tracing and everything. We need to make sure we finish the job on ebola, including making sure we pay those communities like hospitals, like emory and others that helped with this issue. Cdc did a marvelous job in responding and the administration is great in what they did. I just want to make sure everybody that was going to get reimbursed, gets reimbursed. Lastly, one of my companies in my state is equifax, a provider to cms to verify income eligibility for medicare and things of that nature. Make sure you are utilizing those people. They are not the only provider. I know we have a lot of things fall through the cracks and things are paid that shouldnt have been paid because people really werent eligible and they claim they were, and i understand theres an underutilization of those verifications. If you would follow up on that to make sure we are using the available resources which are cost free to us, make sure that those eligible for medicaid are in fact eligible and getting the benefits. Thank you very much. Thank you. I havent asked any questions yet, nor have i even greeted our distinguished secretary. If i can just greet her, then i will ask my questions after you. Welcome. Thank you. The bill on the floor is mine and i have been running back and forth, a bill in the Judiciary Committee as well. I just want to welcome you to the committee and sorry its belated. But im very pleased with the hard work that you are doing. Its a tough job but i think youre doing it in about as straightforward and good a way as i could expect. I just want to let you know im proud of you and want to keep working with you. So listen to our side, too, and we may be able to get a lot done here if we do. But we are happy to have you here. I will have some questions for you after senator casey. Mr. Chairman, thank you very much. Secretary burwell, thanks for being here. Thanks for your stellar Public Service at a difficult time. I have two questions and i will get to them quickly. I hate to pass up the opportunity to report some good news. We need that around here once in awhile. Someones got to talk about good news. Just some numbers. You dont have to respond but i was struck by some of these. Between 2010 and 2014, 87,000 fewer patients died in hospitals due to hospital acquired infections. Thats a good number. 150,000 fewer readmissions which is good for the individual and good for saving money. But in the budget presentation, i was happy to see a lot of things but i will just do some highlights and this wont be fair to every priority, but a couple things. Requiring coverage of eps dt program for children inpatient psychiatric treatment facilities, providing full medicaid coverage for pregnant and postpartum beneficiaries, extending the childrens Health Insurance funding through 2019, and the new initiative or i should say the new dollars for an existing initiative, the maternal infant and Early Childhood Home Visiting 15 billion investment over ten years. It is voluntary and it is evidencebased Home Visiting which is good for the new baby and good for the mom and the family. So all that by way of good news in addition to the 17. 6 million is it newly covered by aca since the enactment. Thats all good news. On the bad news side, you have been asked i know several times about the opioid problem. Terribly significant problem in our state. We have the ranking now in pennsylvania being third highest in heroin deaths. The Coroners Association every one of our 67 counties has a coroner, reporting on how people die, and that number has gone up from about 47 a few years ago to hundreds of deaths every year and thousands if you look at it over several years. So a huge issue and a huge problem. I know you have been working on it and the administrations initiatives. One subset of this, i heard anecdotally that Child Welfare agencies are reporting an increase in foster care placements due to the heroin and Prescription Drug prescription opioid abuse epidemic. How is hhs taking into account the needs of the Child Welfare population as it coordinates its response to this epidemic . I think in a number of ways. One of the most important ways is actually making sure that the mother gets into coverage and health care before she has the baby. Because this is also about the health of the baby and making sure that we do everything we can for an addicted mother and actually, in colorado, i did visit one of the Successful Programs and so making sure that we have that coverage. The coverage that has occurred through the aca in terms of people coming in to the marketplace but in your own state with the expansion of medicaid, we believe we are going to reach more women because step one is making sure they have the coverage. Step two is making sure they are willing to come in. I hope that the conversations we are all having publicly destigmatize women coming in, because thats the other problem thats a barrier. So you dont have Health Insurance so you cant pay for it is a barrier. Then the question of youre stigmatized if you come in. These are some of the issues we are working to do to make sure that we start at the beginning of the childs life in terms of healthy birth and a mother that feels connected to that child and is willing to care for it in an appropriate way. I appreciate your work on this. My last question is on the complex rehab accessories issue that came up at the end of the year where we legislated but now we are in a situation that for the First Six Months of the year, providers will face the same payment difficulties they would have faced if we had not passed legislation. Cms as you know better than i, performs these quarterly updates. We had some discussion with dr. Wakefield when she was here, but just asking that you work with cms to ensure that the congressionally mandated payment change for complex rehab accessories is included in the april update. We will work to implement as quickly as possible. I think you know this was the end of the year. The acting administrator is planning on coming up and having a conversation directly with you about it. We will follow up in that way. Thank you very much. Appreciate your work. Thank you, senator casey. I think i will take time now to ask my questions because i may have to leave again. I have got so many things im doing today that its hard for me to keep up with it all. But welcome again. Pris i appreciate the work youre doing down there. Its very meaningful and very difficult. Almost an impossible agency to run. You are doing good. I do have great concern on the topic of overreach is the Medicare Part d program. There have been rumblings the president may issue an executive order that would allow the federal government to negotiate Prescription Drug prices in the Medicare Part d program. Now, such an executive order would be in violation of the law, as the statute explicitly prohibits such interference in private negotiations. And despite this fact, i take the possibility of an executive order very seriously. Im a strong supporter of a viable pharmaceutical industry as a source of innovation and intellectual property that produces lifesaving drugs and therapies. The Part D Program gets these needed drugs to Medicare Beneficiaries and we need to keep the program as it was originally structured because it works. Everybody knows that part d is one of the most important things that really works. Beneficiaries have choice in Prescription Drug plans, private entities negotiate to keep costs down. Overall spending is significantly less than originally projected. Beneficiaries satisfaction is very high. In fact, its been a tremendous success. Moreover, allowing the government to quote, negotiate unquote, prices is not a new idea. Congress has considered this policy and has chosen against it. The president s Budget Proposal states that it has no budgetary impact. A Congressional Budget Office doesnt see it as a big saver. So having said all that, my question is, secretary burwell, is anyone at hhs working or has hhs worked with the white house an executive order that would allow the government to negotiate prices or on any other changes related to drug prices . With regard to the issue of drug prices, i think you know we are focused on both sides of the issue of drugs. Its not just drug prices. Its about innovation which is why we actually brought everyone in for a conversation about both of those issues at the end of last year, so that we could hear from industry as well as consumers in terms of the issue. As we think about it and the steps that we have taken, we are focused on both that innovation as well as that affordability. I think you know and certainly senator portman raised the issue of deficits and entitlement and mandatory spending, and we take that very seriously and are looking for the opportunities that we can do in terms of drug prices because its becoming an increasing percentage of our Overall Health cost, and we saw great increases in 2014, the most that we have seen in many, many years in terms of the drug prices. So thats why we are focused on the issue. The steps that we have taken to date, though, include the session that we did include closing the doughnut hole which was part of the aca, which at this point has saved seniors 20 billion, ten million seniors, then the third step we had taken to date is on the issue of trying to provide transparency because we do believe that puts downward pressure and have created a medicare let me interrupt you. Im very concerned about this because i think that they fouled it up with regard to the tpa, trade Promotion Authority or should i say, tpp. And frankly, if you dont have data exclusivity time of 12 years which we negotiated, kennedy and i negotiated that, because we know that we have got to get enough data exclusivity time for the companies to recoup their costs, where we can actually get cures, it takes about 15 years and 2 billion, so you need some time to be able to recoup that money, or if you have the five years that they have in that provision, the costs are going to be so high that everyone will be screaming and the bio industry will go down the drain. Thats where were going to find some cures that might really Save Health Care costs over the long run. In the case of pharmaceuticals, im sure if they get that figured, they will be starting to do that to pharmaceuticals which were 1 billion in 15 years and need to recoup those funds in order to go on and create newer drugs, in the case of biotherapies. So im concerned about it. I hope that you will weigh in, because we have got to have some economic sense on these things or well lose the whole pharmaceutical and certainly the whole bio industry because of what i consider to be a stupid provision in the tpp. My time is up. Let me i think the senator is next. Thank you, mr. Chairman. Secretary, thank you for your service. We very much appreciate your career of service to the public. We have talked earlier but let me just point out that the extension of access to emergency Psychiatric Care which was included in the omnibus, i authored it along with senators toomey and collins, is a logical extension of the program through june through september, but allows you to extend it through 2019. Its revenue neutral. But we need the guidance and i know you are working on it. Its very important, particularly for those from 18 to 64 years of age. I just urge you to stay focused on that. We think it is critically important for access to Psychiatric Care. I also thank you for being willing to look at the Pediatric Oral Health care issues that we provided coverage under the Affordable Care act but the oig report indicates that far too Many Americans are not getting access, children are not getting access to dental care. So we need to figure out a strategy to get beyond just coverage to make sure coverage is adequate and make sure theres access to qualified dental services. I want to follow up on the Psychiatric Care act, the deal with the community Mental Health needs. This past week, i had a roundtable discussion in baltimore with experts on Mental Health and addiction services, and we have talked about this several times in the committee, the need for Greater Community access to Mental Health and addiction services. What came out at this meeting was a couple very interesting facts, but the number one priority still is the Reimbursement Structure that does not take into consideration care managers so if you are a hospital trying to be able to deal with Psychiatric Care, someone comes into your emergency room, do you really know how to triage that person into the most effective, least expensive carry setting, do you have that capability. If you are a qualified Health Center, can you be able to deal with walkins and referrals and do you have 24 7 capacity to do this. And the Reimbursement Structure is not terribly friendly towards those who understand that they must have those types of capacities in their facilities. I know that you invited comment last july on how we can make the Reimbursement Structure more effective and i know congress has taken some actions in regards to programs in several states. Can you just update us as to how we are moving forward to encourage communitybased models for integrated collaborative care for Mental Health services . So section 223 in terms of the implementation of an approach where we are trying to experiment both with different payment models and build on the backs of the Behavioral Health centers that are already in communities as well as our federally qualified Health Centers, and thats a step that we took and certainly, senators stabenow and blunt and miss matsui on the house side have been very engaged on this issue. We are ahead of our schedule with regard to implementation as you reflected in terms of doing the demonstrations. In the budget that came up on tuesday, we would like to extend those demonstrations so more of those that applied can start doing the types of things that you are talking about. So we are hopeful that our Budget Proposal and i think miss stabenow, mr. Blunt are both supportive of actually even going beyond what we have in our budget. I strongly support that. Strongly support it. Thank you. Thank you for doing that. Thats very important. My colleagues have been incredible. I would just suggest that we need systemwide changes in the Reimbursement Structure so that we can deal with Mental Health. And i know youre looking at that, it was part of i believe your july inquiry. We should take what we have learned, we know that for every dollar we spend in these settings, we are going to save 6. Yet the Reimbursement Structure doesnt allow creative ways of using care managers in communities that may not be part of this program. So i just urge us to think broader as to how we can make the system work for Mental Health, because historically, it has not and today, its still not. I think what we are hopeful is that we can get the examples and the models to scale in terms of the changes that will do it. The other way, what you are talking about can happen is through our Accountable Care organizations and having visited some of those in new york and seeing the progress they made with integrated Behavioral Health care, we are funding those through our Accountable Care. Its both through 223 as well as through our Accountable Care organizations that we are creating the models we need to have the analytics. Im glad senator stabenow showed up. I know i have one of the real champions on this issue. Yes. Thank you. Thank you, sir. Morning, madam secretary. Good to see you again. Just a couple questions for you this morning. I know that i happen to be the cochair of the Prescription Drug abuse caucus. I know theres a lot of funding throughout the budget for opioid abuse. Theres one account that was zeroed out, i assume the access to recovery account was zeroed out by the administration. My assumption is there are other resources in other parts of the budget, realizing the fact more people are dying because of an overdose than from auto accidents or gun violence. Would you talk to that so that would help some of the folks im hearing from and their concerns . Yes. I think this gets to one of the topics we talked a little about, making sure theres not overlap in programs and we are doing that in the proposal and the money we asked for in the opioid space, there is specifically money around the narcan. We are trying to work on this on two fronts in terms of helping people with the overdose portion of this and that is through our funding and helping communities but we are also working with the private sector to make sure that its taking steps to be able to access it. I think you probably know that in a number of states, we see pharmacies like cvs and walgreens working with the state to do regulations to make it available over the counter so that it can occur not just for First Responders but sadly, Family Members need to. The other thing we are doing across the department in this space is fda has approved the first nassal noloxone making it easier for people to be able to give it to their loved one if they need to. Very good. Thank you. Next question for you. I know you spent some time in [ inaudible ]. We appreciate that. You should come back more often. In 2013, each state was provided with a cms liaison to contact with questions and issues. These were removed recently and replaced with a generic email account and there are some challenges in South Carolina. It seems to be nearly impossible according to the department of insurance for states like South Carolina to get quality answers, especially answers that are necessary from a timely perspective. What i have been told by the doi is that the respondent many times, that they are talking to, doesnt list their names so this via email context, and its signed basically by a regards from the ffm response team. When they do identify themselves, its almost never including that individuals email or contact information. So the long story short is that its very difficult to have an actual conversation via email or phone with a specific person that leads to an Immediate Response that is clear. Two things. One, i will follow up on that. The responsiveness and Customer Service in the space is something, our relationships with the doi, i need to find out exactly which part and does it have to do with the ffm, the federal yes. Okay. I will follow up in terms of that. The other thing is this does get to the issues of resources for cms. I think you probably know that the question of funding for these things, and this particular type of service, we cant do the fees. In our budget this year, fees that are coming in from the ffm will far exceed what we are asking for in an appropriations which is a good thing and we are happy about, but there are Certain Services the fees cant pay for. Some of these. So as you are reviewing the budget, if you look at that. Let me follow up specifically have we changed something and do we need to figure out how people know who to contact. I hear very clearly we need to be able to follow up with someone is what im hearing. Exactly. Exactly. As opposed to a department, a specific person to get more of an Immediate Response. I assume in your budget there is some flexibility to shuffle some of the resources around . We do and we have done. Im sure you probably know that the funding for cms over the past few years has certainly been an issue that has been a challenge for us and we are hopeful, we are at a different place this year. Last question for you. I know you have already answered a couple questions about the challenges around the coopes. The federal government distributed billions of dollars in loans to coops around the country. Recently, in my home state of South Carolina, we have seen coop closures which will likely result in lost coverage, higher premiums and perhaps even higher deductibles. My state alone, about 67,000 could lose their insurance. Sadly, we have heard so far this morning, coops in 22 of the 23 states where they operate are suffering large losses, according to last years results, and they are very few signs that these coops will actually be successful into the future. Whats your next steps . So with regard to the coops, in terms much our next steps, the consumer is at the center of our strategy and our approach to making sure we take care of those consumers. Thats why a number of coops came out before open enrollment and we will continue to monitor with the states who are the lead regulator. Having said that, one of the steps we have taken is make clarity in our guidance so the coops can actually seek a broader range of capital for them to have inflows as they try and work through any issues they have. With consumers at the center, we support the states and we continue to monitor them closely so we understand if there are changes in the facts that they have given us. Yes. Thank you. My time is up. Thank you very much. Thank you, senator scott. Senator schumer, youre next. Thank you. First, let me thank you, secretary burwell. I think you are a superlative secretary. I have seen a lot of them in the many years i have been around here. Nobody has more has a greater grip on whats going on, understands the policies, understands the practicalities and is able to get things done. So kudos and accolades at least from this senator and i know from many more. Okay. So what i wanted to talk to you about is two things. One is the zika virus. I dont know if thats come you so far, but i apologize if it has. Your administration, our administration, has sent us 1. 8 billion in emergency supplemental requests for funding to address the zika virus. We have a window here. We have time. Because the mosquitos that carry it is not going to come for several months yet. So we have time. We are pretty good if we get a handle on intercepting mosquitoborne diseases. Witness what we have done with yellow fever and malaria here in the United States. Im glad you asked for these monies. Our republican colleagues, im going to plead with them to not just talk the talk but walk the walk. You cannot combat these crises, whether zika, opioids, Mental Health or security in our country, without a lean effective government. The private sector is not going to fight zika if we dont have cutting cdc, cutting all the agencies, fda, makes no sense. But what they are trying to do right now or some are trying to do is say that we should not have any new monies, we will use the monies that were set aside for ebola which havent all been spent yet to fight the zika virus which seems to me like robbing peter to pay paul. Ebola, thank god, is not here now but it could come back. So would you please explain to me why we shouldnt do that and rather, have a new allocation of money for zika . What the monies for ebola are being used for, why they are still needed even though the ebola crisis for the moment has subsided both here and in africa . So with regard to our ebola monies, there are three main pots. One, as a budget person, the reports that we send to the congress are fully belated but i think as many of you all know, much of the money we are in the middle of negotiating contracts and using. The biggest pot of the money that is left from the ebola is about 500 million. That has to do with the global Health Security agenda. The Congress Gave us that money and we have committed to 17 countries to help and invest over a five year period so we spend it wisely, our monies go down as their monies go up we are negotiating plans so we have implementation is what we are working on together. Those monies were set over five years to do this. The reason that is so important in terms of why would you take that money, is one of the conversations we didnt have this year was middle east respiratory syndrome. Last year, we had more cases outside of saudi arabia than we have ever had in history but we didnt talk about it because korea was able to handle it. Each year we have something. We have to get these countries ready and actually, zika started in africa and we didnt know. We dont know if they have microcephaly in africa. So some of the money goes to stop ebola from spreading to other countries and dealing with it in existing countries because we all know it will come here if its there. Thats another portion of the money. We know that just recently in sierra leone, a case came back. We were able to detect the case, the sierra leonians were because they were still swabbing, we were still supporting them. Dead body, they swab and test. Thats how it was found. So it didnt spread more. We need to get the job done in the three west african countries, continue our commitment to prevention of not just zika or ebola, but mers and other respiratory got it. Isnt some of the money also to develop a vaccine or some kind of preventive measure . That is the other piece of it. And bioshield and our efforts together with the nih so we would be robbing peter to pay paul. We would be making us less safe against ebola to make us safer with zika if we just didnt put new dollars in zika and use the ebola money for that and you think that would be a Serious Health mistake, is that fair to say . It would be a mistake. Okay. Next quickly, because im running out of time here, puerto rico. We have been talking about puerto rico and the dire situation. I sponsored along with many of my colleagues, some of whom are here, senator cantwell has played a leading role in this, to deal with the problems of puerto rico and we need bankruptcy as number one, but senator hatch has been very, very trying to be very, very helpful on this. We appreciate it. But in addition to bankruptcy and bankruptcy, no money should be a substitute for allowing a territory to declare bankruptcy, we need other monies to help and those would be additional. My question is, how long do you estimate puerto ricos current medicaid allotment to last and what would happen if Congress Fails to provide additional money to their Medicaid Program . Or as we have both proposed to grant them with [ inaudible ] treatment . We continue to analyze. We worry that things in terms of that allotment or that cap could happen as soon as this year and thats part of why we have the proposal that we currently have in the budget to make sure that we treat puerto rico equitably in terms of how other americans are treated with regard to medicaid. Its an important financial issue. Its an Important Health issue for the island. Mr. Chairman, i thank you for that extra minute and appreciate your holding this hearing and always your courtesies. Thank you, senator schumer. Sm senator carper is next. Could you wait just a second . Hold that. Put the time back up. Let me just, i have to leave. Let me just thank secretary burwell for being here as well as all of our colleagues who participated in this hearing. Its my hope that the issues we have discussed here today can be addressed as we work to improve the nations Health Care System and to ensure the taxpayer dollars are used efficiently and effectively. We owe that to the dedicated taxpayers and citizens of this great country. But i would also ask that any written questions for the record be submitted by thursday, february 25th, 2016, and if we can do that, you can answer them as quickly as you can, we appreciate it. Sorry to interrupt you. I wanted to do that. Thank you. Madam secretary, welcome. Great to see you. Great to talk with you this week. Your dad, my mom have spent some time in nursing home care. My mom for dementia and i think your dad as well. I shared with you the other day that i was in on monday, visited a Presbyterian Village nursing home just outside of dover, delaware. Lovely facility. And they are doing something i thought was very encouraging. They have stopped prescribing i will call them antipsychotic medication. Im used to going in Nursing Homes and seeing particularly dementia patients, they are drugged out. They dont know who or where they are. Not very responsive. A lot of people in this nursing home in their 90s and even 100s and they had a fitness center, they are doing yoga, but they dont take the medicines. They reported to me, the number of falls now as compared to what it used to be is like dramatically reduced. I think they have currently over the long term residents, zero percent of them are on antipsychotic drugs. On a personal level but really on your professional level, i just want to know if the department of health and Human Services, Everything Else youre doing, this is in your is this something you are thinking about. We have worked on this issue with respect to trying to stop, reduce or at least reduce the prescribing of these mindaltering drugs for like foster kids. Thats been an important issue. This is Something Like your grandparents or great grandparents. I think theyre on to something at westminster village. Any thoughts . I think it aligns very much with what we are trying to do to get an heed indicated empowered engaged consumer at the center of their care. When we pay people for actually the outcome instead of paying for fee for service in the transaction, thats i think when we get to that. Thats when in a place like that on a regular basis, there is a meeting of the care givers with the family to have the conversations about these things, to talk about them so you can reduce those. I think its all part of the Delivery System reform we are doing and shifting the Payment System so in medicare, i think the other place that we will be pushing on this kind of specific issue is as we try through our Innovation Center to do our experiments in homebased care which mr. Wyden certainly has spent a lot of time promoting, those are the ways that i think it is a lot about payment incentives as well as certainly opioids are a separate category but the type of drugs youre talking about i think have a lot to do with how we pay physicians to care for people and we pay providers to care for people. Its about the quality of their care, defining that and defining that the outcome is value, not volume. Not how many pills you prescribe, not how much theyre taking, but what the situation is for the individual. Good. Thank you. For us, this ones personal. I very much appreciate what you just said. During the last session of congress, actually the last congress, i worked with dr. Coburn and you and some of your colleagues at the administration on issues including improper payments and something called the prime act, the prime act, which dealt with preventing reducing improper medicare and medicaid expenditures. Over the last two congresses we passed bits and pieces weechlt have now enacted i think the entire prime act which is a wonderful thing. Im going to ask you for the record to talk about the implementation of the new law which has been implemented in pieces and how we are doing to curb waste and fraud but not here at this forum. We just dont have time. I would ask, though, that on reducing opioid and painkiller addictions, as i understand it, folks that are in some cases physician assistants, nurse practitioners, are able to prescribe medication for opioid addiction to help increase the number of Health Care Providers who can help us address this epidemic. Could you just talk about i think theres a pilot, i may be confused on this but i think theres a Pilot Program that would folkocus on this area allowing them throughout the country to prescribe medicines for opioid addiction but to do it on a pilot and the question is, is that something we ought to do on a pilot or is this something that we should allow them to do nationwide . Do we need the pilot . I goods thats my question. With regard to the question of medication assisted treatment and broadening the number of prescribers that can do it we have a proposal in our budget that would do broadening. I think there are two separate issues. There is the issue of broader medication assisted treatment and there are different categories of it. One particular issue which is a drug that has limited caps, right now we are in the middle of reviewing that and using our administrative authorities to raise those caps. That drug distinct from some others, there are concerns that it may have greater diversion and so we want to make sure that as we are creating access to it weesh , we do it in ways that we dont have diversion. I think there are two different categories as we think about when we scale things, when we have the evidence that we arent going to create an unintended consequence move more quickly and broadly. In cases where we need some more evidence to make sure that there are reasonable questions being asked, that we do that in smaller settings. Thanks. Thanks. Great to see you. Senator stabenow. Thank you very much. Secretary burwell, we thank you for all your wonderful leadership. I do want to follow up on Behavioral Health and Substance Abuse. Before doing that, i want to thank you for all of the efforts of your department and the administration in helping us with the incredible Public Health emergency in flint and the person that you have put on the ground is really tremendous. And the work thats going on there, i know you will be going next week to flint and so we appreciate your personal attention. As you know, we have a community of 100,000 people who through no fault of their own have seen their water system poisoned and basically in many parts of it, destroyed because of lack of corrosion treatment before switching to the poor quality flint water and up to 9,000 of those are children under the age of 6 who are now exposed and some of the houses have lead levels as high as a toxic waste dump. This is extremely serious. We are still hopeful, we have had difficulty coming together and getting bipartisan support here to help rebuild the pipes and so on, but we are still working and still hopeful we will be able to come together and do something. But thank you for that. Your help. I do want to talk about as you know, another passion of mine we spend a lot of time on, that is implementing what senator blunt and i were able to get passed in the new law to create the structure so that we are not just funding Mental Health and Substance Abuse services from grants that ebb and flow up and down, but a structural change on payments that recognizes when a Behavioral Health specialist, psychologist, psychiatrist, social group, does work that meets quality standards, that they would be reimbursed like we reimburse other Health Professionals under a federally qualified Health Center and we have known actually since president kennedy passed the community Mental Health act over 50 years ago that we needed a structure in place so that we were providing comprehensive health care in the community. Thats really the final gap, Mental Health parity. As you know, under the direction of legislation passed by the congress, we now have qualified community Behavioral Health clinics, definitions of what quality is, like we do for fqhcs, federally qualified Health Centers, and the question is how do we get that available in every community in every state. So the congress was willing to provide enough funding for eight states with planning grants for states interested to see how they could meet those qualifications in order to apply to be one of the eight states. Under your direction and all of the wonderful folks that have been involved in your whole team, hhs, cms, everyone, you have built a Program Ready to go and 24 states have gotten planning grants, 24 states, 24 governors,csts÷ 24 states have we want to do this, we are planning how we meet those quality standards and we currently only can accommodate eight states even though to do anything else we want to do, opioids, Mental Health and so on, it all comes back in the end to having Community Services so people arent going to jail or the emergency room at the hospital, they are getting the service in the community. I wanted first, i noticed that in the president s budget you expand the number of states from the eight we are talking about to 14. There are 24 states that are getting ready to go. I wonder if you might speak to what is our joint efforts, senator blunt and i, bipartisan effort, to actually allow every state thats working to be ready to go to have the opportunity to provide the resources so that we really have Mental Health and Substance Abuse services in the community. Thank you for your leadership in this pace, senator. You and i have spent time together, senator blunt and i have spent time. Through your leadership, moving forward on that establishment of the quality standards and then that imp machination because it is about the infrastructure to implement. Thats why its so important in these communities across the country that lack access. So many communities across our nation actually lack basic access to psychologists, psychiatrists or other Behavioral Health professionals and we do have an infrastructure in place and so now what we need to do is take those quality standards and make sure we pay and thats what i think we believe that the eight demonstrations that were doing, or going to do, we believe is taking that step and our budget i proposal we do more because we think thats the right thing to do to build on this more to get that transition to where we finally treat Behavioral Health issues on par. Its not just about saying were going to do it. Its about having providers to do it and quality measures to pay for. This is a direction we are pushing hard. I think you know we are beating our statutory deadlines in terms of some of this work because we believe in it strongly. Yes. I want to thank you, just take another minute to thank you for doing that. Because you are working hard to meet those standards. Hopefully you proposed expanding that, we want to take it to every state thats interested and frankly, listen to the sheriffs across the country who are tired of having people in jail who ought to be receiving Mental Health or Substance Abuse services or hospital administrators who are treating people. I will never forget talking to the Cook County Sheriff whose director of his jail is a psychiatrist and we say why, its because over a third of the people in his jail need psychiatric help. Under the quality standards that we have now put in place, 24 emergency psychiatric help would be required as part of this Quality Certification and hopefully, congress this year will stied to gidecide to give states that stepped forward the opportunity to put services in place. We look forward to working with you on this. Senator warner . Thank you, mr. Chairman. Thank you, secretary, for your responsiveness and if i can get my questions out quickly, you may be done for the day. I have got three piece, want to thank you, secondly, a concern and third, a question. On the thank you, an issue we talked about a number of times is the Gabriela Miller kids first act which deals with pediatric cancer and celebrates the life story of an extraordinary young woman from leesburg, virginia who passed but advocated for researching pediatric cancer. I was very glad to see that it was fully funded in the president s budget proproposal. We had to work to get that done and im grateful for that. Im also glad the president s cancer moon shot included elements targeted at pediatric cancer, since pediatric cancer is so different than adult cancer. Thank you on the front end of that. On the concern issue, this is just to put on it your radar screen, we are working with cms, we know that due to budgetary constraints, a number of the Community Based care transition programs that initially folks thought might last for five years have been cut to four years. We have a Successful Program in virginia that does this coordinator transition care. Unfortunately, they were cut back without being able to make the full transition to sustainability. We are working with cms and let me just, this is a concern but not asking you to kind of oneoff here, we are working with cms, they have been cooperative but when we see Successful Programs that can and should make the transition to economic viability, i think we have got one here and i again would just appreciate the collaboration and cooperation of cms to try to make this Successful Program make this transition. Finally, a subject again that we have talked about at times. And its one that i think candidly that the American Public is ahead of most of our elected officials and thats around Care Planning and end of life issues. I think that we still remain the only industrial nation in the world that hasnt had this kind of adult conversation about Care Planning, about trying to make sure that issues around end of life are dealt with respectfully but also recognize that this is not about limiting choices but about expanding choices. And i was pleased to see that cms introduced a payment form for physicians to have those kind of conversations. About advanced directives and the other legal entities that come out of those conversations. And these conversations should include Family Members, loved ones, religious advisors. Senator isakson and i have been working on this and were gaining broader based bipartisan support and theres not a member of the senate that i havent talked to that doesnt have a personal story. Mine was my mom had alzheimers for 11 years, nine years of which she didnt speak and i was relatively wellinformed citizen yet we didnt have all of those conversations before it was too late. Were working i guess i would like to assure that a commitment that well continue to work with your staff on the Care Planning codes, how we look at more wrap around services. Were trying to work to make sure that these type of advanced directives can actually travel across state lines because so many loved ones, even if you move forward with this documentation, i know this is something that senator wyden has been engaged in as well. Mom and dad and aunts and uncles move. Trying to make sure that those documents travel with you built into your emr. I would like your comments in this space and again acknowledging that we have, i think for the most part, elected officials have to move beyond some of the horrific language that may have been used six or seven years ago. This is a part of everyones life and it needs to be dealt with and dealt with appropriately. My hope is that the Care Planning act we actually may get this done. If you would like to make a few comments on that. Thank you for your leadership. Because your leadership and senator isakson and others, it helped create the space where we could go forward and make the changes that weve made. In terms of paying. We think thats an incredibly important first step but we know it is a first step. Now the question is how do you implement this so its useful to the people and meets the goals and objectives that i know we share. Were going to continue to work in that space. We welcome the comments and welcome continuing to work with you on the issue. We did this because we believe its an important change and a change about quality of care for people across this country and their families. We take seriously the next step that we need to do and we look forward to working with you on that. I think being able to pay makes a very big difference. And not only being able to pay to have that conversation but also to recognize that peoples wishes ought to be respected. I know its an issue we have talked about and you have been a lookeder on this for many years. My sense is that is a place with the American People are candidly ahead of their elected officials. Theres not a Single Member in this body that hasnt had some experience either with a Family Member or friend. And it just breaks your heart sometimes when you see, i recall one virginian had to go twice as a daughter to make sure that her mothers wishes at 102 in terms of being resuscitated when she had chosen not to have those wishes honored. And i again appreciate the secretarys sensitivity in this issue. It is a hard issue to talk about but it is one that i think in america we need to address and it is not about limiting choices. Its about expanding choices. Thank you. Thank you, senator warner. Its striking. I was going to talk to secretary burwell for a few minutes about the future and how appropriate that senator warner, who along with senator isakson, have really been in the vanguard of laying out some new policies to expand choices for end of life care. One of the areas that im very proud of took years is now as a result of the secretarys good work we have finally put in place whats called medicare care choices. So for the first time older people would not have to give up the prospect of Curative Care in order to get the hospice benefit. And i have been hearing about that since the days when i had a full head of hair and rugged good looks and was director of the gray panthers. Mr. Chairman, is that back in the early part of the 20th century . Its impossible to calculate. But the point, the point is, what senator warner has been talking about is creating more choices. This is not about washington, its not about producing another federal cookie cutter program. Empowering patients and their family. It is high time. And senator warner, you and i and senator isaacson have been prosecuting this case and im very appreciative of it. Medicare starts us down the path. But senator warren is absolutely right about several of the next steps and im with you. Secretary burwell, your last hearing. And one of the assessments i would make as we wrap up is that because of the good work that youve been doing, you and your colleagues, america is not going to turn back the clock. America is not going to turn back the clock on the Affordable Care act. You talked about the increased enrollments. Im particularly pleased that youre making this point that the heart of the aca, right at the center of it is making sure that it was against preexisting conditions. If you add a preexisting condition, youre wealthy. You all have now made it clear. One of the first areas i would like to mention is Newt Gingrich and dom daschle wrote an oped piece a few days ago. I dont think you see that happen every single day. The republican speaker, past democratic leader writing an oped piece. They said lets have a bigger role for the states. Lets have a bigger role for the states in the Affordable Care act. They had a variety of ideas. Pulling the ghofr nors together. To look at approaches. Making sure the Funding Sources were more integrated. I guess in the lingo of the agency, those are funding streams. But to me, its taken the various funds and trying to find a way to coordinate them. I want to be clear, this is not talking about anybody trying to duck the coverage requirements of the Consumer Protections and the law. The political spectrum can figure out how to test various approaches at the state level. What are the possibilities. The authorities lie the authority with states to do things we want. We spoke with ms. Cantwell about the basic program and the steps that new york took in terms of how they wanted to approach. The access has been gained but not lost and were also watching the finances in terms of in terms of the federal government. There are different alternative approaches to that. Hes working towards the kind of care that we were just talking about at the end of life, educated, empowered, engaged consumer at the center of their care throughout their entire life. Those are the kinds of things we want to work with. The constraints in ters of where the boundaries are, affordability and access. We look forward in regard to 1332. We want to hear innovation and ideas. Second question i would like to touch on is a committee project. Im very appreciative of chairman hatchs interest in this. He knows i have been interested in this for years. Medicare of 1965, people stayed in hospitals a lot longer. If you hurt your ankle and it wasnt really serious injury, it was part b of medicare. If it was really serious, you were in the hospital for a few days. That is not medicare today. Medicare today is cancer, diabetes, heart disease, strokes. Thats most of the spending. And we now have a task force, which fortunately is led by senator isaacson and senator warner with their interests in these issues and its really stunning what you come up with when you look at this. After seniors, particularly in areas where you dont have medicare advantage, after seniors get that free physical, thank you Affordable Care act, so often their care, or kind of the nonsystem that sbis exists just sort of leads them off the rails and they end up in a hospital emergency room. And when theyre about to be discharged, nobody even knows who to send a record to. What do you think is ahead there . I think as youre reflecting, chronic care, both in terms of quality and in terms of cost. We know about 80 of total care comes in diabetes, heart disease, other things. From a quality of life perspective and cost perspective, taking these issues on is important purpose atnt center of that, its more integrated care. We need to change the way we deliver care in the country. And were on a pathway to do that. And whether thats in prevention, as you highlighted, the importance of preventive Care Services that are required without additional cost through the Affordable Care act, where a person is responsible for making sure the pieces are together in a way that serves you. I think that connects to a point we discussed earlier, which is making sure we are paying for value, not volume. Were paying for the outcome of your health. And whether thats that prevention up front, or when you do have something, making sure we get the outcome you want. The Payment System is a very important part of the tools we have that drives care that is more integrated with them engaged as part of that care in terms of the choices we were discussing at the end of life, but well before then in terms of your everyday care. I can tell you that, of course, the popular wisdom is that this is an Election Year and nothing is going to get done. Hes set what i think are reasonable kind of principles we ought to work around. Buckle up for that one. Were going to push very hard to advance that this year. I want to make sure we formally acknowledge the improvements to the tanif program. The improvements you all made. Tanif, of course, outside of washington is public assistance. I think we made some real progress. We have more to do to help struggling parents find work. And i think you all have some promising proposals. I just heard about the staff, senator casey made a very good point with respect the spike in foster care. Certainly a factor in that is the Opioid Epidemic. Chairman hatch and i have spent the better part of the last year working on a proposal. Family first would allow states to use their foster care dollars on programs that know how to be effective. Drug treatment and Mental Health that help prevent the need for foster care by keeping families together. And i think the premise is these types of programs, not only save money for the overall system but they also approve the health and well being of vulnerable. You all have a similar proposal as i understand it. Theres certainly a roll here for medicaid. And that is important. Foster care dollars can also be used more efficiently in this space. And i would be interested in whether you share that view. Were trying to make sure that children stay in their home setting as much as possible as long as that is safe ten appropriate, but there are ways to encourage that. And many proposals are around that. We welcome the opportunity, wlar the key ways to support patients who are able to care for that child appropriately. Whey always sensed about your agency and handling the responsibilities there is doing your job well is a contact sport. I admit i went to school in a basketball scholarship. Thats kind of my world. But i see you constantly reaching out to legislators, to state officials. These are advocates, people who often dont have the power and clout. And i just want you to know i really appreciate that. I wish there was more time to get in to some additional issues. I know we talked briefly about the 18month investigation into the hepatitis c drugs. Theres a piece out. The states are aingsing hepatitis c drive. They cant afford to take care of people. By the way, when you ration hepatitis c drug, people get sicker and sicker and people have these very serious illnesses encost even more money. Handling just a small percentage of those who have hepatitis c. And likely to end up with bigger expenses as a result of care being rationed. And i think its a question, were going to start examining here is, we are on the cusp in the United States of having a policy that says, we are going to have spectacular cures for illnesses. And the hepatitis c drugs are cures. That certainly is a debate that wont be for the feint hearted. I will be glad to have you for close to an additional year. I so appreciate the particularly the way you constantly come back to pulling people together. Policies pick up by osmosis. Youre constantly reaching out to people. Its not about accepting each others bad ideas. Bipartisanship is about taking good ideas. Chairman hatch indicated, we have colleagues who may ask additional questions. With that, the finance committee is adjourned. On cspan3, we feature programs that tell the american story. Here are some of the hielg lights for this president s day weekend. Saturday afternoon at 5 00 eastern, author Margaret Oppenheimer talks about the rise to aaron burr. What brought these two celebrities together. On burrs side of the altar, it was jumels money. A marriage to eliza jumel will give him a big pot of money to spend. Jumel had her own motivations for the marriage. On the one hand, she would soon have to begin settling her first husbands eskate. Burr, with his knowledge of the law, could help her protect her assets. But the Main Attraction is the opportunity to enter social circles that have been previously closed to her. Historian dennis frye on the reaction of both southerners and northerners to john browns 1859 raid at harpers ferry. The subsequent execution and the nations divided sentiments as americans headed towards the 1860 election. Historians explore the history of the Death Penalty in america, including the 1976 greg v georgia u. S. Supreme court court case. Theres personal similarities and differences. Jackie was very conscious of history. Jfk was very interested in abraham lincoln, knowledge about lincoln and so jackie did have very much in mind the lincoln precedent for the funeral