[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]





                       REVIEWING THE POLICIES AND
                         PRIORITIES OF THE U.S.
                        DEPARTMENT OF HEALTH AND
                             HUMAN SERVICES

=======================================================================

                                HEARING

                               before the

                         COMMITTEE ON EDUCATION
                           AND THE WORKFORCE
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

             HEARING HELD IN WASHINGTON, DC, JULY 28, 2015

                               __________

                           Serial No. 114-24

                               __________

  Printed for the use of the Committee on Education and the Workforce



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                COMMITTEE ON EDUCATION AND THE WORKFORCE

                    JOHN KLINE, Minnesota, Chairman

Joe Wilson, South Carolina           Robert C. ``Bobby'' Scott, 
Virginia Foxx, North Carolina            Virginia
Duncan Hunter, California              Ranking Member
David P. Roe, Tennessee              Ruben Hinojosa, Texas
Glenn Thompson, Pennsylvania         Susan A. Davis, California
Tim Walberg, Michigan                Raul M. Grijalva, Arizona
Matt Salmon, Arizona                 Joe Courtney, Connecticut
Brett Guthrie, Kentucky              Marcia L. Fudge, Ohio
Todd Rokita, Indiana                 Jared Polis, Colorado
Lou Barletta, Pennsylvania           Gregorio Kilili Camacho Sablan,
Joseph J. Heck, Nevada                 Northern Mariana Islands
Luke Messer, Indiana                 Frederica S. Wilson, Florida
Bradley Byrne, Alabama               Suzanne Bonamici, Oregon
David Brat, Virginia                 Mark Pocan, Wisconsin
Buddy Carter, Georgia                Mark Takano, California
Michael D. Bishop, Michigan          Hakeem S. Jeffries, New York
Glenn Grothman, Wisconsin            Katherine M. Clark, Massachusetts
Steve Russell, Oklahoma              Alma S. Adams, North Carolina
Carlos Curbelo, Florida              Mark DeSaulnier, California
Elise Stefanik, New York
Rick Allen, Georgia

                    Juliane Sullivan, Staff Director
                 Denise Forte, Minority Staff Director
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

                              ----------                              
                                                                   Page

Hearing held on July 28, 2015....................................     1

Statement of Members:
    Kline, Hon. John, Chairman, Committee on Education and the 
      Workforce..................................................     1
        Prepared statement of....................................     3
    Scott, Hon. Robert C., Ranking Member, Committee on Education 
      and the Workforce..........................................     4
        Prepared statement of....................................     6

Statement of Witnesses:
    Burwell, Hon. Sylvia Matthews, Secretary, U.S. Department of 
      Health and Human Services, Washington, DC..................     8
        Prepared statement of....................................    10

Additional Submissions:
    Davis, Hon. Susan A., a Representative in Congress from the 
      State of California:
        CBO Budgetary and Economic Effects of Repealing the 
          Affordable Care Act....................................    55
    Guthrie, Hon. Brett, a Representative in Congress from the 
      State of Kentucky:
        Letter dated April 3, 2015...............................    88
    Chairman Kline:
        Letter dated June 16, 2015 from Annette Guarisco Fildes, 
          President and CEO, The ERISA Industry Committee........    32
        Letter dated June 22, 2015 from The National Coalition on 
          Benefits...............................................    44
        Letter dated June 17, 2015 from Kathryn Wilber, American 
          Benefits Council.......................................    39
        Letter dated June 18, 2015 from Annette Guarisco Fildes, 
          President and CEO, The ERISA Industry Committee........    30
    Wilson, Hon. Frederica S., a Representative in Congress from 
      the State of Florida:
        ASPE Issue Brief dated July 16, 2015.....................   102
    Questions submitted for the record by:
        Allen, Hon. Rick, a Representative in Congress from the 
          State of Georgia.......................................   124
        Barletta, Hon. Lou, a Representative in Congress from the 
          State of Pennsylvania..................................   124
        Foxx, Hon. Virginia, a Representative in Congress from 
          the State of North Carolina............................   123
        Fudge, Hon. Marcia L., a Representative in Congress from 
          the State of Ohio......................................   126
        Mr. Kline................................................   122
        Polis, Hon. Jared, a Representative in Congress from the 
          State of Colorado......................................   127
        Roe, Hon. David P., a Representative in Congress from the 
          State of Tennessee.....................................   123
        Mr. Scott................................................   125
    Secretary Burwell's response to questions submitted for the 
      record                                                        129

 
                 REVIEWING THE POLICIES AND PRIORITIES
                    OF THE U.S. DEPARTMENT OF HEALTH
                           AND HUMAN SERVICES

                              ----------                              


                         Tuesday, July 28, 2015

                       House of Representatives,

               Committee on Education and the Workforce,

                            Washington, D.C.

                              ----------                              

    The committee met, pursuant to call, at 10:02 a.m., in Room 
2175, Rayburn House Office Building, Hon. John Kline [chairman 
of the committee] presiding.
    Present: Representatives Kline, Foxx, Roe, Thompson, 
Walberg, Salmon, Guthrie, Barletta, Messer, Brat, Carter, 
Bishop, Grothman, Russell, Curbelo, Stefanik, Allen, Scott, 
Hinojosa, Davis, Grijalva, Courtney, Polis, Wilson of Florida, 
Bonamici, Pocan, Takano, Jeffries, Clark, Adams, and 
DeSaulnier.
    Staff Present: Lauren Aronson, Press Secretary; Andrew 
Banducci, Professional Staff Member; Janelle Belland, 
Coalitions and Members Services Coordinator; Kathlyn Ehl, 
Professional Staff Member; James Forester, Professional Staff 
Member; Ed Gilroy, Director of Workforce Policy; Callie Harman, 
Staff Assistant; Christine Herman, Professional Staff Member; 
Tyler Hernandez, Press Secretary; Nancy Locke, Chief Clerk; 
Zachary McHenry, Legislative Assistant; Michelle Neblett, 
Professional Staff Member; Brian Newell, Communications 
Director; Krisann Pearce, General Counsel; Jenny Prescott, 
Professional Staff Member; Lauren Reddington, Deputy Press 
Secretary; Alissa Strawcutter, Deputy Clerk; Juliane Sullivan, 
Staff Director; Alexa Turner, Legislative Assistant; Joseph 
Wheeler, Professional Staff Member; Tylease Alli, Minority 
Clerk/Intern and Fellow Coordinator; Austin Barbera, Minority 
Staff Assistant; Jacque Chevalier, Minority Senior Education 
Policy Advisor; Denise Forte, Minority Staff Director; 
Christine Godinez, Minority Staff Assistant; Ashlyn Holeyfield, 
Minority Education Policy Fellow; Carolyn Hughes, Minority 
Senior Labor Policy Advisor; Brian Kennedy, Minority General 
Counsel; Veronique Pluviose, Minority Civil Rights Counsel; 
Dillon Taylor, Minority Labor Policy Fellow; and Arika Trim, 
Minority Press Secretary.
    Chairman Kline. A quorum being present, the Committee on 
Education and the Workforce will come to order.
    Good morning, Secretary Burwell.
    Secretary Burwell. Good morning.
    Chairman Kline. Thank you for joining us to review the 
policies and priorities of the Department of Health and Human 
Services. As is often the case when a Cabinet Secretary appears 
before the committee, we have a lot of ground to cover in a 
short period of time. That is especially true for a Department 
as big, powerful, and costly as the Department of Health and 
Human Services.
    Now, the end of the current fiscal year, HHS is expected to 
spend approximately $1 trillion administering numerous programs 
affecting millions of Americans including child care, welfare, 
healthcare, and early childhood development. At a time when 
families are being squeezed by a weak economy and record debt, 
we have an urgent responsibility to make sure the Federal 
Government is operating efficiently and effectively. It is a 
responsibility we take seriously, which is why this hearing is 
important, and why we intend to raise a number of key issues.
    For example, we are interested to learn about the 
Department's progress implementing recent changes to the Child 
Care and Development Block Grant Program. Last year, the 
committee helped champion bipartisan reform of the program to 
strengthen health and safety protections, empower parents, and 
improve the quality of care. This vital program has helped 
countless moms and dads provide for their families, and we hope 
the Department is on track to implement these changes quickly 
and in line with congressional intent.
    Another vital program for many low-income families is Head 
Start. Earlier this year, the committee outlined a number of 
key principles for strengthening the program such as reducing 
regulatory burdens as well as encouraging local innovation and 
better engagement with parents. The committee then solicited 
the public feedback that would help turn these principles into 
a legislative proposal.
    It was in the midst of this effort to reform the law that 
the Department decided to launch a regulatory restructuring of 
the program. Some of the Department's proposed changes will 
help improve the program. However, the sheer scope and cost of 
the rulemaking raises concerns and has led to some uncertainty 
among providers who serve these vulnerable children. 
Strengthening the law is a better approach than transforming a 
program through regulatory fiat, and we urge the administration 
to join us in that effort.
    These two areas alone could fill up most of our time this 
morning, and I haven't even mentioned services provided under 
the 1996 Welfare Reform Law and the Older Americans Act. Of 
course, as you might expect, Secretary Burwell, on the minds of 
most members are the challenges the country continues to face 
because of the President's healthcare law. Families, workers, 
employers are learning more and more about the harmful 
consequences of this flawed law.
    For example, patients have access to fewer doctors, to 
control costs. It is estimated that insurance plans on the 
health exchanges have 34 percent fewer providers than non-
exchange plans, including 32 percent fewer primary care doctors 
and 42 percent fewer oncologists and cardiologists. The law is 
plagued by waste and abuse.
    In 2014, investigators with the nonpartisan Government 
Accountability Office used fake identities to enroll 12 
individuals into subsidized coverage on a healthcare exchange. 
Just this month, GAO announced 11 of the 12 fake individuals 
are still enrolled and receiving taxpayer subsidies. More than 
7 million individuals paid a penalty for failing to purchase 
government approved health insurance, roughly 25 percent more 
than the administration expected in the worst-case scenario. 
According to the Associated Press, at least 4.7 million 
individuals were notified that their insurance plans were 
canceled because they did not abide by the rigid mandates 
established under the healthcare law.
    The nonpartisan Congressional Budget Office estimates the 
law will result in 2.5 million fewer full-time jobs. This 
reflects what we've heard over and over again from employers 
who have no choice but to cut hours or delay hiring because of 
the law's burdensome mandates. Healthcare costs continue to 
skyrocket. According to the New York Times, health insurance 
companies are seeking rate increases of ``20 percent to 40 
percent or more,'' suggesting markets are still adjusting to 
the, ``shock waves set out by the Affordable Care Act.''
    Finally, after all the mandates, fraud, loss of coverage, 
fewer jobs, higher costs, and nearly $2 trillion in new 
government spending, it is estimated more than 25 million 
individuals will still lack basic healthcare coverage.
    And yet, just last month, President Obama said the law 
``worked out better than some of us anticipated.'' Of course, 
for those who oppose this government takeover of healthcare, 
this is precisely what we anticipated and is precisely why the 
American people deserve a better approach.
    In closing, Madam Secretary, I want to thank you again for 
joining us this morning. It is our responsibility to hold you 
and the administration accountable when we believe the country 
is moving in the wrong direction. However, there are areas 
where I believe we can find common ground and advance positive 
solutions on behalf of the American people. Today's hearing is 
an important part of those efforts, and I look forward to our 
discussion.
    With that, I will now yield to Ranking Member Bobby Scott 
for his opening remarks.
    [The statement of Chairman Kline follows:]

Prepared Statement of Hon. John Kline, Chairman, Committee on Education 
                           and the Workforce

    Good morning, Secretary Burwell. Thank you for joining us to review 
the policies and priorities of the Department of Health and Human 
Services. As is often the case when an agency secretary appears before 
the committee, we have a lot of ground to cover in a short period of 
time. That is especially true for an agency as big, powerful, and 
costly as the Department of Health and Human Services.
    By the end of the current fiscal year, HHS is expected to spend 
approximately $1 trillion administering numerous programs affecting 
millions of Americans, including child care, welfare, healthcare, and 
early childhood development. At a time when families are being squeezed 
by a weak economy and record debt, we have an urgent responsibility to 
make sure the federal government is operating efficiently and 
effectively. It is a responsibility we take seriously, which is why 
this hearing is important and why we intend to raise a number of key 
issues.
    For example, we are interested to learn about the department's 
progress implementing recent changes to the Child Care and Development 
Block Grant program. Last year, the committee helped champion 
bipartisan reforms of the program to strengthen health and safety 
protections, empower parents, and improve the quality of care. This 
vital program has helped countless moms and dads provide for their 
families, and we hope the department is on track to implement these 
changes quickly and in line with congressional intent.
    Another vital program for many low-income families is Head Start. 
Earlier this year, the committee outlined a number of key principles 
for strengthening the program, such as reducing regulatory burdens, as 
well as encouraging local innovation and better engagement with 
parents. The committee then solicited public feedback that would help 
turn these principles into a legislative proposal.
    It was in the midst of this effort to reform the law that the 
department decided to launch a regulatory restructuring of the program. 
Some of the department's proposed changes will help improve the 
program; however, the sheer scope and cost of the rulemaking raises 
concerns and has led to some uncertainty among providers who serve 
these vulnerable children. Strengthening the law is a better approach 
than transforming a program through regulatory fiat, and we urge the 
administration to join us in that effort.
    These two areas alone could fill up most of our time this morning, 
and I haven't even mentioned services provided under the 1996 welfare 
reform law and the Older Americans Act. Of course, as you might expect, 
Secretary Burwell, on the minds of most members are the challenges the 
country continues to face because of the president's healthcare law. 
Families, workers, and employers are learning more and more about the 
harmful consequences of this flawed law. For example:
    * Patients have access to fewer doctors. To control costs, it is 
estimated that insurance plans on the healthcare exchanges have 34 
percent fewer providers than non-exchange plans, including 32 percent 
fewer primary care doctors and 42 percent fewer oncologists and 
cardiologists.
    * The law is plagued by waste and abuse. In 2014, investigators 
with the nonpartisan Government Accountability Office used fake 
identities to enroll 12 individuals into subsidized coverage on a 
healthcare exchange. Just this month, GAO announced 11 of the 12 fake 
individuals are still enrolled and receiving taxpayer subsidies.
    * More than seven million individuals paid a penalty for failing to 
purchase government-approved health insurance, roughly 25 percent more 
than the administration expected under the worst case scenario.
    * According to the Associated Press, at least 4.7 million 
individuals were notified that their insurance plans were cancelled 
because they did not abide by the rigid mandates established under the 
healthcare law.
    * The nonpartisan Congressional Budget Office estimates the law 
will result in 2.5 million fewer full-time jobs. This reflects what 
we've heard over and over again from employers who have no choice but 
to cut hours or delay hiring because of the law's burdensome mandates.
    * Healthcare costs continue to skyrocket. According to the New York 
Times, health insurance companies are seeking rate increases of ``20 
percent to 40 percent or more,'' suggesting markets are still adjusting 
to the ``shock waves set off by the Affordable Care Act.''
    Finally, after all the mandates, fraud, loss of coverage, fewer 
jobs, higher costs, and nearly $2 trillion in new government spending, 
it's estimated more than 25 million individuals will still lack basic 
healthcare coverage. And yet, just last month, President Obama said the 
law ``worked out better than some of us anticipated.'' Of course, for 
those who opposed this government takeover of healthcare, this is 
precisely what we anticipated and it is precisely why the American 
people deserve a better approach.
    In closing, Secretary Burwell, I want to thank you again for 
joining us this morning. It is our responsibility to hold you and the 
administration accountable when we believe the country is moving in the 
wrong direction. However, there are areas where I believe we can find 
common ground and advance positive solutions on behalf of the American 
people. Today's hearing is an important part of those efforts, and I 
look forward to our discussion.
    With that, I will now yield to Ranking Member Bobby Scott for his 
opening remarks.
                                 ______
                                 



    Mr. Scott. Thank you, Chairman Kline.
    And welcome, Secretary Burwell, and thank you for being 
with us today. I look forward to your testimony.
    Today we'll hear about the President's Fiscal Year 2016 
Health and Human Services budget proposals and the Department's 
budget priorities. While the budget was released months ago, 
I'm pleased to see that the word ``priority'' is included in 
the title of today's hearing. Budgeting requires making tough 
choices, and a budget is in fact a reflection of priorities. As 
legislators, we decide what our priorities are and how best to 
invest in our country.
    I was pleased that the President's budget request was 
reflective of many important priorities such as protecting 
access to healthcare insurance for all Americans, giving all 
children a chance to succeed, and reducing inequality around 
the country.
    In many areas, I believe that we've made great progress on 
these priorities. For example, the passage of the Affordable 
Care Act has given millions of Americans access to health 
coverage, some for the first time in their lives. The ACA has 
also helped slow the growth in healthcare costs, closed the 
doughnut holes for seniors, and encouraged and improved access 
to mental health services and preventive care.
    Just weeks ago the Supreme Court decided in another case 
pertaining to the Affordable Care Act, in King v. Burwell. The 
legality of subsidies for those obtaining health insurance 
through the Federal marketplace instead of a Statewide 
marketplace was upheld. The Affordable Care Act was structured 
and designed to improve healthcare insurance coverage and 
access across the entire country, and it has, and now those 
living in Virginia have enjoyed access to insurance subsidies 
just like someone in Minnesota, and because of the outcome of 
the case, they will continue to do so.
    I want to thank Secretary Burwell for her efforts and her 
Department's hard work in implementing the ACA. I recognize the 
challenge that your agency faces in implementing the law with 
limited resources and unlimited attacks, but despite these 
challenges, the ACA is working.
    I was also pleased to see that the President's budget 
request placed priority on giving all children a chance to 
succeed by ensuring robust funding to increase both access to 
and quality of early learning and childcare programs.
    The Republican budget adopted by the House earlier this 
year is not reflective of these shared national priorities, 
despite research showing for every dollar spent on early 
education, there is a return of $7 in reduced costs in other 
parts of the budget. We must invest in quality early learning 
programs because all children deserve being in kindergarten 
with the building blocks to success.
    Now, decades of research has shown that properly nurturing 
children in the first five years of life is instrumental in 
supporting enhanced brain development, cognitive functioning, 
and emotional and physical health. But all too often low-income 
working families lack access to high-quality affordable child 
care and early childhood education, and these children tend to 
fall far behind. In addition to this achievement gap, children 
who don't participate in high-quality early learning programs 
are more likely to have weaker educational outcomes, lower 
earnings, increased involvement in the criminal justice system, 
and increased teen pregnancy.
    Affordable high-quality child care is not just critical for 
children, it is also critical for working parents, because 
child care is a two-generational program. Parents of young 
children need child care to go to work or go to school. And a 
lack of stable child care is associated with job interruptions 
and job loss for working parents.
    Child care ought to be a national priority for America's 
children and to help grow our economy. Just two programs 
throughout the bulk of the Federal role in early education, the 
Head Start program and the Child Care Development Block Grant. 
Unfortunately, because of limited funding, too few children 
have access. This unmet need continues to grow. Only four out 
of 10 eligible children have access to Head Start and only one 
out of six federally eligible families receive child care 
subsidies. We have decades of evidence that investing in 
programs like Head Start and the Child Care Development Block 
Grant work, and the time is to invest in these programs and 
ensure that we're giving all children the chance to succeed.
    Lastly, it's past time for Congress to raise the sequester-
level discretionary spending caps that are stunting the 
progress that we can make as a Nation in important areas like 
health and education. These caps threaten nearly every program 
under the jurisdiction of this committee from low income home 
energy assistance program to the Older Americans Act and 
others. The sequester has led to woefully inadequate investment 
in critical National needs and puts us on a path to another 
government shutdown.
    In coming back to the idea of priorities, investing in our 
Nation's future should be Congress' number one priority, not 
corporate tax breaks or lowering the estate tax. Our focus 
should remain on restoring investments that strengthen our 
Nation's middle class and help hard working American families 
get ahead.
    So thank you, Mr. Chairman, and thank you Secretary Burwell 
for being here today.
    Chairman Kline. I thank the gentleman.
    [The statement of Mr. Scott follows:]

 Prepared Statement of Hon. Robert C. ``Bobby'' Scott, Ranking Member, 
                Committee on Education and the Workforce

    Thank you Chairman Kline, and welcome Secretary Burwell. Thank you, 
Secretary, for being with us and I look forward to your testimony.
    Today we will hear about the President's Fiscal Year 2016 Health 
and Human Services Budget proposal and the Department's policy 
priorities. While the budget was released months ago, I was pleased to 
see the word ``priority'' included in the title of today's hearing. 
Budgeting requires making tough choices, and a budget is in fact a 
reflection of priorities. As legislators, we decide what our priorities 
are and how to best invest in our country. I was pleased that the 
President's budget request was reflective of the priorities that are 
important to the success of families and communities across the country 
- protecting access to health insurance for all Americans, giving all 
children a chance to succeed, and reducing inequality in this country.
    In many areas, I believe we have made great progress in these 
priorities. For example, the passage of the Affordable Care Act has 
given millions of Americans access to health coverage, some for the 
first time in their lives. The ACA has helped to slow the growth in 
healthcare costs, closed the donut hole for seniors, and has encouraged 
and improved access to mental health services and preventive care.
    Just a few weeks ago, the Supreme Court decided another case 
pertaining to the Affordable Care Act. In King v. Burwell, the legality 
of subsidies for those obtaining insurance through a federal 
Marketplace instead of a state-run Marketplace was upheld. The 
Affordable Care Act was structured and designed to improve health 
insurance coverage and access across the entire country. And it has. 
Those living in Virginia have enjoyed access to insurance subsidies, 
just like someone in Minnesota, and will continue to do so.
    I want to thank Secretary Burwell for her efforts and her 
Department's hard work implementing the ACA. I recognize the challenge 
your agency faces in implementing this law with limited resources and 
unlimited attacks. Despite these challenges, the ACA is working.
    I was also pleased that the President's budget request placed 
priority on giving ALL children a chance to succeed by ensuring robust 
funding to increase both access to and the quality of early learning 
and childcare programs. The Republican budget adopted in the House 
earlier this year is not reflective of these shared, national 
priorities despite research showing a return of over $7 for every $1 
spent on early education. We must invest in quality early learning 
programs because all children deserve to enter kindergarten with the 
building blocks to success.
    Decades of research has shown that properly nurturing children in 
the first five years of life is instrumental to supporting enhanced 
brain development, cognitive functioning, and emotional and physical 
health. But all too often, low-income working families lack access to 
high-quality, affordable child care and early childhood education, and 
these children tend to fall behind. Beyond the
    achievement gap, children who don't participate in high-quality 
early education programs are more likely to have weaker educational 
outcomes, lower earnings, and increased involvement in the criminal 
justice system. Affordable high-quality child care is not just critical 
for children, it is also critical for working parents. Child care is a 
two-generation program. Parents of young children need child care to 
work or go to school. And a lack of stable child care is associated 
with job interruptions and job loss for working parents. Child care 
ought to be a national priority for America's children and to help grow 
our economy.
    Just two programs provide for the bulk of the federal role in early 
education: the Head Start Program and the Child Care and Development 
Block Grant. Unfortunately, because of limited federal funding, too few 
young children have access. This unmet need continues to grow - only 4 
out of 10 eligible children have access to Head Start and only 1 out of 
6 federally-eligible families receive child care subsides. We have 
decades of evidence that investing in programs like Head Start and the 
Child Care and Development Block Grant works. It is time to invest in 
these programs and ensure that we are giving ALL children the chance to 
succeed.
    Lastly, it is past time for Congress to raise the sequester-level 
discretionary spending caps that are stunting the progress we can make 
as a nation in important areas, like health and education. These caps 
threaten nearly every program under the jurisdiction of this Committee, 
from the Low Income Home Energy Assistance Program to the Older 
Americans Act supportive programs. The sequester has led to woefully 
inadequate investment in critical national needs and put us on a path 
to another government shutdown. And coming back to the idea of 
priorities, investing in our country's future should be Congress' 
number one priority - not corporate tax breaks, or lowering the estate 
tax. Our focus should remain on restoring investments that strengthen 
our nation's middle class and help hardworking families get ahead.
    Thank you and Secretary Burwell, I look forward to hearing from you 
today.
                                 ______
                                 
    Chairman Kline. Pursuant to Committee Rule 7(c), all 
members will be permitted to submit written statements to be 
included in the permanent hearing record. Without objection, 
the hearing record will remain open for 14 days to allow such 
statements and other extraneous material referenced during the 
hearing to be submitted for the official hearing record.
    It is now my pleasure to introduce our distinguished 
witness. The Honorable Sylvia Matthews Burwell is the Secretary 
of Health and Human Services. Prior to joining HHS in June of 
2014, Secretary Burwell served as a director of the Office of 
Management and Budget, where she oversaw the development of 
President Obama's second term management agenda. During the 
Clinton administration, Secretary Burwell served as deputy 
director of OMB, deputy chief of staff to the President, chief 
of staff to the Secretary of the Treasury, and staff director 
of the National Economic Council.
    Welcome, Madam Secretary. I will now ask the Secretary to 
stand and raise your right hand.
    Thank you.
    [Witness sworn.]
    Chairman Kline. Let the record reflect the witness answered 
in the affirmative.
    Now, before I recognize you to provide your testimony, let 
me briefly remind you or, more importantly, my colleagues of 
our lighting system. We typically allow five minutes for each 
witness to present, although I will be flexible on this 
timeline, given you are our only witness and you are a Cabinet 
Secretary. I would ask you, though, to try to limit your 
remarks, because we have a lot of members who want to get to 
questions, and I will be strictly enforcing the five-minute 
rule and perhaps the four-minute rule. The Secretary has a hard 
stop time at 12:00. We will honor that, and I would ask my 
colleagues to be patient.
    Again, on the lights, when you start, and we'll put the 
timer on, but you can effectively ignore it if you'd like, it 
will be green and then turn yellow when you have a minute to go 
and then red when the five-minute mark is over. And that 
applies only to the Secretary. To my colleagues, when five 
minutes is up, five minutes is up.
    Now, you are recognized, Madam Secretary.

TESTIMONY OF THE HONORABLE SYLVIA MATTHEWS BURWELL, SECRETARY, 
 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON D.C.

    Secretary Burwell. Thank you, Mr. Chairman and Ranking 
Member Scott, as well as members of the Committee. Thank you 
for this opportunity to discuss the President's budget for the 
Department of Health and Human Services.
    I believe firmly that we all share common interests and, 
therefore, we have a number of opportunities to find common 
ground. We saw the power of common ground in the 
reauthorization of the Child Care and Development Block Grant 
Program that happened last fall, as well as the bipartisan SGR 
repeal earlier this year. And I appreciate all of your all's 
work to get that passed.
    The President's budget proposes to end sequestration fully, 
reversing it through domestic priorities in 2016, matched by 
equal dollar increases for the Department of Defense. Without 
further congressional action, sequestration will return in full 
in 2016, bringing discretionary funding to its lowest level in 
a decade adjusted for inflation. We need a whole of government 
solution, and I hope that both parties can work together to 
achieve a balanced and commonsense approach.
    The budget before you makes critical investments in 
healthcare, science, innovation, public health, and human 
services. It maintains our responsible stewardship of the 
taxpayers' dollar; it strengthens our work together with 
Congress to prepare our Nation for key challenges at home as 
well as abroad. For HHS, the budget proposes $83.8 billion in 
discretionary budget authority. This 4.8 billion increase will 
allow our Department to deliver impact today and lay a stronger 
foundation for the Nation for tomorrow.
    It is a fiscally responsible budget, which in tandem with 
accompanying legislative proposals, could save taxpayers a net 
estimated $250 billion. The budget is projected to continue 
slowing the growth in Medicare by securing $423 billion in 
savings as we build a better, smarter, healthier delivery 
system.
    In terms of providing all Americans with access to 
affordable quality healthcare, the budget builds on our 
historic progress in reducing the number of uninsured and 
improving coverage for families, who already have insurance. 
The budget supports our efforts to move towards a health 
delivery system that delivers better care, spends dollars in a 
smarter way, and puts the patient at the center of the care to 
keep them healthy.
    The budget also improves access for Native Americans. To 
support communities throughout the country, the budget makes 
critical investments in health centers and our Nation's 
healthcare workforce, particularly in rural and other high-need 
areas. To advance our shared vision for leading the world in 
science and innovation, the budget increases NIH funding by $1 
billion to advance biomedical and behavioral research, among 
other priorities.
    It also invests in precision medicine, a new cross 
department effort focused on development treatments, 
diagnostics, and prevention strategies tailored to the 
individual genetic characteristics of a patient. To further our 
common interests in providing Americans with the building 
blocks of healthy and productive lives, this budget outlines an 
ambitious plan to make affordable quality child care available 
to working and middle-class families.
    Specifically, the budget builds on important legislation 
passed by this Congress last fall to create a continuum of 
early learning opportunities from birth through age five. This 
change would provide high-quality preschool for every child, 
guaranteed quality child care for working families, grow the 
supply of early learning opportunities for young children, and 
expand investments in voluntary evidence-based home visiting 
programs.
    To keep Americans safe and healthy, the budget strengthens 
health and public infrastructure with $975 million for domestic 
and international preparedness. It also invests in behavioral 
health services including more than $99 million in new funding 
to combat prescription opioid and heroin abuse.
    Finally, as we look to leave the Department stronger, the 
budget invests in our shared priorities of addressing waste, 
fraud, and abuse--initiatives that are projected to yield $22 
billion in gross savings.
    The budget addresses the Department's Medicare appeals 
backlog with a coordinated approach. The budget also makes a 
significant investment in the security of the Department's 
information technology and cybersecurity.
    I want to conclude by taking a moment to say how proud I am 
of the HHS team and the employees that work on Ebola, their 
work every day and their commitment every day. I want to assure 
you I am personally committed to a responsive and open dialogue 
with members of this committee as well as with your colleagues.
    I look forward to working closely with you, and I welcome 
your questions. Thank you.
    Chairman Kline. Thank you, Madam Secretary. The light 
didn't even turn red. I'm unprepared now. I'm at a loss.
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    Chairman Kline. Seriously, I want to thank you, Madam 
Secretary, for your ongoing efforts to keep us informed about 
the Department's progress in implementing the Child Care and 
Development Block Grant Act of 2014, as well as the opportunity 
for committee staff to communicate directly with your staff.
    Can you update us, briefly, on the timeline for the release 
of guidance in the proposed rules in accordance with the Act?
    Secretary Burwell. I think, our staff has had an 
opportunity to go back and forth, and I think that's helpful as 
we're producing the guidelines. And I'm hopeful--I'm not sure 
which particular piece you're referring to, and so I want to 
make sure, and we can follow up on that. But overall, we are 
making progress and hope to get them out.
    One piece that I would like to recognize with regard to the 
implementation of the authorities that you all gave us, there's 
an important piece of the budget that is related to the 
implementation, and one of the things that we were told with 
regard to the authorities, improve the quality, improve the 
safety, and also, improve our ability to serve communities that 
sometimes aren't being served, such as parents that work in 
different hours.
    And so there's funding in the budget that we are talking 
about today on the discretionary side that I think it is 
important to do that, and I do want to raise that as a part of 
this conversation. That as part of doing the implementation, 
there is some funding to do that.
    Chairman Kline. Okay. I'm not sure that's exactly what I 
was getting at, but that's good. Thank you very much.
    Secretary Burwell. And I will get back on the specifics of 
the timing of the guidelines.
    Chairman Kline. Just trying to get a better feel for the 
timeline.
    Secretary Burwell. I'm happy to get back on exactly the 
timetable.
    Chairman Kline. And again, I very much appreciate the 
exchange between staffs, very, very helpful.
    I want to take the remainder of my time, no doubt, and I'll 
try to be brief, but there is an issue having to do with the 
Patient Protection and Affordable Care Act that's just sitting 
out there that really, really needs to be addressed, and that's 
the maximum amount of out-of-pocket limits for cost sharing 
that I'm sure that you've heard about. I've heard from several 
employers recently about this unilateral change the Department 
made to cost sharing, maximum out-of-pocket limits under PPACA.
    We can't seem to determine where this is coming from. The 
statute is pretty clear. There are two separate and distinct 
types of coverage, self-only and other than self-only coverage, 
each with respective out-of-pocket limits. Before this new 
rule, any combination of family member's out-of-pocket costs 
has counted towards the maximum of these out-of-pocket family 
coverage limits. Now, the Department has declared that starting 
in 2016, the individual out-of-pocket limit applies first 
before the family limit applies. That means the cost of the 
employer coverage will increase because insurance will pay 100 
percent of the out-of-pocket costs sooner.
    I understand that you're aware; I have been led to believe 
that you're aware of these concerns. I'm sure that employers 
have raised this issue directly with you and your staff 
probably many times. They certainly have with us.
    We'd like to understand under what statutory authority you 
did that? And then I'd like to enter into the record letters 
from the ERISA Industry Committee, the American Benefits 
Council, and the National Coalition on Benefits, conveying 
their grave concerns to the Department's new embedded maximum 
out-of-pocket limit rule.
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    Chairman Kline. The letters also convey that compliance 
will not be possible by 2016 given that employers' plans are 
already set for next year. It wasn't until May, when additional 
guidance was issued, that most large employers knew this change 
applied to them. So there's real confusion out there, Madam 
Secretary. And, again, I'm fairly confident that you are 
hearing some of this directly, but I want to make sure you 
heard from me.
    Can you commit to at least delay the impact of this, 
really, significant rule change for at least a year, and if 
not, why not?
    Secretary Burwell. So with regard to the issue of the 
question of delay, we are now hearing and receiving feedback. 
We want to take and incorporate that and determine what we 
should do to move forward. I think it's important to note why 
the change was put in place. And the change was actually put in 
place about the consumer and the fact that when one consumer in 
a family hits that individual limit and the question of should 
they hit that family limit and whether you should aggregate or 
the individual. Because, I think actually when consumers 
purchase and how the consumer thinks about this issue, I hear 
and understand, and we are hearing from the companies in terms 
of how they think about the question of the maximum out-of-
pocket limit.
    But if you are an individual in a family, do you think that 
limit is your individual limit, and then there's a broader 
family limit for all. And so once you've hit your individual 
limit, what would happen is you would keep going. And so you 
would not have those things paid for, and you signed up in a 
place where you thought your individual limit was your 
individual limit and your family limit was for all members of 
the family. And so that's how the consumer has tended to think 
about it and at least what we've heard from the consumer side 
of it.
    And so that is why we have gone forward. We are hearing 
comments and want to incorporate those comments and understand 
if it is implementable.
    Chairman Kline. Well, I understand the point of view of the 
consumer here, and I'm not making light of that. But the 
statute we think is pretty clear. And because there is so much 
confusion out there, and there is the uncertainty and arguably 
the inability to comply, we are hopeful that you will commit 
sooner rather than later to a delay of this rule change.
    And I'm going to try to--it's already too late. The light 
has turned red for me.
    But, Mr. Scott, you're recognized.
    Mr. Scott. Thank you, Mr. Chairman.
    Thank you, Secretary Burwell, for being with us today. I 
wanted to ask you a few questions about the Affordable Care 
Act, but, first, I want to thank you for your Department's 
outreach efforts, particularly Joanne Grossi, who is the 
regional director in my area has just been outstanding in 
outreach into the community, making sure that people know about 
it, and during the signup period was all over my district. So 
I'm sure she was all over the region.
    Can you say a word about what the Affordable Care Act does 
for people with insurance in terms of preexisting conditions 
and job lock?
    Secretary Burwell. So two different things that I think it 
does. With regard to preexisting conditions, it creates a 
situation where anyone with a preexisting condition is able to 
get insurance. And so whether it's the people that I've met as 
I traveled across the country that are concerned for their 
children as their children get older, if it's child that has 
asthma or other conditions or someone who has actually gotten 
cancer and is now well and their ability to know that they 
won't be locked out. So preexisting conditions are something 
that are no longer something that creates both health and 
financial worry for people in the system.
    And with regard to the question of lock out and job lock, 
there are many people who wouldn't make changes because of 
their fear of losing coverage. And that is a part of the 
numbers that the chairman stated in terms of the changes that 
occur. Because with regard to the employer-based market, we 
have not, in the two years that the Affordable Care Act has 
been up, seen that shift from employer-based coverage in terms 
of the reduction and percentage of employees that are in 
employer-based coverage. We haven't seen that shift.
    And some of the estimates are about people, though, who 
will choose to make a decision to go do something 
entrepreneurial if they want to start a business or make other 
changes in their lives. And so the lock that was created 
because they were fearful of losing coverage doesn't exist 
because they have an option, and that option is through the 
marketplace.
    Mr. Scott. And what has happened to the growth in 
healthcare costs since the passage of ACA?
    Secretary Burwell. With regard to the growth of healthcare 
costs, thinking about it in terms of we've had some of the 
lowest price growth per capita that we have seen in 50 years in 
terms of slowing of that growth. I think when discussing the 
question of growth and cost growth, while it's a hard thing to 
do and recognize, one needs to look at historical growth and 
then what growth is.
    And so if we look at what was released recently in the 
Medicare trustee's report, which is let's reflect on the public 
sector costs of this growth, what we saw is growth of 1.2 
percent over the period of the last four years. What we saw in 
that period before then was 3.6 percent growth. And so what 
we've seen is a slowing in a lot of different places, both the 
public and the private, of that growth.
    Mr. Scott. And the programs under your jurisdiction, can 
you say a word about the effect of the sequestration if we 
don't do something about the sequestration?
    Secretary Burwell. So as we look at this issue of being 
funded at the lowest level in a decade when one accounts for 
inflation, it is across the entire Department, and whether 
that's an issue of Head Start or child care that we'll focus on 
in this committee, it also is in places like the NIH and our 
research or the CDC, who has been so active this year in so 
many ways, whether that's Ebola or measles, and also in places 
like the FDA, who are doing things like making sure our food is 
safe and that we are watching and taking care and that our 
drugs and diagnostics are safe.
    So it's across the entire Department. Another place that 
this particular committee is interested in, I know, is the 
older Americans and the programs that we have there to support 
those older Americans around food and transportation as well as 
elder justice.
    Mr. Scott. Thank you. Head Start is not in the Department 
of Education. It's in the Department of Health and Human 
Services. Can you explain why it's important--what the services 
to low-income children get remaining in Health and Human 
Services that it would not be available in just an educational 
program and why Head Start is so important?
    Secretary Burwell. So I think that the program of Head 
Start, we have it as part of our continuum at HHS that starts 
with home visiting. And thank you to all of you all who 
supported the sustainable growth rate bill that had the 
extension of the home visiting an evidence -based program that 
starts with that care in the home, visiting the home, and 
helping start children on the right track. And we believe that 
continuum as well as the changes in the authorizations in Head 
Start that you all have done to push to improve quality that is 
all part of a continuum, and the continuum is related to the 
issues that we work on broadly at HHS.
    And whether that's starting the mother on the right 
trajectory with regard to her maternal health so the child is 
born in a certain environment that has been taken care for 9 
months and then continuing that early care, starting that 
learning early and that brain development. The science that we 
know, and having a 5 and 7-year-old, of how quickly that 
neurodevelopment is occurring and how fast they are learning, 
sometimes it surprises me.
    But it is what we believe is a continuum of both health and 
the building block of healthy productive lives that we use at 
HHS.
    Mr. Scott. Thank you, Mr. Chairman.
    Chairman Kline. I thank the gentleman.
    Dr. Foxx.
    Ms. Foxx. Thank you, Mr. Chairman.
    And Madam Secretary, welcome to our hearing. Madam 
Secretary, I appreciate you bringing up the Older Americans 
Act. We're looking at--the Committee is looking at ways to 
promote best practices to combat elder abuse. And I wonder if 
you could talk a little bit about how the Department is working 
with other agencies to protect vulnerable elders?
    Secretary Burwell. So working across the Department and 
obviously, the Department of Justice is a partner with some of 
the work we do. But most recently, whether it's with our 
Departments and States, as well as other stakeholders.
    The White House Conference on Aging, we took an approach 
this year, where we actually went out to communities across the 
country, and this was one of the pillars and issues that we 
focused on and used that as an opportunity to bring in the 
engagement and involvement of both ideas as well as how we can 
implement better as a Department in terms of the issue of elder 
abuse. So we're seeking that input to improve what we are doing 
both within the U.S. Government, but also with a number of the 
players that implement and those are stakeholders on the ground 
and States. Because many of the programs are actually delivered 
and implemented at that level.
    Ms. Foxx. And would you discuss a little bit those delivery 
models of the Older Americans Act and what makes them work 
well? Working with other agencies, I'm sure, is the right thing 
to be doing, but are there ways to implement these similar 
delivery models across other programs across the country, and 
how is the Department providing leadership to do that?
    Secretary Burwell. So I think two--there are many things, 
but I'll just focus in a short time on two things that I think 
are important in this space.
    One is actually the awareness of the issue. Elder abuse is 
something that is not an issue that many focus on and whether 
these providers and the organizations in the community are a 
part of recognizing the issue. It is a little like the issue 
with victims in trafficking, creating a greater awareness of it 
is an important thing to do.
    I think the other thing that we think is important to do, 
is that when these acts occur that justice is served, so people 
know that when they are taking advantage of the elderly, and 
that's a place where we need to continue to work with State and 
local officials on that as well as Federal.
    And I think one very specific example of that is the recent 
takedown that was done on Medicare. You all probably know that 
our most recent takedown, which was a joint effort with us, 
DOJ, the FBI, HHS, OIG, and CMS. It was over $700 million in 
false billing. And many of those examples were around elder 
justice issues where patients were being told they were being 
treated for dementia and were simply being moved from one 
location to another being charged for that and Medicare was 
therefore charged. So I think it is the combination of those 
kinds of things that we trying to bring together.
    Ms. Foxx. Thank you very much for that.
    Congressman Scott brought up Head Start performance 
standards. We know that Head Start is the largest program we 
have working with young children. But we're concerned about the 
impact of the new regulations that you're putting out there.
    Our reauthorization in 2007 required you to have regulatory 
revisions not result in the elimination of or reduction in 
quality and scope of services, but you are talking about a 
reduction of 126,000 children's slots, elimination of 10,000 
teachers' jobs. How can you ensure that the revisions that you 
are proposing are in compliance with the 2007 law?
    Secretary Burwell. We have done three issuances of 
regulations with regard to implement the law, and this is the 
third of those. One of the things we did was make sure they are 
serving low-income communities, the other was making sure that 
there were reviews and people had to reapply for the money, the 
grantees. And so we set standards there, this is the third 
part. And in this part, we are using evidence-based studies to 
improve the quality and safety, which we believe that the 
authorization is what it told us to do.
    One of the things that the Chairman mentioned, that I think 
is important to mention, is we got rid of one-third of the 
guidelines in terms of simplifying and making it easier. With 
regard to some of the things that you are referring to, I think 
you are referring to the extension of the day and the year. And 
the evidence that we have seen, all the scientific evidence 
shows, that moving from three and a half hours to six hours is 
an important effort to provide the quality that we need to 
provide and the summers, having two children right now going 
through their summer, what they lose if they do not have that 
kind of continued education.
    We propose the amount of money that it would take in our 
budget. We're hopeful that we can move forward on that. And the 
other thing is if grantees can't meet that and have reason not 
to, there is waiver ability.
    Ms. Foxx. Thank you.
    Chairman Kline. The gentlelady's time has expired.
    Mr. Hinojosa.
    Mr. Hinojosa. Thank you, Chairman Kline and Ranking Member 
Scott. I strongly support the Health and Human Services budget 
request and ask that we work together to forge a consensus on 
how to ensure that our families continue to have access to 
quality healthcare coverage and adequate funding for Head 
Start.
    We can invest in our preschool programs today or in 
juvenile detention tomorrow. We have heard Pope Francis deliver 
a very strong message all over the world urging leaders like 
us. The Pope says, we must make the right amount of investments 
to address poverty found in older senior persons and children 
in low-income families.
    Madam Secretary, thank you for your testimony on the 
Department's enormous progress we have made since the enactment 
of ACA. It's a pleasure to have you testify before this 
committee.
    Today, in my congressional district, because of the 
Affordable Care Act there are over 100,000 individuals who now 
have health insurance and 88,000 seniors who are now eligible 
for Medicare preventive services without paying any copays, co-
insurance, or deductible. We know that another program, Head 
Start, is a crucial developmental program in my congressional 
district known as the lower Rio Grande Valley. This program 
serves between 15,000 to 20,000 children and families. Head 
Start has made a significant impact on improving the 
opportunities for eligible children, especially our Nation's 
Latino and African American youth. Thank you for your strong 
budget support for this program.
    My first question, what is at stake for our Nation if we 
ignore the ever-growing body of research, and we fail to 
sufficiently invest in quality early learning for our Nation's 
minority children?
    Secretary Burwell. So I think this is why this area in our 
budget, and we discussed the Head Start portion of it, but 
there's also the child care proposal. And part of the child 
care proposal on the discretionary side comes to part of the 
chairman's question in terms of implementing the authorization. 
That's on the discretionary side. The broader proposal that we 
have, which is a larger mandatory proposal, is about making 
sure that there's access on this continuum.
    And so what we do is we take care of that child from the 
moment of that home visiting and the pregnancy through those 
early years of education, and that we do that both for those at 
the lowest level of income, and Head Start is focused on that. 
But child care, and that's a part of what we're proposing is 
child care for working families, that there is supplement so 
that they can afford that, up through that school age. And so 
what we are trying to do is create a continuum, which we think 
was a part of the authorization and some of the concepts of the 
authorization.
    This budget funds it fully. We think it's one of the most 
important priorities. And as we reviewed the budget and put it 
together, it is a place where we made choices that we would 
prioritize and put a lot of our dollars because we think it is 
so important to the long-term health of those children and the 
well-being of our society.
    Mr. Hinojosa. I agree with you, and I recommend that you 
consider adding more emphasis on early reading and writing for 
children from cradle through the fourth year so that they can 
love books and improve their vocabulary and be able to stay at 
grade level and do well.
    In my district, the majority of the uninsured population 
falls under the Medicare--excuse me, falls under the Medicaid 
coverage gap and does not qualify for assistance in healthcare 
marketplace. According to the Kaiser Family Foundation, up to 
950,000 uninsured people would gain healthcare coverage if the 
State of Texas decided to expand Medicaid. What justifications, 
if any, have you heard or received, and how has HHS responded 
to discussions that you've had with the governors like Abbott 
in Texas?
    Secretary Burwell. So with regard to the conversations with 
governors, I spent the weekend at the National Governors 
Association, and the year before that I did as well. In terms 
of any concerns that governors have, what I want them to know 
is we want to expand the program, we want to expand the program 
in a way that implements the statute, which is about expanding 
access and doing it for low income populations so it's 
affordable. But we want to do that in ways that works for 
States.
    And so I think in terms of answering concerns and 
questions, whether it's the negotiations that we did with 
Governor Pence, and I personally participated in a number of 
other governors so that we can make sure that we do this in a 
way that serves the citizens, the States, that may have 
different needs. And so that's, in terms of one of the issues 
that comes up. I want to clearly articulate - I want to work 
with governors and their states.
    Mr. Hinojosa. Thank you. I yield back.
    Chairman Kline. The gentleman yields back.
    I'm going to yield to Dr. Roe, but I want to give members a 
heads-up here. We're looking at a clock and time. I'll be 
recognizing Dr. Roe for five minutes and probably Ms. Davis, 
maybe Mr. Walberg and Mr. Grijalva. After that we are going to 
have to start dropping down. So just start tailoring your 
questions we are going to go to four minutes and see if that 
will make it. I am trying not to go to three or two, but I want 
to give everybody a chance to be involved in this conversation.
    Dr. Roe.
    Mr. Roe. Thank you, Mr. Chairman.
    Thank you, Madam Secretary, for being here. Just some QFRs, 
some questions I want to bring up to begin with and then we'll 
get to the questions. These are things I want your shop to 
answer.
    One is the Medicare wage index or area wage indexes. If you 
look at those around the country, it was never intended to be 
like that. The 20 of the highest are in California and 
Massachusetts, and 14 of the lowest are in Alabama and 
Tennessee. For instance, what you get paid in Santa Cruz, 
California, is 1.7 with the Medicare area wage index and it is 
0.73 where I live. It's putting us out of business. And that 
needs to desperately be looked at.
    The second thing I want to bring up, and I want to know 
what your solution for that is, the second thing I want to know 
are the RAC audits. The RAC audits, certainly, we are all 
against fraud and abuse. But in my State, the Medicare comes 
in, does these audits, withholds the payments, and we win 72 
percent of them. And now, the backlog is so long, you can't get 
in front of anybody to get your money back that you've earned, 
and that's unfair. And I think you absolutely need to redo the 
RAC audits.
    And thirdly, this is a much deeper one, and it may take 
some time, but Medicare is on an unsustainable course, as you 
well know. Last year, in 2014, Medicare spent $613 billion, and 
we took in $304 billion in premiums. That's unsustainable. And 
since its inception, $3.6 trillion, negative, of premiums over 
what we spent on the program. I'd like to know what your 
recommendations are to put this on a more sustainable course. 
Yes, through our reform we did save $2.9 trillion over the 
budget window. That's a start. But I would like to know what 
those other issues are.
    And regrettably, I've got to ask some questions now that I 
don't like asking, but I think are extremely important to ask. 
And also one last thing, question was for the QFR on IPAB. Do 
you think one person, that would be you now currently, sitting 
in that seat, should have the power to determine how Medicare 
dollars are spent if it goes over this formula? I'd like to 
know that, because there's nobody on that 15-panel board right 
now.
    Recently, we've seen two videos that showed Planned 
Parenthood physicians basically having wine and eating a salad 
bargaining over the harvesting and sale of dismembered baby 
parts. I found this incredibly offensive to me as a physician 
and as an obstetrician. Have you seen those videos?
    Secretary Burwell. I have not seen the videos. I've read 
the articles about them.
    Mr. Roe. Well, last week in the Wall Street Journal, it 
reported that you couldn't comment because you haven't seen it, 
but you need to see those, Secretary Burwell, as quickly as you 
can. And it's only eight or ten minutes, but you need to look 
at those videos to see what the rest of us have looked at.
    And given Planned Parenthood's, which I think is horrific 
conduct, Americans may be troubled to realize that Planned 
Parenthood gets over $500 million a year, much of it through 
your shop, through Medicaid and Title X funding. Having said 
that with a significant financial relationship, could you tell 
us what you've done to investigate these activities?
    Secretary Burwell. So, first, because it's so related to 
the budget issues we're discussing today, the RAC issues and 
the backlogs, we have put together a strategy that includes, it 
is just because it is such an important issue and appeal, so I 
just want to make sure there is a budget issue in terms of 
extending the number of people that we can have to review the 
appeals because there are legal judges that we have to bring 
in.
    Second, there are statutory changes. And on the Senate side 
a bill is moving to make changes that will help us, and third, 
administrative actions, including settlement. So, I just want 
to raise that because it is important.
    I want to go on to the broader issue that you've raised. 
With regard to the issue, I want to start by saying this is an 
important issue that people have passion deeply on both sides 
of the issue and whether that's the issues of research that are 
important for eyes, degenerative diseases, Down's syndrome, 
Autism, or the issue of belief. And I want to start there. With 
regard to the question of--
    Mr. Roe. Let me stop you, because my time is about up. Have 
you had any contact with Planned Parenthood yet? On this issue.
    Secretary Burwell. I'm sorry?
    Mr. Roe. With regard to this issue, this sale of the . . .
    Secretary Burwell. No. Planned Parenthood's funding, the 
$500 million, I think you mention I think is a number that is a 
State number. And with regard to Medicaid and States those are 
issues where--
    Mr. Roe. 41 percent of their funding comes through the 
Federal taxpayers. And let me just say before my time runs out, 
because we are limited in time. I found it absolutely amazing 
that Planned Parenthood could complain about a woman having an 
ultrasound before she terminates her pregnancy, and then uses 
an ultrasound so they can harvest body parts to be sold for 
fetal tissue. I found that absolutely astonishing.
    Mr. Chairman, I yield back.
    Chairman Kline. The gentleman yields back.
    Ms. Davis, you are recognized.
    Mrs. Davis. Thank you, Mr. Chairman. And I'm sure there 
will be plenty of investigations on that by my colleagues.
    But I wanted to go on and just ask Mr. Chairman for 
unanimous consent that the CBO's score showing that a repeal of 
the Affordable Care Act, which would add $137 billion to the 
deficit in the next decade, that this report be entered into 
the record.
    Chairman Kline. Without objection.
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    Mrs. Davis. Thank you, Mr. Chairman.
    Thank you very much, Madam Secretary, for being here, for 
your service, and for joining us today.
    You mentioned NIH earlier. I know that you care deeply that 
we continue to fund this at higher rates. We absolutely cannot 
fall behind the global community in how we address science and 
innovation. And so I think that's very, very important. And I'm 
pleased that the President has increased that funding.
    But I also wanted to talk about not just the innovation 
piece of it, but really the access piece and affordability, and 
particularly focus on the changes that you have recommended in 
reforming Medicare Part D.
    And specifically in ways that you call for in the budget 
request in terms of reducing Medicare costs both for the 
government and the consumer and looking at the question of 
giving authority to you and to the Department to negotiate drug 
prices in Medicare Part D. So can you talk a little bit about 
that and why that is part of the budget and why you think that 
this is so important?
    Secretary Burwell. I think that we believe that the 
ability, as we look and address the issue, one of the issues 
that was brought up--the question of the long-term health of 
Medicare and how we work on that, is that we look at some of 
the issues that will be driving costs in the out year. We 
believe that drug costs are a part of that, and we see that 
happening. We see that both in terms of the numbers we see now, 
but in the out-year projections we also hear it from the 
private sector.
    So the belief is, and, you know, having come from the 
private sector and actually having come from a company that is 
known for its negotiating on price, Wal-Mart, the idea that we 
use market mechanisms to try and put downward pressure on price 
is something that we think is important. And so that's why 
we've asked for those authorities so that we can try and work 
with the pharmaceuticals and negotiate to keep downward 
pressure on that price. That's what we hope we can do, and we 
see it as part of the overall issues that we're being asked 
about, how we transform the system for the long term. We 
believe there are things that we need to do and pressure we 
need to put.
    Mrs. Davis. What do you see as some of the key problems 
that you're going to be having as you try to move forward with 
this?
    Secretary Burwell. So I think with regard to this 
particular issue, it's not one, you know, it is a legislative 
and a statutory issue. And so it will take a statutory change 
to grant the authorities to be able to negotiate. That's not 
something that administratively we can do. So it is something 
where the action will sit with the Congress.
    Mrs. Davis. Uh-huh, yeah. Well, thank you for working on 
that. I know it's not a simple way of moving forward, but it 
does seem to make a difference. And there have been so many 
stories lately about how the high costs have, really, not just 
bankrupted families, but made it very difficult for people to 
access important lifesaving drugs.
    I wanted to just for a moment also talk about the 
increasing access for folks here at home. And we know that the 
ACA really has been a huge success in helping to reduce the 
number of the uninsured. I actually have a constituent in my 
district who was going regularly down to Tijuana to get the 
medications that she needs, and this now means, as a result of 
her being insured, that she doesn't have to do that any longer, 
and it has been a big difference in her life.
    So I wondered if you could just talk a little bit about how 
dramatic the increase in the uninsured population has been 
since the implementation of the ACA and what this additional 
coverage has meant in terms of increasing patient outcomes.
    Secretary Burwell. So with regard to that, I will try and 
be brief, and just in terms of numerically the number I think 
you know is over 16 million is the number of reduction in the 
insured. With regard, I think what tells the story better are 
the individuals, and whether that's Anne Ha, a woman who was 
26, uninsured, her mother told her to sign up; she needed 
insurance, she didn't, but in the end she listened to her mom. 
A month later she discovered she has stomach cancer and had the 
coverage that she needed. And that coverage both helped her for 
her health and actually, recently married, and in addition to 
that, though, the financial security in terms of her business 
and her availability to continue on in that way as well.
    So I think it's the individual stories combined with the 
numbers in terms of what we're seeing of what the extended 
coverage means.
    Mrs. Davis. Right, yeah. I particularly have heard about 
that when it comes to type 2 diabetes and the prevention that's 
made a real difference for those folks. So thank you very much 
for your service.
    Thank you, Mr. Chairman.
    Chairman Kline. The gentlelady's time has expired.
    Mr. Walberg, you are recognized for five minutes.
    Mr. Walberg. Thank you, Mr. Chairman.
    And thank you, Madam Secretary, for being here. Thank you 
for reaching out to us before this as well.
    I want to ask you the first question, how many fictitious 
claims have been paid since enactment of ObamaCare, and how 
much has been lost due to this fraud? But to just bring it into 
context here, earlier this month, GAO released a report that 
investigated Healthcare.gov through various undercover tests 
performed throughout the 2014 coverage year. The report 
revealed some stunning things, that the marketplace approved 
subsidized coverage for 11 out of 12 fictitious applicants 
created by GAO resulting in a payment, they state, of about 
$30,000 to insurers on behalf of these fake enrollees.
    For seven of the 11 successful fictitious applicants, GAO 
intentionally did not submit all the required verification 
documents to the marketplace, and the marketplace even then did 
not cancel subsidized coverage for these applicants despite the 
inconsistent and incomplete information.
    And so subsequent to that, how many fictitious claims have 
been paid since the enactment of ObamaCare, and how much has 
been lost due to the fraud?
    Secretary Burwell. So with regard to the example, we take 
very seriously the issue of program integrity and want to 
continue to improve it. We look forward to the GAO's 
recommendations out of that study. We haven't seen those yet. 
We look forward to understanding what they are, because we 
welcome the opportunity.
    With regard to the question of answering the number, 
because GAO didn't find actually that there were fictitious 
claims, they did, when they had individuals who came through 
the system--first, they came to Healthcare.gov, the marketplace 
in terms of electronically, couldn't get through. Then they 
actually came through, through the phones, and that's where 
they got through. At that point, because they are GAO, they 
were able to do things that for everyone else would be perjury; 
that would have up to a $250,000 fine affiliated with it.
    Mr. Walberg. And they were successful?
    Secretary Burwell. And were successful in breaking the law 
in terms of what they were doing to go through.
    With regard to the next step, and there are a number of 
gates. There's the gate at Healthcare.gov, in terms of that was 
where it was caught. Got through at the point, you know the 
question of confirmation of information. Then because they did 
not file taxes, what will happen to these individuals is in 
this year, as per statute, they will no longer be able to get 
subsidies in the next year, because at that point the IRS will 
let us know that they have not filed taxes.
    Mr. Walberg. So, we don't know how many fictitious 
complaints may have been filed already other than GAO?
    Secretary Burwell. No, we don't. We know of the 11 examples 
of GAO--
    Mr. Walberg. We know that.
    Secretary Burwell.--with regard to those that have 
committed--
    Mr. Walberg. Twelve examples, 11 got through.
    Secretary Burwell. With regard to those are the only 
examples we know of because as GAO said in the report, they 
didn't know of other examples other than those that they had 
created.
    Mr. Walberg. They don't, yes. But you don't know either?
    Secretary Burwell. So, with regard to the things we have in 
place, what we do know is we have a number of steps in place. 
And within 90 to 95 days, we go through data matching. And this 
year already, 117,000 people who have not--we don't know that 
they are fictitious, we know that they have not provided the 
right documentation--and the first quarter of this year, 
117,000 people came off.
    Several other hundred thousand people, over close to 
200,000 people, received information saying we did not have 
enough justification for their income and, therefore, their 
APTC, their tax credit, would be adjusted downward.
    Mr. Walberg. What--
    Secretary Burwell. So we are on a constant path of making 
sure we have the information that aligns with what we have been 
told, and if not, we are taking action.
    Mr. Walberg. Without getting into specifics of these cases 
that were successful, again, which shows that there should be 
concern, can you explain to the committee what process has 
likely failed to allow these fictitious applicants to gain 
subsidies?
    Secretary Burwell. So, there are a series of processes that 
occur. And in terms of the gates, when people have lied about 
their information - it's something that can happen in the 
system. It can happen in all of our systems. The way we catch 
that is in the data matching and information. So it depends on 
whether they've lied about which part and that could have to do 
with--
    Mr. Walberg. But which ones failed?
    Secretary Burwell. Pardon me?
    Mr. Walberg. Do we know which ones failed that allowed.
    Secretary Burwell. No, because we have not seen the GAO 
examples. One of the things that would be very helpful to us is 
to actually see the example. Because all we know is what you've 
said. And if we have the information, then we can find where 
the system may not be working. Right now in terms of the 
system, as the examples I gave you--
    Mr. Walberg. What's keeping you from getting the examples, 
then, if that's the case? This came out earlier in July.
    Secretary Burwell. At this point, the GAO has neither given 
us recommendations or--
    Mr. Walberg. Have you asked for it?
    Secretary Burwell. We have asked the GAO in terms of can we 
understand how you did this. They believe they are protecting 
their sources and methods.
    Chairman Kline. The gentleman's time has expired.
    Mr. Grijalva, you are recognized for five minutes.
    Mr. Grijalva. Thank you.
    Thank you, Mr. Chairman, and thank you, Madam Secretary. 
With regard to the GAO question you just received, the gaming 
of the system and the process, is this such a rampant 
phenomenon that it is undercutting the very pinning's of the 
Affordable Care Act or are we dealing with an issue in which as 
you get more information, you deal with it?
    Secretary Burwell. At this point, there are a number of 
gates and efforts on program integrity in place, and that's the 
initial information gathering, which we check at the hub at 
that point, when that goes through, we also--when we don't have 
data matching, as I said, within 90 to 95 days, we review those 
cases, we take action.
    At the point of the filing of taxes and in the examples 
that we are given, folks didn't file their taxes, that is the 
next place where that would occur, and the next gate will occur 
in terms of that people choose not to file their taxes for some 
reason, that is the point at which subsidies will go away.
    We have a number of gates in place. We are implementing 
those. If we can understand places where people think those 
aren't working, we do want to understand that so that we can 
work to improve. We have improved the timetable.
    Mr. Grijalva. But GAO shares the methodology with you and 
those examples. We are waiting--you are waiting for that, 
correct?
    Secretary Burwell. We are looking forward to GAO coming out 
with recommendations, which is the part that has not yet 
occurred.
    Mr. Grijalva. Thank you. The President's commitment to 
early childhood education, it is reflected in the budget 
proposal, $1.5 billion extra for early head start and for head 
start itself. Briefly, if you could tell us, you know, the 
budget levels of spending caps established by the majority, 
what is that going to do to the fact that you are trying to 
build capacity, you are trying to stress quality and 
accountability for providers for these children, and what does 
that do to capacity?
    Secretary Burwell. So with regard to the levels, I think 
that if you are going to meet those levels and you want to 
fully fund head start, what it will mean are dramatic cuts to 
things like NIH or CDC in terms of other places. I think we 
believe we put together a budget that is a budget that as I 
mention, you know, there is savings in terms of deficit 
reduction that comes from the HHS budget as a whole, that we 
put together a plan and an approach that affords us the 
opportunity to fund all of those things.
    But at the current cap levels, you would not be able to do 
that, and so you would not be able to implement the changes in 
head start or you would have to make dramatic choices in other 
places. One of the largest budget areas for HHS is NIH.
    Mr. Grijalva. Yeah. And I think the last point, community 
health centers, that was mentioned briefly in your testimony. 
At least in my community, it is an essential network for health 
delivery, an essential part of the Affordable Care Act delivery 
system. If you could talk to the committee as to that role and 
how the budget that you are talking about is reflecting an--
continuing that commitment that the President made to the 
health centers at the inception of the Affordable Care Act 
discussion?
    Secretary Burwell. And we appreciate the work that was done 
also in the sustainable growth rate bill in terms of these 
issues. The community health centers serve approximately one in 
15 Americans actually are served by community health centers. 
We think they are an integral part of care. They are an 
integral part of primary care, a very important part of making 
sure as we expand access that we have an ability to serve.
    That is a part of why they were extended as part of the 
original Affordable Care Act and are extended now, as we have 
seen in the number of uninsured drops so that there are places 
for people to go as part of that. We believe they are a 
successful part of coverage, especially in communities that 
don't always have as much, and whether that is rural, minority, 
or other communities, that these are an important part of that.
    They are also an important part of integrating behavioral 
health and primary health together so that we can get to the 
place where that type of coverage is one.
    Mr. Grijalva. Thank you. I yield back, Mr. Chairman.
    Chairman Kline. The gentleman yields back.
    We are going to move members to four minutes because we are 
watching the clock. I can't seem to get it to slow down, so Mr. 
Guthrie, you are recognized for four minutes.
    Mr. Guthrie. Thank you.
    Thank you, Madam Secretary. Thank you for being here again, 
and I appreciate it. I want to talk about the employers' 
sponsored health insurance, the small market group definition. 
The Affordable Care Act in Section 1304 expands the small 
market group definition to 100 employees, so of particular 
concern are employers from 51 to 100, because if you are below 
50, you are not mandated to provide.
    Once you are, maybe 100, 102, I don't know what the number 
is, but once you start growing, then you are able to self-
insure when you get a bigger pool because a lot of bigger 
businesses aren't having the same issues.
    So the trap seems to be, and I have heard from a lot of 
employers' insurers and actually, a lot of colleagues on both 
sides of the aisle have been working to try to fix this 
problem. And I have seen estimates of a 30 percent increase 
from different studies. But the issue is, you know, employers 
from 51 to 100, if they go into this small market group 
definition, will have expensive mandated benefits, and there is 
a big concern, as I said. It is bipartisan over here in the 
Capitol, and so I just wondered if you have looked at this 
issue and what actions are you looking at taking?
    Secretary Burwell. So looking at the issue right now, one 
of the things I would ask, if we could follow up with you and 
your staff to make sure that we are getting the comments that 
you are hearing directly from either employers or other groups. 
It would be very helpful. There is, you know, another side in 
terms of expanding the other market that people argue, but we 
would love to hear directly if you have those comments--
    Mr. Guthrie. Absolutely.
    Secretary Burwell.--as we are reviewing that. It would very 
helpful to hear the specifics of why people assume it will work 
the way that you described it working. There are others that 
argue the other side of this issue, so it would be helpful if 
you could follow up on that evidence.
    And so, I want to understand in terms of a policy 
perspective and then the question is would we have authorities, 
and so those are the two questions we are examining right now. 
It is a timely conversation, so if I could ask that we follow 
up with your team or you directly to--
    Mr. Guthrie. Absolutely.
    Secretary Burwell.--make sure we have those comments. I 
would appreciate having the facts from the field to inform our 
conversation.
    Mr. Guthrie. Okay. We will make sure that happens. There is 
a bill, it is H.R. 1624, and it has 158 cosponsors and is 
bipartisan. It is not just--I mean, it is a very bipartisan, 
look at what is going on, and having said that, Mr. Chairman, I 
have a letter actually--and I do have a letter, we will share 
it with you, from 19 employer groups regarding this, and I 
would like to enter into the record, unanimous consent to enter 
into the record.
    Chairman Kline. Without objection.
    [The information follows:]
    
    
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    Mr. Guthrie. Thank you, Madam Secretary, and I yield back.
    Chairman Kline. The gentleman yields back.
    Mr. Courtney, you recognized for four minutes.
    Mr. Courtney. Thank you, Mr. Chairman, and thank you, Madam 
Secretary, again for your accessibility since taking over, and 
it's much appreciated. For the record, I just want to note we 
had a great conversation to talk about the observation coding 
issue, which still is a very, I think, widespread problem out 
there for folks who are discharging from hospital, and 
unbeknownst to them, find themselves in this sort of coverage 
gap for Medicare to cover medically prescribed services.
    Since we spoke about the two-day midnight rule, I have 
already got a sheath of input from folks who, again, I will 
share with you about why that by itself is just not a solution 
to this problem. So but we will move on.
    The chairman mentioned earlier about the insurance rate 
increases that were reported a while ago in the press. I would 
just point out, coming from Connecticut, a State which embraced 
this law, is now in year three of its exchange.
    Just a couple of days ago, some of the insurers who 
participate in the exchange revised downward their initial rate 
request, so for example, Anthem came in at 6.7. They revised 
downward to 4.7. This is prior to insurance department rate 
review. The Co-op, which last year cut its rates by 8 percent, 
came in with a 13 percent rate increase. They revised downward 
to 3.4 percent. And the largest insurer on the exchange, 
ConnectiCare, which is a private health insurance company, they 
came in with a whopping two percent increase earlier. They have 
now revised downward to .7 percent.
    And I point this out because this is a cohort that actually 
has claims experience under its belt now, so that the fear 
amongst the actuaries, that the walking wounded, in the 
exchanges were going to spike up, you know, in the initial 
years. I mean, we are actually seeing incredible stability in 
terms of the rates.
    We also are seeing new insurers come into the marketplace. 
Harvard Pilgrim is now knocking on the door and is coming in to 
sell their product in Connecticut. So again, your Department 
has been boosting the insurance department rate review piece of 
this, and I am just wondering, you know, if you could share, 
you know, from a global standpoint, you know, whether or not 
some of these fears are really overstated?
    Secretary Burwell. So with regard to the rate issue, it 
is--I think what you were pointing to is one of the things 
about the Act that is important is about adding transparency 
and the light of day to things in the marketplace to make a 
market work so that individuals have information and that there 
is pressure in the market to make it work, and that was one of 
the ideas.
    And so when people saw the rates, the rates that were 
reported are only the rates really, in most States, that are 
above 10 percent because that is required. If a company is 
going to raise the rates above 10 percent, part of the law is 
they have to--it has to be posted. We have to report it while 
the State insurance commissioners review it. That is the other 
part of this, is that it needs to be reviewed. It doesn't just 
happen that they propose it.
    If they are going to propose above 10 percent, they need to 
justify it, and so that is a part of the process at work. And 
what you see in terms of Connecticut and what just happened is, 
that creates downward pressure, both in terms of the public 
pressure and the requirement that you have to justify any rate 
increases.
    And so we think, overall, what we have seen last year is 
that the rates come in here and then that there is downward 
pressure. We also see in States like Connecticut and actually 
California just came through yesterday, and their rates were at 
4 percent, which is lower than their increase of last year.
    And so that is what we will continue to watch and monitor. 
The reason we recently had a conversation with the State 
insurers to make sure they know and are using that tool of rate 
review, to put that downward pressure, which we believe is an 
important thing to do, making the market work.
    Mr. Courtney. I mean, as a former small employer who double 
digit requests were--you know, or increases were just a matter 
of course, I mean, to see a 2 percent or .7 percent, or--really 
that is eye popping in terms of--
    Secretary Burwell. The difference.
    Mr. Courtney.--the stability.
    I yield back, Mr. Chairman.
    Chairman Kline. The gentleman yields back.
    Mr. Barletta, you are recognized for four minutes.
    Mr. Barletta. Thank you, Mr. Chairman.
    Secretary Burwell, my district is home to a number of small 
family run businesses that sell premium cigars to adult 
consumers. These job creators have expressed to me concerns 
about the impact of an expansion of FDA's regulatory authority 
under the Tobacco Control Act on their businesses.
    Their shops serve a distinctly adult clientele, and I do 
not believe this category was the intent of Congress in 2009 
when the law was passed. Can you tell the committee what steps 
you are taking to ensure that such businesses, which are a 
staple of Main Street America, are not regulated out of 
existence?
    Secretary Burwell. With regard to right now, as we are in 
the middle of a rulemaking process, I think you probably know 
that we actually proposed two different alternatives as part of 
the rule. To gather the evidence and information with regard to 
the question of premium cigars and how they are or are not sold 
to children, you know, that was a part of what we are trying to 
do, and we are reviewing that and we are in the middle of that 
process now.
    Having said that, as we are in that process, a part of your 
question was the recognition of small employers, and that is 
something that will be taken into consideration, no matter 
where the rule ends. It is something, I think, is very 
important that we do as we think about implementation, and so 
wherever the rulemaking comes out, as we are in the process, 
but I do want to recognize the point that you have made, which 
is making implementation for small employers and small 
institutions possible, whatever it is.
    It is something we consider a real priority and something 
we believe, no matter where you are we can work on as part of 
implementation.
    Mr. Barletta. The proposed deeming rule has been under 
consideration for more than a year. Regulatory uncertainty is 
exceptionally challenging for small businesses, who are trying 
to plan for the future, as you know, open new stores, hire more 
workers, and serve their customers. When do you anticipate this 
rulemaking to be finalized?
    Secretary Burwell. I am hopeful that we will do it as 
quickly as possible. I think the issue you have raised is one 
of many complex issues that we received, I think you know, a 
number of comments on. We are trying to work through how we get 
to a balanced answer is what we are doing and trying to do that 
as quickly as possible. We appreciate the point that you made 
about uncertainty, again, in terms of recognition of what this 
means for the business community, especially small players.
    Mr. Barletta. Okay. Thank you. I yield back, Mr. Chairman.
    Chairman Kline. The gentleman yields back.
    Ms. Bonamici, you are recognized for four minutes.
    Ms. Bonamici. Thank you, Mr. Chairman, and thank you, 
Secretary Burwell, for your testimony, and thanks to you and 
the Department for all your work on so many issues, healthcare, 
precision medicine, I am interested in that, mental health 
services, thank you for your work on early childhood education, 
community and family support programs.
    I want to spend my short time talking about the Older 
Americans Act, which recently celebrated its 50th anniversary, 
and I want to thank Chairman Kline and Ranking Member Scott, I 
know they are committed to working together with my colleagues 
and me to successfully reauthorize the OAA. Thank you to Dr. 
Foxx for calling out the issue of elder abuse, and I want to 
emphasize that elder abuse includes both physical abuse, but 
also financial abuse.
    So I have three questions, and I think what I will do is 
tell you what the three are to save time. First, as we know, 
the population of older Americans is changing rapidly, so can 
you talk about what steps you are taking to modernize the 
administration for community living programs, as our older 
population is becoming increasingly diverse.
    Secondly, when I talk to people about the Older Americans 
Act, they know about the nutrition programs, especially 
programs like Meals on Wheels. We know that the population of 
seniors is expected to double by about 2050, so we all support 
investments that will yield greater efficiency. So can you talk 
about how the Department is promoting evidence-based practices 
among nutrition providers and how you plan to spur innovation 
in those essential nutrition services? We know that oftentimes 
that is the only social contact seniors have as well is with 
that meal.
    And then my third question has to do with the family 
caregiving. Seventy-seven percent of caregivers say that family 
caregiver support services make it possible for them to 
continue to care for their loved ones, it keeps seniors at 
home, but of course, it is hard work, and training in respite 
care services for caregivers are very important. Many of these 
caregivers are in the sandwich generation where they are taking 
care of parents and children at the same time. So what is the 
Department doing to prepare and support a large diverse 
community of caregivers?
    Secretary Burwell. So we will quickly try and work through 
each of these. In terms of the modernization, a part of the 
modernization, as I discussed, how we actually went about doing 
the White House conference on aging.
    Ms. Bonamici. Right, right.
    Secretary Burwell. And getting that input because it was a 
very different approach in terms of being out in the community, 
using technology, including the fact that the White House 
Conference on Aging, actually people could participate through 
technological approaches, and so changing the way we think 
about our work in terms of technology and the fundamental idea 
of people's engagement in our programs and their feedback, 
being more customer friendly and doing it in ways that use 
technology are two things in terms of the modernization.
    In terms of the evidence-based practices around nutrition 
and meals, and I think that is part of a broader category of 
what I would consider prevention and preventative care and 
making sure that we are doing that correctly. And that, I 
think, is actually centered a little less than ACL and a little 
more with CMS, and it is also a part of the Affordable Care Act 
in terms of people knowing that they can do preventative and 
wellness visits without copays.
    Those numbers are increasing. We need to increase them 
more, so the people accessing those services are not at the 
level--they are improving, but it is a place where we need to 
send more time. Nutrition and wellness comes into that as well 
in terms of how it fits into this broader thing that I think 
changes that but changes a larger piece.
    The last piece is the family caregiving and encouraging 
that staying in community at home. And you probably have seen 
our most recent rulemaking at CMS, which is an important part 
of reforming the overall system of delivery of our healthcare 
and paying in ways that encourage that kind of care at home. 
And so the rulemaking and the demonstration we are doing there 
are probably our most effective tools because those are the 
ones that scale broadly and because payment is an important 
part of how people are making these decisions about staying in 
a community versus making a change.
    Ms. Bonamici. Thank you so much. I see my time has expired. 
Thank you, Mr. Chairman.
    Chairman Kline. Thank the gentlelady.
    Mr. Carter, you are recognized for three minutes.
    Mr. Carter. Thank you, Mr. Chairman.
    Ms. Burwell, earlier this year you received a letter, along 
with Secretary Lew, from a group of employers with workforces 
who have variable hours, and it was specifically to address the 
employer notice and appeals process, because it is very 
important for employers to get notification about employees who 
have received subsidies; otherwise, those employees are going 
to be facing tax penalties if they declined a more affordable 
employer plan and accepted the subsidies, so this is very 
important.
    It is my understanding that, as of yet, none of those 
employers have received anything from HHS. Can you give me an 
idea, just a date of when you expect to give notification to 
employers?
    Secretary Burwell. Mr. Carter, this issue is one I am not 
specifically familiar with, but my understanding of what you 
are talking about is it is a Treasury issue because what you 
are talking about is tax information on the individuals in 
terms of they received an APTC, and that is a matter of--
    Mr. Carter. Okay. Can you just get back with me and let me 
know a date when we can expect for that to be resolved and 
start--
    Secretary Burwell. I am happy to raise with Secretary Lew 
the question that you have raised.
    Mr. Carter. Fair enough. Fair enough. Okay. Notification to 
the employers. You would agree that those employers who have 
multistate locations, it would be better if they got one 
notification as opposed from every State? That is also 
something I am very concerned about, and I hope you look into 
at that as well.
    You do agree, obviously, that it is a burden on these 
employees when they have a tax penalty at the end because they 
didn't accept the employer's more affordable plan. So that is 
what we are trying to get at now, right?
    Secretary Burwell. What we want to do is make sure that 
where employers should cover, as appropriately, that they are 
providing coverage, and if the employee makes a choice to not 
accept the coverage by an employer, that they don't receive 
subsidies they shouldn't in terms of--
    Mr. Carter. Right, right, but it would have helped if the 
employers had gotten notification, so that is what we are 
trying to achieve here.
    Also, right now you are using a paper system. Do you have 
any idea when you will be going to a computer system?
    Secretary Burwell. A paper system, I am not sure with 
regard to what you are referring to. I am sorry.
    Mr. Carter. Okay. Well, I will get clarification on that 
and send you a letter later.
    Secretary Burwell. Okay. Okay.
    Mr. Carter. In your opening statement, you said that over 
$100 million would be given to states and used for prescription 
drug abuse.
    Secretary Burwell, I am a pharmacist, the only pharmacist 
currently serving in Congress. I have witnessed firsthand 
people's careers, people's lives, people's families being 
ruined, and people actually losing their life as a result of 
prescription drug abuse. And one of the limitations on that for 
pharmacists is that Medicare limits pharmacists as to what they 
can do with this in the way of compensation.
    There is a bill, H.R. 592. I hope that you will look at 
that closely. This is something that needs to be addressed. 
This is an epidemic. This is one of the biggest drug problems 
that we have in this country, prescription drug abuse, one that 
has really gotten out of control. As a member of the State 
Senate in Georgia, I sponsored the prescription drug monitoring 
program that is now law. This is something that we really need 
to work on, and we can help you in our profession, and we want 
to help you, but please look at that bill, H.R. 592.
    And Mr. Chairman, I yield back.
    Chairman Kline. The gentleman yields back.
    Mr. Pocan, you are recognized for three minutes.
    Mr. Pocan. Three minutes. Thank you, Mr. Chairman. I will 
go really quick. Thank you for being here, Secretary Burwell.
    First, I am glad to see that NIH increase in the budget. 
The funding, as you know, with the sequester, it has been 
especially hard. I have the University of Wisconsin in my 
district, which has a lot of research going on. One of the 
things that we have noticed because of this cutback of funding 
is that now the age of the average first time grant recipient 
is 42, and it used to be 36 in 1980. A lot of young researchers 
are looking at a lot of other areas to go into, and we want to 
keep the talent there.
    Senator Baldwin and myself and others have introduced a 
bill called the Next Generation Research Act trying to address 
some of those concerns. I am just wondering if you could very 
briefly just address how we can try to help those younger 
researchers as we move forward in NIH funding.
    Secretary Burwell. I think it is about creating a certainty 
in terms of the years that we have been through recently with 
regard to everything from sequester to shutdown, the ability to 
create the certainty. It is just like the certainty we need to 
create for those small businesses that were referred to.
    People having certainty in knowing how things are going to 
run in regular order and assurance of the funding is how people 
are going to make their decisions. If you are making a decision 
to get a Ph.D. in a particular area, that is a long period of 
time you are making a financial commitment, and you want to 
know there is certainty at the other end.
    So I think the thing that we can do is create certainty 
around funding streams, that the funding for this type of 
research, basic research and other research that NIH does, is 
going to be there, and so that is one of the things we want to 
work to do, which is why we have in this budget a billion 
dollar increase.
    Mr. Pocan. If you could take a look at that Next Generation 
Research Act, too, working with a lot of those younger 
scientists, we have had some ideas, too, we would like to 
propose, at least while the sequester is still out there.
    Secondly, and I am going to piggyback a little bit on 
Representative Hinojosa's question around the States that 
haven't done the Medicaid expansion. Unfortunately, States like 
my State, Wisconsin, where Governor Walker is, you know, in the 
increasingly smaller number of States that hasn't done this, we 
would save about $400 million over the next two years in our 
State. Almost 85,000 people would have additional healthcare.
    You know, as you look in--and I am glad you just met with 
governors about this, but you know, as a Member of Congress, 
this is very frustrating. I actually do everything I can to get 
resources back to my State, and then I see something like this. 
You know, what can we do for the States like Wisconsin that are 
just really caught in this bad spot because we have governors 
that refuse to expand this?
    Secretary Burwell. So with regard to, you know, that is 
where the decision, as know, sits with the governors and State 
legislatures, not all States. Some States, it is just the 
governor, and so continuing to work. But I think one of the 
most important things is articulation of the benefit, both the 
economic, job creation, and what it means in terms of State 
budgets as well as the individual. Obviously, that is the place 
where we focus our most attention.
    Mr. Pocan. I am just going to wrap this thing. If you also 
need names of people who have told us they benefitted from the 
Affordable Care Act, you know, I go into little towns in my 
district, Spring Green in rural Wisconsin, small business, you 
know, they come and they grab their husband from upstairs, the 
wife had to tell me this is the first time they have had 
healthcare. I have had caregivers stop me in the grocery store 
crying because it is the first time in her adult life she has 
been able to have healthcare. If you also want those kind of 
things, we are more than glad to share those through our 
office.
    Secretary Burwell. Thank you.
    Chairman Kline. The gentleman's time has expired.
    Mr. Russell, you are recognized.
    Mr. Russell. Thank you, Mr. Chairman.
    I would like to thank you, Madam Secretary, for your 
distinguished service both to the Nation and also, to your 
charitable work.
    As a small business owner that has a small workforce well 
under the 50 threshold, I have seen a 68 percent increase in 
health insurance that I provide my employees over a two-year 
period. Do you believe increasing the cost of insurance will 
encourage or discourage small businesses providing insurance?
    Secretary Burwell. With regard to the 68 percent increase, 
is it people taking it up, or is it the cost itself?
    Mr. Russell. It is the cost itself. We are part of a pool, 
being a light manufacturer, and so, you know, we can't do the 
groups on our own, but we can pool with others. And we have 
seen a 68 percent increase in two years.
    Secretary Burwell. Is it particularly incident-driven, 
having, you know, worked as a small employer at one point in 
time, when we would have, you know, we had a couple of very 
large cancer cases or we had a number of pregnancies at one 
time, was it those kinds of things? Because what we want to do 
is get to the issue.
    What you are describing is a case that is not the 
experience that we have seen for most, and what I want to do is 
understand it.
    Mr. Russell. Sure.
    Secretary Burwell. So we can understand why--
    Mr. Russell. We have not even filed claims. We have been in 
business for five years.
    And my second question is, in the HHS' 2011 report entitled 
``Drug Abuse Warning Network,'' it cited that 455,000 emergency 
room visits were directly associated with marijuana use. 
Further, supporting documentation shows multiple adverse health 
effects.
    Do you believe the President's policies in not enforcing 
Federal law on illegal marijuana States that violate the law 
promote or prohibit HHS' goals on emergency care reduction and 
drug abuse prevention?
    Secretary Burwell. So, with regard to the HHS role in this 
space of marijuana, we are the research, the regulator, the 
educator, and the treatment. And with regard to the issue that 
you have raised in terms of the question of the health impacts 
of this, it is something that we are spending time on. You may 
know we recently actually changed a rule that will lead to 
increased research that we hope will afford us the opportunity 
to do more and better education in the space of the damage.
    Mr. Russell. And then my final question and you certainly 
don't have to comment on the ongoing investigations that will 
be necessary and that sort of thing, but given that HHS 
provides significant Title X funding to Planned Parenthood, do 
you believe personally that the harvesting of infant body parts 
to be moral?
    Secretary Burwell. So as I said, this is an issue, an 
important issue, that has strong passion and strong beliefs 
about the importance of the research and other beliefs, and 
what I think is important is that our HHS funding is focused on 
the issues of preventative care for women, things like 
mammograms and cancer prevention screenings with regard to our 
relationship there.
    With regard to the other issues, the attorney general, I 
think, has right now, is under review to make determinations on 
what is the appropriate next step.
    Mr. Russell. I yield back my time. Thank you, Mr. Chairman.
    Chairman Kline. The gentleman yields back.
    Ms. Adams, you are recognized.
    Ms. Adams. Thank you, Mr. Chairman. Thank you, Ranking 
Member Scott. Madam Secretary, thank you for being here, and 
some of my questions have already been answered.
    But let me first of all say that I have, over the years, 
appreciated Planned Parenthood's good work in promoting 
healthcare for men and for women, and I am a little bit 
disheartened by all the attacks to undermine the good work that 
they do. But having said that, let me move on to Affordable 
Care.
    My State of North Carolina is one of those 24 that did not 
expand Medicaid. We are looking specifically at--with all of 
the great benefits, I am still perplexed why our governor and 
our legislature decided not to do that, 317,000 more North 
Carolinians would have had it. I know you met with the 
governors.
    My question is when we look at North Carolina having one of 
the highest rates of uninsured adults in the country, standing 
at 24 percent, it is critical that we take a serious look. And 
what are the options? Are there options for folk in my State 
and other States that have not expanded Medicaid that--who may 
want to consider it in the future, are there options that they 
have?
    Secretary Burwell. So with regard to the options for the 
individuals, I think, you know, that is why community health 
centers are going to continue to be extremely important in 
terms of ensuring that people who don't have coverage have 
care. They are an important part of that.
    With regard to the options in terms of States making those 
decisions to do that expansion, we want to work with States, we 
want to provide them with different options and opportunities. 
That is what the 1115 waivers are about. We have done that. We 
have done that with Governor Pence in Indiana, and that program 
is up and fully running. There are other governors that we're 
having those conversations with, and we look forward to the 
opportunity to understand what are the core considerations of 
the State in terms of moving to reduce that coverage gap that 
you describe in North Carolina, which is one of the largest 
states in the Nation now.
    Ms. Adams. Thank you very much. For somebody in my 
position, I did serve in the legislature for 20 years. I am 
still at odds with the governor and the State legislature about 
it, so can you give me any suggestions about how to kind of 
push them along and to get closer to ensuring the low income 
people in North Carolina who it will--
    Secretary Burwell. I would certainly defer to you on how to 
work with your own State governor and legislature.
    The only thing I will say is when you look at Kentucky and 
the analysis that's been done, in the State of Kentucky--and 
this is by, you know, an accounting firm in the University of 
Louisville, 40,000 more jobs and 30 billion flowing into the 
State by 2021, and so that, from an economic perspective, just 
seems to be an anchor of a place to talk about.
    Ms. Adams. Yes, ma'am. That makes great economic sense for 
us to do it. I'll certainly continue to push those folk in 
North Carolina. Thank you, Madam Chair--Mr. Chair. I yield 
back.
    Chairman Kline. I thank the gentlelady.
    Mr. Allen.
    Mr. Allen. Yes, thank you.
    Thank you, Mr. Chairman, and thank you, Madam Secretary. 
You've got a tough job. It's hard to deal with some of the 
issues that are coming out of this process, but I can tell you 
in Georgia, ObamaCare is not real popular. We are having major 
problems down there.
    In fact, most physicians I meet with say that nothing's 
changed. Emergency rooms: people show up still without health 
insurance. They see very few patients. You might check with 
some of the hospitals. You know, their elective surgeries are 
off something like 80 percent because of the high deductibles, 
so just, you know, one problem after the other. But what I want 
to zero in on is this Planned Parenthood thing.
    And I would like some commitment from you here today on 
when your Department will conduct an investigation on this 
very, very serious matter. Not only is it unconscionable, but 
they are breaking the law, and it's a big issue with the people 
of this country. I mean, it's what I hear about every day, what 
are we going to do about this? Can you tell me when we going to 
do something about that?
    Secretary Burwell. I do want to--just one moment on your 
Affordable Care Act--
    Mr. Allen. Yeah.
    Secretary Burwell.--and that issue. And the question of 
expansion in a State like yours, and what we see in Arkansas is 
we've seen as a percentage drop the number of uninsured that 
are coming in emergency rooms, we've seen actually a dramatic 
drop, and so, as a part of the issue there and how we think 
about rural hospitals, which I know are an important issue in 
your State as they are in my home State.
    With regard to the Planned Parenthood issue, as I've said, 
this is an important issue and one that there is passion and 
emotion and belief on many sides of the issue, and I want to 
respect that.
    With regard to our funding, I think you know we do not fund 
abortions as the Federal Government except for the Hyde 
exceptions, which have been in place for many years. Our 
funding for Planned Parenthood is in another issue space. With 
regard to the issue you raised, which is a question of whether 
it's a legal issue, and there are laws and there are statutes 
that guide the use of fetal tissue that are in place and should 
be enforced.
    With regard to investigating or looking into those issues, 
as I said, because it is a statutory legal issue, the 
Department of Justice and the attorney general has said she has 
taken those issues under review and will determine what the 
appropriate next step is.
    Mr. Allen. And that would include your investigation? I 
mean, it should be like all hands on deck on this thing.
    Secretary Burwell. With regard to the question of a legal 
matter, and you know, I defer to our colleagues at the Justice 
Department, we will support them in anything they need or want 
from us, and we always do that, but with regard to making those 
decisions of the question of an investigation of a legal 
matter--
    Mr. Allen. So you don't have personnel that can look into 
this?
    Secretary Burwell. With regard to what we do we have at the 
Department of HHS is, this is not an issue in terms of us 
funding this specific issue. When we do have issue--
    Mr. Allen. You deal with Medicare fraud.
    Chairman Kline. The gentleman's time has expired.
    Mr. DeSaulnier.
    Mr. DeSaulnier. Thank you, Mr. Chairman. Thank you, Madam 
Secretary. Briefly, on the issue of Planned Parenthood, as I 
understand it, there are multiple investigations in California. 
The State attorney general is investigating the issues, 
including if the people who actually took the film violated the 
law.
    But I have two areas for questions for you. One is your 
work on prescription drug abuse. As my colleague from Georgia 
mentioned, it's a very large issue, 45 Americans die a day, 
according to the Center for Disease Control. The U.S. has less 
than 5 percent of the world's population, but we consume over 
80 percent of the opioids in the world. It's a huge cost issue 
both financially and from the human side.
    So in California, we are switching to an electronic 
monitoring system. It's been getting up, and even people who 
question it are starting to support it. So my question is, what 
are things that you might think--and I'll ask both questions 
and let you go, given the time constraints, that we might be 
able to do on a Federal level to help States like California, 
New York, and Georgia.
    And then secondarily, coming from a high cost State where 
we're very proud of the ACA in California, sort of the opposite 
side of what one of my colleagues brought up being from the Bay 
area, provider rates and attracting primary care physicians, so 
if you could address those two things quickly, I would 
appreciate it.
    Secretary Burwell. I'm sorry, the second issue?
    Mr. DeSaulnier. The second question was the opposite side 
of high cost States and reimbursements rates, and then because 
of that, we're having a difficult time attracting primary care 
physicians in California, particularly young people to go into 
that field.
    Secretary Burwell. On the primary care, let's just start 
there, in terms of how we are structuring our graduate medical 
education proposal in this budget, it is actually to focus 
funding for GME on places like primary care and rural districts 
where we have shortages and other specialties. So what we're 
trying to do is use our tools at hand to encourage people to go 
into those specialties and create more of a pipeline to go to 
places.
    With regard to the issue of prescription drug abuse, 250 
million prescriptions in one year in the United States. That is 
enough for every adult in the country. This is an acute 
problem. One, prescribing it. I think that number itself tells 
you something about we got to go after prescribing. The 
congressman's comments about PDMPs, prescription drug 
monitoring program, essential, get those up, get those working 
in the States.
    That's a lot of what I'm spending my time in conversations 
with governors, whether Governor Baker in Massachusetts or 
Hickenlooper, in Colorado, been to visit both.
    Second is access to Naloxone. Naloxone is the drug that 
when someone is in overdose, actually saves their life, and so 
the question of how that's accessed is a very important thing 
in creating in a State-by-State basis.
    The third is medicated assisted treatment, and for all 
those who are addicted, trying to get that transition. I met a 
woman in Colorado who has been clean four years, and her 
journey there from having her wisdom teeth taken out, becoming 
addicted and going to heroin is a journey we don't want people 
to travel, and so getting that medicated assisted treatment and 
those other things in place are three specific evidence-based 
approaches.
    Mr. DeSaulnier. Thank you, Madam Secretary. Thank you, Mr. 
Chairman.
    Chairman Kline. I thank the gentleman.
    Mr. Bishop, you're recognized.
    Mr. Bishop. Thank you, Mr. Chairman.
    Thank you, Madam Secretary, for being here today. I 
appreciate your testimony and the discussion. I know there are 
a dozen windows that are opened up right now, but I'd like to 
talk to you specifically about the exchange enrollment issues 
that I'm seeing in my office.
    It's an ongoing concern I'm hearing from constituents, and 
I want to make sure while I have your attention, that I address 
the concern.
    The Government Accountability Office recently put out an 
alarming report highlighting various shortcomings of 
Healthcare.gov, which resulted in numerous fictitious enrollees 
gaining access to coverage and subsidies paid by the American 
taxpayers. In the meantime, as I said, I've heard from any of 
the number of my constituents, one anecdote after the next, 
very frustrated with regard to how this is working, purchased 
or tried to purchase on the Web site insurance, only to have 
their coverage canceled because of a minor mistake they made on 
their application.
    And by the time they get to me, they are furious, and I 
can't say that I blame them. As a parent, who has a family and 
is expected to provide for my family, my heart goes out to 
them, but it becomes me being the reason why.
    They also have problems getting the issue corrected and 
lackluster communication with the Department, how we can 
correct the issue, long wait times, there is just so many 
issues with regard to this. And GAO's information suggests that 
significant fraud is being--is being rewarded, while at the 
same time some of these minor mistakes are being punished. I'm 
wondering what we can do to address that if you've had this 
same communication from other members, if we're addressing 
them, and if you could just quickly comment on that.
    Secretary Burwell. So first of all, with regard to the 
communication coming into your office, please reach out, reach 
out to me directly, let's work on those individuals and work 
through those individual issues, so please make sure, just 
reach out to us, our office, we will work on those.
    Mr. Bishop. Okay.
    Secretary Burwell. With regard to, though, actually it's 
both sides of the coin because the GAO, we don't actually know. 
We don't know when they falsified, whether they falsified a 
Social Security or what, the small issues. What we're trying to 
do is program integrity, and that's what your folks are getting 
caught in because they have done that, and we're doing it in a 
strict way. That's what people are feeling is because we are 
trying, if you do not provide the data that's required to say 
your income is X or to say that you are of a certain status, 
that you know, that's what's happening to the examples.
    And so actually, we don't exactly know because the GAO 
hasn't told us what those examples are. Those are actually two 
very related things in terms of us doing the program integrity 
that we're being asked for. We don't know that the examples of 
the GAO are more than the examples that you're talking about.
    When we get to recommendations, we may know that, but at 
this point, we don't, and so right now, what we're doing is 
trying to do program integrity, but we want to make sure that 
if there are individuals--because many of the people are like 
you said, we don't have the right information but they still 
may be eligible, so please let us know about those examples.
    Mr. Bishop. Thank you, Madam Secretary. I yield back.
    Chairman Kline. Thank you. The gentlewoman, Ms. Wilson.
    Ms. Wilson of Florida. Thank you, Mr. Chair. I ask 
unanimous consent that the Office of the Assistant Secretary 
for Planning and Evaluations' research brief showing that 
increases in cost sharing can discourage low income individuals 
from accessing necessary medical care which can have negative 
health consequences be entered into the record.
    Chairman Kline. Without objection.
    [The information follows:]
    [Additional Submissions by Ms. Wilson follow:]
    
    
    
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    Ms. Wilson of Florida. Secretary Burwell, thank you so much 
for being here today and for working with Florida, especially, 
and our head start and elder care and all of the other things 
that you do. I appreciate your testimony on how ObamaCare is 
working for the American people, and I call it ObamaCares, 
because I believe that Obama cares about the people of this 
Nation, and that's why we have this healthcare law.
    It's here to stay. It's the law of the land. The people of 
Florida are much better off because of this. We have led the 
Nation in new enrollments through the Federal exchange. My 
district Florida--in my District 24 has the third highest 
number of people in the Nation who benefit from subsidies. 
Unfortunately, we have not expanded Medicaid, but I thank you 
for your commitment to working with the Florida legislature and 
the governor to expand Medicaid, and consider me as a partner 
in this pursuit and hopefully for a better outcome in the 
future. I also want to thank you for helping securing low 
income pool funding for Florida. That was very special to us.
    I want to thank you for your testimony on the importance of 
investment in high quality early learning, so I commend you and 
the President for your commitment to expanding and investing in 
early education. I have several questions. I want to try to 
combine them in one.
    The President's budget includes an additional $1.5 billion 
to improve quality head start. Why is this crucial? What is 
head start doing to ensure that all head start children and 
early childcare are eligible, have access to high quality early 
learning? What is at stake if our Nation ignores the ever 
growing body of research? And can you describe how the revised 
program performance standards will help, and can you please 
speak to the negative impact of spending caps?
    Secretary Burwell. So I will try and get through as many of 
those as I can with our time. One is with regard to the 
changes, there are a number of changes that are part of the 
proposal, and they are about using the evidence with regard to 
extending the day and the question of extending the year, but 
there are other important changes in terms of what curriculum 
should be used in terms of the teachers and those 
participating.
    There are also a number or safety issues, making sure that 
the grantees and others that are doing the services do it in a 
safe way. We also try to reduce the bureaucracy to make it 
easier for people to come in and apply and be a part of that 
system. So we put the money in the budget to match the changes 
that we have proposed as we go forward.
    With regard to the ramifications--
    Chairman Kline. I'm sorry; the gentlelady's time has 
expired.
    Mr. Messer.
    Mr. Messer. Thank you, Mr. Chairman. Thank you, Secretary 
Burwell, for being here. I'd like to talk a little bit about 
the 49'er phenomena under the Affordable Care Act, the idea 
that the Affordable Care Act only applies to businesses of 50 
or larger, and so there's has been questions about some 
businesses staying at that 49 threshold, not being willing to 
hire that 50th person because they would make themselves 
subject to all the mandates and requirements of the President's 
healthcare law.
    The administration has helped ease that burden somewhat by 
delaying that 50 figure by making it up to 100 so that 
businesses that were 100 and less wouldn't be forced to --
wouldn't be required to comply with the law.
    Could you talk a little bit about the rationale of lifting 
that to 100? Why was it businesses 100 and less that the 
administration said wouldn't be subject to the law up until 
2016?
    Secretary Burwell. So I think there are also two different 
issues in terms of application proportions of the law.
    Mr. Messer. Yeah.
    Secretary Burwell. And some of those have to do with what 
benefits but also what category, and so I'm not sure if 
you're--
    Mr. Messer. Like the employer mandate example. You're not--
    Secretary Burwell. If it's a question of the category in 
terms of--
    Mr. Messer. You're not subject to the employer mandate 
under your delay until--for businesses of 100 or less until 
2016. I'm just trying to get at what was it that made you 
decide to lift it to 100 from the 50.
    Secretary Burwell. So with regard to that issue, it is 
that, you know, 96--you know, as we look at the number of 
employers, and even when we go to those higher levels, I think 
we believe that employers at that level should be providing 
that type of care and can do that, and we can do that in a way 
that you can do it if there are pooled markets in affordable 
ways, and that's what we believe that can be done because we 
want to make sure that small businesses that have this--
    Mr. Messer. But to the precise question of why you lifted 
it from 50 to 100, why was it that you guys said businesses 100 
and less could be delayed until 2016? Because the law says 50 
and less.
    Secretary Burwell. So, just want to make sure you're 
referring to which piece, because we've already had a 
conversation earlier, I think you heard about a particular 
question of the provision, of whether or not 50 to 100 applies 
to whether those small businesses, which market they will be, 
and those are two different things.
    Mr. Messer. Again, I'm reclaiming my time because I only 
have so much time. I think it's clear that you guys have 
acknowledged that businesses of 100 and less are small 
businesses that make it difficult to comply with all the 
elements of this law. I've actually introduced legislation, 
H.R. 2881, the Small Business Job Protection Act of 2015 that 
would make that level of 100--businesses of 100 employees and 
less--the permanent standard under the law, just essentially 
continuing the delay that you guys moved in to 2016.
    It's not really a trick question. I think that the reality 
is, is that there are a lot of very small businesses of that 50 
or less employees, and the mandates and requirement of this law 
are difficult to comply with. I think businesses of 100 and 
less--while I'd like to see the mandate go away entirely--
they're at least a different kind of business than a business 
of 50 and less. Appreciate your testimony.
    Secretary Burwell. Thank you.
    Chairman Kline. The gentleman's time is expired.
    Mr. Polis.
    Mr. Polis. Thank you, Madam Secretary. Back in April I had 
the opportunity to visit the head start program at the 
Wilderness Early Learning Center in Boulder, and I've seen 
firsthand the benefits head start can provide for kids and 
communities.
    As you know, head start's grants are given to nonprofits, 
community centers, and often traditional public schools, but to 
my knowledge, no charter schools have ever received head start 
grants and very few have applied. Can you talk about what your 
agency is doing to clarify guidance so that charter schools, 
which are public schools that have the autonomy to offer unique 
curriculum for students, know that they're eligible to apply 
for head start grants and understand how to meet head start 
requirements?
    Secretary Burwell. This is an issue I'm not familiar with 
in terms of charters and application for head start, so one 
we'll have to get back to you.
    Mr. Polis. Great. We'd be happy to hear from you about a 
specific plan to make sure that charter schools are aware of 
the opportunity to apply and what they need to do.
    Earlier this year, as you know, the FDA published revised 
recommendations pertaining to blood donations by gay men. The 
policy change eliminated the lifetime ban and replaced it with 
a one year deferral policy, which on the margins can save a few 
more lives.
    While it's a positive step forward, I'm hoping you can 
speak about your opinion of whether the new policy truly 
reflects the most up-to-date science on the issue. As you know, 
the large majority of gay men don't engage in risky behavior 
and are not at higher risk of contracting HIV than the general 
population. In fact, the FDA's own blood drive survey found 
that the prevalence of HIV in gay male blood donors, was just 
.25 percent, actually lower than the overall prevalence of HIV 
in the total U.S. population, which is .38 percent.
    Would the FDA consider a policy that screens for specific 
risky behavior rather than grouping all gay men into one black 
blanket high risk category?
    Secretary Burwell. With regard to the policy that we have 
announced, we've tried to move the policy forward based on the 
scientific evidence that we have in front of us, both with 
regard to issues of self-reported monogamy as well as the 
penetration of HIV in particular populations. We always welcome 
the additional--
    Mr. Polis. I believe it's self-reported abstinence, not 
self-reported monogamy; is that correct?
    Secretary Burwell. I will have to check exactly what is the 
self-reported--my indication.
    Mr. Polis. I think if we could move for it, would you be 
supportive of moving to self-supported monogamy?
    Secretary Burwell. What we are always open to is reviewing 
evidence in terms of the decisions that we're making in this 
space. We believe that the decisions that we've made at this 
point are evidence based. If there's additional evidence that 
we should know about, we always welcome it.
    Mr. Polis. Well, I'm looking forward to your implementation 
of the self-reported monogamy recommendation, which I am 
certainly in strong support of, as an indication of risky 
behavior, certainly in those who are in monogamous or married 
relationships would be at much lower risk than those who are 
not, and I yield back.
    Chairman Kline. The gentleman yields back.
    Ms. Stefanik.
    Ms. Stefanik. Thank you, Mr. Chairman, and thank you, Madam 
Secretary, for your testimony today.
    The President's healthcare law mandates certain employers 
provide healthcare coverage to their employees and will soon 
tax employers if that coverage is too generous. And Section 
1511 of the healthcare law requires employers to automatically 
enroll new employees and continue enrolling current employees 
into their healthcare coverage, giving employees only a very 
small window to choose to opt out.
    This mandate takes away the ability for employees to choose 
coverage that best meets their needs, and it could result in a 
loss of take-home pay to cover possibly more expensive health 
insurance than they otherwise would not have chosen.
    I've introduced H.R. 3112, the BE OPEN Act to eliminate 
this harmful and unnecessary provision. But could you 
specifically discuss whether mandatory auto-enrollment can 
trigger individual mandate penalties for employees receiving 
subsidized exchange coverage?
    Secretary Burwell. With regard to the specific of that 
implementation issue, that is an issue that I would defer to my 
colleagues at Treasury. The implementation of the tax portion 
that I think is within the context of what you're referring to 
is a Treasury issue. I think, as you probably know, we have 
guidance out for comment right now, and so with regard to the 
specifics of that, that's a place where I would defer to my 
colleagues with Treasury, and we can take that question and 
give it to them.
    Ms. Stefanik. Let me ask this question a different way. 
What about those employees who become enrolled in double 
coverage because of this mandate and they miss the 90-day 
window in which to opt out? Should those employees, in your 
opinion, be penalized by paying multiple premiums because of a 
requirement imposed on by employers in the ACA?
    Secretary Burwell. With regard to the specifics of this 
question in terms of the detail of how it would be implemented, 
I would want to know and understand what the implementation is 
that the Treasury is thinking with regard to this issue, so I'd 
want to coordinate with my colleagues at Treasury.
    Ms. Stefanik. Sure. I look forward to getting a response 
from the Department of Treasury, but I also believe that this 
is duplicative and it's an unnecessary mandate requiring 
employers to automatically enroll employees into health plans 
where they have little choice and sometimes they don't have 
knowledge of that.
    So I understand you want to defer to the Department of 
Treasury, but I think it's an important broken aspect of the 
ACA where I'd like HHS' feedback on. I yield back.
    Chairman Kline. The gentlelady yields back.
    Mr. Jeffries.
    Mr. Jeffries. I thank you, Mr. Chair, and thank you, Madam 
Secretary, for your testimony here today as well as for your 
tremendous leadership.
    I want to begin by asking a question about sort of 
providing care to some of the most disenfranchised, 
economically isolated individuals, in this particular case, 
many of the constituents that I represent. Over the last 
several years, we've had a crisis throughout Brooklyn with the 
closure of several safety-net hospitals, and in other 
instances, significant financial distress that many of these 
safety-net hospitals have experienced, largely as a result of 
perhaps the overutilization of certain aspects of the hospital, 
the emergency room for issues that can be taken care of in a 
primary care context.
    And for instance, the fact that, traditionally, in many 
socioeconomically disadvantaged communities, you've got a mix 
of individuals who are either on Medicaid or totally indigent 
and uninsured, the access to private insurance traditionally 
has not been a healthy mix, and it's created a situation where 
many of these safety-net hospitals are under severe financial 
distress.
    That's beginning to change given the onset of the 
Affordable Care Act, which is tremendous, but there's still, I 
think, is an effort to begin to direct individuals more into 
the primary care context and away from the overutilization of 
these safety-net hospitals. Could you speak more about that, 
what the administration is doing and where you think we need to 
go?
    Secretary Burwell. So one of the things that the 
administration is doing is part of the overall effort. There 
are many new people who are newly insured, and the actual 
employee-insured based population has many new--access to many 
new services in terms of prevention.
    And so at CMS, one of the things we are working on is 
something called, ``Coverage to Care,'' and it's both for those 
that are newly insured, but it's also for those that are in the 
insurer base market to help people understand how to use that 
coverage to access a primary care physician, to get a health 
home so that we can start to solve some of these issues and to 
do things as simple as some people, and even in the employer-
based market, understanding your bill. Those kinds of things 
are often complicated and difficult to do.
    So at CMS, we are having a program. We are working on it. 
We want to use the resources that are part of the teams that 
have helped get people insured to make sure we're moving that 
information. It comes back also to that Medicare point I raised 
earlier that many people in Medicare don't know that they can 
get access to these services without copays. So we want to 
focus on greater education to get people into those primary 
care settings.
    Mr. Jeffries. And is enhanced Medicaid reimbursement for 
primary care services also a part of what can be helpful moving 
forward?
    Secretary Burwell. It is. And as you know, we've proposed 
to extend that.
    Mr. Jeffries. Thank you. I yield back.
    Chairman Kline. The gentleman yields back.
    Mr. Brat.
    Mr. Brat. Thank you, Mr. Chairman. Thank you for being with 
us today. I have two quick questions. I guess I just got dinged 
from five minutes down to three, so I'll make it real quick.
    On ObamaCare overall: productivity, claims that it's good 
for the economy. The basics in 2014, CBO reported they expect 
ObamaCare will result in a 2.5 million person job reduction and 
full-time equivalent employment by 2024. And so if you do the 
math on that, 2.5 million people times 40 hours a week is 100 
million hours, and then you do that for the year, and you get 
100 million times 50 weeks in a year, and you are at five 
billion hours in labor productivity gone due to this single 
program, and that's the response I get when you walk door-to-
door, small business to small business, from people on the 
street is like we can't hire anybody, this is devastating us, 
and so I'll ask for your remarks on that.
    The economy is already struggling to keep up with a kind of 
a 2 percent rate, if that, and so the claim that the program is 
good for the economy, I struggle with. And then secondly, I'll 
just ask you a quick one and ask for your response. At the 
micro-level, I have constituents who have approached me with 
concerns about FDA's proposed rules to regulate premium cigars.
    Premium cigars don't have youth access issues, sold in 
adult establishments. The specific goal of the Tobacco Control 
Act were to limit youth access and prevent negative health 
effects from habitually used products, neither of which apply 
to premium cigars.
    So, shouldn't the FDA leave this category out of 
regulations? By the FDA's own estimation again, over half of 
premium cigar stores and manufacturers will be shut down if FDA 
chooses option one in the proposed regulation. And so on this 
level, too, how do you justify the regulation when it's 
eliminating so many jobs and will have such a great impact on 
my constituents?
    Secretary Burwell. With regard to the premium cigar issue, 
I think one of the things we asked for was the evidence, the 
evidence with regard to child use, and so, that's why we put 
out two different proposals. As we review that, it is about the 
evidence we receive with regard to the question of premium 
cigars and child use, getting to the core part of the statute 
that you articulated, and we'll continue to work on that.
    With regard to the broader economic issues, I think in that 
same CBO report, what we do know is the reflection of what 
happens in the out years with the Affordable Care Act in terms 
of why there's long-term deficit reduction and it's also both 
about productivity as well as cost, and we see large numbers in 
terms of those out years, and so as that works through the 
system.
    I think the other thing is we think about these issues of 
jobs and job creation. We know that we have had the longest 
stretch of job creation as a Nation in terms of constant 
stretch of job creation. And the other thing that we see in 
that is we have not seen any rise in the number of people who 
are looking for, you know, at that 40-hour level.
    Mr. Brat. Let me ask you on that. The generic phrase, ``we 
have seen an increase in jobs,'' isn't consistent with the 
clear evidence that the workforce participation rate is at its 
lowest in history, so yes, I mean, we're gaining jobs, the 
population is bigger, but the labor force participation rate is 
at it's all time low, can those be squared?
    Chairman Kline. I'm sorry; the gentleman's time has 
expired. We're jamming up against the clock here.
    Mr. Brat. Thank you.
    Chairman Kline. Mr. Takano.
    Mr. Takano. Thank you, Mr. Chairman.
    Madam Secretary, I understand that my colleague from 
California, Mr. DeSaulnier asked you about graduate medical 
school education. I just want to associate myself with those 
remarks. In Riverside County, which I represent, there are 
about only 34 primary care physicians for every 100,000 people, 
half the number of doctors needed to provided adequate access 
to care. And I understand that the GME levels have been frozen 
under the Medicare and Medicaid budgets since around 1996, so I 
associate myself with the exchange.
    I hear from many of my colleagues about rising healthcare 
costs, and Mr. Courtney of Connecticut commented on the slow 
rates of growth there. In that case, it's a good thing. The 
Affordable Care Act is bending the cost curve. Last year, 
healthcare spending grew at the slowest rate on record since 
1960, and healthcare price inflation is at its lowest rate in 
50 years.
    Just this week, as you mention in your testimony, 
California released its premiums for the 2016 planned year. 
Statewide, the average increase in premiums is just 4 percent. 
It's even lower than last year and a far cry from the years of 
double-digit premium growth we had before the ACA. Covered 
California also announced that if consumers shop around, they 
can reduce their premium by an average of 4.5 percent. That's 
incredible.
    Madam Secretary, can you share more about how the ACA is 
containing healthcare costs?
    Secretary Burwell. I think you've outlined a number of the 
places that it is in terms of that downward pressure on 
premiums and also what happens in competition, your point that 
people can go on the marketplace and shop in the individual 
market.
    We have also seen some of that downward pressure in overall 
price. It's also in the employer-based market. And the only 
other piece that I would mention is I think it's important to 
reflect that we've had a reduction of $317 billion in the 
projected Medicare spending from the period of the passage.
    Mr. Takano. Real quick, before my time is up, how many 
years has the solvency of the Medicare trust fund been extended 
thanks to the ACA?
    Secretary Burwell. It is I want to say 17. It's at 2030, 
and when we came in, it was in the 2017, 2019 range.
    Mr. Takano. So it's increased--with increased--
    Secretary Burwell. Thirteen to 17 years.
    Mr. Takano. By 17 years.
    Secretary Burwell. Thirteen to 17. I want to go back and 
check exactly. It is 2030, and I think that previous number--I 
just don't know what the previous historical number was.
    Mr. Takano. So the cost containment seems to be working, 
and I congratulate, you know, all of us for standing by the 
law. And I know there's much more that we need to do to fix it. 
And I'm going to run out of time, I'm pretty sure, so Mr. 
Chairman, I yield back.
    Chairman Kline. The gentleman yields back.
    Ms. Clark.
    Ms. Clark. Thank you, Mr. Chairman, and thank you, Madam 
Secretary, for being here today. I appreciate your leadership 
in so many areas, especially early childhood education and 
access to affordable high quality healthcare for all Americans.
    Today I want to focus in my brief time on a topic that has 
come up with my colleagues from Georgia and California around 
the opioid crisis, and I commend you for your recent 
announcement and hope that Congress will support the 100 
million that you want to invest in this crisis.
    As you know, it doesn't matter when it comes to opioid 
abuse, whether you are rich or poor, your level of education 
attainment, but an area where we are seeing growth is in women 
using heroin, which has more than doubled in the last decade.
    I introduced legislation called, Protecting Our Infants 
Act, which focuses on care for babies that are being born 
dependent to opiates, but it also looks at the effectiveness of 
programs specifically aimed at women and helping with substance 
abuse disorders.
    Can you discuss any efforts that you have made to evaluate 
and respond to the circumstances of unique populations, 
including young women and others, in addressing this crisis?
    Secretary Burwell. With regard to, I think that it is 
especially important for young women, especially pregnant young 
women, to get into medicated assisted treatment quickly. And, 
actually, just a week ago, I was in Colorado visiting a clinic 
that did this work. And they do it, obviously, they do 
medicated assisted treatment, but they are an integrated 
facility so that a woman can come work on these issues at the 
same time she gets her prenatal care in a facility that is all 
in one place.
    And so the emphasis and importance on medicated assisted 
treatment is something that we believe is a key part with this 
type of population, especially the pregnant women, so that 
we're protecting that newborn.
    Ms. Clark. Another area, shifting gears, but still talking 
about pregnant women and new moms, is the issue of postpartum 
depression.
    Secretary Burwell. Yes.
    Ms. Clark. I just dropped a bill today looking at this, 
hoping to expand grants to States. one in seven new moms are 
going to experience this depression. Can you talk about your 
efforts in this area, and what you think we can do to improve 
screening and access to treatment?
    Secretary Burwell. We believe that this is an essential 
part of prenatal and maternal care. As part of the prenatal 
care, making sure people know and understand this issue. We 
believe it's part of the full integration of behavioral health, 
and that's something that was done through the Affordable Care 
Act; it's something that was done in terms of the Mental Health 
Clarity Act, and making sure that we bring the--so it's all 
about maternal care. It's not about one or the other. This is 
an element of maternal care.
    And so making sure that we have the right wellness visits 
and the right questions being asked as part of those wellness 
visits, and that is the integrated care that we believe is part 
of delivery system reform across the board.
    Ms. Clark. Thank you.
    I yield back.
    Chairman Kline. I thank the gentlelady.
    Mr. Curbelo, you are wrapping up here. You are recognized 
for three minutes.
    Mr. Curbelo. Thank you very much, Mr. Chairman.
    And thank you, Madam Secretary, for your time and for your 
testimony here today.
    The rising costs of healthcare coverage remains a major 
issue for people in my community. I'm talking employers and 
employees. And one issue that's starting to come onto people's 
radars is the Cadillac tax, the 40 percent tax on so-called 
high-cost plans has resulted in many employers already making 
changes to their plans to avoid hitting the tax in 2018 
because, at the same time, they also have to offer minimum 
value coverage to avoid an employer penalty. So, it's a careful 
balancing act that a lot of employers are trying to make.
    According to Towers Watson, 84 percent of large businesses 
surveyed expect to make changes to their full-time employee 
health benefits over the next three years. We hear stories now 
of how employers are making plan design changes such as 
increasing cost sharing and narrowing provider networks.
    Miami-Dade County Public Schools, the second largest 
employer in the State of Florida, reported to me that they 
could see devastating effects as a result of this tax from an 
estimated $500,000 impact in 2018 up to a $10 million impact in 
later years.
    Madam Secretary, if we are concerned about the costs of 
coverage, wouldn't it make sense to get rid of this excise tax 
because it's forcing the costs of coverage to go up for 
employees? Shouldn't the answer be to get rid of it and allow 
employers to offer the health benefits their employees are 
requesting and willing to pay for?
    I really see this as one of those examples where the 
government actually ends up hurting the people who most need 
the help. When you're talking Miami-Dade County Public Schools, 
it's a lot of teachers; it's a lot of low-income earners, and 
now they face losing their health insurance or seeing fewer 
healthcare benefits as a result of this tax. Could you share 
some of your views on this issue?
    Secretary Burwell. Yes. One of the things is that for those 
populations and for those communities, the types of increases 
that we were seeing in terms of the percentage increase in 
premiums already existed. Some of the shifts that you're 
talking about in terms of how companies are doing cost sharing 
and their networks and deductibles, those things were occurring 
already.
    By having the downward pressure of the excise tax in terms 
of the question of people's interests and companies and other 
employers' interests in trying to control their healthcare 
cost, we believe it's something that actually does put downward 
pressure on overall costs. I think the other issue at hand that 
we all have to consider with regard to this excise tax is the 
Federal deficit and the question of any changes and how it 
interrelates with the Federal deficit.
    So, those are the two issues that I think come to the 
floor. The question of whether or not overall it has downward 
pressure on prices and then the second is the fiscal 
responsibility.
    Mr. Curbelo. But do you have any concern for those low-
income earners who don't make a lot of money but at least for 
many years and I can speak as a former board member of Miami-
Dade County schools, they knew that they had a good healthcare 
plan that they and their family members could rely on. They may 
lose those plans. Is that a concern for you?
    Chairman Kline. I'm sorry. The gentleman's time has 
expired. We are exceeding the hard stop time.
    I'd like to recognize Mr. Scott for any closing remarks 
that he has.
    Mr. Scott. Thank you, Mr. Chairman.
    Could I ask one question--
    Chairman Kline. Please.
    Mr. Scott. Just a brief question. My distinguished 
colleague from Virginia asked about people who might lose their 
job because of the Affordable Care Act. Could you make a quick 
comment about the effect of job lock and how that creates the 
situation you referred to?
    Secretary Burwell. Just that the question of job lock and 
those numbers have to do with many people are going to make a 
choice to start their own business.
    I think the other thing in terms of job creation as I said 
with the Medicaid numbers, what we see is increased jobs 
because of some of the changes.
    Mr. Scott. And so when you talk about people leaving the 
job, that's because they were only working on the job because 
they had a preexisting condition and wouldn't have insurance 
before, and they count that as a bad thing that they have 
another choice to leave their job I think is not looking at the 
positive effect that the Affordable Care Act has.
    And so I want to thank you for talking about the 
President's priorities, especially healthcare, early childhood 
education, the effect of sequester on all of your programs, and 
I look forward to working with you as we go forward with the 
budget.
    Secretary Burwell. Thank you.
    Chairman Kline. I thank the gentleman.
    Madam Secretary, I just have a quick follow-up to clarify 
an earlier question you were asked about Planned Parenthood. I 
know that came up a couple of times as you pointed out an issue 
that there's a lot of passion. I just want to be clear, is it 
your testimony that the Department of Health and Human Services 
has no intention of looking into this matter?
    Secretary Burwell. What the Department of Health and Human 
Services will do, and we didn't discuss it today, is with 
regard to the issue of our grantees and the Department of NIH, 
part of HHS that does our research, there's funding with regard 
to grantees, and some of those grants actually use fetal 
tissue. With regard to that, what we are doing is making sure 
that what we do have in place, which is clarity around the 
issue of the fact that for any of those grantees that are going 
to do that research, that as they come through the process and 
before we do the grant making, there are terms and conditions 
that clearly list what the law is with regard to fetal tissue. 
They need to assert and certify that they understand the laws 
and that they will abide by that.
    And then on an annual basis, with regard to when they re-up 
the grants, we ask them to certify, again, that they will obey 
the laws and the terms and conditions of which this is a 
specific place.
    So, with regard to the piece that interacts with the 
Department, these are steps that we are taking to make sure 
that we have appropriate procedures in place to make sure that 
people know the law and certify that they are abiding by it.
    Chairman Kline. And so, the activities which have been so 
important to so many of us that have been revealed in these 
videos that are the actions of Planned Parenthood, you believe 
that is solely a matter for the Department of Justice; is that 
correct?
    Secretary Burwell. With regard to the determination of if 
the law has been broken, that is the Department of Justice. If 
there are any concerns at all with our grantees, we would want 
to refer that to our IG and/or the Department of Justice, 
depending on those circumstances.
    Chairman Kline. Okay. Thank you.
    I really want to thank you. You were very indulgent here. 
We have gone over by eight minutes. I appreciate your patience. 
We very much appreciate your coming today. And there being no 
further business, we're adjourned.
    Secretary Burwell. Thank you, Mr. Chairman.
    [Questions submitted for the record and their responses 
follow:]


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    [Secretary Burwell's response to questions submitted for 
the record]


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    [Whereupon, at 12:08 p.m., the committee was adjourned.]

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