Transcripts For CSPAN2 Key Capitol Hill Hearings 20140509 :

whole house and the american people deserve to know how i came to the decision that brings us here today. on september, 11th, 2012 a terrorist attack in libya left four of our country men dead, including our ambassador. since that time four committees of the house have been investigating these events and those committees have done great work. all of the chairmen and members of their respective committee deserve our graditute. last week a line was crossed in two places. it came to light that the whitehouse did more to obscure what happened and why versus what we were led to believe. second, we know the instruction defied a congressional subpoena. we sought the full truth and the administration tried to make sure they would not find it. which means they tried to prevent the american people from finding the truth as well. these views compel the house to respond as one institution and establish a committee that is robust and will do their house work while the house committees on the priorities. i have asked trey goudy to head the investigation. i will convey to you what i conveyed to him: this doesn't need to be, shouldn't be, and will not be a partisan process. four americans died in a well coordinated assault and we will talk take short cuts to the truth, accountability or justice. and we will not allow any sideshows that distract us from those goals. our system of government depends on transparency and accountability and either we do this well or we face the terrifying prospect of our people having less knowledge and power over their own government. we owe it to future generations to make the right choice. i ask all of the members of this body to reflect on this matter and ask you to support this resolution. i yield back. >> again, the house voted earlier to approve the creation of a special committee to investigate the 2012 benghazi attack. that vote was 232-186. next, president obama's choice to replace kathleen sebelius as health and human service secretary. she takes questions from members of the senate health committee. sylvia burwell who serves as a whitehouse budget director received statements of support from a number of republicans on the committee. senator tom harkin of iowa chairs the two-hour hearing. get started here. oh. >> the committee on health education labor and pension comes to order. >> we have convened this hearing to consider the nomination of sylvia mathews burwell to be the next secretary of the department of health and human services. ms. burwell, thank you for joining us today. ms. burwell is currently serving as director of the office of management and budget, a position to which she was confirmed by a vote of 96-0 in april 2013. ms. burwell has proven herself as an effective and dynamic manager, with experience and skill in leading a wide range of organizations. recently, i had a very productive meeting with ms. burwell and concluded that she is a deeply impressive nominee and is eminently qualified to serve as the next secretary of health and human services. the united states faces serious public health challenges, many of which require urgent answers. very often, the entire world looks to hhs for leadership. just last friday, this country confronted the first ever incident of mers (middle east respiratory syndrome) within our borders. hhs responded quickly to educate the public, investigate the situation, and develop a path forward. that was done through the cdc. the gold standard for public health in the world. china has named its public health system china cdc. we will count on our next secretary for exactly that kind of informed, decisive action in the face of future challenges and crises, and to provide a steady hand overseeing an incredible range of activities across the department. for example, she will be responsible for research efforts at the national institutes of health, among other agencies. this federally-sponsored research has made the united states the world leader in biomedical innovation, and has resulted in countless discoveries and breakthroughs, from the extraordinary application of genomics to cutting-edge pharmaceuticals to an unprecedented understanding of the human brain. ms. burwell also will be in charge of another long-time priority of mine, disease prevention. she will lead our nation's efforts to transform our health care system from a "sick care system" into one that focuses on wellness and prevention, not just at the doctor's office but also in our schools, workplaces, and communities. ms. burwell will oversee the food and drug administration - a critically important agency that protects and promotes public health by helping to keep our nation's food and medical product supplies safe, among other things. in fact, fda now oversees items accounting for 25 cents out of every dollar spent by americans. the department also ensures that we can meet the health care and education needs of our most vulnerable citizens through programs like the community health centers, ryan white hiv programs, and the head start program. the secretary is also charged with oversight of programs that support millions of americans with disabilities. medicaid makes it possible for many with chronic disabilities to remain in their homes, to go to work or school, and to be active members of society. in tandem, the administration for community living implements policies that help people with disabilities to stay in their homes, neighborhoods and places of work, with the result that people are healthier, happier, and have better quality of life. and of course ms. burwell will have the critical role of overseeing implementation of the affordable care act. we can be proud that, thanks to the affordable care act, we have seen 4.8 million new medicaid enrollees, and more than 8 million more americans have signed up for health insurance in the marketplaces. but there is more work to be done to continue successfully implementing the law and reforming our health care system. the list goes on and on, but i've made my point that, as secretary, ms. burwell will shoulder incredibly important responsibilities that matter deeply to the health and wellness of the american people. we look forward to hearing from ms. burwell, today, about her vision and priorities for the department of health and human services. and we welcome this opportunity to question her about many of the issues that this committee will continue to oversee going forward. i also wanteded to mention that senator franken, a member of this community, wanted to be here but is attending the funeral of former congressman jim overstar today. i will ask general alexander for his statement. >> thank you. good to have you here ms. burwell. i will use my time for questions. let me tell you a story. my father drove train engines and that he would turn and head trains in the right direction. we want to repair the damages that obamacare has done and prevent future damage as responsively and rapidly as possible. we would like proposals that increase freedom, choices and lower cost. we trust americans to make these decisions ourselves. we believe that is the american way. four years ago, congress and the president made what we believe is a historic mistake. they passed a 2700 page bill. we don't believe in trying to rewrite the whole health care system. let's go step by step with more freedom, choices and lower cost. let's go back to the health care summit at the blare center. six hours with the president all on national tv. i was asked to speak first for the republicans and i said what was withdrawn with the president's plan was it would increase health care cost and it has. usa today reported health care spending rose at the highest in 35 years. and the hill reporters say premiums will double or triple in the country next year ever n with subsidies. many americans are finding the copayments are so high we cannot afford insurance. we said people would lose doctor choices and we said it would cancel policies and it has. 2.6 had their plans outlawed by obamacare and millions more who get their care through small businesses find the sim thing happening. we said it would lose jobs and cause jobs. the president of costa rica is holding job fairs for medical companies driven out of state. we said medical beneficiaries would be hurt and they have. the average cut is $317 between this year and next. the only bipartisan would be the opposition. gallop tasaid it is 54%. and i said everyone who vote forked that should be going home and be governor. and there are 16 governors who have not implemented to cost. we said let's go step by step and the democratic friends said that is not a plan. and i said you are write washington isn't wise enough to rewrite 20% of the economy. if you are waiting for senator mcconnell to wheel in the wheel barrow you will be waiting till the moon is blue. we suggested if you like your plan you can keep it and if you find another policy in another state that fits your needs you can buy it. if you are a small employer you can combine your purchase power to offer lower-cost insurance. we would allow any american to by catastrophic events with a health savings account. if you were an employee we would benefit you for employ health regulations. you by yourself supervise the spending that is as much as the entire congress appropriate every year. we hope in the next congress we have a republican majority in the senate and we will be able to do for our health care drivery system what my grandfather did for the trains heading west. we would like to head them in a different direction. republicans would like to repair the damage that obamacare has done, we would like to prevent future damage as responsiblely and rapidly as we can. we trust americans to make those decisions for ourselves. we believe that is the american way. since obama will still be in office for the next two years, if you are confirmed we will need your help to do that. >> thank you very much, senator alexander. before i introduce ms. burwell i will call on two senators. i would first recognize our friend and colleague senator mccain. welcome. >> thank you very much. i hope senator mansion appreciates. i thank you chairman for allowing me to be here. many of us in this room strongly disagree about the merits of obamacare and what the path forward should be to reform our healthcare system. i fought against it, both on the floor of the senate for 25 days, and in this very committee, in fact. not only did i oppose passage of obamacare, but i offered the first republican-sponsored amendment to stop the nearly $500 billion in cuts to medicare that were contained in the bill. i continue to believe that obamacare must be repealed and replaced and have introduced legislation to do just that. notwithstanding that disagreement, i am pleased to introduce sylvia burwell, who has been nominated to serve as secretary of the department of health and human services. sylvia's previous experience as deputy director of the office of management and budget during the clinton administration, as well as her work with the bill and melinda gates foundation, the walmart foundation, and her current work as director of omb, make her well qualified to be secretary of hhs. i would like to add, mr. chairman, that i visited bentonville, arkansas, to see firsthand walmart's operation. i would recommend to all of my colleagues a trip to arkansas there to see an incredible success story from a small town store to the world's largest retailer. ms. burwell, to say i was impressed would be an understatement. walmart is truly an american success story, and one of this country's leading corporate sylvia's stewardship of the walmart foundation, which last year made $1.3 billion in charitable donations, greatly contributed to the philanthropic mission of the company. regardless of my objections to the affordable care act, the department of health and human services needs competent leadership in the position of secretary. i believe ms. burwell has the qualifications to run hhs and have been assured that she will work with members of congress and be more responsive to its members than her predecessor. when sylvia was nominated to be director of the omb, i said that position 'is perhaps the toughest job in washington.' the position for which she is currently nominated is perhaps the most thankless. that is why i advised her against taking the leadership position at hhs. after all, who would recommend their friend take over as captain of the titanic after it hit the iceberg? obviously, she ignored my advice and accepted the nomination anyway, continuing her pattern of public service. as the members of this committee well know, the scope of hhs goes far beyond one law. the food and drug administration, the national institute of health. they add up to a trillion budget and 80,000 employees. she will have her work cut out for her. i highly recommend ms. burwell and hope the committee gives her their full consideration. >> thank you for being here, senator mccain. i know you have a busy schedule so if you need to leave. and now we will turn to senator mansion. welcome. >> thank you chairman, and senator alexander, let me just say senator rockafeller wanted to be here. he was unable to this morning. i am so thankful and honor to be sitting here in his behalf and my own behalf and all of the people in west virginia. i want to put a personal touch because sylvia comes from where we do. she comes from a railroad area and knows about turning the engine. she knows how to do it and watches it. we are a product of our environment and if we go back to where we came from, how we were raised, the families raised with, and the communities who nurtured us. in west virginia, this is a beautiful place. the blue stone dam is in her backyard and people fish and enjoy the recreation. her father, william matthews, is an eye doctor and well-respected. he is a first generation greek immigrant. came with a hard working ethics we come from when people are wanting the american dream and her grand parents were seeking that. her mother, the honorable cleo matthews is a dear friend of mine. she was the mayor of the area. tough. senator mikulski, you and cleo would get along absolutey to a t. when i was governor, i never had anyone i enjoyed with more than the conversations from her mother who let me know what i was doing wrong and how i could fix the state. i took most of them to heart. her mother was a math teacher. everything you see in this young lady is because of her environment and how she was raised. she is grounded and calls every week back to her friend two of her closest friends she grew up with from first grade on. she is a rode scholar. i don't think any of us would question her ability. and also her performance as a public servant. think what she could do in the private sector. if fortune was her driving goal, think where she could be. she has never done. i think ever time we had a chance we overwhelmingly nominated her. we are not here to change anyone's mind on what they believe about the affordable care act or obamacare if you will. we are hear to get the more talented and responsible person that can lead us. and senator you said we can get that train moving in the right direction and sit down and listen to each of us. we all have concerns and want to see it better. we want all-americans to have access and make sure it is working and affordable. there is not a person that understands numbers more or has more experience or compassion for american because she has proven it in terms of what she has been given up in the form of monetary needs. i am honored to be here. i am sorry senator rockafeller -- he is, too. but on behalf of every west virginian, we are proud. she has made every american proud and i think she will do the same in this position. as you consider whether you like health care or don't, i would like your vote to be based on who you think is the most competent person that can make sure we can count on the services. her mother is watching right now. i hope i said all of the right words and i hope dr. matthews you are proud of dianne. >> senator mansion, thank you very much for that strong endorsement. i know you have a busy schedule and you are excused if you so desire. thank you, senator mansion. well, a lot has been said about your past, but it bears repeating. director of the office of management and budget, confirmed by the senate on april 24th, 2013. she previously was president of the walmart foundation and before that she was president of the global development program at the bill and melinda gates operation. she was first cheap operator as well. deputy chief of staff during the clinton administration and chief of staff to the secretary of treasury and staff director of the staff economic council. for her federal government service, she workeded for mckinsey and company. she served on the board of council of foreign relation and met life. she received an ab from har vard and aba from oxford where she was a rode scholar. thank you for your long career of public service. i welcome you. and your statement will be made a part of the record. the floor is yours. i know you have friends and family and if you would like to introduce them. >> thank you for inviting here today. i am honored president obama has appointed me as secretary of health and human services. with me is my sister, brother-in-law and two friends and my husband steven. [ applause ] brother-in-law and two friends as well as my husband, steven. i want to thank senator mccain. [ applau >>se i want to thank senator mccain and senator mansion for their kind word and i am honored to be introduced by such extraordinary public servants. i am grateful for my husband and children for the support and i want to recognize my parents for instilling in me the israel of public service. as a second generation greek immigrant, i was raised to be thankful for the opportunities this nation provide and appreciate the responsibilities that come with them. throughout my childhood, my father was a doctor and a small business man and my mom was a teach sk teacher and set a great example in me. it is that example that is part of why i sit here. whether in the public or private sector i focus by work on building strong relationships, building strong teams, and delivering results. in my roll as omb director i worked with members of this committee and other toes return the budget process to regular order and drive toward progress on the issues we all care deeply about. if confirmed, i look forward to working alongside the remarkable men and women of the department of health and human services to build on their work and ensure children, family and seniors have the building blocks of healthy and productive lives. these issues are fundamental to all of us. whether it the chronic condition of the child we love or the safety of the food we eat every day. i respect and appreciate the challenges before us. as we meet today, scientist are working to find cure for the most serious diseases and experts at the cdc are working to prevent them from spreading. the food and drug administration is protecting the food we eat and the drugs the doctors prescribe us. millions of our children benefit from head start. thanks to the instruction for community living, millions of millions are living with dignity. the department's work to ensure affordable health care through the affordable care act is making a difference in the lives of communities and strengthening the economy. all of this work, forms the foundation of a stronger middleal class, better economy, and heathier communities. mr. chairman and members of the committee, thank you again for the invitation to speak today and also thank you because i have valued the converitations we have had over the weeks. i am hopeful we will work together to deliver impact to the american people. with that, i am happy to answer your questions. >> we will start a round now of five minute questions. as i mentioneded in the opening statement, i have been focused on turning the sick care system into a health care system. one that doesn't focus on repairing the damage but prevents it in the first place; keeping people healthy. that is why i was proud to offer the prevention part of the affordable care act. senator mikulski and i worked on that closely. a dedicated funding stream designed to promote prevention and make communities across america heathier. investments have supported a range of initiatives. obese campaigns and tips from former smoker campaigns and many more. these investments improve and save lives and are good for the nation's fiscal health. will you ensure that community based efforts are at the forefront and maximizing the critical invests from the prevention and health fund for the health of the american people? >> senator, first, thank you for your leadership in the prevention space. in my current role, i have an opportunity to work with you on the issues as well. prevenezuela is an incrediblely important as we think about the overall system. it is something that doesn't receive much emphasis but it is contributing to better health and cost in the system. if i am confirmed, i think we want to work in the federal system to promote prevention and build on some of the efforts that are occurring in the private sector where companies are doing this type of work and measuring the result and i think we can use things there that will help increase what we are doing in the public sector. >> thank you. i appreciate your commitment to that. prevention is in schools, communities, with work places and every aspect of our life. as the secretary you have the ability to reach into all of those areas. secondly, and in keeping with that theme of prevention, last week, former fda commission, james heny wrote a report for the government and food industry to address the amount of salt in our food supply. it has been 44 years since the conference on food nutrition and health issued recommendations highlighting sodium in hypertension. it has been four years since a report was released saying the fda use their authority to require organizations to reduce the sodium. despite over a 100,000 lives could be saved annually if the sodium levels were cut in half, inaction continues. your nomination is an opportunity to reset on this critical health issue and i hope she is right given the health potential, how will you work and commit to work on turn the side on the issue of sodium reduction? >> senator, the issue of sodium reduction in the broader issues of things we consume and how they affect our health, i think there are two things in thinking about them as a priority. the first is making sure people have the right information. having bent part of a large grocer in my last role, when one works on nutrition and healthy eating, which was something the great for you label at walmart was introduced and on products that tell people. one is about the information and people knowing what works and doesn't in an easy way. when you are in the grocery store the average time is limited. people are working, they are going home and on their way home and doing it. so providing the right information is part. and athen providingb access and tools. so i think it is an important priority. if the issues of sodium, if c confirmed what has been going on and hasn't. but they are broader principles that guide the way about that. >> i appreciate that. information is important. but it is also important for the fda to issue regulations as they have in the past on food and the contents of food and transfat and everything else. but we haven't done anything on sodium so i hope through your agencies and the food and drug administration will take a look at that. senator alexander? >> thank you, ms. burwell. i talked about proposals that republicans have to move our health care delivery system in a different direction. one that emphasis choice, freedom and hopefully lower cost for americans as they buy the health insurance plans. let's talk about a few examples. for example, obamacare outlawed about 5 million individual health care plans. the administration reacted by saying if you like your plan you can keep it for a year. giving the states that option and now they have said about two more years. that cut in half the number of plans outlawed. would you be will to expand that longer to allow people to keep the plans they had? >> senator, when i think about the implementitation of the affordable care act. one is accessibility, affordability -- >> i only have five minutes. what about an answer to the question. would you extend the three years that you now allow states to have to help people keep the plans they want to keep. >> i was mentioning the three goals is because i think any action taken one should be doing in the context of implementing those goals. the changes are part of a transition period as people are transitioning to a point where we can implement a system where pre-existing conditions are covered, women and gender issues can't be discriminated. >> is that a yes or no? >> at this point, i think we want to see what is happening to the issues of implementation. >> okay. buying from state lines. a young girl from tennessee had a plan that cost her $53 a month. it was outlawed by obamacare and went on the exchange and she is playing $450. it has limited benefits but it fits her budget. would you favor letting her buying the kentucky plan? >> senator, that is something i want to look into. you have to consider if the markets work in each state. can you still keep the system up and working and care being provided. >> i was thinking about more choices for emily so she can buy a plan that cost $50-$70. here is another idea. former secretary shultz suggests that obamacare allows americans under 30 to buy a major medical plan to avoid a financial catast issue so you can sleep at night. why not let any american buy a plan and combine that with an x expanded health savings account. that would give more choices and opportunities to buy plans that fit budget and health care needs. >> the issue of quality health care plans is an important part of the affordable care act. that is a part of creating a system that will work and one thing that is a challenge is making surelife othe pieces fit together so you do thethis in your opening comment with regard to cost and access. >> one of the major reasons emily is paying more for her policy is because washington is deciding what she can afford and needs. i would like to give her more choices. what about, i am a former governor, what about giving states more flexibility with medicaid? when i was governor, it was 8% of the state budget today it is 30%. 15 governors won't expand medicaid even. why not trust states to give individuals more choices like the cover-10 plan emily had? why not expand that flexibility as a way of giving more choice? >> when the question of how one works with states and if i were confirmed the issue of how we work with states is there is a number ouch examples where flexibility has been granted rather that is arkansas or somewhere else. flexibility and principles are important. and where you instant in that space is important and how i would think about that. >> we had a conversation about getting answers from your department to reasonable questions about the implementation act. if is good for mcdonald's to show how many hamburgers they sold, it would be good for us to know. i would ask you to focus on answer the questions that members of congress ask you as we go forward. thank you, mr. chairman. >> thank you, senator. now is senator warren next. >> thank you chairman and thank you ms. burwell for being here. there seems to be broad bipartisan agreement we need to reduce the federal health care spending. the republicans say we need entitlement reform but they should not forget that was passed as part of the affordable care act and it is working to reduce medicare spending. in 2009, before obamacare, the medicare trust fund was projected to go bankrupt in 2016 now it is solid until 2026. and now every budget since the aca past continued to show bigger savings than the report before. in fact, last month, cbo projected that medicare spending from a 2014-2020 will be $500 billion less than they originally projected after the bill was passed. that is a cut in federal spending which is six times bigger than all of last year's idotic sequester cuts which slashed vital funds to research, head starts, and meals on wheels and the republicans want to appeal it. ms. burwell, we know reductions in medicare cost are the result of many different factors, but as an expert in federal budgeting, do you think it is important to say an important factor in the efficiency of the affordable care act has resulted in the reduction of medical care? >> yes, i do. the period from 2014-2020 which is the window cbo scored. health care cost for decreased by $900 billion. i think that is an important contribution to the issues of hopefully those are changes that two do things: reduce cost and maintain quality and hopefully improve quality in some cases. the implementation of the changes of the affordable care act are reducing the deficit and providing great savings. the only thing i would also add is the current budget proposal that is before the congress from the president right now -- the y say that will increase the trust by five years. that builds on the number you said. 2017-2026. >> thank you. i think that is important. i want to ask you another question about building on the successes of the affordable care act and that is the aca established the center for medicare and medicaid invasion to test new models for payment such as bundled payment. western massachusetts is part of bundled payment project and their private health care system has used this model for years. by bundling payment for hip and knee replacements they reduced the cost of treatment by $2,000 and reduced hospital read mission and complication. cbo projects playing bundled payments like bay states nationally could save medicare about $46.6 billion over the years. so it gave the authority expand successful demonstrations to a wider range of health care providers so we can cut cost without compromising care or improve care at the same cost. i want to ask about your strategic plan using our authority to expand the efforts where the data demonstrates we can get better outcomes at lower cost. >> with regard to my philosophy and i think it is important to have things being database. having the opportunity to do grand making where sun sees and creates models. you want to find the models that are the most successful and which ones are likely to scale. that is what we need. so you have to consider both. you want to get the largest impact you can. that is a combination of what the measures are of success and your ability to make it go broadly across the nation. >> thank you. the affordable care act gave us tools to help reduce the cost of health care and improve outcomes and i am glad to hear you plan to use them. thank you, mr. share chairman. >> you know there is no challenge i have before me than senator than getting the savannah harbor expansion project done in my state. i have worked for 16 years to go through the steps at noah, epa, core of engineers, fish and wildlife, to get every approval including getting the vice president to join us on the docks and make the quote we were going to get it done come high or hell water. you delivered the news to us that we would not be able to move forward on the plan that we thought we included the right words to move the program forward. we got the bad news at the last minute. we have had discussions about how important this is to my state and country. the support of savannah isn't a georgia issue. it is an issue for the trade for the united states of america. it is net positive export port. it has met every requirement and i don't know want you leaving omb until i know we can move forward on the savannah project and i would like you to respond to that question. >> with regard to where we are with legislation, the port is an important effort and i agree isn't just about georgia but economic issues and growth of the nation and core infrastructu infrastructure. we think it is very important and the vice president and president have spoken on the issue and want to move forward quickly on the port. optimistic the bill will pass and we can move forward with the project. we look forward to working with you to make sure under -- once that happens, we can move the project forward. my role and responsibility as the director of the office management and budget has to do with protecting and i think the army core has a back log of $60 billion and we need the reauthorization and for congress to speak. when congress speaks on this project we believe is important we look forward to moving forward. >> in a letter sent to you by the members of the georgia delegation about questions how the project was stopped all of a sudden i want to quote your answers: it is essential we don't create special allegations of taxpayer resources. what exception were you referring to in terms of the port of savannah? >> it would be waving the 902 -- there was a rule put in place saying if an army core project exceeds cost by 20% the congress needs to speak again and that was matter that is a rule that is about making sure we have fiscal responsibility with the army core. this is a terrific reject and a high return on investment. there are many other army core projects that don't meet the test. so having congress partners with us in doing fiscal control is important. >> we are within two weeks of passing the 902 and what special exception would like if it were to go forward. any impediment you see? >> i look forward to continuing the conversation and i think it can go forward. >> i look forward to doing everything we can to solidify that. >> senator mikulski. >> thank you, mr. chairman and ms. burwell welcome to the conformation hearing. we welcome your husbands, friends, and i am sure you would want your mother and father here. they worked so hard for you to get the education you need that helps bring you here today. ms. burwell, i know you personally and i admire you professionally. i knew of you when you worked with the clinton instruction and the major foundations you worked for. and got to know you during the year at omb as we went through a very rough time. you were new at omb and i was new as the chair of this committee. i must say i admired your integity. what you said you meant and did. we appreciate your responsiveness of when we asked we got answers. and third we like the fact you were compitant and had the ear of the president of the united states so again when we needed those answers. so we know that. but let me tell you where i am as the senator from maryland. we need a ceo. and secretary kathleen sebelius has done a great job during a very difficult transition time at hhs. but what we see in maryland is some of your greatest federal assets at hhs are in my state from cms that does medicare and medicaid, the national institute of health, and i have the highest rates of noble prize winner and the highest amount of poverty. i need a chief executive officer. we need someone who brings executive skills to this job. 80,000 people work for hhs. you have the largest budget other than defense, the largest dome domestic budget. money, management and moral are the issues we see. money is our job. sometimes we do it well. sometimes we don't. but we need someone in management who can tackle the tough problems whether it is cleaning up the techno site of the healthcare.gov website. or going across the silos of the agencies. and we have a moral problem. my federal employees have been battered by the budget and you i i know we have a moral problem. whether it is ndh or another organization. my question is particularly in the gates and walmart jobs, can you tell me the executive experience you have that you think can help put your arms around the bureau that is silos and fragmented and help work with congress on funding that enables the agencies to do the mission. >> first, i will think about how i think about management and leadership. first, i think you need to start with goals, defining roles and responsibilities. and part of that is analytical that includes listening as well as analyticals and data. that is the first step. another step is building strong teams and empower them. and giving them the tools to su succeed. the third part is a part of thinking through when you need to drive with analytics and when you need to understand there is emotion. it is sometimes how people perceive an organization or issue. the perception is their reality. if people believe that how do y you drive for charge. i worked at the gates foundation and worked from doing innovative funding to vaccine to delivery of medical care in the under developed world. at the walmart foundation, i was able to work at that time the world's largest grocer and retailer. the work we did in the space of hunger as well was an example. >> i appreciate that. my time is up. i just know that many people will focus on health care and it is my passion. but the human service part of your portfolio is absolutely crucial and today isn't the day, but we need to work together on this issue of the unaccompanied children coming across the border so they have a home, a way to get to a home and we have a way of providing the funding. >> senator, looking forward to woking on that important issue for those children. >> senator roberts. >> thank you, mr. chairman. thank you ms. burwell for coming. the senate majority leader harry reid last august was asked if the goal was to move the affordable care act to a single pay payer system and he said yes, yes, yes and similar comments were made by nancy pelosi and the president of the united states. did you agree that is a difference? it is your goal to see the affordable care act expanded beyond single payer? >> the law is a market base system and that is what it sign-up and running and putting people in situations that are private insurance systems. if confirmed i look forward to making that system work as best as possible in cost and access. >> one of my biggest concerns with the affordable care act is the independent payment advisory board. ipab. it was created by the law of. the board is supposed to be made up of 15 people that will say what needs to be reformed. they have no accountability and their decisions are impossible to overturn. despite having points any members, the president's budget proposed to expand the role considering the law requires reports in 2014, do you know when the president will make the appoi appointments to this unelected board and in the absence of the board, the hhs secretary will have an authority to acted as a board member of one. would you use your authority if elected? >> i think it is important that beneficiaries cannot be impacted so any changes is not toward beneficiabe beneficia beneficiaries and i am hopefully that ipab never needs to be used. it can only be triggered and in the current window it is our estimate it would never be ac activated. this is about controlling health care cost and fiscal issues for the future and i am hopefully that we can make sure it is never triggered because we put in place the mechanisms to do that control. >> that is my hope and i appreciate that. i am not quite as optimistic as you. but we will go over that. obamacare has been delayed 31 times and 22 were done by the administration. you have approved 15-22 delays and this included the second delay of the employer mandate. my question is about fairness. i get that from individual kansans. get that from individual ... kansans. the administration gave business an extra year and many cases two extra years to comply with the employer mandate. do you think it's fair to give business a delay but not individual americans? and what further changes, if any, to existing law and regulations do you anticipate having to make before december 31 of this year? >> senator, i think the changes that you referred to are a number of different things that have been taken by different departments, treasury or hhs, and a number of the examples that i think you're referring to, with regard to what is happening as this process goes forward, from the administration's perspective, what we are trying to do is common sense implementation within the law. that's the objective and what is worked on. with regard to the specific issue you raised which is the issue of the employer mandate, and that specific question, as we think through transitioning, one of the things that we've tried to do is listen and hear. and one of the things that private sector has said is, it was difficult to get the reporting to the right place where it could then be applied and done. the changes that were made were to try and do that transition. with regard to individuals, there are a number of other things that are happening to help with those transitions. and whether that's the hardshippish shoo us or other issues. so this is about transition to a changed system. co b'd like to see those as you see transitions come back so we can at least have some consequential emboldenment. i am out of my allotted time mr. chairman but i will be submitting further questions and i hope you will respond in a timely manner particularly with regard to transparency for insurance plans offering public exchanges and again thank you for coming. >> thank you. >> thank you senator roberts. senator bennett. >> thank you mr. chairman. it's nice to see ms. burwell and thanks for being here today. i am very happy that you have the experience that you do and i wanted to ask you a couple of questions along those lines. when i number of years ago became superintendent of the public schools i carried the budget of the school district around with me for six weeks. i worked with budges before in the private and public sector. finally six weeks then i realized that i wasn't reading a budget that i was understand as a management tool but an accounting tool. it was a tool that could demonstrate compliance with the state regulator and the federal regulator. it was not about private outcomes for kids which is what we were supposed to be doing. my sense having been here is that we face the same thing when it comes to health care. the morass of regulations and the reimbursement policies and the uncertainty that's caused by the fighting over budgets that leave people with insecurity about what the future is going to look like i think creates an environment where people are less capable of getting into a pattern of continuous improvement. people that are out there delivering services to people rather than just yelling at each other in washington d.c.. and they are weary about this. i think they feel they remind me of my teachers and principals in the district that felt the same way. i wonder if you could tell us a little bit about your theory of the case for attacking that management side of the work that you now will have to do at hhs and cms and how your work at omb is going to reform that. one last point. in this existential debate we are having on the role of the federal government and the founding fathers and all that compact and what we have lost is with the where can people really like which is an efficient and effective federal government and an efficient and effective partner of state and local governments create any wages to perspective and i will yield you the rest of my time. >> also in the context of the end -- m part of the omb in terms of the role in the past year. with regard to the issues of management when you look at our budget you will see we articulate what is a second term management at janda the three elements of that reform elements of the agenda are efficiency, making sure we use a taxpayer dollars the best and last week there was announcement read we had four departments and will be doing shared services which is a private-sector way to get some of that deficiency in effectiveness which gets to your point about customer service. it's about serving the customer. the customer for the federal government are numbered for customers. individual states and local governments and the private sector when they interact with people like the fda how do we make sure we are doing back? the doing back? the 30 areas how do we is the management of the federal government to support economic job creation and on may 9 it will be the first anniversary of the use of open data and putting that data out there to create economic development. the last his people and having had a chance to work on all of those issues and then working with the departments to have there olds connect to their money. to your point about is that a document that is about checking the boxes or is it a document that reflects how we spend dollars to deliver impact. those are the ways of my current experience has allowed that. >> on that last point i'm not sure how you want to approach it but one thought is that without people that are dedicated every day to coming in and thinking about how do we get rid of the box-checking and replace it with stuff that really matters. in your tenure i hope you will do that. i also want to mention senator burr i think he's now gone but he and i have had good luck with therapies that the fda in you and i talked about at the other day. i would like the opportunity to work with you to see where we can expand the notional sense without which was where possible and where feasible we should be accelerating approvals so that the united states holds onto its leadership and bioscience at a time when they're playing with countries in the world that would like to outcompete us. >> welcome that opportunity and one of the things that work like that if you look at those innovations and think about how to does apply more broadly to the broader portfolio? i'm sure there are things we can learn that apply to the broader portfolio. >> things that can reform the broader culture of the agency as well. thank you mr. chairman. >> thank you senator bennett. senator enzi. >> thank you mr. chairman and thank you ms. burwell for mating with me yesterday. i have a few questions. i think i mentioned this topic yesterday. you're in your tenure at omb we saw a massive failure of a web site which was healthcare.gov and that's a web site the administration had three years and $600 billion to build. i know from personal experience first users couldn't logon and then we couldn't see plans available and then we got kicked off and then usernames weren't recognized. from folks i have talked to even users who made it to the end of the process often didn't get confirmation they had enrolled in the plan with a health care mandates. as director of omb you were responsible for the oversight of agency performance and information technology. what role did you play in the development testing and approval of the web site collects. >> senator first i think it's important to recognize that the president of the secretary of the administration is said which the rollout was unacceptable. with regard to the role that omb plays the direct implementation on a day-to-day basis of i.t. projects is done on the department by department basis. omb has a process called text that which is what happens when we have cases healthcare.gov being an extremely, of an approach we used to get in and quickly correct the situation by applying high-quality resources and a search of resources to the problem which is what was done. in addition at omb is part of follow-up and part of the end role that i play we spent time examining very specifically what we think our areas of improvement in i.t. procurement and delivery and i don't want to use all of our time but i'd be happy to articulate what those are. >> i will continue on this anyway. the administration contends that we need a highly visible problem with the web site have been fixed but i don't think the work has been completed on the less visible backend information which of course all of us would like to have. it's necessary for the programs. i think there've been warnings from the same as that failure to get this fixed by marc would mean that quote the entire health care reform program would be jeopardized in quote. is that the reason for justifying the need to award a no-bid contract and why haven't the problem's been fixed? >> senator if i'm confirmed the issues of information technology especially around healthcare.gov would be a top priority for me. with regard to the issuance of contracts that something the department specificaspecifica lly does and omb doesn't play a role in so i'm not able to speak to the specifics of contracting. if confirmed though this is something that of course would be a top priority to make sure that the system both the specifics are talking about and they backend you are talking about or something i will pay attention to. >> i will have some follow-up questions on that later than when you are in that position i guess. in february "the new york times" reported that one in five people who complied with the individual mandate and paid their premiums in january at that time cms spokesman said if administration couldn't say how many people have paid their premiums. on april 30 the house energy and commerce committee reported that only 67% of the enrollees gave their first premium by april 15 read when the administration disputes this figure come to while it disputed it you haven't released your own official numbers yet i don't think. when will the government ensure that has paid the premiums and is covered at the required individual mandate? >> senator i will start with my philosophy about a the information it has to fund will will -- fundamental parks. at my time at omb the regulatory agenda which is sometimes a controversial document is something i've worked hard to get up in the spring and fall on time and will be again this year. with regard to the specifics of the data that hhs has at this time that's not something in my current role. i know there were hearings yesterday. i spoke to this matter where the insurance companies articulated the range because they are the people providing information the information. so if i am confirmed that is something i want to understand at what pace that happens. >> but you haven't released official numbers yet. >> no sir i don't think the insurance companies have given final numbers. >> the insurance companies. i will have follow-up questions on that in writing. thank you mr. chairman. >> thank you senator enzi. senator murphy. >> thank you very much mr. chairman. there was a remarkable hearing in the house on the subject yesterday which house republicans called to testify in part as to what they believe to be incredibly low rates of premium payments. the headline from "the new york times" this morning is called by republicans health insurance deliver unexpected testimony that wasn't part that wellpoint suggests that 90% of their customers have paid premiums and suggest the numbers are in the low to mid-80% range. they also according to this article declined to endorse republicans predictions of sharp increases in insurance premiums. next year this comes on the heels of the health affairs report that suggest suggests that though there certainly have been cancellations of policy since the law was passed not out of step with the rate of cancellations that happened before the law was implemented a new gallup survey shows an absolutely astounding number of people who are uninsured a 25% drop according to gallup over the course of the third quarter into the second quarter this year. i say all this because i think this increasing avalanche of good news and the positive data about the implementation of the affordable care act is going to ultimately lead to a much broader public acceptance and support for the law and yet we still have the tale of two countries. we have states like connecticut that have worked hard to implement the law. we have doubled our initial expectations in terms of the number of people we thought what an we thought would enroll and then you have states that are at best not implementing the law and in some cases trying to undermine the law. i guess my question is how do you attack this issue of states that are not doing the things that for instance connecticut and california are doing and maybe respond in part to some things he said referring to a question by senator alexander. what are the ways in which we can work in a flexible manner with the states as they may be wake up to the reality of how well the implementation is going after your initial botched rollout? what are the ways in which we can work with some of those states that haven't done things like connecticut to try to make this work and in all 50 states rather than just a handful? >> i think there are two things it does come back to the point about the flexibility. as one of the points and what's important is to send a signal that folks are willing to have the conversations. as i said it's important if there are fundamental principles to articulate those in terms of the change you're trying to get but be willing to have the the conversations and hear the ideas. i think that's what happened in the arkansas case and if i'm confirmed that something i hope we as a department can continue to do. with the guard to the other thing about the relationship to get that happen, the other thing with regard to how other states will come is a think as people see what happens in the form of implementation and while i understand the point of senator alexander made about cost of medicaid which is an important one i think where people are also going to see are the changes in terms of health and if it's in the states that have implemented those from a health perspective and i think we are going to start seeing some of the cost benefits in terms of reduction of indigent care. many of us are from rural pleases and he knows the pressure that puts on small rural institutions and hospitals praising both the result as well as the willingness for conversation or the two ways that one can make progress on that front. >> let me ask you a big question about system reform that may being give a short answer to. you have heard a lot from us on our hope that you are able to speed up the pace of the delivery system reform changes that hhs but one of the tensions is between the necessity to build bigger systems that can really track outcomes of coordinating care and the desire to make sure we have competitive marketplace. connecticut is a state for insensate may 10 years from now only have two health care systems. how do you balance ultimately this need to build good integrated systems of coordinating care which may require more doctors working for hospitals for instance while making as possible what is driving the change you're getting both in terms of quality and price. >> thank you. thank you, mr. chairman. >> thank you, mr. murphy. senator murkowski. >> welcome to the committee. as i was walking over here, i accounted a number of individuals that are here on the hill today for als advocacy day. a cause that you and i both share and are committed to and assuming that you're confirmed to this position, look forward to working with you aggressively to make a difference in this horrible disease. we had an opportunity to visit last week. and i appreciate the time that you gave me. in the visit i explained to you the situation in alaska where we are a very high cost state. our insurance costs are equally high. second highest in the nation. our demographics, our geography just cause us to be a little bit different. you mentioned the need for flexibility within rural areas. there's nothing more rural than alaska. we're so challenged with this. i shared with you that we have over 139,000 uninsured individuals. less than 10% of those individuals have enrolled in health care plans. and in looking at the numbers behind it, it really comes down, again, to the cost. the aca has more than d i shared with you a 19-year-old alaskan can pay 911 dollars back in 2013 for one of the premier plans if they buy the most comparable plan now for that same product that plan is more than double the cost at over $2300. i walked through the statistics with 64 years old. mr. chairman i'm going to be submitting for the record a document that my staff has put together with premier blue cross that shows the gao recorded data on premiums in alaska in 2013 as compared to where we are now. so again there can be better understanding as to what we are facing here. we have not worked to reduce the cost of health care which we must do and i appreciate senator murphy has said about delivering reform but in the meantime the financial burden to our families is such that they are looking at this and saying i'm better off just paying the fines it will come with a so i'm asking you to take a look specifically at what we are facing in alaska. i also want to bring up with you a conversation that i had with firefighters from my state from different parts of the state up in the matsu borough. i talked to firefighters up there, up in fairbanks down in the southeastern part of the state and concerns about application of the aca within the emergency services there, a concern about implementing, a concern about the 30 hour workweek. what i heard from the mayor in matsu was that they have moved their emergency personnel to a 29.9 hour per week cap for nonfull-time employees. many of the stations are reducing the ours beyond the required 29 .9 224 hours per week to include personnel who work both as emts and his firefighters. this is an issue for us where our growth in these areas are growing. we rely on our emergency services for folks because they cover enormous areas. what we have seen is a real chilling effect here on employment particularly as it applies to our first responders. i guess i would ask more of a question in the same bed do you agree we have a problem with this? there are few senators and i joined with senators collins and donnelly to help address this. do you see an opportunity for us to address this definition of 30 hour workweek and the implications that is having on not only edms but other areas of the economy here? >> senator i would like to learn more about the specific example you are referring to india schiff broadly overall in terms of job creation that has occurred since the affordable care act 9.1 million private sector jobs. the san francisco fed just released a report that said the part-time issues are consistent with a recovery. having said that we would like to learn more about the specific issue you raise. with regard to specific legislation that changes the numbers. one of the things there are a couple of concerns when cbo score that legislation in terms of costs but also a million people in that setting would loose their employer-based care. we would want to understand the specifics about the situation you are talking about as well as coming to understand better the piece of legislation. >> i'm happy to provide that to you as well as the other information. i will also be submitting for the record mr. chairman a couple of different questions one on head start but something timely in the news right now and that is the issue of the fda proposed rules on e-cigarettes. i have got a real concern here that we are setting forward a proposed rule that does not look to the flavoring is going into these e-cigarettes, the impact on our children. some of the studies that we have seen so i would like your views and your perspectives on that as well. thank you mr. chairman. >> thank you very much senator murkowski especially on the e-cigarettes issue. if you need help or support let me know. you are right on target on that one. thank you. senator baldwin. >> thank you mr. chairman and thank you ms. burwell for your time here today and talking about your vision for the department. i appreciate the opportunity we have had to speak in advance of this hearing. i wanted to talk about a couple of different topics but including the fact that the health care system has been plagued forever with a lack of transparency and gathering data disseminating and sharing data is incredibly key to helping physicians understand where they live with regard to other physicians practices, helping understand where hospitals and how they go about pricing things, with her costar and helping patients make wise decisions about choosing providers particularly if they need an operation or a specific treatment. this is an issue where we have seen some variation from state to state. i'm proud to tell you that in the state of wisconsin i think we have been a real leader with an organization called the wisconsin health information organization. it intends to be an all payers claim database that does some further analysis, disseminate information to increase transparency combat help improve quality, help rein in costs yet we have had some frustrations with regard to access to medicare claims data. i worked with a number of my colleagues on a bipartisan piece of legislation called the quality data quality health care act which would fix this by expanding what's known as the qualified entity program to allow entities to analyze and redistribute medicare data to those who can best use it for quality improvement and cost reduction purposes. and i was really pleased to see that the president's budget supporting many of the reforms that are contained within that they'll. i wonder if you can speak directly to the issue of expanding the current what's known as the qualified into the program and its potential to improve quality to reign in costs but also to talk more extensively about the role you would play in increasing transparency across our health care system? >> with regard to the specifics of the expansion the program i would look forward if confirmed to working on that issue specifically as you mention in the budget. there are some parts of doing that. the broader issue of transparency is something we talked about in a number of forums in terms of data and information and also specific we for how it helps with the delivery system issues. i think getting the information as i said that may be a link that is as important as the issue we are discussing about how you balance single entities that start developing in terms of the dominance in the market. i think information in markets is an important thing. the more we can get it to the individuals as well as the providers. as you mentioned in the beginning of your comments it is actually about the doctors also as well seeing the information so with regard to how i think about the issues i believe this is an important part of both quality and cost and is both important for individuals as well as insurers as well as doctors and the more we can have any information that was provided recently i think was important information that was recently put out by hhs. i think it's also important as we think through this information to make sure that it has context when we put out the information making sure individuals and others can use it in a way that it is given the appropriate context because the data without that can something to something that doesn't provide the insight that one would hope that way. >> thank you. i'm short on time and i'm going to place another question before you read we may have to have your answer in writing but i wanted to get to something very wisconsin specific regarding the affordable care act implementation. we had the good news last week that nearly 140,000 wisconsinites have signed up to the marketplace. it was 60,000 beyond the targets set pride to the enrollment period and this was despite fierce ideological attacks against the affordable care act both in watching 10 and in our state government. but unfortunately across america ended my home state of wisconsin some governors have not taken full advantage of the opportunity to expand coverage specifically medicaid coverage. governor walker is one of those governors and he failed to seize that opportunity and their consequences in my state are fairly severe. 77,000 wisconsinites are losing their medicaid or what we call badger care coverage because of that decision. other states are working with the federal government. iowa and arkansas in particular to find new innovative ways to expand coverage to these very vulnerable populations. so i want to know if you can follow up an hour afterwards what options would be available to wisconsin that are not currently being pursued. will the department continued to help make sure that these 77,000 people who are losing their badger care are successfully enrolled in the marketplace, to and certainly will the state of wisconsin have an opportunity to reconsider their decision at this point not to expand medicare? >> senator if i am confirmed i would want to work with cms on the specific issues, the flexibility to help those 77,000. >> thank you very much. senator burke. >> thank you mr. chairman. ms. burwell welcome and thank you for the opportunity to meet with you to share some thoughts and to hear yours. i want to ask you a couple of questions in specific areas. do you consider medical and public health preparedness and response programs to be a matter of national security and if you are confirmed how will you ensure that these programs beat prioritize to fulfill their mission and the pandemic hazards are paired in this act be fully implemented? >> senator i do consider it a matter of national security and i had the opportunity to discuss a number of these issues and thank you for your leadership in this space because i think it's very important. i'm excited that there was a reauthorization that occurred and that the congress spoke to these matters and now we want to work to implement what was reauthorize and 2013. if i am confirmed on these issues. i think they're very important terms of how we think about what are the tools we have and then how we get access to those tools when we need them. i think you have spent a lot of time as a conversation reflected thinking about the best ways to make sure that we a have what we need if something bad does happen and then how you effectively and efficiently in the most cost-effective way scale up in the time for them to do that and that's something with me i would look forward to working on. >> what opportunities do you see to improve regulatory certainty across the department particularly with the fda? >> i think with regard to the issue of regulation more broadly just in terms of my philosophy and experience in time at omb since the year year that i have been year that i've been at omb we have reduced the regulatory backlog by almost 75% and have moved to a more timely regulatory agenda. in terms of what i've done i think about those issues. i think one of the things as an institution would want to spend time in conversations like ours learn what people believe are the critical path issues to more specific issues that protects the health of the american people but also supports our economy because it's an important part of economic growth. >> thank you. senator mikulski -- senator murkowski mentioned earlier. we don't know yet what causes als. mikulski as well. two oh the key you first have to figure out the causes and i go through this process. what if we got to that point and all of a suddendelay? >> first i want to thank the senators that have mentioned the als issue. with regard to that specific issue, my understanding is that that work is going forward in terms of the cancer study and if i am confirmed that is something that i would want to work to make sure that we do in the most expedited fashion. >> mr. chairman, on a personal note, i know that the committee will not vote on director burwell's confirmation but we will in the finance committee. i would li i will vote for it in the finance committee and it's one of the primary reasons that she doesn't come with a single experience that would make her a good secretary. she comes with a portfolio of experience that would make her a tremendous asset at addressing some of the challenges that agent -- agency specifically and uniquely has. i look forward to her confirmation being quick and our ability to then work together to be every bit as quick and i think the chair. >> thank you senator. >> thank you very much senator burr. senator casey. >> chairman burwell thank you for your appearance here today your testimony as well as your commitment to do the job i think you will do at hhs but i guess in a larger sense we thank you for your substantial and enduring commitment to public service over a number of years now and all of the positions that you have had. i wanted to raise in the limited time that we have at least two major questions with regard to children. it's my opinion that our country still lacks a real strategy. we have made substantial progress in children's health insurance and i'll talk about that in a moment. still no substantial national commitment to early learning to the extent i hopefully with. it could use an awful lot of work as well as strategies to make sure children can have enough to eat and get nutritious food. i still think we lack the basic strategy for our children just like we have a strategy for national defense or other major priorities. i wanted to start with the children's health insurance program, a substantial bipartisan achievement over the last generation. as you know from your work during the clinton administration that was a bipartisan effort. one of the models and not the only model but one of the biggest and successful early models before the clinton administration was in pennsylvania my home state. because of models like that we now can see that 8 million children are covered. more need to be covered in their efforts as you know to do that. these aren't exact but around 200,000 children in pennsylvania are covered by the children's health insurance program. having said all that the best news -- the bad news is the funding will expire for chip at the federal level it will be called schip expires at the end of september at number one and number two there have been efforts made and i have to say some of this has been in both parties, to intentionally or unintentionally undermined chip over the last couple of years. we are going to fight real hard to make sure that we preserve it and we funded at all costs. i wanted to ask you about the impact on children's health if we fail to extend the funding for the children's health insurance program and what you would do to make sure that doesn't happen. >> senator as you reflected this is a program that i have a chance to work on and be a part of the initial passage during the clinton years and something that we thought was very important and what's great is to come back and see the progress that you just articulated in terms of those 8 million children. this is a program that is delivering in a program that is successful. in the administration whether it might omb roll or if confirmed in the hhs role i look forward to working with the congress to make sure that we continue what is a successful program delivering for children in an important way. >> i would appreciate that exists it's a major priority of mine but i think we share that with a lot of people across the country. secondly you and i had a chance to discuss her nomination and talked about the long acronym meaning children's household graduate medical education. another area where there are substantial bipartisan support this committee and members of this committee and senator isakson and i are working with a number of members of the committee and chairman harkin most prominently making sure that program was reauthorized in a remarkably bipartisan effort. it's now been reauthorized for five years. we actually have a copy of the bill signed into law. that doesn't happen too often around here. that's the good news. the bad news is i think they're still some folks in the administration that's a different view about how to move forward with it. maybe you would agree with the reauthorization of it but even would question that. i think i'm most concerned about the funding of this program which is the one program tremendously successful that allows us to train graduating medical folks and graduate medical education who will specifically work in children's hospitals and without this program we would be in big trouble. i would ask you that as you contemplate other strategies on this and other ways to fund it that you consult closely with me and others in the committee as we move forward. i would ask for your commitment on that. >> senator i would welcome that opportunity. >> thanks very much. >> senator casey thank you. senator hagan. >> thank you mr. chairman once again director burwell thank you for being here today and thank you for your service and the other administrations as well as a wimpy and we will look forward to working with u.s. secretary of hhs. i wanted to ask about medicaid expansion. north last year and north carolina are legislature decided against expanding the state's medicaid program and as a result about 500,000 people who would have qualified for coverage through medicaid are now not able to do so. these are some of the most vulnerable citizens in our society who will continue to seek care in emergency rooms and then will leave chronic conditions unmanaged which we know is detrimental not only to their health but the economy too. it leads to higher costs for the patience. drives up costs for hospitals and drives up costs for the insured who still will pay higher prices to cover their care. director burwell can you compare the experience of states that have expanded their medicaid programs to those that haven't bar that have commented specifically on the health of newly eligible enrollees and whether there's any increased costs to states for health providers like hospitals? >> senator i think what we are going to do is we will continue to see information as the laws implemented but i think in states like my home state of west virginia we have rdc and a decrease in the number of uninsured and both in terms of a think it will be two things over time both an increased quality of care for people which translates to their individual lives but also translates to the economy in terms of what people are able to do with their productivity over time we will see that. i think we are also seeing the cost issues in terms of the engine care pressure that is being put across states when they have people who are coming with insurance. so i think we are going to see more and more that date over time. i think right now in a number of states we rdc the number of uninsured dropping. >> can you compare what happens if an adult with say a 35-year-old woman from one of the major cities in my state without children and this individual falls under the federal poverty line of $11,000 a year. this individual has heard about the marketplace. she goes to the library and toxin navigators asked to sign up and yet this person has done the right thing. she sought out coverage to protect her against high medical bills help her get health insurance but what options will that woman have if a state like mine does not expand medicaid? >> it will depend in terms of her level. i think you describe the level and the details of each state and it depends on her income and whether she would be eligible for subsidies. if not. >> she falls under that gap. >> she receives a hardship if she applies. hardships exemptions are about affordability and in this case the specifics i would want to check the details of what you describe but that is an issue of affordability because in a state where medicaid had expanded she would have that opportunity. >> so a state that have expanded it she would have had access whereas the 24 states that have an expanded it there is these huge numbers of people. in my state 500,000 that are still without coverage, there is no way for them -- nowhere for them to turn because they certainly can't fund a normal insurance policy on $11,000 a year. >> with regard to what the federal government policies trying to do is to make sure that they have a hardship exemption. it doesn't address the fundamental issue that you are talking about which is do they have health care coverage? >> just to be sure if a state expanded its medicaid program last year what with the cost to a state e. for covering the newly eligible population? what with the state have to pay in 2014? >> senator a think on a state-by-state basis those are numbers that i would want to look into and get back to you on. with regard to the question of coverage in terms of the state paying -- i'm sorry i didn't understand the question. that would be zero. >> so for three years. >> the federal government will pay for those years. >> thank you. now i want to ask a question on the healthcare.gov on the rollout. you know when it failed to launch i led a group of 15 senators calling on the inspector general in gao to conduct an independeindepende nt investigation into the causes of the technical design and implementation failures and i was really pleased when the ig in the gal agreed to conduct these investigations i look forward to the reports when they come out later this summer or the fall. when you are confirmed what lessons will you take from last year site failure issue of minister the next open enrollment period and how can you improve the management of the healthcare.gov? >> with regard to the lessons from what happened in healthcare.gov a couple of things in my role at omb that we have examined and looked that there are a number of things thinking about i.t. procurement as well as delivery. one is you do not connect the business owner and the i.t.. that connection generally does not occur. it's a problem of experience in the private sector. that an integrated approach of the business center in the i.t. implementer working together a the second thing i think is a problem and the problems i'm articulating her once when you think about as the federal government specifically and help there ... it traditionally we have done waterfall approach of building approach. when one is doing information technology more iterative approach where one tests in small pieces and moves and learns is a better approach to doing procurement not set up to do that in terms of how we set standards and expectations. the third thing that is important of i.t. procurement and delivery's ownership and accountability in terms of a single individual being the person that does that integrating of the individual in the i.t. side and business side. those are all things that even right now gsa three weeks ago implemented some of the things we think will improve the ability of providers to get access and work in that way. >> thank you. thank you mr. chairman. >> thank you center hagan. senator whitehouse. >> thank you chairman. welcome is burwell. in the your summary of your very impressive career you describe yourself as having had the opportunity to lead large and complex organizations. in each of my worlds i focused on building strong teams forging relationships and delivering results. has it been your experience in delivering those results that having solid clear performance metrics is an advantage? >> it's an advantage to know where you are headed. >> that's part of the accountability you just described to senator hagan correct? >> yes. knowing where you are headed and how you measure with you get there not as important parts be under the affordable care act we have made significant progress in cleaning up some of the mess in the insurance market abuses like people being chucked out for their policies were denied coverage because of a pre-existing condition. that has been good. the access issue has been moved in a very good direction with 8 million people signed up. that leaves the third big issue which is the cost of the system. a very well-regarded report came out russell recently that predicted that spending on health care which consumes nearly 18% of the nation's gross domestic product will continue to grow 1.2 percentage rates faster than the economy over the next 20 years. a brookings expert rather punctually said this. if we cannot get health care spending under control there is no hope for the federal budget. the main hope if you don't get health spending under control is global warming gets us all first before health care spending gets us all. so we can work on climate change separately but there is a win-win you're confirmed, to w with me and work with a considerable number of other senators who share this concern to set some definable metrics for our progress at lowering the cost of health care by improving the quality and delivery of health care. would you be willing to do that? >> senator, if i am confirmed, i look forward to working with you and a number of your other colleagues, actually on both sides have brought up this issue. i look forward to working with you on it. >> to get it done. >> senator, i think the core objective is to improve the way we deliver health care, to improve quality and reduce costs and that's what the objective would be. >> and you agree that clear performance metrics would advance that objective? >> i agree that metrics are an important part of that. i think one of this things that one wants to do is understand what are the right metrics. in my experience in terms of when you're trying to scale and ab change, you need to thi you need to think about what is the metric you need to measure against so determining that you can do that is the other thing that i think is important. is it measurable, is that the right measure and then can you scale it and if that's what you're trying to do? is of the types of questions i have historicahistorica lly considered when i think about the issue of metrics. >> outlook for two working with you honeys metrics. just to give you a preview of coming attractions i think there should be a cost savings metric an actual dollar and a date that can be attributed to this process and i think it might be helpful in getting to the goal and articulating it for regular consumers to have some sweet of subordinate metrics like we are going to knock down hospital-acquired infections by 80% by the state. we are going to have as this many doctors moved off of fee-for-service and more outcome based payment systems by the state. i think we can successfully build a good suite of performance methods that will advance this and i appreciate the attention of the committee to the senate's and been something we have looked at repeatedly. i see chairman murray from the budget committee and we are looking at it from the budget committee perspective. i concur with a senior fellow at the brookings institution if we cannot get health care spending under control there is no hope for the federal budget and there's a good way to get it under control without having to resort to hacking away at fees and eligibility and what people are entitled to under their policy. thank you. >> i just have to add parenthetparenthet ically 75% of all spending in medicare is -- most of which are preventable. if you want measurable data look at that. our own budget person senator murray. >> thank you mr. chairman and i have to say at the outset that i'm really pleased the president chose such a qualified competent and experienced nominee someone i obviously know very well. i've had the opportunity now to work very closely with director burwell for many years during her time as president clinton's economic budget team. her distinguished service at the gates foundation and her current position now of course is director of the office of management and budget. this is a very impressive record and i really applaud you. you have excelled at every step. back in the clinton administration mr. chairman should play a central role in crafting policies that help lead to a very broad-based economic growth and budget surplus that we all remember by the end of the 90s. in her foundation work she took on an entirely different challenge and managed a very successful organization with a global region for the past year as we all know director burwell worked very successfully with us here in congress to bring much-needed bipartisanship back to the budget process and at the same time she was overseeing critical programs from medicare to the affordable care act from a budget perspective. i really believe she has the necessary qualifications and i'm delighted to have a few minutes here. i don't want to take much time but i did want to just say take this opportunity and give us the chance to hear from you how your professional experience has really prepared you to meet the challenge of managing a very large agency with a lot of different critical functions. >> i think my time at a number of different agencies that i've been in have helped with a couple of things. one is that clarity of focus on impact and i think that comes back to the conversation we were just having with senator whitehouse and how one needs to getting quick we make sure you define very clearly what your goals are and then build the institution, build the teams and part of that empowering of those teams is making sure that they know what their roles are and what their responsibilities and accountabilities are. the other thing that i think is a particular important part that i have learned in working in the foundation space and all the jobs that i had when i think about the problem-solving, you think about what is the problem you're working on? what is the solution and then the third circle is whatever entity that you are whether it's a walmart or the bill and linda gates foundation or the federal government what is your institution best at? so you are applying the skills of the piece you are working on or where you are the best at. i have had a chance to work with a lot of public-private partnerships both side -- inside and outside the government and seen a number different things but i think framing core goals building good teams and that empowering them to do the work are the most important things. >> i'm looking forward to seeing you doing that at this agency. i did want to also mention that you know i'm a very strong champion for early childhood education. there are several key early learning programs had start and the development of grant that will be within your purview at hhs if you're confirmed. i wanted to ask you how you will continue her agencies work to expand and strengthen those key federal investments. >> i think those are important vestments as senator casey talked about the issues of children i think we have a process that started with murray ryan that led to rogers mikulski and that process has produced some of the funding that i think can jumpstart the proposals of the budget right now that are important parts of continuing on that, to try and build on existing distribution mechanisms are you're not creating new systems. they built three head start and use of the things that make sure the programs that are in place have quality measures. so i'm hopeful that we can work if i'm confirmed either in my own d slot or hhs moving those issues of early childhood education forward. as you know because i have a six and a half in a a half and a fornes zero these are issues that i look at every day and how can we make that a reality for all the children in this country so they have the tools to succeed. >> we have a boat coming but i just wanted to just mention that it was reported that the uninsured level is at its lowest point since january 2008 when gallup is first started tracking that and in states like my home state of washington that you know so well where we built our own exchange and expanded medicaid. the rate of uninsured is decreasing even faster. we enrolled nearly a million people for coverage so i am delighted by that and i hope that you use my state and your state to really help replicate some of those good experiences across the country and i look forward to working with you. >> thank you senator. >> thank you senator murray. senator sanders. >> thank you very much mr. chairman. welcome ms. burwell. unlike senator roberts i believe in a medicare for all single-payer system. i think there's something wrong when in our great country that are the only nation in the industrialized world that does not provide healthcarhealthcar e for all of its people and that we have spending far more than most other countries on health health -- health care outcomes. in that regard in the aca legislation supported strongly by senator harkin that would give flexibility to states to move in different directions including the single-payer. as you know the state of vermont intensity that. right now we can't do that until 2017. we have applied for a waiver. this residence supports that waiver. would you help the state of vermont work with hhs to make sure that we can facilitate that process to lead the nation in that direction? >> center if i'm confirmed i look forward to working on that issue with you and the state. >> thank you. another issue that is dear to my heart and i'm no senator harkins hard and we have worked together on it and that is the crisis of primary health care indeed to go forward with community health centers. one of the reasons i voted for the affordable care act is that the majority leader senator harkin and i and others worked very hard to substantiate expanding committee health centers and in fact in the last four or five years i think we have 4 million more people to gain access to the health centers in my states. about one quarter the people will get their primary health care through community health centers. we are in a difficult problem right now because we are facing a cliff as you know and that is as a result of the aca funding we were able to expand community health centers. effect cliff goes into effect it will be an absolute disaster. you and i have chatted about this for a number of occasions. were you working with the president have provided a strong budget for community health centers and for the national health service corps. will you fight to make sure that we continue to strongly fund community health centers throughout america? >> senator as you and i have had the opportunity to discuss being from arra lace in the u.s. i actually understand the role of community health centers and communities like the one i grew up in so this is something i believe is an important part of our system. i believe it's an important part in terms of prevention. in terms of treatment as well am i believe it's an important part of an efficient and effective health care in terms of costs. >> that investment but here's my question. stay with me. the president and you have helped make his budget strong but will you help us fight to make sure that we continue to have the funding and not see that cliff which would be a disaster for community health centers all over this country? can i get your support on that? >> senator the budget we put together is the first up in that process to do that. >> okay. and in a related issue we are not going to half strong committee health centers are primary care in this country must we have the physicians and the nurses and the other staff that we need. to my mind also the aca working with senator harkin and others we have tripled funding for the national health service. people say that's a whole lot of money but do you know what? is still not enough. .. providers that we have to getting out to underserved areas in america. will you work with some of us, with myself, senator harkin and others, to make sure that we adequately fund the national health service core to do debt forgiveness or scholarships for medical school students who want to practice in underserved areas >> this is an issue that throughout the budget you see support for. and whether that's in the issue that you just raised in terms of the national health core, it's also in how we think about not just positions but there are also provisions that are about nurses and other people that are part of the primary care system. >> that's exactly correct. >> i think that's another important piece that we need to work on. >> what i worry about -- thank you. i agree with you.

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