>> the committee will come to order. i'd like to welcome everyone to the -- this morning's hearing. today we consider the nomination of sima vermia to serve as administrator for the centers for medicaid and medicare services. welcome. we're so happy to have you here and your family as well. i appreciate your willingness to lead this key agency at this critical time. and i see that your family joined you here today to lend support, so i extend a warm welcome to all of you and to them as well. cms is the world's largest health insurer. covering over one third of the u.s. population through medicare and medicaid alone. it has a budget of over $1 trillion and it processes over 1.2 billion claims a year for services provided to some of our nation's most vulnerable citizens. having dealt with cms extensively in your capacity as a consultant to numerous state and medicaid programs, you know full well the challenges the agency deals with on a daily basis. i suspect you also know that the job you've been nominated for is a thankless one with numerous challenges. there are opportunities in those challenges and i believe you're the right person for the job and that you will make the most of those opportunities. the failings of obamacare are urgent and must be addressed in short order. over the past six years we have watched as the system created under obamacare led to increased costs, higher taxes, fewer choices, reduced competition, and more strains on our economy. under obamacare, health insurance premiums are up by an average of 25% this year alone. under obamacare, americans including millions of middle class americans have been hit with a trillion dollars in new taxes. and under obamacare, major insurers are no longer offering coverage on exchanges and earlier this week we learned that another major carrier will exit the market in 2018. as congress works to change course with regard to our ailing health care system, cms will play a major role in determining our success. i applaud the step the agency took yesterday under the leadership of hhs secretary price with a supposed rule to help -- with a proposed rule to help stabilize the individual insurance markets. but there is much more work to be done and i'm confident that if you're confirmed, and i expect you to be, you will be a valuable voice in driving change. i'd like to talk specifically about medicaid for a moment. the medicaid program was destined to be a safety net for the most vulnerable americans. as such, i understand and value the moral and social responsibilities the federal government has ain ensuring health care coverage for our most needy citizens. i'm committed to working with the states, and other stake holders as i think everyone on this committee is, and of course the american public to improve the quality and insure the longevity of the medicaid program. we must also acknowledge that the medicaid program is three times larger, both in terms of enrollment and expenditures, than it was just 20 years ago. additionally, the medicaid expansion under obamacare exacerbated pressures on the program that at a time when many states were also facing difficult choices about which benefits and populations to serve. and as a result, we have a responsibility to consider alternative funding arrangements that could help to preserve this important program. we also need to consider various reform proposals that can improve the way medicare operates. miss verma, we will need your assistance in both of these efforts and your experience in this particular area should serve you well. on the subject of miss verma's experience, i want to note for the committee that she has been credited as the creative force behind the healthy indiana plan, the state's medicaid alternative. this program provides access and quality health care to its enrollees, while ensuring that they are engaged in their care decisions. the program continues to evolve, while hitting key metrics on overall enrollees very satisfied with their experience as i understand it. while we may hear criticisms of this program from the other side of the dais here today, we should note that hhs and cms leaders under the obama administration repeated the approved waiver necessary to make this program a reality. miss verma has assisted a number of other state medicaid programs as well. her efforts all have the same focus, getting needed high quality health care to engaged patients and to engage patients in a fiscally responsible way. this is exactly the mind set we need in a cms administrator. now, miss verma, as if the challenges associated with medicaid are not enough, to keep you busy as cms administrator, you will also be tasked with helping to ensure the longevity and solvency of the medicare trust fund, which is projected to go bankrupt in 2028. that's already come down from 2032, i believe. all told, between now and 2030, 76 million baby boomers will become eligible for medicare. even factoring in deaths over that period, the program will grow from approximately 47 million beneficiaries today to roughly 80 million in 2030. maintaining the solvency of the medicare program will continuing to provide care to an ever expanding beneficiary base is going to require creative solutions. it will not be easy. we can't put it off forever, and the longer we wait, the worse it will get. now that i've had a chance to discuss the challenges facing cms and some of miss verma's qualifications, i would like to speak more generally about recent events. we have gone through a rough patch on this committee, as we dealt with president trump's nominations. i don't want to rehash the details of the past few weeks, but i will say that i hope that recent developments do not become the new normal for our committee. as i said before, i'm going to do all i can to restore and maintain the customs and traditions of this committee, which is also operated with assumptions of bipartisanship and comedy and good faith. with regard to considering nominations, that means a robust and fair vetting process. a rigorous discussion among committee members and, of course, a vote in an executive session. on that note, maybe the ic treatment of nominees is starting to thaw today, i hope it is. one tradition that has been absent before this session has been the introduction on many occasions of nominees by senators of both parties from the nominee's home state, especially in cases when the nominee and the home state senator have a relationship. i'm pleased to say that the senior senator from indiana, as we refer in that tradition, but appearing here today, and so is our other senator from indiana. i thank the senators for taking time to appear today and to introduce their constituent. i'll give them' chance to do so in just a few minutes. with that, i look forward to miss verma sharing her vision and views here today. also, i look forward to what i hope will be a full and fair committee process that allows us to process this nomination and report it to the full senate in short order. i'll now at this time recognize our -- my co-chair on this committee, senator wyden for his opening statement. >> thank you very much. welcome to you, miss verma and our colleagues from indiana. i thought it worth noting with the hoosier basketball tradition, miss verma, it looks like you brought close to two squads of basketball players and we welcome you and your family today. it is obvious that the health care post we'll discuss today is not exactly dinner table conversation in much of america. but the fact is, it is one of the most consequential positions in government. agencies responsible for the healthcare of over 100 million americans who count on medicare and medicaid. it plays a key role in implementing the affordable care act. that's why cms needs experienced and qualified people for the job. people who know the ins and outs of the whole system, medicare, medicaid, and private insurance. the agency needs a strong and experienced authority and this is particularly true now, when it does appear that some of my colleagues on capitol hill, many in the administration, are looking to make radical changes in american health care. in my view, many of these proposals would take the country back to the days when healthcare was mostly for the healthy and the wealthy. so we're going to start with the promise of medicare, which has always been a promise of guaranteed benefits. that makes up more than half of the agency's spending, about $2 billion plus a day. with more seniors entering the program each year, there is an awful lot to do to protect, and, in my view, update the medicare guarantee for this century. that means addressing the high cost of prescription drugs. it means making the program work better for those with chronic illnesses. like heart disease and cancer. that's the majority of the medicare spending today. it is going to take bipartisan support. privatizing medicare is the wrong direction in my view. it is important to hear today, miss verma, how your views different from some of the policymakers who are advocating those kinds of approaches, literally be interested in turning the program into a voucher system. additionally, if confirmed, you're going to play a key role implementing the medicare physician payment reforms. it is essential that they be implemented as intended by the congress, because we want to start moving healthcare from paying for volume to paying for value. also, the agency implements rules of the road in the private insurance market, and today many of those rules amount to bedrock values for health insurance and the country. it means not discriminating against those with a pre-existing condition, no matter what. it means setting the bar for what type of medical care insurance companies have to cover. and it means letting young people stay on their parents policy until 26. unfortunately, just yesterday, the agency released a proposed rule that in my view goes in the opposite direction. from where i sit, the message from yesterday's rule is insurance companies are back in charge and patients are going to take a back seat. the open enrollment period, for example, was cut in half, from three months to six weeks, if somebody dropped coverage during the year for any reason, insurance companies could collect back premiums before an individual can get health insurance again. and insurance companies would have free reign to offer less generous coverage at the same or higher cost. this, again, sounds to me like it is going back to yesteryear when the healthcare system really did work for the healthy and wealthy. now, the administration has been saying, of course that the best is yet to come. evidence, it seems to me, suggests otherwise. the president could have taken steps to create more stability on a bipartisan basis. but instead issued an executive order on the day he was sworn in, that is obviously now creating market uncertainty and anxiety. don't have to look much further than humana's decision in the last day or so. so we want to hear from you about how you're going to implement this program that millions of americans, you know, count on. and how you're going to do it, even though we have republicans here who want to unravel the law. in short, i want to see us get beyond what is coming to be known as repeal and run. and repeal and run goes beyond disrupting the individual market. it would also end the medicaid expansion that brought millions of low income vulnerable americans into the health care system. and this is an area obviously where you have extensive experience. i want to discuss some of the trade-offs associati s associate efforts and i'm concerned about the possibility as i have been informed that somebody making barely $12,000 a year would get locked out of health coverage for no less than six months because they couldn't pay for health care due to an upcoming rent check, for example, or an emergency car repair. there has been an independent evaluation indicating that 2500 people were bumped from coverage due to situations like this. i've also seen in that same report that more than 20,000 persons were pushed into a more expensive, less comprehensive medicaid plan because they couldn't navigate this system that you all put in place. now, i want to wrap up with just two last points, mr. chairman, one, with respect to taking these ideas on a nationwide tour, i'm not there yet. and i say that, you know, respectfully, we'll hear more about the program. and here's the point with respect to the states. and we touched on it in the office. we authored section 1332 of the affordable care act. saying that states can do better. states have an idea of better coverage, lower costs, god bless them, we're all for it. but we can't use 1332 or any other provision for the states to do worse. one last issue that i want to touch on deals with miss verma's work. as i understand it, you had a consulting firm, you were awarded more than $8.3 million in contracts directly by the state to advise the state. and that was why you all were managing the programs and in effect you were the architect. at the same time, as has been told to me, you contracted with at least five other companies that provided hundreds of millions of dollars of services and products to these programs, hp enterprises, millman, maximus, health management associates, roche diagnostics. in at least two of the firms, the terms of the state contracts appear to have had you in effect overseeing work that the firms performed. now, george w. bush had an ethics lawyer, richard painter, wasn't exactly a liberal guy, and he said, yesterday, that this arrangement, i'll quote him, clearly should not happen and is definitely improper. in effect said that you are on both sides of the deal, helping manage state health programs while being paid by vendors to the same programs. he said that was a conflict of interest. i want to hear you respond to his assertions. so we're going to want to know more about your work for companies that did business with the state, and one of the questions will be if you're the cms administrator, if you're confirmed, would you recuse yourself from decisions that affect the companies who were her clients. i'll look forward to your testimony with the two indiana senators, you're running with the right crowd, and thank you, mr. chairman. >> thank you, senator. i'm pleased to hand over my normal witness introduction duties to a pair of our distinguished colleagues. both senators from the hoosier state will introduce miss verma as a statement and testament to her work and to her as a person. i ask that the senior senator from indiana, mr. donnelly, start the introduction and then turn it over to senator young. senator donnelly, go ahead and proceed. >> thank you, mr. chairman. thank you for inviting me here today. it is a pleasure to be here with my friend and colleague, senator todd young, to recognize this important accomplishment of a fellow hoosier. as you know, anytime the president nominates an individual for a leadership position in our government, it is an honor and a reflection of the tremendous trust and respect he has in that person. for this reason, i am pleased to be here today to help recognize miss seema verma, and introduce her to this committee for your consideration. i have always held a personal belief that we accomplish more when we work together. in indiana, we call that hoosier common sense. in working collaboratively to help hoosiers get access to quality healthcare is something miss verma and i had the opportunity to do together. as many of you are already aware, she has played a central role in crafting medicaid policy in many states, including our own. in indiana, she worked with governor daniels and then governor pence as well as other state and federal partners to take advantage of opportunities made possible by the affordable care act, to expand medicaid through the healthy indiana plan. also known as h.i.p. today, it improves health care outcomes and has played a critical role in combatting the opioid abuse and heroin use epidemics. hundreds of thousands of hoosiers currently have health insurance through hip 2.0. a program is an example of what is possible when we work together. as i have shared with miss verma and i'll share with you, i am deeply concerned about the future of health care in our country. as well as the rhetoric surrounding the current debate. i firmly believe that maintaining access to critical programs like medicaid and medicare and building upon the progress of the aca is fundamental to both the physical and financial well-being of thousands of americans across our country. it is my sincere hope that this administration working with this committee and others will approach medicare and medicaid with a thoughtful and pragmatic consideration these critical programs deserve. i have watched miss verma take this common sense hoosier approach and i hope she uses this opportunity today to share with you her vision for how she can work together with all of the members of this committee and congress as a whole to expand access to quality healthcare and protect and build on the progress we have made over the last several years. with that, chairman hatch, ranking member wyden, members of the committee, thank you for allowing me to introduce miss verma. to her and her family, congratulations on this tremendous honor. i look forward to miss verma's testimony and i thank the committee for the hard work and consideration of miss verma for this very important position. >> thank you very much. senator, you now can proceed. >> thank you, chairman hatch, ranking member wyden and members of the committee. it truly is an honor to be with you, to introduce a fellow hoosier, seema verma to be administrator for the center for medicare, medicaid services. president trump could not have made a better choice in selecting seema to lead what is arguably the most important office within hhs. an office that covers the health care needs of over 100 million americans, with a budget of almost $1 trillion. in her 20 year career, as an innovator in the healthcare sector, she worked extensively with a variety of stake holders, from both sides of the aisle, to deliver better access to healthcare. as president, ceo and founder of svc, she helped several states to redesign their archaic medicaid systems. including in my home state of indiana. seema revolutionized the medicaid program as architect of the healthy indiana plan, which we know as h.i.p. she transformed a complex, rigid, medicaid system into one where hoosiers are back in control of their healthcare needs. since 2007, h.i.p. achieved impressive results. hoosiers are more likely to seek preventative care, take their prescription medications and seek primary care services at their physician office, not the emergency room. seema's innovative idea is working and is proof of concept that medicaid can be more efficient than a one size fits all approach. she accomplished this with the support and buy-in from people, again, on both sides of the aisle. and at all levels of the process. by putting the mission above politics, she demonstrated a willingness to work with anyone, anyone, who was willing to do the same. she worked with democrats in the indiana state house, she worked with the obama administration to find common ground on how to best provide quality healthcare to hundreds of thousands of low income hoosiers. and it worked. as cms administrator, seema will have the ability to use her extensive experience to help other states achieve what we have in indiana. better health outcomes for our most vulnerable. i look forward to working with her. i thank you, sir. >> well, thanks to both of you, senators. that's a real honor for the committee to have both of you come and i know miss verma really appreciates it. >> thank you. >> we know you're busy, so we'll let you go. miss verma, we now turn to you for your comments and your feelings on this nomination and then we'll turn to questions from the senators up here. >> good morning, chairman hatch, and ranking member wyden. i appreciate and am grateful for your consideration of the nomination by president trump to be the administrator for the centers for medicare and medicaid services. and i thank you for the time that many of you have spent with me in advance of the hearing. i appreciate hearing about your priorities. before i begin my statement, i would like to take a moment to introduce my family. with me today are my parents mr. and mrs. verma, and my husband, sanjay and my two kids, maya and shawn. and the rest of my family and friends that are here with me, i really appreciate it. thank you. i often have been asked by my family and my friends and many members of this committee why i would be interested in this job. i was honored and humbled and accepted president trump's call to service because i understand what is at stake. i have never stood on the sidelines of our nation's healthcare debate, merely pointing out what is wrong with our healthcare system. more than 20 years ago, when i graduated from college, i started my career working on national policy on behalf of people with hiv and aids, as well as for low income other mo to improve birth outcomes. i fought for coverage, greater access and improving the quality of care and of continued to fight for these issues for the past 20 years. but i am deeply concerned about the state of our health care system as there is frustration all around. many americans are not getting the care that they need, and we have a long way to go in improving the health status of americans. doctors are increasingly frustrated by the number of costly and time consuming burdens. healthcare continues to grow more and more expensive, and the american people are tired of partisan politics. they just want their healthcare system to be fixed. and i know this not simply because i worked in healthcare, but because of how intimately it affected my own personal life. my mother is a breast cancer survivor, due to early diagnosis and treatment. and a few years back, my neighbor aidan was diagnosed with a stage four neuroblastoma. he was only 4 years old, a large tumor had been growing for some time, maybe since he was born, and it was wrapped all around his kidney. aidan went through excruciating, painful chemotherapy, radiation, stem cell treatment, and surgeries, all experimental. this may, aidan will celebrate his 12th birthday. and both my mom and aidan are testaments to the grace of god and the ingenuity of the american healthcare system. this is why people travel from all across the world to get care in the united states. i want to be part of the solution, making sure that the healthcare system works for all americans. so that families like my own and aidan's have the care that they need. i want to be able to look my children in the eye, and tell them that i did my part to serve my country and to have a voice for people that don't often have one. this is a formidable challenge. but i am no stranger to achieving success under difficult circumstances. my father left his entire family to immigrate to the united states during the 1960s and pursued four degrees while working to earn money. on my mother's side, my grandmother was married at the age of 17, with no more than a fifth grade education. but my mother went on to be the first woman in her family to finish a masters degree. my patient parents made a lot of sacrifices along the way to provide me with the opportunities they didn't have and taught me the value of hard work and determination. i'm extremely humbled as a first generation american to be sitting before this committee after being nominated by the president of the united states. it is a testament to the fact that the american dream is very much alive for those willing to work for it. and it is my dream and my passion to work on the front lines of healthcare to improve our system. throughout my career, i have brought people together from all sides of the political spectrum, to forge solutions that worked for everyone. one of my proudest moments in my career was watching the indiana legislature pass the healthy indiana plan, which was a program for the uninsured, with a bipartisan vote. cms is a $1 trillion agency, and covers over 100 million people. many of whom are amongst our nation's most vulnerable citizens, providing high quality, accessible healthcare for these americans isn't just a luxury, it is a necessity and often a matter of life and death. should i be confirmed, i will work with cms team to ensure that the programs are focused on achieving positive health outcomes and improve the health of the people that we serve. to achieve this goal, i will work towards policies that foster patient centered approaches, that increase competition, quality and access while driving down costs. patients and their doctors should be making decisions about their healthcare, not the federal government. we must find creative ways to empower people to take ownership for their health. we should support doctors and providing high quality care to their patients, and ensuring that cms' rules and regulations don't drive doctors and providers from serving the people or beneficiaries. if confirmed, i will work towards modernizing cms' programs to address the changing needs of the people they serve, leveraging innovation and technology to drive better care. i will enthis ur that efforts around preventing fraud and abuse are a priority, because we can't afford to waste a single taxpayer dollar. i will work towards ushering in a new era of state flexibility and lead is ership to drive bet outcomes. if i have the honor of being confirmed, i will carry this vision along with my strong belief in open communication, collaboration and bipartisanship. i will work with you, be responsive to your inquiries, concerns and value your counsel. i thank you for the consideration of my nomination. >> well, thank you so much. we really appreciate your willingness to serve and i look forward to getting you through this process. let me just -- i have obligatory questions to give you. first, is there anything that you are aware of in your background that might prevent a conflict of interest with the duties to the office of which you have been nominated? >> i met with the -- consulted with the office of ethics and indicated any areas i thought would be an issue and i will be recusing myself of any matters that would present any potential conflict. >> thank you. do you know of any person, or any reason, personal or otherwise, that would in any way prevent you from fully and honorably discharging the responsible tilities of the off to which you have been nominated? >> i do not. >> do you agree without reservation to respond to any reasonable inquiry? let me see here. i have a hard time getting the pages apart. any reasonable summons to appear and testify before any -- for any duly constituted committee of the congress, if you are confirmed? >> i do not. >> you're willing to do that? >> i am willing to do that. >> okay. >> finally. do you commit to provide a prompt response to any questions provided by any senator on this committee? >> i do. >> thank you. let me get into some questions. i know you're aware of the historic bipartisan and medicare access and chip reauthorization act that i had a lot to do with, 2015, called macra. among other things, got rid of the dreaded formula and i'm pleased that our work on the implementation of these changes continues to be bipartisan. both in how republicans and democrats in the congress have worked together an how congress had worked with the obama administration. in fact, the obama administration took great pains to engage physicians and other stakeholders through the initial implementation phase. now, it strikes me that this process of consultation early and often should be the rule and not the exception. what is your view on how to engage stakeholders to approve -- to arrive at best policy decisions for medicare and other cms programs? >> thank you, senator. and i applaud congress's efforts to pass macra. i think it's an important step forward not only to providing more stability to providers but also moving us toward better outcomes. you know, in terms of stakeholders i think that the most important thing we can do is engage with stakeholders as quickly as possible on the front end and all the way through the process, understanding stakeholder perspective and what folks are going through on the front end. what their challenges are. and as we're developing policies and programs to have that open communication i think is helpful toward any successful implementation. it's not a one-time thing. it's not just on the front end. it's all the way through the process. and even after the program's established, it's always important to have that dialogue with stakeholders because they can tell you what's working and what's not working. and when you think of new ideas and you're thinking about implementing them, they can help you figure out whether it's going to work or not. i know i've had that experience in my career and i've always found it very helpful and an integral part of success. >> as the baby boomer generation ages, the number of persons age 65 and older in the united states is expected to dramatically increase, fueling an increase in the demand for long-term services and support. notably, medicaid is the primary payer of these services. what changes, if any, should be made to meet the expected increase in demand while ensuring the fiscal sustainability of the medicaid program? >> i think medicaid is a very important program. it's been the safety net for so many vulnerable citizens. when i think about medicaid program, i think about some of the individuals that i've met. one person in particular i think about is a quadriplegic. he's on a breathing machine and he requires 24-hour care. i think about the mother of a disabled child. and this is the face of the medicaid program. as we think built medicaid program and where we are today, i think we can do better. we have the challenge of making sure we're providing better care for these individuals. but the program isn't working as well as it can. there's a very intractable program and it is inflexible and states in situations of going back and forth and doing reams of paperwork and trying to get approvals from the federal government, and at the end of the day, are we achieving the outcomes that we want to achieve. as i think about the medicaid program i think there's an opportunity to make that program work better so we're focusing on improving outcomes for the individuals that are served by the program. >> in 2014 i worked closely with senator wyden and leaders from the house ways and means committee to enact a bipartisan, bicameral law called the improving medicare -- let's see here. improving medicare post acute act transformation or impact act. it serves as a critical building block to serve future medicare post-acute quality measurements and payment reform. specifically, the impact act requires the collection of standardized data to help medicare not only compare quality across the different post-acute care settings but also improve hospital and post-acute discharge planning. our goal was to produce data-driven evidence that congress can use to debate the best way to align medicaid post-acute payments. and those that improve outcomes and save taxpayer dollars, and our intention is to ensure that we are able to do this type of thing. i want to ensure that beneficiaries are receiving the highest quality post-acute care services in the right setting at the right time. now, will you commit to working with me and members of congress and this committee and the post-acute provider community on the implementation of the impact act? >> it would be my pleasure to work with the committee, stakeholders and anyone else that was interested to make that program a success. >> well, thank you. we'll turn to senator wyden. >> thank you very much, ms. verma, and thank you for your testimony. i want to start with a comment you made that you were committed to coverage, which of course is what this is all about. unfortunately, what i've seen since the beginning of the year has been basically about rolling back coverage. and in fact congressman price sat in your seat a couple of weeks ago and refused to commit to making sure that no one would be worse off in terms of coverage. now, the president said in his campaign, and i quote, "we're going to have insurance for everybody. the american people are going to have great health care, much less expensive and much better." that's what the president said. yesterday cms did the exact opposite. the first rule to come out of the agency, the agency that you would like to head, after secretary price was confirmed meant less coverage, higher premiums, and more out-of-pocket costs for working families. how would you square what president trump said in the campaign with what cms did yesterday? >> in terms of the rule that you speak of, i have not been involved in the development of that rule out of respect for the committee and for the nomination process. i have not been involved in that. i have not been to cms. so i haven't been involved in that, and i can't speak to that. what i can tell you is i am committed to coverage. i've been fighting on this issue for 20 years. and i will continue to do that if i'm confirmed. >> but i just read you quotes, and it's not like atomic secrets or classified materials. what the president said is very different than what cms did yesterday. and you read newspapers. you're a very informed person. talked about cutting the enrollment period. i'm looking at the headline. cut the enrollment period in half, which really is going to limit our ability to get the very people we need most, the younger, healthier people. so one more try. how would you square what the president said with what happened yesterday? >> i think the president and i are both committed to coverage. i cannot speak to the rule. i have not had an opportunity to review that. but again, i think the president and i both agree that we need to fight for coverage and make sure that all americans have access to affordable, high-quality health care. >> what troubles me about yesterday is once again insurance companies are coming first and patients come later. tell me one thing you would change to put patients first. >> one thing that he i would do is i think it's very important that patients be in charge of their health care, that patients get to drive the decisions about their health care, that they get to make choices about what kind of health care plan works well for them. i think it's important that our patients have access to quality coverage, to the doctors, to their choice of doctors and their choice of plan. >> could you get us a specific on that? because that's an admirable philosophy but i still don't know. yesterday was good for insurance companies, and it was bad for patients. i'd like to have a specific example, and we'll keep the record, you know, open, of something you would do to put patients first. and i respect the fact that you've articulated a philosophy but i really want to know a specific about what you'd do to put patients first. let's move on with respect to another area of responsibility you'll have, and that's prescription drugs and medicare because we all know these prescription costs are just clobbering families and seniors, the federal government and a whole variety of the stakeholders that you refer to. as the administrator of the agency you're going to have an opportunity to address this problem. the president's been vocal on it. again, give me a specific change to medicare part d that you would suggest to bring costs down. >> i think that the issue of drug pricing is something that all americans are concerned about and the president is concerned about that as well. people want to make sure that when they need the drugs, when they're going through an illness, i think about my mom, i think about my neighbor aidan, and when they need the drugs that they need, they want to know that they have access to it and that it's affordable. so i think we're all concerned about that specific issue. part d i think has been a good program. it has expanded access to medications for people that didn't have it before. and i think the structure of the program in terms of how it puts senior citizens in charge of their health care, they can go on plan finder, go online -- >> my time is up, ms. verma. i voted for part d. still got the welts on my back to show for it. i asked you for a specific change going forward that you would do to help seniors and others hold down their costs. as you know, there's discussion of making changes so that medicare could bargain. is there one specific you could give me? and the reason that the medicare question is so important is not only does this affect older people so dramatically but your experiences on the medicaid side. and i respect that. people have different experiences. so i very much would like to hear a specific on this key medicare issue that you would actually be for. >> i would be for policies that continue to put senior citizens in charge of their health care, that puts them in the driver's seat of making the decisions that work best for them so that they can figure out what plan covers the medications that they need, what plan is affordable to them and allows them to make the decisions about their health care and that gives them access to the medication that's they need, that doesn't limit that in any way and that is affordable to them. >> my time is expired. i still didn't get a specific example. i happen to be for a host of things on transparency, on negotiation, on trying to make sure we squeeze more cost savings out of the middle men. i'm going to hold the record open. but i've asked you for specifics in two areas, putting patients first and how you would hold down the costs of part d. respectfully, i didn't get a specific. we'll hold the record open for it. i think senator grassley, are you going to call out names on your side or -- >> i'm next. [ laughter ] >> that didn't take much time. >> what i'm going to talk to you about is things that have happened in cms in the past. and hopefully coming from an administration that wants to drain the swamp, i think i would expect changes to be made under your leadership in this agency. and i would suggest you probably can't do anything about the suggestion i'm going to give you to respond to the last question of my colleague. but if you would push doing away with pay for delay programs between brand drugs and generics i think it would go a long ways to helping get drugs cheaper. cms has told me that it does not have much authority to do anything against some frauds committed against its programs, even if those actions are in cms's own words, quote unquote, a clear violation of the laws. and common sense tells me that if it's a clear violation of the law cms can do something about it. and if that's their attitude there i would ask you to see whether the past interpretation is right by checking that interpretation. but in a january 28th letter to me about the medicare drug rebate program cms said it could tell a manufacturer when its drug is misclassified and then, quote unquote, attempt to reach an agreement. in other words, after the money's been stolen from the taxpayers take some trouble to get it back if you can reach an agreement. but there are a lot of tools the government has to fight fraud. and the most effective one we have the false claims act. since 1987, when i got that law in place, the department of justice has used the false claims act to recover more than 33.9 billion dollars just lost from just the health care fraud alone. but cooperation between the department of justice and the health care program administrators is very important in these cases. it seems like cms could at least have picked up the phone and given the department of justice a head ups when these manufacturers refused to cooperate and properly classify their drugs. so a pretty simple question, it might even be called a softball question, but it's pretty important to me, would you commit to proactively cooperating with the department of justice in fraud cases and fully supporting the use of the false claims act to combat fraud on government health care programs? >> i will absolutely do that. and i applaud your efforts on the false claims act. i think it's been an integral component of preventing fraud and recovering dollars when there is fraud. so i thank you for your service and your work on that. >> next question. in the fall of 2016 and in january of 2017 i sent several oversight letters to cms regarding the steps that it took to hold mylan accountable for misclassifying the epipen as a generic under the medicaid drug rebate program. cms has publicly stated that it "expressly advised mylan that their classifications of the epipen for purposes of the medicaid drug rebate program was incorrect," end quote. however, cms has failed to fully respond to my oversight request and refuses to provide records of communication with mylan. cms has also not been entirely clear as to what the authority has to do with -- to correct drug misclassifications. because of epipen's misclassification the government and states are owed hundreds of millions of dollars from mylan, congress and the american people are owed answers. so if confirmed, would you commit to fully responding to my oversight requests and providing the requested records of communication beyond mylan and cms? i hope that's a short yes. >> that is a short yes. >> in light of epipen's misclassification and potentially other drugs that have been misclassified under medicaid, what steps will you take to ensure that drugs are properly classified under medicaid? >> i think what happened with the mylan pen and the epipen issue is very disturbing. the idea that perhaps medicaid programs which are struggling to pay for those programs, that they could have potentially received rebates is disturbing to me. so if i'm confirmed, i would like to review the processes in place there in terms of the classifications, in terms of brand and generic to ensure that time of thing doesn't happen again. >> and what you just said you want to do i want to do. and that's why i want those communications from cms. i hope you can get them for me. >> i'd be happy to work with you on that, senator. >> senator stabenow. >> thank you very much. and welcome. welcome to you and your family. the first thing, many, many questions i have, first regarding medicare, do you believe that medicare programs should negotiate the best price for seniors on medicare? >> i think we need to do everything we can do to make drugs more affordable for seniors. and i'm thankful that we have the pbms and the part d program that are performing that negotiation on the behalf of seniors. >> do you believe we could get a better price if medicare was negotiating as the va does, as other private entities do to get the best price for seniors? >> i think that competition is the key to getting good prices. and i -- >> is that yes or no on negotiation? >> i don't think that's a simple yes or no answer because i think there are many ways to achieve that goal, and the goal is to make sure that we're getting affordable prices for our seniors. i mean, if we look at the part d p program and the way that the pbms have negotiated this, we know that when there is a lot of competition, the price goeses down, and with we have to figure out ways, and i'm happy to work that out to inkrecrease the competitiveness and support the part d program. and what i like about the part d program is that it puts seniors in charge about the decisions of the drugs they find, and to use the plan finder tool, and it can put the medications that they need and then -- >> i will stop, because i don't have a lot of time. >> sure. >> so under the repeal of the affordable care act, actually seniors would begin to pay more because the gap in coverage for those who use a lot of medicine would appear again. so we have closed that no gap for seniors and that would reopen. do you support that as part of the are repeal? >> as i said before, i think it is important to help the the seniors to get the most affordable drug prices -- >> do you support in returning to the gap in coverage for seniors under part d? >> i support access for seniors to have access to medications that they need and they choose. >> and let me ask now for following up a little bit more on yesterday's decision regarding cms. one of the things that they decided to do yesterday was to cut in half the open enrollment period for people to get insurance from three months to six weeks. do you support that? >> no, i have not had a chance to review that rule. i was not involved in the development of that with respect for the process. >> does it seem like a good idea? from your standpoint to shorten the amount of time. >> i want to review the implications of that and i was not before as i said for respect of this process not been to hhs or cms and not involved in the development of that rule, so i would look forward to reviewing that and would be happy to report back to you after i have had a chance to review that. when we look at a important set of provisions of the act that i call the patience provision, and anybody winsurance regardless of who it is, they have more ability to get the care that they are paying through the insurance and it is not the insurance company, and so there are a number of things that, that folks can now count on, and one is having an essential set of basic health care services that are designed so that when insurance companies are betting that a basic set of services that as a woman you will get maternity care and mental health care will be covered the same as physical health and substance abuse and so on and a basic set of services, and do you support that as being a basic set of essential services in the health care system? >> i support americans being in charge of the health kcare. i support americans being able to decide what benefit package works best for them. i think it is hard to know what works for one person might not work for another person. and i think it is important that people be able to make decisions that work best for them and their families. as the mother of two children, and you know, in a family, i know that what we are looking for, and what i am looking for might not work better for another family, and i support americans being in control of the health care and making the decisions that work best for them, and their families. >> do you believe that women should have to pay more for to get prenatal care and basic maternity care as coverage as a rider, and extra coverage. >> and you know, i'm a woman and so i support women having access to the care they need. i have two children of my own and i have appreciated the services -- >> should we as women be paying more for health care because we are women? >> i think that women should be able to make the decisions that work best for them. >> but if the decision is made by the insurance company as to charge how can we make that decision prior to the affordable care act i have said many times that 70% of the insurance companies in the private marketplace did not cover basic maternity care and looked at was imas being a pre-existing condition, woman, and different kinds of health services that we need, and weren't provide and weren't viewed as essential services which has changed now where women have what are basic services for us covered as basic services where we don't have to pay extra as a rider to get basic care, and so i am asking if that makes sense? >> obviously, i don't want to see the women discriminated gai against. i'm a woman and i appreciate that. i also believe that the women have to make decisions that work best for them and their family, and some women might want pa maternity coverage, and choose and may not feel like that. so it is up to women to make the decision that works best for them and their families. >> thank you. thank you, mr. chairman. >> as you can imagine, we are now having two votes, and there is nobody here to question, so i think that what i will do is to recess for about 15 minutes. i am sorry to interrupt like this, but that is the life of a u.s. senator. we sure appreciate you and your patience, and i appreciate the way that you are answering the questions, straight up, and your expertise really comes through. so with that i will just recess for about 15 minutes, and hopefully i can get to the second vote and be right back. >> we are about to recess and return to the senate floor to vote. >> well, thank you, mr. chairman, an congratulations on the nomination, ms. verma. thank you for pay ing a courtes call to my office and we had a very good discussion and you have an impressive record with regard to medicaid and further innovation and flexibility for a program. i must say that the opening statement was not only relevant and right on point, but it is inspiring as well. thank you for that. i think that i would speak for all members of the committee. we need to make a copy of our statement available here, mr. chairman, because virtually ever every member and test them on it, and bring it back together. >> okay. i agree with that. >> and as co-chair of the health care caucus, i am particularly concerned about how regulations coming out overyof your agency do not work, and how we monitor the payment and delivery models better tailored to the communities and the needs of the low volume of patients and the high number of medicare and medicaid patients and i know a that you are familiar with that work in indiana and how do we work our small and rural providers without disadvantaging them due to the yunique populations they serve, and secondly, would rural relevant quality measures or different data thresholds be encouraging participation and certain value-ba value-based pay for performance programs? >> thank you for your question, senator. you know, rural health provider providerers have unique and special challenges. i mean, often, they are the only p providers in their communities that are providing services, so when people come to them, they are dealinging with a variety of health issues, and it is not primary care and preventive care, but it could be specialty care, and they don't have access to the services. the challenges for them is that even attracting a workforce and finding providers to come out to the regions is a challenge, and it is difficult. because they have those multiple challenges, it is difficult for them when there are lots of rules and regulations coming down from the federal government. as a small business owner and working with small physician offices, you sort of understand that it is difficult sometimes when they are on the front lines and trying to manage such very complex situations to also deal with rules and regulations is difficult. that being said, we want to ensure that all americans have access to high quality health care, and we have to be very careful with the rural providers to make sure that they are not putting additional burrdens on them that are actually, you know impact accessibility to care or quality to care. so when it comes to the rural providers, we need to support them through the process. we need to make sure they have the appropriate technical assistance to get to where they need to be, and understanding that, you know, understanding that the demands they have on the time might impact their ability to implement those regulation regulations. >> i really appreciate that. we have, i think that we have 83 and probably more today critical access hospitals. and i know that you have the same situation in indiana, and thank you for your statement. as a member of both the health and finance committee as many of my colleagues are, we often see the disconnect of the new and exciting therapies approved by the fda and reimbursement policies of cms and take for example last year, one biosimilar was approved by the fda and guidance documents were still outstanding, and cms proposed and finalize ad payment policy that could stifle innovation in this area. how would you anticipate working with the fda to ensure that cms is providing the best policies for the taxpayer? >> i believe that collaboration and coordination is critical within the hhs. i appreciate secretary price and his leadership there and careful coordination and collaboration between similar agencies or the sister agencies is important. i think that being on the front end, and discussing with them, and understanding what their intentions are, and what is coming down the pipeline and making sure that cms is prepared to and coordinated with any efforts of the fda has. >> i must tell you in overall health care delivery system, and in talking to the many hospital administrators and the rural providers and cms, the term used in the pasts is it's a mess. i know that you will fix that. but there is a cms is the center for consumer information and insurance oversight, cicio, and i thought i knew most of the acronym acronyms. and what part do you see them paying under your leadership? >> if i am conu firmed, my job is to implement the law. so they are currently cicio enforcing the law, and so my role with cicio will depend on how congress depends what to do with the affordable care act, and so i will make that outcome with the affordable care act. >> mr. chairman, i have to say that i'm impressed with the statement, and i know that we have had several senators talking about unraveling of the obamacare. we had a entire insurance company leave the market, and another one describing it as a death spiral and we need a rescue team to make sure that the bridge is still there and build new bridges. that is what would be my take on th that. thank you so much for your testimony, and thank you for the leadership that i know that you will bring to cms. >> thank you, senator. >> well, thank you, senator. and while we are waiting for other questioners, let me ask a question. one of the issues that this committee has focused on over the past three years is the large backlog of medicare appeal s resulting from the audits from cms contractors and at the same time improper payments pose a threat of the well-being of the medicare and medicaid programs, and so what are your views on how tole balance the need for robust program, integrity and, also, also, claims ak ccuracy wh the need to ensure the timely payment to providers without causing them too much undue burden? >> that is a very important question. fraud and abuse if i am confirmed is a top priority. that is what i'd call, you know, should be low hanging fruit as we are looking at the medicare fruit, and ensuring the sustainability over the long term, and given the medicare trustee's report about the future of medicare and running out of money at some point, and we can't afford to waste a single taxpayer dollar. thinking about fraud and abuse, and especially with the fraud prevention is looking to have effort to be on the front end and not waiting to do a pay and then chase, but really on the front end addressing fraud. so as we are developing programs to ensure that we are putting the procedures and the policies in place so that we can identify fraud and abuse on the front end. the issue that you raise in terms of the backlog and the burden that it puts on the providers is something that concerns me. we want to make sure that with cms' policies that we are not preventing the providers from participating in the program and being active in it. and the backlog and the things like that have really made it difficult for the providers, and where they are not getting paid for these types of issue, and so it a balance that we have to check with being aggressive on the fraud and abuse, and not penalizing and focusing our penalty efforts on the bad players without penalizing provi providers who are trying to do the right thing. >> thank you. sta states are increasingly moving the medicaid programs into the managing care delivery system. with managed care representing almost 40% of federal medicaid spend spending. and now, in the last year, the cms released an updated framework for medicaid managed ca care. what if any changes do you believe are important to federal and state oversight of medicaid managed care? >> i think that managed care has been an important opportunity for states if it gives them the ability to set a capitation rate with providers and to hold the managed care companies accountable for meeting that financial demand and also an opportunity to identify the goals and the outcomes and hold these companies accountable for the care and the outcomes that they serve or that they provide. in terms of the regulatory framework and the managed care role, and i think that we probably need to move to an era where we are holding the states accountable for the outcomes, butting havi inhaving the state through pages and pages of regulation, my question is for that regulation, what does it do to improving health outcomes for the individual? i'm all about wanting to make sure that we are being appropriate with the health care dollars and managing the resources effectively, but looking at the regulation sx that regulation helping states improve the health outcomes, and sta states will spend millions of dollars to implement that particular regulation, and we have to ask ourselves, what will we achieve? so there are some important developments within the managed care regulation, but if i am confirmed, i want to take a look at it to make sure that we are not burdening the states with the additional regulations. >> okay. let me ask you this. your written statement alludes to providers struggling to deal with the administrative burdens, and while we need the providers to be accountable for the care they provide and the associated government spending, it is crucial to minimize the reg regulatory requirements of taking time away from treating the patients. we have heard the concerns regarding the very specific requirements that are a part of medicare and medicaid electronic health record of the medicare, medicaid and medicare electronic health record incentive program. we are also hearing that many other requirements are unneeded or outdated. so how do you think that cms can best go about the important task of reducing the unnecessary regulations? >> well, i think that one of the places to start is by talking to doctors and having open communication and collaboration with physician, a if i am confirmed that is a priority for me to touch bases with the providers aed on the understand the issues of them getting in the way of them providing the health care to the patients they serve, and i would want to identify the provisions that are asking providers perhaps to consider maybe not participating in the program, and starting with that open communication, and dialogue and working with them to understand what their concerns are. >> well, thank you. i think that i will turn to senator wyden for any questions that he has. >> thank you very much, mr. chairman. and again, ms. verma, i would try to get a sense of how you would approach those thing, and that is why i asked apropos what cms did for one example specific to putting the patients first and the same with respect to medicare part d. this, colleagues touched on and the members feel very strongly about rural practices and rural patients and we feel very strongly about making sure that we get macra right. and when i am home in oregon i get asked about questions of two key parts of the payment system a lot. i get asked about virtual groups and the definition of more than nominal risk. and people say, hey, what's this go going to mean for the small and rural practice? now, obviously, this is not dinner table conversation either, but for the doctors in rural oregon and small practices, they say that this is really going to tell us about whether we are going to be succeeding in the brave new world of payment systems. so, tell me a little bit about how you as administrator look at something like this, and i mean, senator thune for example has also been concerned about the virtual groups. how would you go about constructing and implement iing the virtual groups. >> i think that small providers, rural providers in terms of ma krshc macra it is a challenge for them and it is a worthy goal, but we have to be supportive of them through the process of implementing it. in terms of the providers taking risks, and the smaller provides, that's a larger mountain to climb. i think that they are going to be reluctant to take the risks when they are starting out. many small providers and rural providers don't have financial reserves that the bigger health systems have. in terms of putting them on the hook, a lot of them when we think about health outcomes and holding the providers accountable for outcomes, a lot of it depends on the patients, and thinking about the strategies of how we can engage patients to be a part of the equation so they that have the same investment, and some investment to work with the providers towards achieving outcomes. and in terms of smaller providers and rural providers taking on risk, that is going to be a formidable challenge. >> and on virtual groups, what is your take on, let's say the most important thing to make them work? >> well, i think they we have to continue to work with them to understand what their specific concerns are, and trying to address it, and at the end of the day, those are going to be the challenges that we are going to have to work through with them. and what i have found is that listening to folk, and understanding what their concerns are, and trying to see to the best of our ability if we can try to address the concerns. >> and what about the whole question of nominal risk, and again, i want to keep this open-ended enough so that it is not, you know, we want to hear about, you know, paragraph 3, line 2. i just want to get a general sense of how you'd approach it, because this is what rural physicians and patients are going to talk to me about. i have town hall meetings in a couple of days, and how about nominalk? >> well, i -- nominal risk? >> well, i don't know if the rural or the small providers want to take the risk at all, and when we are designing the programs, we have to keep in mind their specific needs, and taking on risks is something that insurance companies have done, and some of the larger health care systems have done. and if we are look agent the aco models we know that very few providers and even large health systems have been comfortable taking on the risk, and so this is a considerable challenge for the smaller provides. some of them may or may not want to do that. >> so does that mean, and when i listen to that, it sounds a little bit like ms. verma wants to keep the fee for service. >> i think that fee for service, and there are concerns for fee for service that is rewarding volume over quality and outcome s, and so i am not suggesting that works better. i believe that there is something to be said, and i support the efforts to increase the coordination of care and to hold the providest accountable for outcomes. i think though that in terms of holding providers accountable for the outcomes, and it is another thing the altogether to have them accepting risk. >> so let's do this like we did the other two questions. i would like in writing, because this is so important for rural practices, rural providers, i would like even one specific that you would pursue to try to address these issue, and the reason that i am asking is because it is a big lift. no question about that. there is no question that trying to keep a rural practice open is a big lift. but these are the questions that provid providers are going to ask me. they are going to when they see me and say, ron, you are on this committee, and you deal with issue, and how is the government going to go about doing it? i want to have one additional question later, mr. chairman, but let us add that to the matter of the specifics both with are respect to putting patients first as opposed to insurance companies first as we heard yesterday and the pharmaceutical question where i would like a written answer. i think that given the fact that these matters are move on a fast-track, we are going to need to have your answers certainly within the next three days or so, okay. i will have one additional question, mr. chairman. >> why don't you ask it now. >> we only have a couple of minutes on the vote. that is why we have the -- >> oh, so we both have to go, don't we? >> mr. chairman, if you are willing, we could do the vote, and i have one additional question, and i assume that you will want to make a closing statement at the end, and i would like to, too, and we have some senators coming back. so i think that -- >> you have time. >> okay. >> we will come back. >> we have 10 minutes on the vote. >> we will come back. >> okay. let me use a little built of the ten minutes to ask another question. there is great provider interest in participating in the projects to change the way that payment is made to incentivize the providers and the way they deliver care. and the way that these payments are run through the center of medicare and medicaid innovation center, but some are conducted independent of it such as the accountable care organization program, and while all of the programs involve some type of formal evaluation, there is understandably great interest in knowing what works and what does not as soon as possible. and what is your view to testing different medicare payment approaches, and how to best assess the results? >> a couple of thing, and one, i would say that first of all, i support the efforts around innovation, and it is important that we are always trying to climb the highest mountain, and that we are never satisfied with where we are and always trying to figure out how to do better and better quality health care, and improved delivery service, and so innovation is important, but as we are looking at testing new ideas, that process has to make sure of a couple of things. we have to make sure that we are not forcing, and not mandating the individuals to participate in an experiment or some type of a trial that there is not consent around. that is very important. and that is first off. and evaluation is the first component and obviously, that is why we are having to do that to understand whether it can be transferred or used for a larger population or policy of the program. and so evaluation is a critical component of that, and that need s to be set up on the front end, and it needs to be, you know, on the before the evaluation goes full scale, and it should be done on a small population or on a small frame first before it is expanded, but that evaluation needs to be done on the front end all of the way throughout the process. as it is expanded or before it is expanded those results should be shared with the stakeholders and i hope that with members of congress and there should be discussion about that and before that becomes formal policy. >> thank you. let me ask one more question while we are waiting for some of the senators to come back, and then i have to vote again. and seeniors have to choose to enroll in the fee for service or the private insurance option called medicare advantage, and according to the cms approximately 18.5 million people, and roughly 32% of all medicare beneficiaries have signed up for a medicare advantage plan this year. typically the medicare advantage plan offers extra benefits such as dental, vision, hearing or wellness and require smaller copayments and deductibles than the traditional medicare. and sometimes the seniors pay a higher monthly premium to get these extra benefit, but they are financed through the plan savings, and traditional medicare does not limit the patient out of pocket spending for the part a or part b services causing some seniors to buy supplemental coverage called medigap insurance. people who do not have retiree coverage or who cannot afford medigap supplemental insurance finds that medicare advantage plans offer the extra benefits that traditional medicare does not cover, and protect them from higher than expected out of pocket spending. i had a lot to do with the medicare advantage by the way, so i will tell you that in advance. ms. verma, can you commit to working with the committee and congress to preserve and strengthen the successful medicare advantage program? >> i can. and it would be my pleasure to work with you on that. i think that the medicare part c or the medicare advantage has been a great program for seniors. what i like about it is it is offering choices for the se seniors, and they have the ability to figure out again in part d what plan works best for them, and the fact that it p provides them the opportunity to have additional benefit, vision, and dental services, i think that it is very important and the fact that it provides more choices for seniors is an important component of the program. so i'd be happy to wshg with you on that. >> thank you. i notice that senator crapo is going to pass, and senator, i will call on you next, and i have to have the staff follow-up on this. >> right. >> okay. >> thank you for being here. i don't don't thithink that i w back, but we will continue on until we get this hearing over. >> senator cassidy. >> [ inaudible ] -- we are both f familiar with the data from m.i.t. that showed the expansion in some states that medicaid expansion in some states, and not just medicaid d, but it did not do much for the health outcomes, but the indiana plan seems to have an effect on outcomes, and can you comment on the nature of the structure of giving folks health savings accounts, and some information on their part as to what it did with the expenses and the outcomes. >> thank you for the question. it is always a pleasure to talk about the healthy indiana plan. the healthy indiana plan is about empowering individuals to take ownership of the health. we believe in the potential of every individual to make decisions about their health care. >> i will interrupt you briefly, because some say that the health savings accounts are not appropriate for those lower income suggesting they lack the technical ability or the sophistication to handle that, but you are suggesting that in the plan in indiana it was 100 to 138% of the poverty level? >> healthy indiana and even people at zero percent of no income -- >> they were enrolled in the plan? >> yes. and they were enrolled in the plan. just because individuals are poor it does not mean they are not capable of makings decisions. it does not mean that they don't want to have choice, and that they shouldn't have those choices. they are capable of making the decisions about the health care, and just because somebody is poor doesn't mean they shouldn't have choices, and that they are not capable of making decisions about their families and themselves. >> and it is my understanding that in your plan the e.r. visits went down. and in other states when there is an expansion, the e.r. visits go up, but in indiana, the e.r. visits went down, an kd so con xh concommit ly that is the plan? >> we saw better outcomes, and better preventive use, and less e.r. use, and more satisfied with the care, and they had better adherence to the drug regimens that the doctors prescribed. >> and a skeptic would say splitting bit those who make contributions and those who did not, you is end up with two populations, the ability to contribute reflected something underlying. i assume you did a regression analysis of some sort, and did you find that to be the case? >> no, what we found is that the individuals actually making the contributions towards their care were actually sicker individuals, and they had more complex illness, and yet when they were making contributions towards the care, they had better health outcomes than the individuals who were health y r i -- healthier to start with. >> so the folks who were healthier and had disposable income, and valued the health care more and reflected in the contribution and positive correlation of adherence. >> yes, better drug adherence, and more primary care and pre n preventive care, and these were not by small margins, i would add, and looking at the primary and the preven ztive care, they were margins of 20%. so there were significant differences for the individuals, and what it shows is that we can empower the individuals to take ownership for the health, and people, just because u they don't have income doesn't mean they are not capable, and they don't want to have choices. and we believe in the dignity and the potential of the individuals to make decisions, and happy to do that and they have better outcomes. >> the key factor in the academic leadership and you talk about the activated power, so to what degree is the patient engaged in the partner of their health and to what degree does he or she participate related to each other, and that turns into causative outcomes, and lower costs? >> yes, that is what we saw in the indiana plan. if we compare the indiana plan to other states, we have found that it costs less, and reduce the number of insured in the state at higher levels than other states who have run more traditional programs. so we have done it at a lower cost and had better outcomes, and reduced the number of uninsured. >> but there is a federal role in this, and so it is possible to reduce the federal role to zero in a plan such as yours and be viable in a state with a high poverty rate? >> so in indiana, negotiating the healthy indiana plan, and achieving the waivers, and the governor asked for the healthy medicare plan for the expansion and he asked before the supreme court decision which made it optional and it took us, and he wrote that first letter in 2010, and it took the federal government almost five years to make a decision about whether this program could work. so i think that, you know, it is something that we need to look at or that i would hope that congress would want to work on, because that type of back and forth -- >> and so the process can be made more efficient, but again, the federal dollars are essential as well. >> exactly. >> thank you. i yield back. >> thank you, senator cassidy. senator nelson. >> good morning. i enjoyed talking to you on the telephone. do you support turning the medicare program into a voucher system? >> i support the medicaid or the medicare program being there for seni seniors. and people are making contributions into that program. >> and so would that include the voucher system? >> i think that i don't support that and i think that what i do support is giving choices to seniors and making sure that progr program is in place. what we have seen is that efforts and there is a lot of conce concerns about the future of -- >> excuse me for interrupting. i didn't understand. >> and the fellow who is now the sek tear of hhs had taken a position as congressman s supporting the voucher system. turning medicare into the voucher system, and do you support that? >> so let me back up with the answer here, and try to explain this a little bit more. i think that what i have seen in terms of different types of options that are being discussed around medicare, and those are borne out of the individuals who want to make sure that program is around. i want to make sure that the program is around for my kids. so, you know, what we know from the trustee's report is that -- >> to make sure that it is around, you are saying that you would consider alternatives? >> i think that i'm not supportive of that. i think that we need to -- but i think it is important that we look for ways of making sure that the program is sustainable for the future. >> okay. let me give you one of the alternatives. one of the alternatives is to increase the age from 65 to 67. do you support that? >> you know, i think that ultimately what direction we go into is up to congress. as the administrator of cms, my job is to carry out whatever congress decide s s is the best course of action for the medicare program, and i would hope that we would work towards making the program more sustainable so that it does exist for future generation, and that it is a program that provides high quality care and accessible care and gives seniors options. >> so you don't believe that you should be involved in the policy, but leave it up to the congress? >> it is the role of the cms administrator is to carry out the laws created by congress. >> all right. let me ask you, and there is another availability that seniors enjoy which is the doughnut hole was closed which means that seniors in florida spend about $1,000 less out of their pockets by drugs being reimbursed through medicare. so, in the medicare prescription drug program, and now i know that you had a question close to this, but what i need to know is do you support the provisions in the aca that close the coverage gap to make prescription drugs more affordable? or closing the doughnut hole. yes or no? >> i support efforts to make the availability of medications affordable and accessible for seniors. i want to make sure they have choices about the medications that they need, and that that coverage is affordable to them. so i support efforts in terms of -- >> let me -- i am running out of ti time. i am just trying to get clear your thinking on this. so if a senior, since you support making drugs affordable to seniors, but if a senior had to the pay $1,000 more dollars out of their pocket, per yeardr, is that something that you would support? >> ultimately what happens with the donut hole is really up to congress and how we move forward on this. as the role of the administrator, my job would be to emplemeimplement the policy legislation -- >> so back to the policy by congress. here's one you may be able to answer. how about as you know on dual eligibles, the federal government gets a discount from the drug companies for the dual eligibles that are eligible as medicaid until they get to 65, then they get their drugs from medicare. but then there is no discount. would you support requiring drug manufacturers to pay drug rebates to made care for the dual eligibles? >> as i said before, i support efforts to make drugs more affordable to seniors. i think this is an issue that we're all concerned about, the president's concerned about as well is that we need to make it more affordable. i would look forward to working with congress on strategies that can help it be more affordable while maintaining accessability. >> i'm sorry you have the constraints put on you so that you can't answer these questions forthrightly. those are the questions that i can tell you senior citizens are begging to hear the answers, because if you had approached this as candidate trump had saying he was going to protect m medicare and social security and not have any cuts, your answers would be different. and they would be clear. but you've chosen to go the route that you have and i'm sorry that you have those kind of constraints. thank you, mr. chairman. >> thank you, senator nelson. for the benefit of the members of the committee, the order remaining of those who haven't asked questions is isaacson, brown, heller and scott. that's the order we'll go in. unless somebody pops in that is still on the list. first of all, i'll just make a statement. you don't have to comment unless you want to, but words are strange things sometimes. in the veterans administration, three years ago republicans and democrats joined together to create the choice program to try and expedite veterans getting services and to maximize the use of the va in the private executor. and all those were because the access to the private sector gave the veterans better access. so the veteran had the choice and used the private sector and the veterans administration to do it. i think that's a good example of where choice made a difference. delivered health care. didn't change the cost. made access ability better. choice sent a bad word. it can be a good word. it's been a good program and it's worked ever since. are you familiar with that program? >> i'm not familiar with that program, but i agree with you that choice is critical. when there's choices and there's competition and we've got folks that are trying to attract our beneficiaries to the system, so choice and competition are very important to driving better quality and outcomes and lower cost. >> in georgia we have 1.9 million georgia ans on medicaid. 1.3 of those are children. half of the children born in my state are born with medicaid benefits. are you committed as we go through the reforms and the enhancements and the improvements to the program to keep children foremost in our mind for coverage. >> as a mother of two children i certainly understand the importance of health care for children. one of the things that i'm reminded of in my work with the medicaid program and with the chip program, remember hearing a story about a woman and it was after the chip program had been passed. but she talked about how she had a child who's an infant, probably one or two years old, maybe not infant, about one years old. she had gone to the doctor and he child had an ear infection and the doctor gave her a prescription just for a simple antibiotic to treat the ear infection. she went home that night and she had a choice to make. if she filled the prescription, she wouldn't have enough money to pay for meals for the whole family and so she made the painful decision of not filling the prescription and feeding her family for the whole week. and what happened to that child is that because of his untreated ear infection, he ended up losing his hearing and going deaf. and so i'm always reminded of that story. that child now needs lots of different services to help him through and that's something that could have been prevented. so it's very important that children have access to high quality services. that's really important so that we don't have situations like that. >> thank you for your answer. are you familiar with the 21st century bill that passed. >> i am. >> it's a great piece of legislation. one of the provisions in that bill which is very important to us on home health care, it provided for reimbursement for medical equipment, on home health care and home infusion through medicare. something we want to make sure, because under the aca home health care was almost totally removed from being reimbursed and having had personal experiences, i know home health care is the best environment to deliver health care services and the least cost to the government. i hope you'll look closely at that 21st century cures building and the home infusion we put in it to see that it get implemented. >> i'd be happy to work with you on that. i applaud congress for coming together on a bipartisan basis to pass that law and i think it's going to have a pretremend impact on the health care of americans and i appreciate your efforts and would be happy to work with you. >> leftly when i was in the state legislature years ago the biggest thing we fought was a lot of fraud and medicare and medicaid. that still is a problem today. i am very familiar with it from the business i was in, the verification of eligibility is very important to make sure you have minimal fraud and minimal waste. are you committed to using the resources that are available in the private sector to verify eligibility where it is important? >> i am absolute committed to that. >> thank you very much. senator brown, i'm sorry to tell you, but senator mendez slipped in. he's going to be one ahead of you. >> thank you, mr. chairman. ms. verma, congratulations on your nomination. one of the successes of the affordable care act was the establishment of a nationwide benefit standard called the essential health park packages. one of amendment was to ensure that coverage for behavioral health services are available in every plan purchased through the marketplace. that's to ensure that a child in georgia or indiana or new jersey has equal coverage and equal access to the care that they need. i've heard from countless families about the anxiety they have over losing access to critical autism services through a change in the essential health benefits that allows insurance companies to deny coverage which is especially acute in states that lack a state based requirement. do you agree that a child a access to insurance that kcover a condition like autism should not be based on what state they live in. >> i appreciate your question. my husband is a child psychiatrist so he deals with those issues on a day in and day out basis so i certainly understand the concern. i have been advised by the office of government ethics not to participate on issues regarding mental health services because my husband is a psychiatrist and that it account impact his practice. >> with all due respect, autism sent a mental health issue. autism is an illness that we are still trying to develop the essence of its cause but at the end of the day i use it by way of example. are you suggesting that you cannot tell the committee a simple answer to the question that it shouldn't matter where you live in the nation, that in fact you should have access to the same coverage as any other child? >> i think that all americans should have access to the health care services that they need. however, in the issue that you're asking me to comment, i've been advised by the office of government ethics not to participate on matters that because of my relationship, my husband's practice, to not -- >> did they define to you the list of things that fall under this category? >> he does treat children with ought tic autism, so they have asked me not to engage on matters -- >> that's pretty amazing to me. let me ask you this. as you know, congress has to act this year in a package of medicare extenders. which of those medicare policies do you consider to be your top priority? >> i have not reviewed that particular regulation, but would be happy to review that if i'm confirmed and work with you on that. >> well, let me just say medicare is a big part of what cms deals with. and i would have thought that in preparation for this hearing you'd have a sense of these are extenders that are almost on an annual basis or bi annual basis and giving you a sense of what you will be advocating as it relates to medicare. your role as the cms administrator is more than just executing simply the laws of the country which certainly you would. but it is also a policy development, heavy position, that the president and the secretary of health and human services and the congress relies on which drafting laws that ultimately would have impact in your per am ter. so you have no idea as to which one you consider the most significant? >> at this point i would want to review that before i gave you my opinion on that particular area. >> let me ask you this. during our meeting in my office you referred several times to able bodied beneficiaries as we were speaking about medicaid. do you believe that low income and working las individuals who gained access to medicaid thanks to the affordable care act expansion should be eligible for medicaid? >> i think that -- >> i think that's a simple yes or no. do you believe they should have access to medicaid eligibility? >> i think that all americans should have access to high quality health care services. >> that's not an answer. that's not responsive to my question. i'm asking about medicaid specific. >> when i think about the medicaid program, i think about it almost in two different parts. there's the part of the medicaid program that serves the aged and the blind and the disabled. that's a very different population than some of the able bodied individuals. but at the end of the day, all americans should have access to high quality affordable health care coverage. >> well, i will just simply say unresponsive to my questions. i can't vote for someone to be the admip -- administrators of one of the most significant if i cannot glean what your answers are to these questions. it's very difficult. i have not been against the president's nominees. i have voted for several of them. but you've got to give me more than that. i hope your responses to written questions will be more enlightening for me. thank you, mr. chairman. >> thank you. congratulations on your nomination. we had a great discussion about innovation in the pacific northwest and i wanted to follow-up on that. to my colleague's point, there's been a lot of discussion about block granting medicaid. are you in favor of that? >> when i think about the medicaid program, i will say that the medicaid program as a status quo is not acceptable. i think that we can do a lot better for the many people that depend on this program. we're talking about disabled individuals, people that are developmentally disabled,mentally disabled and we can do a better job than what we have today in the program. we know we're not delivering great health outcomes. there's been study after study that shows that even people that don't have medicaid have better health care outcomes. >> do you think there are problems with block granting medicaid? >> i think that when i look at this, i think we need to think about how we can make this program work better. the status quo is not acceptable. this is the united states of america and we can do better for our vulnerable populations. we can hold states accountable for producing better outcomes. >> so are you endorsing block granting? >> i'm endorsing the program being changed to make it work better for the citizens that rely on it. >> so you're not endorsing block granting. i'm just trying to understand because this is the debate as far as i'm concerned and i know that several of our colleagues probably those in the house are very adamant about this. so i'm just trying to understand where you are on that question, whether you either are for it or against it or have concerns about it or epdondorse it. i'm giving you a little more room than my colleague gave you. >> i appreciate that. thank you. what i support is the program working better and whether that's a block grantor a per capita cap, there are many ways that we can get there. but at the end of the day, the program isn't work as it should. when you've got one state spending $4,000. you have another state spending $15,000 for the same population. can we show the outcomes are better? can we show that individual had accessible to high quality care? what we know is going on at the state level is in terms of accessability. one third of doctors aren't taking medicaid patients. that means for a disabled person when they're sick they call the doctor and some of the doctors won't even take them and the doctors that are taking them they're having to wait for a long pest riod of time to get c. i think we can do better for these people. i support efforts to get us there. >> well, i would say this. this whole notion that capitating our block granting, we know what the results of those have been. it's resulted in a 37% cut. if you just extrap lated that out, unless you assume that you have these states who would step up and cover those populations, my colleague senate hatch was talking earlier about the increase in population. the increase in population is what's driving the cost. so coming up with a better strategy for that population like rebalancing that i had a chance to talk to you about, way more cost effective in our state. we save $2.5 billion by taking people out of nursing home care and putting them in the community based care. but trying to capitate or saying we're going to block grant it. if you said to me state -- and the state didn't come up with any more funds, if you applied that same 37% you'd be cutting over 100,000 people in king county off or 43,000 people in spokane off. that reduction, that other block granting programs have received over the last 15 years, it would be like cutting a million people in ohio off of medicaid unless the state came up with more money. so my point about this is i hope you'll be an advocate for the innovation in medicaid that instead of trying to nickle and dime poor people on a co payment or administrative cost, come up with the strategies like rebalancing that give people real opportunities to deal with this population, save costs, and keep people in a better healthy situation. that's why i have grave, grave concerns about this notion of block granting medicaid or the citation as you mentioned. >> i agree with you this is what it should be about innovation, but what's going on in the medicaid program today is that we have a very inflexible system. when states are trying to do creative things and i agree with you in terms of rebalancing incentives and giving medicaid b beneficiaries being served, but the way the system is set up they have to go to the federal government for routine changing. it can take years to get a waiver done. we need to create a medicaid program that allows states to be innovative and have that flexibility so they can focus on producing better outcomes for individuals. i strongly do not want to see anyone not get health services. we're talking about the most disabled and vulnerable people in our population. we can do better. we should be able to deliver better outcomes for these individuals and hold states accountable for high quality coverage. this isn't about kicking people off the program. it should be about improving outcomes. >> we'll have more chances. my time is expired. i hope you remember innovate, don't capitate. >> thank you, mr. chairman. i'm going to follow-up on senator cantwell's points. welcome. you're a product of my state of maryland in education. we're very proud of your accomplish mentes. it's nice to have your family here. i want to talk about minority health and health disparities in this country. part of the affordable care act was to put a focus on it. we now have a national institute. there's a good reason. because historically minorities have been discriminated against in our health care system. we look at health care results on diabetes, heart disease, infant mor tatality and other indicators and we know we have a problem. we've been making progress on that problem. that's what i want to refer to senator cantwell's point with resources. resources are important. ii every polish decision we make and at the white house is driven by what are the policy results but far too often it's drifb by the budget numbers. that's the reality. that's what we deal with. and senator cantwell's point is if you move to a block grant in the medicaid program, the odds are it's going to be to fill a budget number, not to fill a policy driven objective. who is vulnerable? the most vulnerable people in our society. in maryland almost 70% of the medicaid population are from communities of color. that's in my state of maryland, 70%. so when we expanded the opportunities for medicaid under the affordable care act, it made a big difference. you may be familiar with the greater baten health center. i've been visiting that center for many years. they're now able to provide mental health services and pediatric dental services and giving access to care in i vulnerable community because of the expansion of medicaid. if we were to go to a program that's innovative but doesn't have the resources to implement vulnerable people are going to get hurt. so i just want to get your understanding as to the importance of resources. we're not going to improve our health care system by telling people of means that they can't spend money on health care. they can get the health care that they need. it's the vulnerable population that is going to be challenged. and as tough as budgets are here, budgets in annap lis and other states around the nation are even tougher. medicaid is such a large part of the state budget that when you say we're going to innovate but we need to invest no innovate, they don't have the money to invest to innovate. then they have to look at let's eliminate dental or the essential benefits that senator menendez was talking about. so tell me how you're going to advocate for the poor. how you're going to advocate for those who are challenged in our system. i don't know all the answers of the indiana system. and you i had a chance to talk about it. i applaud you for looking for innovation in your state. but some terp printerpreted don the resources to pay and if they don't they're put in a system to deny benefits they need. i'm interested how you see this system being fair to our most vulnerable. >> well first of all, i would say i have fought for coverage for better out comes, for v vulnerable populations my entire career, with hiv and aids. the issues that you raised around minority health are near and dear to my heart. i'm a minority and i understand you have different cultural norms that impact the different type of how care is delivered and the type of advice that we give to individuals that are minorities so i certainly understand that. you talked about the healthy indiana plan and making sure people have resources for their health care. we looked at in the healthy indiana plan was all about choices. we believe in the individual dignity and the empowerment of the individuals to make their choices about their health care. and what we found is that what wh we gave people those choices, they made good choices and they had better health outcomes. we saw emergency room usage go down. >> that's what we're seeing under the expansion of medicaid in the state of maryland with many more people ensured. we are seeing much less use of emergency room care. much more preventative health care because we now have more people in the medicaid system. about 250,000 more in our state. so yes the expansion of third part coverage is important but the walt is also important. if you don't have preventative care, you don't have pediatric dental, we know what happened in our own state of maryland with a tragic death. i appreciate we're looking for innovation. but if you don't have the basic coverage, if you don't have the alt ability to provide the essential services, it's the vulnerable who are going to suffer. >> i don't want to see the vulnerable suffer. i've been working on that particular issue my entire career. i've done this on the local level creating programs in marion county and i've done that on the state level f. confirmed i will continue that fight. >> thank you. thank you, mr. chairman. >> senator brown. you finally made it. >> thank you, mr. chairman. thank you. thanks for coming to my office and speaking. i was a little disturbed with senator nelson's comment or question about medicare eligibility age at 67 or even 70 as you're future boss has both sponsored legislation at 67 and was not willing to tell the committee he had changed his mind or was opposed to and it vouch medicare. i was concerned when you sent us up to congress. i would hope that you -- i'm not asking this as a question, but i had hoped you would look at cms as a platform to, one, tell your boss the secretary of hhs and your ultimate boss the president who said he wouldn't do those things in the campaign but then he nominates congressman price but i hope you use that as a platform to stand up against two things. they're devastating to working class americans. couple questions. first is simple. form governor kasich extended medicaid in ohio 700,000 plus people now have medicaid coverage. ohio's former medicaid director had an excellent relationship with cms. my question is, this one's the easy one, i'd like to ensure this positive working relationship and i'd like to ask you to commit to sitting down in person with director sears and perhaps if you choose a group of medicaid administrators to discuss my states and their states priorities and concerns when it comes to the medicaid program. i'd like to ask you to do that the first few months on the job. >> that would be my pleasure to do that. i feel strongly about working with states in open relationship and partnership. >> thank you. during our meeting you spoke about chip and what it's done. in 2010 when congress improved chip by streamlining enrollment processes and increasing outs reach efforts and other things, we now have 95% of children in america now with affordable comprehensive health insurance. what's want to love? secretary price mentioned in this hearing that he would support an eight year extension of chip. the current chip program. it's important that when we upgraded chip in 2010 and streamlined it so it's a clean law now and easily understood, do you agree with secretary price that congress should act quickly to pass an eight year extepgz ae extension and do you agree that should be an eight year extension of the current chip program? please give me a yes or no. pretty simple. eight years and clean chip. >> i support the reauthorization of the chip program and agree with congressman price that we need to do this to the fullest extent possible and i look forward to working on congress with that. i've got two kids of my own. >> questions were precise. do you agree to eight years that he suggest snd. >> i support the reauthorization as long as possible. >> eight years would be possible? >> eight years or more. >> i know it's congress. what you don't want to acknowledge or don't understand is your recommendation to this congress, you can say it's up to congress of course. ultimately laws are. your recommendation to congress, if you and secretary price would say we want eight years extension and you would also say we want a clean extnension and not a roll back, it would really, really matter. i think you would get every democrat and you would get most republicans and that would take that off the table. it would take the uncertainty out of all these programs that we just kind of limp along extending it a year or two or three or five at a time. i ask you again will you recommend eight years and will you recommend a clean chip extension? >> i will recommend and support the reauthorization of the children's health insurance program for as long as possible. i think it's very critical that children have access to high quality services. you and i talked about this in our office about my experience with this. so i support children having access to health coverage. >> it would sit with me more if you said yes and yes but i appreciate the answer. beginning march 8th let me ask you about another issue. hospitals will be required to give notices to applicable medicare beneficiaries as required under the notice act which congress i'm sure you're aware passed last year. if confirmed will you commit to aggressively enforcing the -- those notice requirements for hospitals? yes or no? >> if i'm confirmed as cms administrator, it is my job to follow the law and to implement the programs as designed by congress. >> okay. the moon notice is an important first step. but it doesn't fix the issue of observer status, the underlying three day stay requirement, hospitals are increasingly caring for medicare beneficiaries as outpatients under observation status as opposed to admitting them as in patients. while the classification of a hospital stay doesn't affect the level of care that a beneficiary receives. it has significant repercussions for the three day requirement and for medicare coverage. do you support changes to the three day stay requirement? >> that's something i would want toto review and would look forward to working with you on that. >> do you have opinions of the three day stay requirement? >> i would want to review that in more detail. >> do you know what it is? >> i do know what it is. >> tell me a little about it. >> but i'd like to review that at this point and be happy to work with you on that. >> secretary price who apparently knows more about the observation status issue raised it during his confirmation hearing. he specifically mentioned he'd like to work on improving this role. i assume you would work with him on that. so can you give me any thought auto what you would do at cms to improve the three day requirement? >> i think we need to work with providers on this. i know there's been some issues there in terms of skilled nursing facility and the impact of the role on patient's ability to get in with that, so i would want to review that more carefully and be happy to give you my comments. >> that was less than satisfactory. i appreciate the effort. it's a huge observation status is a huge concern for beneficiaries across my state. we get calls as i'm sure in indiana some of your counterparts were doing medicare got calls but i know that senate nelson and others have been working on this issue for years and i hope we can work on it. thank you. thank you, mr. chairman. >> mr. heller, i apologize, but senator slipped in. i have to go to him next. >> thank you, mr. chairman. i hate it when that happens when i'm down there. my apologizes. ms. verma, thank you for being here. welcome. thank you for your willingness to serve. i know this has been touched on already, but i wanted to follow-up because when the macro final rule was released last november i was concerned about the decision to delay implementation of virtual groups. then acting administrator indicated that details were being worked out and cms was soliciting feed lack. the role stated implementtation would not come until 2018. i am concerned with how we roll out new payment systems in rural areas. will you make it a priority of yours to ensure that virtual groups are timely and effectively implement snd. >> i would be happy to do that and happy to work with you on that issue. >> and how do you plan on engaging with those rural and sole practitioners to ensure that this is a viable option they can take advantage of? >> i think the rural providers and frontier providers are very unique situations. when we're thinking about policy, we need to engage with them on the front end to understand what their concerns are before policies are rolled out. to make sure that we are understanding the impact on them. things that work well in an urban community don't necessarily work well and i think sometimes living in d.c. we don't have that understanding. so anytime i think we have a policy we need to work with rural providers with frontier providers on the front end to understand what their concerns are and what the potential impact would be. then once something is out there, we need to make sure we have that continued collaboration and communication so that there are problems and there are issues that we can address them in a timely way so that we're not impacting patient care and that we have a commitment to providing high quality care and access. >> i'm glad to hear you say that. additionally the gao had recently released a report. in fact, it was in december that list the hurd dells that small practices may face when trying to participate in macro's new payment models. as cms moves away from fee for service and toward rewarding quality, i want to ensure that rourl providers in my state will be ability to participate in new methods increase quality and reduce cost. aside from the previously mentioned virtual groups, how would you go about ensuring that small and rural providers have access to these programs? >> i think it's critical that we make sure in rural areas and frontier communities that we have that high quality health care. again, it goes back to collaborating with them. these programs i think have an enormous promise to deliver high quality care and move us in a different direction, but we need to work with those providers on the front end to make sure that they can handle these new regulations and rules. what i find is that in the rural communities, they're stressed in providing care. they have a lot of e nonormous burdens and we need to make sure rules and regulations don't prohibit them from providing high quality care. having to deal with a lot of rules and regulations can be difficult. we need to be supportive of them by providing technical assistance, make sure we're able for communication and supportive of them throughout the process of implementation. >> i'd like to turn quickly to one other issue. as to the meaningful use program for electronic health records, given the program's somewhat rocky track record, what do you believe is the use of the program at this point? >> i think that electronic health records have enormous process. i think it's helpful for physicians in terms of doing data and evaluation. but it has been a rocky start. i think as a patient i've gone to the doctor's office and even seen signs in the wait objection room that says we're going to be delayed or it's going to tag a while because we're still getting used to electronic mael health records. i've been in the room with my doctor when they're staring at their computer instead of looking at me as i tell them about my health care issues. we need to make sure it's working for providers and patients. if we're going to have electronic health records, then we should make sure it fulfills its promise so if somebody goes to the emergency room, even if they were in a different hospital or provider system that the doctors can pull up the information and that they have that oi oh tho-- those tools ab medications a person is on. we need to make sure it's fulfilling its promise. there is -- i think there's a lot of potential there in terms of prompts. i hear that physicians like the ability to, when they're talking to a patient, being able to say what pharmacy do you like and immediately send that script. there's a lot of value there. but we need to make sure that t it's also you filling its promise and giving us the things it's supposed do. so when you show up in an emergency room you have all that information. sometimes i know we've come short on some of those things. that's something where i think we need continued efforts around that. >> final point. i look forward to working with you. i mentioned in our discussion or meeting, better coordination between the indian health service and cms. that's an issue we've had lots of problems with my state of south dakota and i hope we can make a lot of head way. >> senator heller, your time has arrived. >> terrific. congratulations to you and also to your whole family that's there behind you. your kids are very patient. i notice that she's getting a little fidgety. maybe need to hurry up a little bit. glad you're here and glad the family is here. 20% of the state's population in nevada is on medicaid. another 15% of the population is on medicare. we discussed in my office how important it was for you to strengthen and protect these programs and how critical that was for the state of nevada. i want you to know i appreciate the conversation that we did have in my office. like everybody else, i would assume on this committee, everybody's a strong supporter of medicare and i share that. i will say also i have not supported and will not support legislation that does weaken medicare. so before i get started, mr. chairman, not quite sure who is playing mr. chairman at this point, i'd like to submit for the record a letter that i received from the speaker of the house in the nevada legislature. i asked secretary price if he would -- >> without objection it will be made a part of the record. >> terrific. let's go to a couple questions i want to maintain in the conversation that we've been having here on medicaid if you don't mind. nevada as you're probably well aware is one of 32 states that chose to expand eligibility for the medicare program. numbers since the expansion, nevada medicaid enrollment increased from 350,000 to over 600,000. as of july of 2016, medicaid enrollment in nevada is 200,000 people greater than what was projected before the expansion. i've had numerous conversations. i had a conversation with the governor. i've had conversations with state employees. i've had conversations with state employees. our state legislature, our hospitals that are all very seriously concerned about moving this program to a block grant. they're concerned that they will not have the appropriate funding to cover clearly all 600,000 that are on the program and on medicaid. they're concerned they do not have the staff to implement changes. also concerned about with a part-time legislature they will not have the time needed to draft different medicaid programs. so i guess my question to you is whether you're sympathetic to these concerns for these block grant states, these expanded block grant states like nevada and do you understand those concerns? >> i absolutely understand those concerns. i've worked with states for almost 20 years now, so i understand the concerns. i understand the state budgets. i understand the states that have expanded and the states that haven't expanded. we want to, i think in terms of the medicaid program, for me, the opportunity is about improving health outcomes. we're talking about very vulnerable population. these are individuals that it's a safety net. they don't have another place to turn. if you're disabled, if you're paralyzed, medicaid is the program. but what we have today doesn't work well. we know that studies after studies have showed that the outcomes aren't great. we know that states are spending different aims of money, $4,000 in one state, 12,000 r$12,000 ir state. do we ask these individuals about their care? i think that this -- the conversations that we're having should all be around improving health out comes and trying to do a better job here. i don't want to be about hurting states. that's where i come from. that's what i know. i've worked with a lot of different governors. i understand that where they are in terms of state budgets. there's not a whole lot of extra money. i think this is about giving states, putting states in a leadership role so they can manage their programs better. i think that when states are closer to the people they serve than the federal government and they have a better understanding of what can work in their state than the federal government. i think we've heard from some of the senators today about rural areas for example. they have special challenges there. frontier areas. so some of the things that are coming down from washington in terms of a one size fits all approach doesn't always work. each state should have that flexibility to design a program that works better for the people that they're serving. and they're better positioned to make those decisions than we are in d.c. so i think that this is an opportunity to create flexibility so that they're not having to go to the federal government every time they want to make a simple and routine change. and what we've seen in the medicaid program is that because it's so inflexible, there's not a whole lot that you can do in designing your program. and so what states do often when times are tough is they cut provider rates. in 2012 we had over 44 states either freeze or cut provider rates. and that has an impact on access to care. but they're doing that not because they don't care about the people they serve. it's because the program is so inflexible. i think an opportunity to give states more flplex built is an opportunity to improve health outcomes. >> is it fair to say you're pushing a block grant approach? >> i am pushing an approach that improves the medicaid program because i don't think the status quo is acceptable. i think we can do better for disabled people and for people that are very vulnerable and that are dependent on this program. i think we can do better improving outcomes and making sure that individuals aren't receiving health care in the emergency room. and that their health is actually improving. >> my time's up. are block grants on the table or off the table? >> i think anything should be on the table that can improve health outcomes for this very vulnerable toplation. >> so it's my understanding that block grants are on the table. >> i think block grants, per capita cap, anything we can do to help outcomes and create a level of accountability for states i think we should explore all of those options and i look forward to working with congress on this. >> thank you, mr. chairman. thank you for being here. we're excited for the opportunity to lies before you. i am co the chair of the six sell caucus. every valentine's day i have a chance to the children's hospital at the university of south carolina and hang out with kids that have been hospitalized several times for year, often times with cancer or a chronic condition that resurfaces. sick el cell disease has accounted for somewhere around 246,596 emergency room visits as a principle diagnosis in 2014. the young lady blind me who is a student at my alma mater. she has been in and out of the hospital as a youngster, 15 years old, a number of times. and having an opportunity to see the challenges that so many families face and the necessity of medicaid as their primary provider raises a lot of questions. one of the questions i would love to get your input on is what are your thoughts about innovative things cms can do to reduce readmissions, decrease costs for providers and payers, and improve care for those with sickle and similar conditions? >> anybody on the medicaid program, they're in a vulnerable position, whether it's age, disabled, or having a disease specific condition, they're completely dependent on this program. as i said in my opening statement, sometimes this is a matter of life and death. they have no place to turn. so we need to assure that we have the best possible program, better quality, better outcomes. and i think that those decisions and the ability to do that should come at the state level. the state has a better understanding of the delivery system and of the snecitizens t they serve. they're in a better position to make shows additions. in terms of readmissions and really focusing on outcomes, i think on the federal level it's important to establish what are the expectations of the program. what are we going to hold states accountable for. it should be quality and it should be access buiability. >> have you found working with the state of indiana there are a couple things you thought worked really well on the state level that you would like to see on the national level? >> well, first i would say that every state is different. >> i know. >> as i worked with states, i might be known for the healthy indiana plan and people say do the healthy indiana plan nationally. every state has a different opinion. i've never actually had a state that wanted the healthy indiana plan in entirety. they looked at it. took things that they liked about it and applied it and they design their own programs. so i think that's why we need to have a program that's flexible and allows states to do what works best for them. >> there's no doubt most of us consider the 50 states the labs tore of democracy where good things happen. without any question having a national model where we've taken the best ideas from those states is an important part of your responsibility moving forward. i know that you've consulted with a number of states, including south carolina for programs like the pay for success financing models where medicaid basically pays for performance. which i think is a fantastic model. what do you see as the future of the paid for success model in medicaid and what is the appropriate role for cms in that process? >> well, i think that, you know, the concepts around that program are critical. i think instead of micromanaging the process, i think we need to sort of -- we need to say definitively he are the outcomes are we are driving towards. i think right now we're managing the process. we're not holding states accountable. in terms of south carolina, one of the very innovative things they've done there is the application of the nurse family partnership for low income families or for low income first time mothers. having that home visiting program i think is an idea, an excellent idea. but again, that program, you know, had a lot of thought. it took many, many, many months to get that program approved through cms. that's a great example of how the state has this idea and it's innovative. it's been proven in other communities. and to be able to do that on a readily basis without having to go through that long process of approvals, i think that's an idea and the importance of having state flexibility. >> thank you, mr. chairman. >> thank you, mr. chairman. first of all, i want to thank you for you the opportunity i had to meet with you before. i do want to ask unanimous consent to the statement that i put in the record. >> without objection. >> we do have an outstanding nominee before us that has had a good life outside of washington and she doesn't need to be subject to personal attacks or made into a symbol of partisan discord. i really get distressed at the way these hearings go where we try to push for some things in actual legislation that ought to be reviewed and again reminding that she gets to make good suggestions. we get to pass the final laws. since i met with you i've read a lot more about you. you haven't just studied medicaid and medicare and other health situations. you've actually been hands on. you've done things. you actually helped states to make the process work better. you have a track record. and it's very impressive. i think around here that makes you over qualified unfortunately. you haven't been cutting people off of medicaid and medicare. you have experience that's worked at the state level. you and i talked about frontier and rural and that's been emphasized here again because we have several states represented that are frontier and rural. w wyoming has the low of the population in the nation. the last administration doesn't like energy and we are the energy state. and so our state has had to make some very tough decisions. a year ago the legislature in their budgeting had to cut 8%. when the session finished they found out that wasn't enough. so the governor had to cut 8%. now they're into the second year on the biennial budget and they came back and found out they have to cut another 8%. that presents a lot of problems not just in the health care area, but across the board, education particularly is being devastated by that. but they're working through it and they'll get it. when i met with you i also talked about medicare's com pet t tiff bidding program and we talked about unique challenges of rural and frontier states. i want to know if you'll be willing to continue to have a dialogue about how that competiti competitive bidding process can ensure that people actually get what they think they're getting and what we think we're buying n. your view, is it going to be important for cms to avoid putting in place the one size fits all programs? >> i think that's absolutely critical. working for states, what i see is that they're all different. their delivery systems are different. their patient populations potentialli potentially different. so a one size fits all approach z doesn't always work. what you're bringing up of the competitive bidding is an excellent example. some providers are being paid. they're rural providers but are being paid at a rate that's more appropriate for an urban area. i think that's the type of policy where understanding how that's going to impact a rural provider, a frontier provider on the front end and having that discussion so that we're not having problems later on down the line. and if we are having issues, then we need to be responsive to that. we want to make sure we are not impacting beneficiary access and that seniors and other folks that depend on cms programs always have high quality care and they have access ability. we don't want to see our policies and our programs are actually preventing providers or that we're losing providers or they don't want to see medicare or medicaid beneficiaries. so be very careful with policies so that we're not pushing providers out of the system but actually providing attract ors to the program. when we attract providers to the program, we are giving our seniors medicaid beneficiaries, we're giving them more choices. when they have choices, that's what's going to drive quality in the system and hopefully lower costs. >> again, you've demonstrated what you've talked about. you're not just talking about something you studied in a book or wrote a ph.d. paper on. as you know dual eligible individuals are a complex and expensive patient population. it affects both medicare and medicaid. are you committed to working at the federal level and with states at the state level to address the mounting financial concerns about the dual eligible population? >> i think we must address that issue. as we have in the aging baby boomer population and we have more and more folks going to be coming into the medicaid program and medicare program, we're going to need to have closer collaboration and make sure that we have the incentives in place to manage that program well and to assure that we are providing comprehensive, coordinated quality care to those individuals and we need to make sure the program works well for those beneficiaries. >> thank you for your outstanding presentation and your family has to be really impressed as am i with your capability of answering and your vast knowledge. >> thank you, senator. >> the rafrnking member would lying to ask a question or two and then we'll wrap it up. >> i do have a couple quick questions. let me also say i very much appreciate how this has been handled by you. you've made it clear the senators get to ask the questions that are important and that's the best bipartisan. as we move to wrap up, i just want to make that clear. i have questions that remain. one stems from this horrible tragedy you described where the family was forced to choose between food or -- putting food on their table or paying for a kripgz to treatprescription or chose food and the child lost their hearing permanently. what i've been told about the healthy indiana plan that you designed, if you had an individual who was making barely $12,000, had the same kind of choice and chose not to pay their premium, they would be cut off from coverage for six months. so that individual would not get treatment for an ear infection or another -- or other such condition. is that correct? this is what i've been told and i would just like you to tell me if that's correct or not. >> the healthy indiana plan is about empowering individuals to -- >> with all due respect, just is that correct? because we looked at the figures with respect to poverty and as i understood it at 12,000, that person would be cut off. is that right? >> the way the healthy indiana plan works is that people that are above the poverty level, above 100% of the poverty level make contributions into their haelg health savings account. they make those contributions. they get monthly statements so they can see how that money is being spent f. they complete their preventative health care services, then they have the ability to rollover that amount that's in their savings account to offset their contributions. if they haven't completed their preventsive services they can still rollover because the contribution they're making is theirs and they own that. in terms of what you indicated, if somebody doesn't make a contribution into their account or chooses to not to make that conviction, just like it is in the affordable care act, just like it is in the exchanges, for the same population, individuals make contributions, they have 30 days to make that contribution. if they don't, they're terminated from coverage and they can't reenter until the open enrollment period. so that is the exact same coverage that is the exact same policy. in fact, the policy that we have in the healthy indian plan gives people 60 days -- >> there's a three month grace period in the aca. >> there is's 30 day period where they continue your health coverage. but after that they suspend payment. so the individual actually does not have payment for their health care services. then they can't reenter the program until special enrollment period. with the healthy indiana plan they actually have a 60 day grace period. and then they can -- before they're terminated from the program. >> i'm going to ask this in writing, but we've reviewed this and if they make $12,000 they're terminated. i'm going to ask you that in writing. let me go on to the ethics question. this was reported in the indianapolis star. i guess that's the big paper in your state. that while you were running the state of indiana's medicaid program you and your consulting firm were paid millions of dollar by companies that did business with the state including hewlett packard and they provided management services to indiana medicaid. so the question became the indiana ethics regulations on conflicts of interest do not technically apply to you because you were a contractor and not a state employee. but my question deals with essentially basic ethics principles because it is hard to see how it's okay to basically orchestrate the state's health programs and then get paid by the contractors the state highs to carry out those very programs. so let us set aside indiana law. we understand that. i understand that those indiana rules do not technically apply to you. because you are a contractor. but how is this not a conflict because you are sitting in effect on both sides of the negotiating table? >> let me start by saying that i hold honesty and integrity as part of my personal philosophy. i demand that of my employees and i set that example for my own children n. terms of the issues that you raise in indiana, we sought an ethics opinion. we sought counsel on this to make sure there were no issues. on a practical level, on a day-to-day level, we weren't negotiating for hp. what we were doing for hp was helping hp develop communication materials for when they were putting out system changes so that people understood what those changes were. so helping them with communications materials. what we were doing for the state was around policy and helping them develop programs. and so the -- there was not overlap. when there was, when there was potential or when we were working on programs, we would recuse ourselves, so we were never in a position where we were negotiating on behalf of hp or any other contractor with the state that we had a relationship with. we were transparent with the state knew about our relationships. i think they issued a statement indicating on -- in a response to the indianapolis star article that they were aware of our relationship, we disclosed that relationship, and on a practical day to day level, we didn't engage in anything that would put us in a situation we were supervising their work, negotiating their contracts, and we made that very transparent on the front end. so if there was ever an issue, you know, i've been in meetings where we were talking about contractors, talking about implementing a program and when it came to a vendor we had a relationship with, i would recuse myself, get up and leave the meeting so there was never any issue. i think the state has spoken on this and the work we have done with hp and these other vendors has extended over three separate governors and over six secretaries of health. >> so the recently ousted head of the state agency administering your contract told this paper the star that you once attempted to negotiate with state officials on behalf of hewlett-packard, while being paid by the state. so let's do this. because obviously there are differences of opinion. my concern was, it wasn't just one company. it wasn't just hewlett-packard. but it was these -- the wide array of companies that i listed, millman, maximus, and a wide variety of services. and my concern is, it is very clear that indiana ethics rules don't apply to you in a technical sense, because you were a contractor. no dispute about that. but it sure looks to me like you were on both sides of the table as a lot of money was being decided. and i think that really leads me to my last kind of point for today, miss verma. you've been asked a lot of questions. and my own sense, and i've listened carefully to my colleagues, these were not gotcha questions. these were questions that were appropriate given the fact that if confirmed, you're going to head an agency that is involved with a trillion dollars spending and healthcare of 100 million people, or thereabouts. i think these questions were designed to get a sense of how you would approach them. and i felt very strongly, i enjoyed our conversation, i decided i'm going to try to give you as much real estate as i could, in getting a sense of how you would approach it. that's why i asked the question about pharmaceutical prices, which is huge. and so important to people. and i said i'm going to ask miss verma to give me one example, just one example of what she would do if confirmed in this position. and we didn't get it in that area, and in the rural area and in a variety of others. so the chairman will take us through the rules for getting the questions for the record. but i'm going to be reviewing those questions and responses very carefully because when i'm troubled about today is for questions that i thought were appropriate, for a job like this, trillion dollars worth of spending, we're not really getting much of a sense of how you would approach it. and i think that this committee needs answers. i think the public needs answers. and i'll look at your written questions very carefully and look forward to talking with you further. >> thank you, mr. chairman. >> thank you, senator. i want to thank miss verma for appearing here today. this hearing is an important part of our committee vetting process, and i must say that not surprisingly you, miss verma, have acquitted yourself very well. i look forward to miss verma being reported out of the committee and being confirmed by the senate. my goal is for this to all happen expeditiously. it is critical that we get a strong skilled leader in at cms administrator. it is essential to our efforts for collectively addressing our nation's many healthcare challenges. our current administrator, who is not confirmed, but he had all kinds of conflicts. but we allowed him to go forward. very bright guy, had a lot on the ball. and here you are, somebody who really has proven to be a tremendous leader in healthcare, not just in indiana, but as an example to the rest of the states. and all i can say is that you'll be a strong skilled leader as cms administrator. now, it is essential for us efforts for collectively aggressing our nation's many healthcare challenges that we get you there. senator portman, do you still have some questions? i didn't notice you came in. i'm ready to wrap up. >> i apologize. i've been here twice, listening, dutifully and had separate hearings going on at the same exact time. i've been bouncing back and forth. but i would like the opportunity to ask my questions. i have not had the chance to do that yet. >> go ahead then, proceed. >> i apologize. thanks for your patience, mostly, miss verma, to your children who have been very patient. i've been watching them, amazing at their age, my kids never could have done that. so i heard a lot of back and forth earlier and let me just go to some of these issues, first of all, i like what you're saying about patients taking more responsibility for their own health. and how you have a healthcare system that encourages that. i think we talked about innovation earlier, part of the innovation has to do with that. we want people to leave healthier, stronger lives and part of that is providing that incentive within our healthcare system. we talked about leveraging technology and innovation, i like that. and many of us in our states are doing some things that are innovative as you know. the state of ohio has an innovative healthcare director, who i know you've worked with before, and a lot of this is about taking the existing dollars and using them more effectively to create better care. and i think that's a great opportunity, frankly, in a healthcare system in need of more innovation and the technology part can be exciting and also very expensive so it has to be dealt with appropriately. you said more state flexibility, and later you talked about holding states accountable for outcomes. looking not at the input as much, and the volume, but looking at the output and the quality, and i think that's something where you find a lot of agreement on both sides of the aisle here. you also made the comment with regard to medicaid that at some times it can take years to get a waiver. and i have to say, it is worse than that. sometimes you can't get a waiver. and as you know, because you're involved in putting together ohio's waiver, we were not able to get a waiver to give the flexibility to provide more innovation, better quality care, more wholistic care, focusing on prevention and wellness and getting people into the healthcare system, not just when they have an emergency, but to have a better health outcome by having primary care physicians and so on. that's something that concerns me, that it is not just about -- it takes too much time often to go through the process, but we can't get these waivers sometimes. the obama administration rejected the ohio application. healthy indiana plan was accepted, and you're very involved not just in developing that, but in implementing that. so if you could just speak briefly about what is the best thing about the healthy indiana plan, and is it some of the characteristics i talked about earlier or others, and how could that be taken nationally. then i want to talk about medicaid expansion specifically. >> i think about the healthy indiana plan and what it has done is that it gives dignity to individuals. it empowers them. it recognizes their potential to fulfill their dreams. we don't assume just because somebody's poor that they don't want choices about their healthcare, they don't deserve choices that they don't want to be involved, that they're not capable of making decisions. and what we have found is that when we do that, when we create a situation, they're actually more engaged in their healthcare and their engagement leads to better outcomes, leads to lower emergency room, more primary care, more preventative care, higher satisfaction and better drug adherence. >> that's what i want to hear, because that's what we should all hope for. that people have access to affordable care and that the results are, you know, better health outcomes because they're taking more responsibility for their own health and have the ability to do that, including access to primary care. so here's a situation in ohio. we have about 200,000 people who get coverage with the exchange, 212,000 as of yesterday, but we have over 700,000 people in medicaid expansion. when people talk about affordable care act in ohio, they talk about it in terms of some of the mandates on small businesses, some of the issues that have resulted in higher costs to provide healthcare, higher premiums, up the 91%. there is focus on the exchanges which are important in ohio. but what is more important for us is the over 700,000 people in expanded medicaid. and you talked a lot about this today. and what you might support, not support, in terms of how do you give more authority and responsibility back to the states. so that's my question for you. i am very concerned that we not move forward too quickly with the replacement and leave those people behind. i'm also very supportive of a better system including much more state flexibility along the lines of what governor kasich wanted with his waiver request that was rejected, so help me to understand how we can ensure that we do provide coverage to these people, particularly in my state, you know, the prescription drug, heroin, now fentanyl issue is huge and the treatment provided to people in ohio is often now through medicaid expansion. and we want people to get into this treatment. again that provides them better health outcomes. so talk to me briefly about that. i know you don't have much time thanks to me being at the end here, but how can we be sure we can get a good flexible plan to cover those people and even a better way than they're getting under medicaid expansion? >> i think that, first of all, i support coverage and i think the individuals that are being served on medicaid through the exchange support people having coverage because for the issues you raised. people are facing substance abuse, opioid addiction, they need coverage. and we need to address that issue. but if we look at what the affordable care act has done, people talk about coverage, well, coverage doesn't necessarily translate to access to care. i was in the -- today, with an uber driver and asking him about his coverage and he said he had gotten coverage through the exchanges, through the affordable care act, but he said i can't do anything with it. because my deductible is $6,000. and, you know, i can't get to the doctor. i still can't afford it. and so i think that that's a great story of coverage doesn't necessarily translate into access. so, you know, awe mo as we mov different system, those are things we need to keep in mind, through medicaid or another coverage vehicle and we need to make sure we're providing high quality care and also provides accessible care. >> thank you. and we look forward to continuing that conference. and i know i'm over time, but i do think this is going to be the key issue for us in ohio is how do we ensure in that transition we provide that coverage. thank you, mr. chairman. >> thank you, senator. miss verma, you've been very patient and you've been very intelligently answered the questions of my colleagues. so i -- the committee received several letters in support of miss verma's nomination that i ask be added to the record without objection. finally, i would ask that any written questions for the record be submitted by 5:00 p.m. tomorrow, february 17th, 2017. with that, with that, we want to thank you for being here, thank you for your answers, thank you for your patience, and we'll adjourn this hearing. thanks so much. >> thank you, senator. tonight, on american history tv in primetime, a look at u.s. soviet relations, beginning at 8:00 eastern, historians discuss the cold war summits between the united states and the soviet union from 1985 to 1991. that will be followed by a 1958 u.s. information agency film explaining different forms of communist propaganda. at 10:15, u.s. air force academy instructor captain jeffrey copeland will teach a class on the use of american jazz musicians as state department sponsored ambassadors in africa during the cold war. and then we'll round out the night with the commemoration of the 25th anniversary of the nun-luger act with comments from sam nunn and richard lugar, tonight on c-span3. this weekend on american history tv on c-span3, this saturday morning at 9:30 eastern, we're live from the library of virginia in richmond for an all day symposium on civil war monuments, the history of their construction, in the north and the south and how public perception of confederate monuments has changed. then at 8:00, in lectures in history, hampton sydney college professor john coombs on how the rise of tobacco consolidated the power of wealthy virginia planters and london merchants in the 17th century. >> instead of accepting the price that this random ship captain might have to offer me, i instead will send the tobacco over to england on my own account, and i'm going to pay a commission to someone to market it there for me. this developing consignment trade ties larger planters of virginia and maryland to these english merchants. most of them in london. >> sunday at noon on oral histories, we continue with our series of interviews with prominent african-american women from the explorations in black leadership oral history collection. dorothy height served as president of the national counsel of negro women from 1957 to 1998 and received the presidential medal of freedom and congressional gold medal. >> i grew up and even in my religious experience, working with people of different religious backgrounds, was a feeling of the importance of openness and how much each one contributes to the other. there is no superior, no inferior. >> and at 8:00, on the presidency, historian catherine clinton talks about what happened to president lincoln's family after his assassination. >> the morning of may 19th, convinced his mother might do herself harm, and prodded by a team of medical and legal experts, robert lincoln filed an affidavit to have his mother tried on charges of mental incompetence. she could be held against her will due to, quote, insanity. >> for our complete american history tv schedule, go to c-span.org. up next, a look at the future of the north american free trade agreement or nafta, hosted by the washington international trade association, participants discuss what changes or revisions to the agreement might be pursued by the trump administration. the first panel focused on the potential foreign policy and political implications of renegotiating a trade agreement, and then the second panel features private industry representatives, talked about their preferences for what to include in any potential nafta update. thank you, ken. it's a real pleasure to be here this morning. thanks for organizing this very, very timely session on nafta 2.0. as someone who has been involved

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