[Senate Hearing 115-229]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 115-229

                       NOMINATION OF THOMAS PRICE

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

                                 HEARING

                               BEFORE THE

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                                 on the

                             NOMINATION OF

                    THOMAS PRICE, TO BE SECRETARY, 
                DEPARTMENT OF HEALTH AND HUMAN SERVICES

                               __________

                            JANUARY 24, 2017

                               __________

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                          COMMITTEE ON FINANCE

                     ORRIN G. HATCH, Utah, Chairman

CHUCK GRASSLEY, Iowa                 RON WYDEN, Oregon
MIKE CRAPO, Idaho                    DEBBIE STABENOW, Michigan
PAT ROBERTS, Kansas                  MARIA CANTWELL, Washington
MICHAEL B. ENZI, Wyoming             BILL NELSON, Florida
JOHN CORNYN, Texas                   ROBERT MENENDEZ, New Jersey
JOHN THUNE, South Dakota             THOMAS R. CARPER, Delaware
RICHARD BURR, North Carolina         BENJAMIN L. CARDIN, Maryland
JOHNNY ISAKSON, Georgia              SHERROD BROWN, Ohio
ROB PORTMAN, Ohio                    MICHAEL F. BENNET, Colorado
PATRICK J. TOOMEY, Pennsylvania      ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada                  MARK R. WARNER, Virginia
TIM SCOTT, South Carolina            CLAIRE McCASKILL, Missouri
BILL CASSIDY, Louisiana

                     Chris Campbell, Staff Director

              Joshua Sheinkman, Democratic Staff Director

                                  (ii)
                            
                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman, 
  Committee on Finance...........................................     1
Wyden, Hon. Ron, a U.S. Senator from Oregon......................     4
Isakson, Hon. Johnny, a U.S. Senator from Georgia................     6

                         ADMINISTRATION NOMINEE

Price, Hon. Thomas, M.D., nominated to be Secretary, Department 
  of Health and Human Services, Washington, DC...................     9

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Grassley, Hon. Chuck:
    ``Grassley Says Emory Psychiatrist Didn't Report $500,000 in 
      Payments,'' by Jacob Goldstein, The Wall Street Journal, 
      October 3, 2008............................................    77
    ``Top Psychiatrist Didn't Report Drug Makers' Pay,'' by 
      Gardiner Harris, Money and Policy, October 3, 2008.........    78
Hatch, Hon. Orrin G.:
    Opening statement............................................     1
    Prepared statement with attachments..........................    80
Heller, Hon. Dean:
    Letter From Hon. Aaron D. Ford and Hon. Jason Frierson to 
      Senator Heller, January 10, 2017...........................    89
Isakson, Hon. Johnny:
    Opening statement............................................     6
McCaskill, Hon. Claire:
    Distribution of Federal Tax Change by Expanded Cash Income 
      Level, 2017, Summary Table, Tax Policy Center, December 15, 
      2016.......................................................    91
Nelson, Hon. Bill:
    ``A Premium Support System for Medicare: Analysis of 
      Illustrative Options,'' Congressional Budget Office, 
      September 2013.............................................    92
    ``GOP Split on Reforming Health Care,'' by Jennifer 
      Haberkorn, Politico, April 30, 2012........................   138
Price, Hon. Thomas, M.D.:
    Testimony....................................................     9
    Prepared statement...........................................   139
    Biographical information.....................................   141
    Responses to questions from committee members................   171
Stabenow, Hon. Debbie:
    Statements and testimonials..................................   253
Wyden, Hon. Ron:
    Opening statement............................................     4
    Prepared statement with attachments..........................   281

                             Communications

American Association of Hip and Knee Surgeons (AAHKS)............   289
Association of Web-Based Health Insurance Brokers (AWHIB)........   289
Brasch, Steven P., M.D...........................................   292
Choat, Lesli, MT (ASCP)..........................................   293
Claybour, Richard and Jill.......................................   294
Darrow, Robert K.................................................   294
Gyetvan, Angela Wilson...........................................   295
Human Rights Campaign............................................   296
LeadingAge.......................................................   298
Murzyn, Debbie...................................................   299
National Center for Lesbian Rights (NCLR)........................   300
Quinn, Marilyn D.................................................   303
Ravanesi, Stacey.................................................   304
Subaiya, Indu, M.D., MBA.........................................   305
Treatment Action Group (TAG).....................................   307
Vallance, Elizabeth..............................................   309

 
                      NOMINATION OF THOMAS PRICE,
                     TO BE SECRETARY, DEPARTMENT OF
                       HEALTH AND HUMAN SERVICES

                              ----------                              


                       THURSDAY, JANUARY 24, 2017

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:02 
a.m., in room SD-215, Dirksen Senate Office Building, Hon. 
Orrin G. Hatch (chairman of the committee) presiding.
    Present: Senators Grassley, Crapo, Roberts, Enzi, Cornyn, 
Thune, Burr, Isakson, Portman, Toomey, Heller, Scott, Cassidy, 
Wyden, Stabenow, Cantwell, Nelson, Menendez, Carper, Cardin, 
Brown, Bennet, Casey, Warner, and McCaskill.
    Also present: Republican Staff: Chris Campbell, Staff 
Director; Nicholas Wyatt, Tax and Nominations Professional 
Staff Member; Jay Khosla, Chief Health Counsel and Policy 
Director; Kimberly Brandt, Chief Health-care Investigative 
Counsel; Brett Baker, Health Policy Advisor; and Erin Dempsey, 
Health-care Policy Advisor. Democratic Staff: Joshua Sheinkman, 
Staff Director; Michael Evans, General Counsel; Elizabeth 
Jurinka, Chief Health Advisor; David Berick, Chief 
Investigator; Laura Berntsen, Senior Advisor for Health and 
Human Services; Beth Vrabel, Senior Health Counsel; Adam 
Carasso, Senior Tax and Economic Advisor; Matt Kazan, Health 
Policy Advisor; Anne Dwyer, Health-care Counsel; and Ryan 
Carey, Press Secretary and Speech Writer.

 OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM 
              UTAH, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The committee will come to order. I would 
like to welcome everyone to this morning's hearing. Today we 
will consider the nomination of Dr. Tom Price to be the 
Secretary of the Department of Health and Human Services.
    I want to welcome Dr. Price to the Finance Committee. And I 
appreciate his willingness to serve in a position of this 
magnitude, especially at this particularly crucial time.
    When Obamacare was pushed through on a series of party-line 
votes, Republicans in Congress warned that the new health-care 
law basically would harm patients, families, and businesses. 
Not to put too fine a point on it, but we were right. And the 
next HHS Secretary will play a pivotal role as we work to 
repeal Obamacare and replace it with patient-centered reforms 
that will actually address costs, among other things. This will 
be an important endeavor, one that will and should get a lot of 
attention here today, but it should not be the sole focus of 
the next HHS Secretary.
    HHS has an annual budget of well over $1 trillion. Let me 
repeat that: one department, $1 trillion. HHS encompasses the 
Centers for Medicare and Medicaid Services, the Centers for 
Disease Control and Prevention, the National Institutes of 
Health, the Food and Drug Administration, and many others. It 
is no exaggeration to say that HHS touches more of the U.S. 
economy and affects the daily lives of more Americans than any 
other part of the U.S. Government.
    I firmly believe that Dr. Price has the experience and 
qualifications necessary to effectively lead this large and 
diverse set of agencies, and many people share that view. He 
has had a wealth of experience in the practice of medicine, 
understands these problems, and has been a great member of the 
House of Representatives.
    For example, past HHS Secretaries Mike Leavitt and Tommy 
Thompson strongly support his nomination. Physician 
organizations that know Dr. Price's work, including the 
American Medical Association and most surgical specialty 
groups, enthusiastically support him. The American Hospital 
Association and other health-care stakeholder groups do as 
well.
    Perhaps the Healthcare Leadership Council, representing the 
broad swath of health-care providers, said it best in stating 
that, quote, ``It is difficult to imagine anyone more capable 
of serving this Nation as the Secretary of HHS than Congressman 
Tom Price.''
    Unfortunately, in the current political environment, 
qualifications, experience, and endorsements from experts and 
key stakeholders sometimes do not seem to matter to some of our 
colleagues. At least that appears to be the case, since none of 
those who say they oppose Dr. Price's nomination seem to be 
talking about whether he is qualified. Instead, we have heard 
grossly exaggerated and distorted attacks on his views and his 
ethics. On top of that, we have heard complaints and a series 
of unreasonable demands regarding the confirmation process 
itself. Of course, these tactics have not been limited to Dr. 
Price.
    My Democratic friends have taken this approach with almost 
all of President Trump's Cabinet nominees, as Senate Democrats' 
unprecedented efforts to delay and derail the confirmation 
process and apply a radically new set of confirmation standards 
has continued unabated.
    To that point, let me say this. I have been in the Senate 
for 40 years, and I think my record for being willing to reach 
across the aisle is beyond any reasonable dispute. And I have 
certainly done it with my fellow Democrats here on this 
committee. In fact, from time to time I have taken lumps in 
some conservative circles for working closely with my 
Democratic colleagues. I have, on some occasions, voted against 
confirming executive branch nominees, but far more often than 
not I have opted to defer to the occupants of the White House 
and allowed them to choose who serves in their administrations. 
I have taken some lumps for that too.
    I am not bringing any of this up to brag or to solicit 
praise from anyone in the audience. I raise all of this today 
so that people can know I am serious when I say that I am 
worried about what my colleagues on the minority side are doing 
to the Senate as an institution. While the overriding sense of 
comity and courtesy among Senators has admittedly been in 
decline in recent years, I have never seen this level of 
partisan rancor when it comes to dealing with a President from 
an opposing party. I have never seen a party in the Senate, 
from its leaders on down, publicly commit to not only opposing 
virtually every nomination, but to attacking and maligning 
virtually every single nominee.
    Now, let me be clear. I am not suggesting that the Senate 
start rubber-stamping nominees, nor am I suggesting that any 
member of the Senate should vote against their conscience or 
preferences simply out of respect for tradition or deference. 
What I am saying is that the same rules, processes, courtesies, 
and assumptions of good faith that have long been the hallmark 
of the Senate confirmation process, especially in this 
committee, should continue to apply regardless of who is 
President. If what we are seeing now is the new normal for 
every time control of the White House changes hands, the 
Senate, quite frankly, will be a much lesser institution.
    Unfortunately, our committee has not been entirely immune 
to the hyper-politicization of the nomination process. We saw 
that last week with the Mnuchin hearing. And I regret to say 
that I think we are likely to see more of it today. I hope not.
    Case in point: I expect that during today's hearing, we are 
going to hear quite a bit about process and claims that Dr. 
Price's nomination is being rushed and that the nominee has not 
been fully vetted. These allegations are simply untrue.
    President Trump announced his intent to nominate Dr. Price 
just 3 weeks after the election. Dr. Price submitted the 
required tax returns and completed questionnaire on December 
21st. That was 35 days ago. And by any reasonable standard, 
that is sufficient time for a full and fair examination of the 
nominee's record and disclosures.
    By comparison, the committee held a hearing on the 
nomination of Secretary Sebelius, the Democrat nominee, 16 days 
after she submitted her paperwork. For Secretary Burwell, it 
was 17 days. In other words, the time between the completion of 
Dr. Price's file and his hearing has been more than that of the 
last two HHS Secretaries combined. And by the way, both of 
those nominees received at least a few Republican votes in this 
committee and on the floor.
    Outside of extraordinary process demands, Dr. Price has 
faced a number of unfair attacks on both his record as a 
legislator and his finances. On the question surrounding 
finances, I will defer on any substantive discussion and first 
allow Dr. Price to defend himself from what are, by and large, 
specious and distorted attacks. For now I will just say that I 
hope that my colleagues do not invent new standards for 
finances, ethics, and disclosure that are different from those 
that have generally applied in the past. There is a saying 
involving both stones and glass houses that might be applicable 
as well.
    With regard to Dr. Price's views and voting record, I will 
simply say that virtually all the attempts I have witnessed to 
characterize Dr. Price's views as being, quote, ``outside of 
the mainstream'' have been patently absurd unless, of course, 
the only ideas that are in the, quote, ``mainstream'' are those 
that endorse the status quo on health care and our entitlement 
programs.
    In conclusion, I just want to note that the overly partisan 
treatment of nominees and distortions of their records is a 
relatively new development on this committee. My hope is that 
we can begin to set a new standard here that we can all be 
proud of, and that we will work to reverse recent trends and 
have a fair and open discussion of the nominee and his 
qualifications.
    So with that, I will turn to our distinguished ranking 
member, Senator Wyden.
    [The prepared statement of Chairman Hatch appears in the 
appendix.]

             OPENING STATEMENT OF HON. RON WYDEN, 
                   A U.S. SENATOR FROM OREGON

    Senator Wyden. Thank you very much, Mr. Chairman.
    Colleagues, the American public heard many promises about 
health care from the new administration. No cuts to Medicare or 
Medicaid. Nobody hurt by ACA repeal. ``Insurance for everybody 
. . . much less expensive and much better.'' Congressman 
Price's own record undercuts these promises.
    I am going to start with ethics and undisclosed assets. 
Congressman Price owns stock in an Australian biomedical firm 
called Innate Immunotherapeutics. His first stock purchase came 
in 2015 after consulting Representative Chris Collins, the 
company's top shareholder and a member of its board. In 2016, 
the Congressman was invited to participate in a special stock 
sale called a private placement. The company offered the 
private placement to raise funds for testing on an experimental 
treatment it intends to put up for FDA approval. Through this 
private placement, the Congressman increased his stake in the 
company more than 500 percent. He has said he was unaware he 
paid a price below market value.
    It is hard to see how this claim passes the smell test. 
Company filings with the Australia Stock Exchange clearly state 
that this specific private placement would be made at below-
market prices. The Treasury Department handbook on private 
placements states, and I will quote: ``They are offered only to 
sophisticated investors in a nonpublic manner.'' The 
Congressman also said last week he directed this stock purchase 
himself, departing from what he said was his typical practice.
    Then there is the matter of what was omitted from the 
Congressman's notarized disclosures. The Congressman's stake in 
Innate is more than five times larger than the figure he 
reported to ethics officials when he became a nominee. He 
disclosed owning less than $50,000 of Innate stock. At the time 
the disclosure was filed, by my calculation, his shares had a 
value of more than $250,000. Today his stake is valued at more 
than a half-million dollars. Based on the math, it appears that 
the private placement was excluded entirely from the 
Congressman's financial disclosure. This company's fortunes 
could be affected directly by legislation and treaties that 
come before Congress.
    It also appears the Congressman failed to consult the House 
Ethics Committee following other trades of health-care stocks. 
That was required, as they are directly related to two bills he 
introduced and promoted. Even if some of those trades were not 
made at his direction, he would have been made aware of them 
when he filed his Periodic Transaction Reports with the House 
of Representatives.
    Set aside the legal issues. It is hard to see this as 
anything but a conflict of interest and an abuse of position.
    Another key question on the Finance Committee's 
biographical questionnaire is whether nominees have been 
investigated for ethics violations. The Congressman has been 
the subject of two investigations stemming from fundraising 
practices. This too was not disclosed. The committee needs to 
look into these matters before moving the nomination forward.
    Now to policy. On the Affordable Care Act specifically, and 
the scheme known as ``repeal and run,'' the secret replacement 
plan is still hidden away, but already the administration 
charges ahead with a broad executive order that endangers 
Americans' health.
    As the Budget chairman, Congressman Price is the architect 
of repeal and run. If his repeal bill became law, 18 million 
Americans would lose their health care in less than 2 years. In 
1 decade, you would go from 26 million uninsured to 59 million. 
Repeal and run raises premiums 50 percent in less than 2 years. 
Costs skyrocket from there. The market for individuals to buy 
health insurance collapses. No-cost contraceptive coverage for 
millions of women, gone. By defunding Planned Parenthood, 
nearly 400,000 women would lose access to care almost 
immediately, hundreds of thousands more would lose their choice 
to see the doctors they trust. The Price plan takes America 
back to the dark days when health care was for the healthy and 
the wealthy.
    His other proposals do not offer much hope that the damage 
will be undone. There is a big gap between the Trump pledge of 
``insurance for everybody and great health care'' and the 
Congressman's proposals.
    In another bill, the Empowering Patients First Act, the 
Congressman brings back discrimination against people with 
preexisting conditions such as pregnancy or heart disease. He 
gives insurers the power to deny care and raise costs on those 
with preexisting conditions if they did not maintain coverage. 
In effect, the bill said insurance companies could take 
patients' money and skip out on paying for the care they need.
    The Price bill also gave insurers the okay to reinstate 
lifetime limits on coverage and charge women higher rates 
because they are women. It gutted the tax benefits that help 
working people afford high-quality coverage. It slashed the 
minimum standards that protect patients by defining exactly 
what health plans have to cover. All this from a bill called 
Empowering Patients First. I have seen a lot of bills with 
ironic titles. This one, colleagues, takes the cake.
    Here's the constant. The Congressman's proposals push new 
costs onto patients. Massive cuts to Medicare were proposed in 
the Price budget, as another example. In my view, the Congress 
has a duty to uphold the promise of Medicare. It is a promise 
of guaranteed benefits.
    The Congressman advocated privatizing Medicare, cutting it 
almost a half-trillion dollars. After his nomination, he said 
he wanted to turn the program into one with vouchers within the 
first 6 to 8 months of the administration. He supports 
``balance billing'' so seniors would have to cover extra 
charges above what Medicare pays when they go to the doctor. 
More extra costs for seniors on a tight budget. In addition, 
the Congressman calls for block-granting and capping Medicaid, 
which would shred a vital safety net for our most vulnerable.
    Medicaid insures 74 million people. More Americans rely on 
Medicaid to pay for nursing home care and home-based care than 
any other program. The program pays for nearly half of all 
births and covers millions of children. It is a critical source 
of mental health coverage and substance abuse treatment, vital 
at a time when our communities are battling the opioid 
epidemic.
    I will close with just two additional points. If confirmed, 
the head of HHS, the Health and Human Services Department, is 
the captain of the Trump health-care team. Now the Congressman 
says patients should be at the center of care. I agree with 
that. When I look, however, at the Congressman's proposals, I 
do not see the patient at the center of health care. I see 
money and I see special interests at the center of health care.
    Now finally, let me just make a point with respect to the 
process and the comments of my good friend, Chairman Hatch.
    Colleagues, the process here is exactly the same process to 
a ``t'' that this committee has used for 20 years. It is the 
process that applied, for example, to Tom Daschle; it applied 
to Ron Kirk.
    I will enter into the record a specific set of details 
about how this is the process that is exactly what was done on 
a bipartisan basis for 20 years. And I will make that a part of 
the record.
    [The information appears in the appendix on p. 278.]
    Senator Wyden. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    [The prepared statement of Senator Wyden appears in the 
appendix.]
    The Chairman. I am pleased to hand over my normal witness 
introduction duties today to our colleague, the distinguished 
Senator from Georgia, Senator Isakson, who will introduce Dr. 
Price.
    And so, Senator Isakson, please proceed.

           OPENING STATEMENT OF HON. JOHNNY ISAKSON, 
                  A U.S. SENATOR FROM GEORGIA

    Senator Isakson. Well, thank you, Chairman Hatch, Ranking 
Member Wyden, and fellow members of the committee. I am proud 
to have a seat right up there on this committee and enjoy being 
a part of it.
    And I could not be prouder than to introduce Tom Price to 
you today. This is the second time I have had the occasion to 
introduce Tom in the last week. The first time I was called, it 
was to introduce him at the HELP Committee, which I also serve 
on, and I was proud to do that. And I gave what I hope was the 
best introduction I could possibly give for a man whom I have 
known for 30 years. I have known him as a family man, as a 
legislator, as a member of our community, as a great physician, 
and a great friend.
    And it was easy to do that one. But since that last week, 
things have changed. I feel like I have been asked to be a 
character witness in a felony trial in the sentencing phase of 
a conviction.
    There are things that have been said the last week or so, 
just to me, that need to be refuted. So I am going to take all 
the positive things and say them at the end, but try and begin 
by saying there are a few things out there that need a 
perspective all the way around.
    I am very proud that Tom has submitted his income tax 
returns. A couple of things that the ranking member mentioned 
came from those submissions. Some of the things that came out 
in a memo last night about property taxes, those were de 
minimis items that came out, one late tax payment in Nashville, 
TN, one late tax payment in Washington, DC. Late, not unpaid--
just late, and I have done that myself a couple of times.
    On Innate Immunotherapeutics, that was a disclosure that he 
made, and the valuation difference on a private placement is a 
normal thing. It is an eyes-of-the-beholder placement in terms 
of what you assess it at. And this was merely an assessment as 
to what you disclose in terms of its worth, not whether you 
disclose it or not.
    Tom is a good man. He is a family man. He is a physician. 
He is an honorable man. And I am proud to be here today, not to 
defend him, because he does not need defending, but to praise 
him for the things that he has done.
    You know, I think it is important for all of us to look at 
a Secretary nomination, whether it is Secretary of Defense, 
whether it is Health and Human Services, and say, ``What am I 
really looking for in terms of this person?''
    Well, first and foremost, I am looking for a person who 
understands the American family. Tom is a great family man. In 
fact, his wife Betty is here. Raise your hand, Betty.
    Last week I told her to stand up, and she was in a crowd 
and I could not get her to do it, so I am going to get her to 
raise her hand this time around. Betty is a great lady and a 
great wife. Their son Robert, I guess, is still in Nashville, 
TN singing country music. Is that right? So he could not be 
here today, but Lamar Alexander appreciates that part very 
well.
    Tom is active in his church, active in his community, 
understands the needs of families, and understands the 
relationship of health care to a good family.
    Secondly, who would I ask to spend $1.1 trillion of my 
money? I do not have that much, of course, but that is how much 
Tom will oversee at HHS. What would I look for in a person to 
handle that much money?
    I would look for a little bit of experience. And Tom has it 
in terms of being a legislator. I would look for somebody who 
understood where that cost was going and what he needed to do 
to manage it. And Tom is that type of person. I would look for 
somebody I would trust with that amount of money, even though I 
do not have it, but if it were mine.
    Third, does he understand health care? Let me tell you a 
little bit about Tom and his medical practice. It is called 
Resurgens Orthopaedics. Resurgens Orthopaedics is the 
consolidation of a number of small orthopaedics firms around 
the State of Georgia into the largest orthopaedic provider in 
our State.
    Tom was one of the leading persons who pulled that together 
and, in fact, ran the practice for a while himself. They are my 
doctors. In fact, 26 years ago Resurgens saved my young son 
Kevin's right leg after a terrible automobile accident. And I 
have never forgotten what they did for him in a terrible crisis 
that we had in our family.
    But they are a great medical firm. He understands medicine. 
And he has run a comprehensive medical program.
    Fourth, I would want to understand if he knew the 
legislative process. You know, when the President calls Tom in 
and says, okay, we are going to go to the Senate and the House, 
we are going to sell our package, Tom has to have the ability 
to convince 535 people that the President is right or that the 
administration is right. You do not want somebody going up 
there who has not walked into a legislative meeting before, 
somebody who has not been in the political process before. Tom 
has been there and done that. And he is the type of guy you 
could trust to make the sale and represent the administration 
and the people.
    Fifth, I would want somebody who is accountable. Tom is an 
accountable type of guy. In fact, I joked last week and said he 
is one of those rare ones of us who actually reads the bills. 
In fact, when I have a big question, I will usually come talk 
to Tom late at night and say, ``Tom, what do you know about 
House Resolution 3742?'' and he will tell me.
    He is not exciting. He is sometimes boring, but he is 
always right, because he is always prepared. But he understands 
you need to be accountable in this business. You need to be 
responsible for what you do and responsible for what you say.
    Now, there is a rumor that has been spread around by some 
people that Tom does not support the saving of Social Security. 
Let me tell you a little story. A few weeks ago, in fact at the 
end of the campaign in October, I was called by AARP and Tom 
was called by AARP. They said, will you two go on the road for 
us and do presentations around the State in your congressional 
districts about how you are going to save Social Security?
    And I guess Alpharetta, GA was the first place. Tom and I 
went one night and spent the whole night before a room full of 
seniors defending saving Social Security. So anybody who is 
passing that rumor around, hey, go ask AARP who is going to 
save Social Security, go ask the people who are active in that 
business who is going to do it. Tom Price understands the value 
of Social Security and the value of Medicare. And being 
eligible for both, I would not be up here promoting somebody 
who is going to take it away from me, I guarantee you that.
    Now, let me tell you one other thing. Four years ago, I sat 
in this committee room and in the HELP Committee and I 
questioned and I asked all that I could of Sylvia Burwell. And 
when it came time for a vote, I voted for her because she was 
the right person at the right time for the administration to 
put in as head of HHS.
    Dr. Tom Price is the right man at the right time for the 
right job. He is my friend. He is a man I have known for 30 
years. He has unquestioned character and unquestioned ability. 
And he will be a great Secretary of HHS.
    I thank all of you for taking my calls earlier when I 
called before this meeting. I urge you to give him the courtesy 
of your time to listen to what he has to say, ask your thorough 
questions, and I hope you will see fit to nominate an honorable 
man, an accountable man, and a good man to be the next 
Secretary of Health and Human Services.
    And I yield back, Mr. Chairman.
    The Chairman. Well, thank you, Senator Isakson.
    I tell you, Tom, you could not have a better introducer 
than Senator Isakson. I mean, he is not only highly respected 
by all of us in the Senate, Democrats and Republicans, but he 
is very, very articulate, as you can see. And I think he did a 
very good job talking about you and your future here in this 
committee.
    Now, I have some obligatory questions for the nominee. 
First, is there anything that you are aware of in your 
background that might present a conflict of interest with the 
duties of the office to which you have been nominated?
    Dr. Price. I am not.
    The Chairman. Do you know of any reason, personal or 
otherwise, that would in any way prevent you from fully and 
honorably fulfilling this responsibility?
    Dr. Price. I do not.
    The Chairman. Do you agree, without reservation, to respond 
to any reasonable summons to appear and testify before any duly 
constituted committee of the Congress, if you are confirmed?
    Dr. Price. I look forward to that.
    The Chairman. Finally, do you commit to provide a prompt 
response in writing to any questions that may be submitted to 
you or addressed to you by any Senator of this committee?
    Dr. Price. I do.
    The Chairman. Well, thank you. Those are the obligatory 
questions that we ask of everybody.
    Let us turn the time over to you, Dr. Price, Congressman 
Price, to state whatever you would like to state here for the 
committee this morning.

     STATEMENT OF HON. THOMAS PRICE, M.D., NOMINATED TO BE 
SECRETARY, DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, 
                               DC

    Dr. Price. Thank you so much, Chairman Hatch and Ranking 
Member Wyden, and to all the members of this committee, for the 
opportunity to speak with you today and to engage in a 
discussion about the road ahead for our great Nation.
    I want to thank Senator Johnny Isakson so much for his 
incredibly gracious introduction. As he mentioned, we have 
known each other for 30 years or so. I am so grateful for his 
friendship and his kindness. Our State is so grateful for his 
leadership and his service. And we are blessed to have had it.
    I wish also to especially thank my wife Betty, of 33 years, 
who joins me here today. Her support and her encouragement and 
her advice--which I will remind you is always correct--and her 
love that she has given me over those past 33 years, I am more 
grateful for that than I could ever say.
    Over the past couple of weeks and months, I have met with 
many of you individually and gained a real appreciation for the 
passion that you all have for the critical work that is done at 
the Department of Health and Human Services. Please know that I 
share that passion, which is why I am here today and why I am 
honored to have been nominated to serve as the next Secretary 
of Health and Human Services.
    We all come to public service in our own unique ways that 
inform who we are and why we serve. My first professional 
calling was to care for patients. That experience as a 
physician and later as a legislator has provided me a holistic 
view of the complex interactions that take place every single 
day across our communities. And today I hope to share with you 
how my experience has helped shape my understanding of and 
appreciation for the Department of Health and Human Services.
    From an early age, I had an interest in medicine. My 
earliest memories, though, were of growing up on a farm in 
Michigan, where I lived until I was 5 years old when our family 
moved to suburban Detroit.
    I spent most of my formative years being raised by a single 
mom. Some of my fondest memories as a child were those spent 
with my grandfather, who was a physician, and I would 
occasionally spend some weekends with him when he would make 
rounds, which meant that we got in a car and went to people's 
homes and made house calls. And I will never forget the warmth 
and the love with which he was greeted at every single door. 
Those impressions are seared in my memory.
    After graduating from medical school from the University of 
Michigan, I moved to Atlanta, which I have called home for 
nearly 40 years. It is where I met my wife Betty. It is where 
we raised our son. I did my residency at Emory University and 
Grady Memorial Hospital, where I would later return in my 
career to serve as the medical director of the orthopaedic 
clinic.
    Throughout my professional career, I cared for and treated 
patients from all walks of life, including many, many children. 
And anyone who has ever had the privilege of treating a child 
knows how fulfilling it is to look into the eyes of a mom or a 
dad and say how we helped heal their son or their daughter. My 
memories of Grady are filled with the gracious comments of 
parents and of patients for the team of health-care specialists 
with whom I had the privilege of working.
    After 25 years of school and training, I started a solo 
orthopaedic practice. Over the years, this practice grew, as 
Senator Isakson mentioned, and it eventually became one of the 
largest non-
academic group practices of orthopaedics in the country, for 
which I eventually served as chairman of the board. During 20 
years as a practicing physician, I learned a good bit about not 
just treating patients, but about the broader health-care 
system and where it intersects with government.
    A couple of vivid memories stand out. One is the number of 
times when patients were remarkably angry about the individuals 
figuratively, not literally, standing between themselves and 
their physician in the clinic room, making it so that what the 
physician was recommending might or might not be possible, 
whether it was from insurance or regulators or government or 
the like.
    And then there was the day that I remember vividly when I 
realized there were more people in the office behind the door 
where we saw patients in the front clinic area trying to fight 
with insurance and regulators and government than there were in 
front of the door actually caring and treating patients. And it 
became clear to me that our health-care system was losing focus 
on its number-one priority, and that is the patient.
    As a result, I felt compelled to broaden my role in public 
service and help solve the issues harming the delivery of 
medicine, and so I ran for the Georgia State Senate.
    I found Georgia's State Senate to oftentimes be a 
remarkably bipartisan place where collegial relationships were 
the norm. This is the environment in which I learned to 
legislate, reaching across the aisle to get work done.
    In Congress, I have been fortunate to have been part of a 
collaboration that broke through party lines as well to solve 
problems. Just this past Congress, as you will recall, it was a 
bipartisan effort that succeeded in ridding Medicare of a 
broken physician payment system and which has now begun the 
creation of a system that, if implemented properly, will help 
ensure that seniors have access to higher-quality care.
    If confirmed, my obligation will be to carry to the 
Department of Health and Human Services an appreciation for the 
bipartisan, team-driven policymaking in what has been a 
lifetime of commitment to improving the health and well-being 
of the American people. That commitment extends to what I call 
the six principles of health care: affordability, 
accessibility, quality, responsiveness, innovation, and 
choices.
    But Health and Human Services is more than health care. 
There are real heroes at this department doing incredible work 
to keep our food safe and to develop drugs and treatment 
options driven by scientists conducting truly remarkable 
research. There are heroes among the talented, dedicated men 
and women working to provide critical social services, helping 
families and particularly children have a higher quality of 
living and the opportunity to rise up and achieve their 
American dream.
    The role of the Health and Human Services Department in 
improving lives means it must carry out its responsibilities 
with compassion. It also must be efficient and effective and 
accountable as well as willing to partner with those in our 
communities already doing remarkable work. Across the spectrum 
of issues and services this department handles, there endures a 
promise that has been made to the American people. And we must 
strengthen our resolve to keep the promises our society has 
made to senior citizens and to those most in need of care and 
support.
    That means saving and strengthening and securing Medicare 
for today's beneficiaries and future generations. It means 
ensuring that our Nation's Medicaid population has access to 
quality care. It means maintaining and expanding America's 
leading role in medical innovation and of the treatment and 
eradication of disease.
    So I share your passion for these issues, having spent my 
life in service to them. And yet, there is no doubt that we do 
not all share the same point of view when it comes to 
addressing each and every one of these issues. Our approaches 
to policies may differ, but surely there exists a common 
commitment to public service and compassion for those whom we 
serve.
    We all hope to improve the lives of the American people, to 
help heal individuals and whole communities. So with a healthy 
dose of humility and an appreciation for the scope of the 
challenges before us, with your assistance and with God's will, 
we can make it happen. And I look forward to working with you 
to do just that.
    Mr. Chairman, I thank you for the opportunity to be with 
you today.
    [The prepared statement of Dr. Price appears in the 
appendix.]
    The Chairman. Well, thank you, Dr. Price. I cannot think of 
anybody who could give a better analysis of why this position 
is so important to them.
    Let me start with this question. The Department of Health 
and Human Services is one of the largest departments in 
government, employing, I think, nearly 80,000 employees and 
encompassing over 100 programs covering a large range of 
complex and diverse issues.
    Now, you have described to a degree, but if you could 
elaborate a little bit more, can you describe how you will 
prioritize and oversee the large array of issues for which you 
will be responsible? And tell us, what in your history has 
prepared you to lead the Department of Health and Human 
Services, such a multifaceted department?
    Dr. Price. Thank you, Mr. Chairman. As you and members 
know, the mission of the Department of Health and Human 
Services is to improve the health and the safety and the well-
being of the American people. I am committed to that mission, 
but in order to do that, you have to put together teams of 
individuals in each sector of health and human services. And my 
history, wherever I was--whether it was in my clinical practice 
or in the State legislature or Congress or the work that I did 
in communities--was just to bring forward the greatest quality 
of talent that we could assemble.
    Second is to understand the scope and the issues. And 
clearly, having the experience both in the clinical arena as 
well as in the legislative arena, I understand the scope and 
the issues.
    And then finally, focusing on results. I think oftentimes 
it gets kind of muddy up here in Washington, what we do. We 
name the programs, we make certain that the resources are there 
to be able to provide money for the programs to be run, but 
oftentimes I think we drop the ball on whether or not we are 
actually accomplishing the mission. Are we truly improving the 
health and the safety and the well-being of the American 
people?
    So one of the major goals that I have is to look at the 
metrics that we are looking at at the department to make 
certain that we are accomplishing that mission and that goal.
    The Chairman. Thank you. The Center for Medicare and 
Medicaid innovation, CMMI, has begun numerous initiatives over 
the past few years, some of which have generated much 
controversy. Could you tell us your position on the work in 
CMMI and how it should or should not be continued in the 
future?
    Dr. Price. Thank you, Mr. Chairman. Innovation is so 
incredibly important to health care and the vibrant quality of 
health care that we need to be able to provide to our citizens. 
Innovation, in fact, is what leads quality health care. It is 
what expands the ability of health-care professionals to be 
able to treat patients. So I am a strong supporter of 
innovation, and I think one of the roles that we as 
policymakers have is to incentivize innovation.
    The Center for Medicare and Medicaid Innovation is a 
vehicle that might do just that. I think, however, that CMMI 
has gotten off track a bit. I think that what it has done is 
defined areas where it is mandatorily dictating to physicians 
and other providers in this country, in certain areas, how they 
must practice. So whether it is a geographic area that includes 
67 or 68 areas in our country that have to perform a certain 
procedure in a certain way and use a certain implant in a 
certain way because the government says they have to 
mandatorily, without exception, or whether it is 75 percent of 
the Part B Medicare drug demo, what is called a demonstration 
project, which dictates to physicians and other providers they 
must use an in-patient setting, that, to me, is no longer a 
trial, that is no longer an experiment, that is no longer a 
pilot project to determine whether or not an innovative 
solution might work. That is changing the way that American 
medicine is practiced by folks making decisions here in 
Washington as opposed to patients and families and doctors 
making those decisions.
    So I am a strong supporter of innovation, but I hope that 
we can move CMMI in a direction that actually makes sense for 
patients.
    The Chairman. Well, thank you so much. Medicare has lost 
more than $130 billion--that is with a ``b''--to improper 
payments over the past 3 years. The program has also been above 
the legal billing error rate threshold of 10 percent for the 
past 4 years.
    Given that Medicare trustees have issued grave concerns 
about looming Medicare insolvency if we stay at the current 
spending levels, will your administration actively champion our 
Medicare Integrity Program so that we can recover a much higher 
percentage of the billions of taxpayer dollars lost each year 
to billing mistakes and ensure that Medicare will be in place 
for future American seniors?
    And also, as a former practicing physician who has 
experience with Medicare and Medicaid programs, do you have any 
insights into steps you think should be taken to address the 
multi-billion-dollar problem of waste, fraud, and abuse in 
these programs?
    Dr. Price. Yes, thanks, Mr. Chairman. Nobody supports care 
being billed that is not needed or has not been provided. And 
this is one of those areas that I think we need to be very, 
very focused on.
    I am certain that there are some bad actors out there. I 
think they are a minority, but there are some bad actors out 
there. And I am certain that if we were to focus specifically 
on those bad actors in real time--which is what happens in 
every other industry in our country where that real-time 
information is available and acted upon--instead of trying to 
determine whether every single incident of care is necessary, 
if we were to focus on those individuals who were the bad 
actors specifically, then I think we could do a much better job 
of not just identifying the fraud that exists out there, but 
ending that fraud.
    The Chairman. Well, thank you.
    Senator Wyden, we will turn to you now.
    Senator Wyden. Thank you, Mr. Chairman.
    Congressman, I am going to start with the trading in 
health-care stocks. Your position is that the trading was legal 
because, in your view, it complied with House rules. I think 
there are debatable legal questions, but there are other 
matters.
    Innate Immunotherapeutics is an obscure Australian company 
that develops a treatment for immune system disorders and plans 
to seek FDA approval. Innate's fortunes are affected by 
congressional action.
    Today, the total value of your shares exceeds a half-
million dollars. Yet on the Office of Government Ethics 
disclosure form you filed as a nominee, you significantly 
undervalued the stock. You failed to include the value of more 
than 400,000 shares you bought at a significant discount during 
a private stock sale made available to specially chosen 
investors around Labor Day. You also significantly 
underreported the value of this purchase to the committee. It 
is worth more than twice what you reported.
    You heard about the stock from a House colleague who is a 
board director of this Australian drug company and the largest 
shareholder. You got in on private placements not available to 
the public. In these private placements, you bought over 
400,000 shares at discounts that were as much as 40 percent 
cheaper than the price on the Australian Stock Exchange. And 
you were sitting at the time on committees that have 
jurisdiction over major health-care programs and trade policy.
    ``Yes'' or ``no,'' does this not show bad judgment?
    Dr. Price. Well, if what you said was true it might. But 
the fact of the matter is, that is not the case.
    Senator Wyden. We have a paper trail, Congressman. We have 
a paper trail for every comment I have made. ``Yes'' or ``no,'' 
does this not show bad judgment?
    Dr. Price. No.
    Senator Wyden. Well, I just----
    The Chairman. Well, let him answer the question too. I 
mean, you have kind of indicated he did something wrong. Let 
him explain why it was not wrong.
    Senator Wyden. It was a ``yes'' or ``no'' answer.
    The Chairman. No, I want him to be able to handle that 
problem.
    Dr. Price. Maybe it would be helpful if you laid out the 
accusation, sir.
    The Chairman. Be fair.
    Senator Wyden. Well, you purchased stock in an Australian 
company through private offerings at discounts not available to 
the public.
    Dr. Price. If I may, they were available to every single 
individual who was an investor at the time.
    Senator Wyden. Well, that is not what we learned from 
company filings. Company filings with the Australian Stock 
Exchange state that this specific private placement would be 
made at below-
market rates. The Treasury Department says it is only offered 
to sophisticated investors in a non-public manner. We have a 
paper trail for every one of the statements that I have gone 
into. And trading in stocks while you sit on two committees 
introducing legislation that directly impacts the value of the 
stocks----
    Dr. Price. What legislation would that be, Senator?
    Senator Wyden. We will take you through the various bills. 
But the reality is, this has been cited on a number of 
occasions.
    Dr. Price. The reality is that everything that I did was 
ethical, above-board, legal, and transparent. The reason that 
you know about these things is because we have made that 
information available in real time as required by the House 
Ethics Committee.
    So there is not anything that you have divulged here that 
has not been public knowledge.
    Senator Wyden. Your stake in Innate is more than five times 
larger than the figure you reported to ethics officials when 
you became a nominee.
    Dr. Price. And if you had listened to your committee staff, 
I believe you would know that our belief is that that was a 
clerical error at the time that the 278E was filed. We do not 
know where it happened, whether it was on our end, whether it 
was on the end of the individuals of OGE. But there was not any 
malicious intent at all.
    Senator Wyden. Congressman, you also reported it in the 
questionnaire to the committee, and you had to revise it 
yesterday because it was wrong.
    Dr. Price. And the reason for that is because I, when asked 
about the value, thought it meant the value at the time that I 
purchased the stock, not the value at some nebulous time when 
we supposedly made a specific gain.
    Senator Wyden. I want to get in one other question, if I 
might. This weekend, the President issued an executive order 
instructing the Department and other agencies to do everything 
possible to roll back the Affordable Care Act. If confirmed, 
you will be the captain of the health team and in charge of 
implementing the order.
    ``Yes'' or ``no,'' under the executive order, will you 
commit that no one will be worse off?
    Dr. Price. What I commit to, Senator, is working with you 
and every single member of Congress to make certain that we 
have the highest-quality health care and that every single 
American has access to affordable coverage.
    Senator Wyden. That is not what I asked. I asked, will you 
commit that no one will be worse off under the executive order? 
You ducked the question. Will you guarantee that no one will 
lose coverage under the executive order?
    Dr. Price. I guarantee you that the individuals who lost 
coverage under the Affordable Care Act, we will commit to 
making certain that they do not lose coverage under whatever 
replacement plan comes forward. That is the commitment that I 
provide to you.
    Senator Wyden. The question again is, will anyone lose 
coverage, and you answered something I did not ask.
    I will wrap up this round by saying, will you commit to not 
implementing the order until the replacement plan is in place?
    Dr. Price. As I mentioned, Senator, what I commit to you 
and what I commit to the American people is to keep patients at 
the center of health care. And what that means to me is making 
certain that every single American has access to affordable 
health coverage that will provide the highest-quality health 
care that the world can provide.
    Senator Wyden. I am going to close by way of saying that 
what the Congressman is saying is that the order could go into 
effect before there is a replacement plan. And independent 
experts say that this is going to destroy the market on which 
millions of working families buy health coverage. And on the 
questions that I asked, will the Congressman commit that nobody 
will be worse off, nobody will lose coverage, we did not get an 
answer.
    Thank you, Mr. Chairman.
    The Chairman. Well, how can anybody commit to that? 
[Laughter.]
    Let me just say, Dr. Price, you have been accused here of 
investing in securities that you had a direct effect over in 
Congress and you disclosed the wrong value of shares you owned 
in Innate Immunotherapeutics.
    Now Dr. Price, let me just say this, has a diversified 
portfolio with Morgan Stanley in a broker-directed account. 
Correct me if I am wrong on any of this, Doctor. The portfolio 
includes both health-care and non-health-care stocks. His 
financial adviser designed the portfolio and directed all 
trades in the account. The advisers and not Dr. Price have the 
discretion to decide which securities to buy and sell.
    On March 17, 2016 in a rebalancing of the portfolio, the 
financial adviser directed the purchase of 26 shares in Zimmer 
Biomet worth under $3,000. The adviser notified Dr. Price of 
the purchase on April 4, 2016, and Dr. Price disclosed them on 
his House periodic transaction report on April 15th.
    Now, Dr. Price began his legislative effort related to the 
comprehensive joint replacement demonstration project in 2015. 
With one exception, all of Dr. Price's stocks are held in three 
broker-
directed accounts. Neither he nor his wife direct or provide 
input regarding investments in these accounts. Innate 
Immunotherapeutics is the one exception.
    Now, Dr. Price decided to invest based on public 
information regarding his work on multiple sclerosis treatments 
as a disease. He has been intimately involved in treating for 
years. He directed the investments based on his own research 
into the company. He invested $10,000 in the company in January 
2015 and reported the investments to House Ethics in February 
of that year. He made an additional investment in September 
2016 and also disclosed that investment.
    He has corrected his filing regarding the value of his 
shares. He has agreed to divest all shares in the company. Is 
that a correct set of remarks?
    Dr. Price. I think your summation is correct, sir. And I 
just would point out that anybody who knows me well knows that 
I would never violate their trust. And I know the environment 
that we are in here--you mentioned it in your opening 
statement--but I appreciate you correcting the record.
    The Chairman. Well, thank you.
    Senator Carper. Mr. Chairman?
    The Chairman. Yes, sir?
    Senator Carper. Just an inquiry. You just consumed about 2 
minutes beyond your opening statement. And in the interest of 
fair play, is it appropriate for someone to note that 2 minutes 
is also owed to Senator Wyden or somebody on our side?
    The Chairman. Well, he already did go over 2 minutes, so it 
is no problem.
    Senator Carper. Okay. But as we go forward in this process, 
I would just ask you to keep that in mind.
    The Chairman. Well, I am not going to relinquish my role as 
chairman----
    Senator Carper. No, I understand.
    The Chairman [continuing]. To correct errors that are 
promulgated here. But I have always been good about giving time 
that you need, so I will try to do that.
    Senator Carper. Thank you.
    The Chairman. But I am also not going to allow things that 
are false to go forward without some sort of comment.
    Senator Carper. All right.
    The Chairman. We just cannot allow this to happen.
    Senator Wyden. Mr. Chairman, just a unanimous consent 
request.
    The Chairman. Yes.
    Senator Wyden. I have a bipartisan disclosure memo I would 
like to ask be made a part of the record, because it will 
document what I have stated.
    The Chairman. Without objection.
    [The memorandum appears in the appendix on p. 283.]
    The Chairman. Senator Roberts?
    Senator Roberts. Did you really wink at me and smile? Bless 
your heart, thank you. [Laughter.]
    Good Doctor, thank you for coming. I think it is important 
to make clear right off the bat that, even if Congress and the 
incoming administration were to do nothing, absolutely nothing 
amending or repealing parts of the Affordable Care Act, the law 
is not working.
    Dr. Price. Right.
    Senator Roberts. It is collapsing. The prices are 
unaffordable, the market is nearly nonexistent, with few 
options in several States and counties. This year, one out of 
every three counties in this country only has one insurer 
offering coverage on the exchange.
    What tools do you have, or will you have when you are 
confirmed, which could be utilized over the next couple of 
months to provide stability and improve the individual 
insurance markets, make them more appealing so that insurance 
carriers will want to come back and provide more coverage 
options as we transition away from the Affordable Care Act?
    Dr. Price. Well, thank you, Senator. I think it is 
incredibly important for us to admit here what the American 
people know, and that is that this law is not working. It 
certainly is not working for folks in the individual and small-
group market.
    You have premiums that are up significantly; they were 
supposed to go down by 2,500 bucks; now they are up more than 
2,500 bucks on average. You have deductibles that have 
escalated to $6,000 to $12,000. You have, as you mentioned, 
States where there is only one insurance provider. You have 
one-third of the counties in this country where there is only 
one insurance carrier.
    This is maybe working for government, maybe working for 
insurance companies, but it is not working for patients. And so 
what we need to do is make an effort to try to reconstitute the 
individual and small-group market. And that begins, I believe, 
by providing stability in our conversation and in our tone.
    And one of the goals that I have is to lower the 
temperature in this debate, to say to those providing the 
insurance products across this country, we understand; we heard 
the challenges that you have.
    They are already exiting the market. What we need to do is 
to say, there is help on the way to allow us to reconstitute 
the individual and small-group market and allow for folks to 
gain the kind of coverage that they want for themselves and for 
their family--not what the government forces them to buy--that 
allows them to purchase coverage at a reasonable amount, that 
makes it so that they do not have deductibles through the roof, 
where they have the ability to pay the premiums and the 
deductible as well.
    So there are so many things that we ought to be focusing on 
to make certain, again, that the American people have access to 
the highest-quality care that is affordable for them.
    Senator Roberts. Doctor, I have 84 critical access 
hospitals in my State. They are all part of the rural health-
care delivery system, which is under great stress. As we have 
seen when I visit with hospital administrators all throughout 
Kansas--there was a time I knew every one of them--they are 
scratching their heads over regulations coming out of HHS, CMS, 
and all the other agencies that you will oversee when you are 
confirmed.
    I mention the meaningful use program for electronic health 
care records. Doctors used to spend, what, 10 to 15 minutes 
with patients. It is now down to about 2 or 3, and then they 
have to report immediately on what was going on.
    The 96-hour rule for critical access hospitals, numerous 
other documentation requirements--it seems to me there is a 
lack of understanding of our provider shortages in our rural 
areas. We are just hanging on by a thread, and these one-size 
regulations from Washington simply do not translate to rural 
Kansas or any other rural area as far as population----
    My question is, how will you work to ensure an effective 
but smarter, less-burdensome rulemaking process?
    Dr. Price. Well, this is really critical, Senator, because, 
as you mentioned, in the rural areas--Georgia is the largest 
State geographically east of the Mississippi, and we have a 
large rural population, and critical access hospitals are so 
important to communities around our State and truly around this 
Nation.
    But the regulatory scheme that has been put in place is 
choking the individuals who are actually trying to provide the 
care, so much so that you have physicians and other providers 
who are leaving the practice, who are leaving the caring for 
patients, not because they have forgotten how to do it or they 
have grown tired of it, but because of the onerous nature of 
the regulatory scheme coming out of Washington, DC.
    The meaningful use project that you mentioned makes it that 
much more difficult. We have turned physicians into data-entry 
clerks. And you just have to ask them what they are doing. And 
if you talk to patients, what they recognize is that, when they 
go in to see their doctor, they see the top of his or her head 
as they are punching the information, the data into a computer, 
as opposed to that sharing of information that is so vital and 
necessary between the physician and the patient for quality 
health care.
    So, one, a recognition of the problem is incredibly 
important, a recognition of the importance of rural health care 
in our Nation and how it needs to be bolstered up, and then 
looking at the consequences of what we do as government.
    As I mentioned earlier, oftentimes I do not think we look 
at the consequences. We pass the rule, we pass the regulation, 
we institute it, we think it is the greatest thing since sliced 
bread, but in fact what it is doing is harming the very 
individuals who are trying to provide the care. You do not get 
that information unless you ask.
    Senator Roberts. All right, I appreciate that. My time is 
up.
    Thank you, Mr. Chairman.
    The Chairman. Senator Nelson?
    Senator Nelson. Thank you, Mr. Chairman.
    Congressman, I enjoyed our visit yesterday. We had a 
discussion, when you were kind enough to come visit me, about 
the fact that I have in the State of Florida 4 million-plus 
seniors on Medicare, and they are petrified of the idea of 
privatized Medicare.
    And I talked to you about this. And you talked about the 
premium support system that you are advocating. And you pointed 
to a study that was done by CBO. You mentioned that you would 
send me a copy, and we have not gotten it. So what I did, I 
went and got the copy myself, and it is from September of 2013. 
And what it concludes is opposite of what you said with regard 
to high-cost States like Florida.
    Medicare is going to be spending 4 percent less under the 
proposal that you were talking about in this CBO report, lower 
than current law, and beneficiary costs will decrease by 6 
percent on the average, which is what you said yesterday. But 
in high-cost regions like Florida, you are going to have a 
higher beneficiary cost than current law under your premium 
support proposal.
    Annual premiums in Florida would increase 125 percent 
according to the CBO chart on page 71. CBO says that the annual 
premium in a high-cost region like Florida would be $3,600 
compared to the current law of $1,600. That is a 125-percent 
increase. So please help clarify what you were saying yesterday 
as it applies to Florida.
    Dr. Price. Yes, thank you, Senator. And I enjoyed our time 
together as well.
    When we talk about Medicare, it is important for everybody 
to appreciate, as I know that you and your colleagues do, that 
the Medicare trustees, not Republicans or Democrats, the 
Medicare trustees have told all of us that Medicare in a very 
short period of time, less than 10 years, is going to be out of 
the kind of resources that will allow us as a society to keep 
the promise to beneficiaries in the Medicare program.
    What that means is--and it is important to appreciate what 
that means--it means that we will not be able to provide the 
services to Medicare patients at that time, which is very, very 
close, if nothing is done.
    So my goal is to work with each and every one of you to 
make certain that we save and strengthen and secure Medicare. I 
think it is irresponsible of us as policymakers to allow a 
program to continue, knowing--knowing--that in a few short 
years it is not going to be able to cover the services that we 
are providing. So that is the first point, that the current 
Medicare program, if nothing is done, as some have described 
it, goes broke.
    The second point is that my role, if I am confirmed and 
have the privilege of serving as the Secretary of Health and 
Human Services, my role will be one of carrying out the law 
that you all in Congress pass. It is not the role of a 
legislator, which I had when I was working to try to formulate 
ideas to hopefully generate discussion and get to a solution--
--
    Senator Nelson. Okay. Let me be so rude as to stop you, 
because I am running out of time. Remember that Donald Trump in 
the campaign said that he was not going to cut Medicare 
spending.
    And I would also point out to you a legislative solution--
one of the greatest examples on Medicare is 1983, when we were 
just about to go bust and it took two old Irishmen, Reagan and 
O'Neill, to agree to come to an agreement that made, in this 
case it was not Medicare, it was Social Security, actuarily 
sound for the next half-century.
    Let me ask you, Representative Price: you had made a 
statement that it was a terrible idea for people who had 
preexisting conditions to have the protection of insurance 
against those preexisting conditions.
    And what I would like to ask you is, if you please, in 
light of President Trump expressing his desire to retain this 
basic protection, do you think his proposal to continue the ban 
on discriminating against people with preexisting conditions is 
a terrible idea?
    Dr. Price. No, and I am not certain where you are getting 
that quote from. What I have always----
    Senator Nelson. It came from a Politico talking points 
memo, May 1, 2012.
    Dr. Price. Well now, there is a reliable source. 
[Laughter.]
    What I have always said, Senator, is that nobody--nobody--
--
    Senator Nelson. So you did not say it is a terrible idea?
    Dr. Price. I do not believe I ever made that statement. 
What I have always said about preexisting conditions is that 
nobody, in a system that pays attention to patients, nobody 
ought to be priced out of the market for having a bad 
diagnosis. Nobody. That is a system, again, that may work for 
insurance companies, may work for government, but it does not 
work for patients.
    So I believe firmly that what we need is a system that 
recognizes that preexisting conditions do indeed exist and that 
we need to accommodate them and make certain that nobody loses 
their insurance or is unable to gain insurance because of a 
preexisting condition.
    Senator Nelson. Mr. Chairman, as I close, I would like to 
insert in the record the September 2013 Congressional Budget 
Office analysis of premium support systems for Medicare.
    [The analysis appears in the appendix on p. 92.]
    Senator Nelson. And I would invite you, Congressman, to 
please respond with the CBO report that you said yesterday 
supports your position, because this one does not.
    Dr. Price. I look forward to that. Thank you, sir.
    The Chairman. Senator Menendez?
    Senator Menendez. Well, thank you, Mr. Chairman.
    Congratulations, Congressman Price.
    Let me ask you a series of questions. Given your medical 
training and time spent as a practicing physician, I have a 
couple of simple ``yes'' or ``no'' questions to start off with.
    In your medical opinion, does HIV cause AIDS?
    Dr. Price. I think that the scientific evidence is clear 
that HIV and AIDS are clinically, directly related.
    Senator Menendez. In your medical opinion, have immigrants 
led to outbreaks of leprosy in the United States?
    Dr. Price. I do not know what you are referring to, but I 
suspect that there are instances where individuals have an 
infectious disease, and they come to the United States and that 
that----
    Senator Menendez. I am not asking about an infectious 
disease. I am asking specifically about immigrants in the 
United States causing leprosy in the United States, in your 
medical opinion and scientific background.
    Dr. Price. Again, I do not know the incident to which you 
refer. Are you referring to a specific incident?
    Senator Menendez. There are statements that have been made 
in the public domain that immigrants have led to outbreaks of 
leprosy in the United States. As the person who is going to be 
designated as the director of Health and Human Services, that 
is not only the national, but the world's health epicenter, I 
want to know, in your medical opinion, is there such a 
causation?
    Dr. Price. Any time you get two individuals together in any 
relationship whatsoever, whether it is an immigrant or a 
visitor, and one individual has an infectious disease, then it 
is possible that that individual transmits that infectious 
disease----
    Senator Menendez. Including leprosy?
    Dr. Price [continuing]. Whether it is the flu or a cold.
    Senator Menendez. Including leprosy? Including leprosy?
    Dr. Price. Any infectious disease whatsoever.
    Senator Menendez. In your medical opinion, do abortions 
cause breast cancer?
    Dr. Price. I think the science is relatively clear that 
that is not the case.
    Senator Menendez. In your medical opinion, do vaccines 
cause autism?
    Dr. Price. Again, I think the science in that instance is 
that they do not, but there are individuals across our country 
who are very----
    Senator Menendez. I am not asking about individuals; I am 
talking about science, because you are going to head a 
department in which science, not alternate universes of 
people's views, is going to be central to a trillion-dollar 
budget and the health of the Nation.
    Can you commit to this committee and the American people 
today that, should you be confirmed, you will swiftly and 
unequivocally debunk false claims to protect the public health?
    Dr. Price. What I will commit to doing is doing the due 
diligence that the Department is known for and must do to make 
certain that the factual information is conveyed to, obviously, 
the President and to the American people.
    Senator Menendez. And that factual information will be 
dictated by science, I would hope?
    Dr. Price. Without a doubt.
    Senator Menendez. Okay. So let me ask you about Medicaid 
specifically. And let me just say I am a little taken back 
about your answer on the question of immigrants and leprosy. I 
think the science is pretty well dictated in that regard too.
    Let me ask you this. One of the most beneficial components 
of the Affordable Care Act was the expansion of the Medicaid 
program that resulted in 11 million people nationwide and over 
half a million in New Jersey gaining coverage, many for the 
first time. It is one of the biggest programs on the Republican 
chopping block with proposals to not only repeal the Affordable 
Care Act's Medicaid expansion, but going further and gutting 
billions in Federal funding to the States.
    There is no doubt that this would result in catastrophic 
loss of coverage for tens of millions of low-income families 
and lead to tens of billions in losses to safety-net and other 
health-care providers.
    Do you recognize Medicaid to be a valuable program and 
consider the coverage it provides to 74 million Americans to be 
comprehensive?
    Dr. Price. Medicaid is a vital program for health care for 
many individuals in this country, but one that has significant 
challenges. There is one out of every three physicians who 
should be seeing Medicaid patients who are not taking any 
Medicaid patients. There is a reason for that.
    If we are honest with ourselves, we would be asking the 
question, why?
    Senator Menendez. Well, if that is the case that one in 
three does not treat Medicaid patients, you have to ask 
yourself, is that because Medicaid reimbursements are so low? 
And since provider reimbursements are set at a State level, 
will not cutting Federal funding and hitting States with higher 
costs only lead to lower provider rates? And how many doctors 
would actually treat former Medicaid beneficiaries when they no 
longer have any coverage or ability to pay?
    So, even if there is only one of three, there are still two 
of three who are providing the services; imagine if you do not 
have coverage.
    Which goes to my next question. You have advocated to, in 
essence, block-grant Medicaid. Now, the essence of Medicaid is 
an entitlement, which under the law means, if I meet these 
criteria, I have the right to have that coverage under the law. 
When you move to a block grant, you remove the right and you 
make it a possibility subject to whatever funding there is 
going to be.
    Do you recognize that in doing so you risk the potential of 
millions of Americans who presently enjoy health-care coverage 
through Medicaid no longer having that right?
    Dr. Price. I think that it is important to appreciate that 
no system that the President has supported or that I have 
supported would leave anybody without the opportunity to gain 
coverage. Nobody.
    Senator Menendez. Well, that is not my question, so let me 
reiterate my question. Medicaid, under the law as it exists 
today, is a right. Is that not the case, ``yes'' or ``no''?
    Dr. Price. It is an entitlement program----
    Senator Menendez. And as an entitlement, does that not 
mean, if you meet the criteria, that you are entitled to the 
services?
    Dr. Price. If one is eligible, that is correct.
    Senator Menendez. One is eligible, meaning you have a 
right. When you move to a block grant, do you still have the 
right?
    Dr. Price. No. I think it would be determined by how that 
was set up if, in fact, that was what Congress did. Again, the 
role of the Department of Health and Human Services is to 
administer the laws that you pass, not to make the law.
    Senator Menendez. Yes, but I would just simply say to you, 
I know in our private conversation--and I appreciate you coming 
by to visit me--you suggested that your role is that of an 
administrator of a large department. Well, that is not even 
what the Vice President said when you were nominated. He said 
he expected your experience, both medically and legislatively, 
to help drive policy. And even beyond the expectations of the 
Vice President in that regard, when we have the ability of the 
Secretary to dictate regulation, that is policy.
    So please do not say to me, I am here just to do what 
Congress says. I respect that you will follow the law and do 
whatever Congress says. But you will have an enormous impact. 
And based upon your previous opinion as it relates to Medicaid, 
ultimately block-granting means a loss of a right. And then it 
is just a question of funding, and then we will have a bigger 
problem with a number of providers' will to provide.
    And so I hope we can get to a better understanding of your 
commitment to Medicaid as it is, as an entitlement, as a right.
    Dr. Price. Thank you, sir.
    The Chairman. Senator, your time is up.
    We will go to Senator Carper now.
    Senator Carper. Congressman Price, welcome to you and to 
your wife.
    There is a verse of scripture--you mentioned earlier that 
you are active in your church--in the New Testament, in Matthew 
25, which speaks to the ``least of these.'' When I was hungry, 
did you feed me? When I was naked, did you clothe me? When I 
was thirsty, did you give me to drink? When I was sick and in 
prison, did you visit me? When I was a stranger in your land, 
did you take me in? It says nothing about, when my only access 
to health-care coverage was going into the emergency room of a 
hospital, did you do anything about it?
    What we sought to do with the ACA was to do something about 
it. And we did not, in this room, invent the Affordable Care 
Act. The genesis of the Affordable Care Act goes back to 1993 
when Hillary Clinton, first lady, was working on what was 
called Hillarycare. And a group of Senators, led by Senator 
John Chafee, a Republican from Rhode Island, developed 
legislation co-sponsored by, I think, 23 Senators, including, 
as I recall, Senator Orrin Hatch and Senator Grassley.
    And what he did in his legislation, what he proposed in his 
legislation, was to use really five major concepts. One, to 
create large purchasing pools for folks who otherwise may not 
have access to health-care coverage. He called them exchanges 
or marketplaces.
    He also proposed that there be a sliding scale tax credit 
to buy down the cost of people getting coverage in those 
exchanges within the different States.
    The third thing he proposed was the notion that there 
should be an individual mandate. He wanted to make sure people 
got covered, and he realized if they did not mandate coverage 
or people getting coverage, then you would end up with 
insurance pools that health insurance companies could not begin 
to cover; it just would be unworkable.
    He proposed, as well, employer mandates. And he proposed, 
as well, the notion that people should not lose their coverage 
because of preexisting conditions.
    Those are not Democratic ideas. Those were proposed by 
Republican leadership actually in the Congress at the time. And 
when Governor Romney developed his own plan in Massachusetts, I 
do not know, a decade or so later, he borrowed liberally from 
those ideas.
    When they instituted it, as you may recall--they instituted 
what I call, what others call, Romneycare--they found they were 
doing a pretty good job on covering people, but not such a good 
job on affordability. And what took place over time was, they 
found out they had insurance pools where a lot of the people 
were not young, they were not very healthy, they were older, 
and they needed more health care. And as a result, the 
insurance companies, in order to be able to stay in business, 
had to raise the premiums.
    I do not know if any of this sounds familiar to you, but it 
sure sounds similar to what we have seen in the last 6 years or 
so with the Affordable Care Act.
    To the ideas of Senator Chafee and the ideas of Governor 
Romney, we have added some things. We have encouraged States to 
increase the number of people they cover under Medicaid by 
raising to about 135 percent of the poverty level the 
eligibility under which people can receive health care. We have 
encouraged a focus on prevention and wellness: not just 
treating people when they are sick, but also trying to make 
sure that people stay healthy in the first place. We provide 
funding for contraception. We provide funding for programs that 
are intended to reduce obesity. We have programs that are 
intended to reduce smoking, the use of tobacco.
    This is not a ``yes'' or ``no'' question. What was wrong 
with that approach? What is wrong with that approach?
    And the last thing I will say is this, before you answer. 
The health insurance companies found it difficult to stay in 
business in the State group exchanges across the country. One 
of the reasons why they were unable to is because, I think--
really we learned this from Massachusetts--we did not raise the 
fine or, if you will, we did not have the incentive high enough 
to get young, healthy people, like my sons, into the exchanges 
across the country.
    S&P, I am told, has just put out, about a month ago, an 
update looking at the financial health of the health insurance 
companies in this country as they have tried to figure out how 
to price this product. And it seems like, according to S&P, 
believe it or not, they seem to have sort of figured it out, 
because the financial health of the health insurance companies 
has begun to stabilize. Your reaction to this, please?
    Dr. Price. Well, as I mentioned either in my opening or in 
response to a question, the principles of health care that all 
of us hold dear--affordability and accessibility and quality 
and choices for patients--I think are the things that we all 
embrace.
    The next step, how we get to accomplish and meet those 
goals and those principles, is where it takes working together 
to do so.
    The program that you outline has much merit, whether it is 
making sure that individuals with preexisting illness and 
disease are able to access coverage, whether it is the pooling 
mechanisms which I have actively and aggressively supported for 
years, there is a lot of merit there.
    So again, what I am hopeful that we are able to do is to, 
in a collegial, bipartisan way, work together to solve the 
remarkable challenges that we have.
    One of my physician colleagues used to tell me that he 
never operated on a Democrat patient or a Republican patient, 
he operated on a patient. And that is the way that I view the 
system. It is not a Republican system, it is not a Democrat 
system, it is a system where hopefully we are focusing on the 
patients to, again, make certain that they have the access to 
the highest-quality care possible.
    Senator Carper. Thank you for that. Let me just conclude, 
Mr. Chairman, by saying I will use an analogy. There is a large 
building, and there are people in the large building. And there 
is a fire in the large building, but for some reason they 
cannot use the stairways and they cannot use the elevators. And 
they look out the windows and there are firefighters down in 
the street saying, ``Go ahead and jump, we will save you,'' but 
they do not have any safety nets.
    And my fear is, if we repeal what I have described, the 
system that I described, that we put in place, the Affordable 
Care Act, largely founded on Republican ideas which I think 
were good ideas, and we do not have something at least as good 
in place to catch those people as they fall from the building, 
we will have done a disservice to them and to our country.
    Thank you.
    Dr. Price. Thank you.
    The Chairman. Thanks, Senator. Your time is up.
    Senator Burr?
    Senator Burr. Thank you, Mr. Chairman.
    And a quick reminder that the Affordable Care Act was 
passed with not one Republican vote in the House or the Senate.
    So, Dr. Price, a couple of questions just to cut to the 
chase. Are all of your assets currently disclosed publicly?
    Dr. Price. They are now and they always have been.
    Senator Burr. Okay. Are you covered by the STOCK Act 
legislation passed by Congress that requires you and every 
other member to publicly disclose all sales and purchases of 
assets within 30 days?
    Dr. Price. Yes, sir.
    Senator Burr. Now, you have been accused of not providing 
the committee information related to your tax and financial 
records that were required of you. Are there any records you 
have been asked to provide that you have refused to provide?
    Dr. Price. None whatsoever.
    Senator Burr. So all of your records are in?
    Dr. Price. Absolutely.
    Senator Burr. Now, I have to ask you, does it trouble you 
at all that, as a nominee to serve in this administration, some 
want to hold you to a different standard than you were held to 
as a member of Congress, and I might say the same standard that 
they currently buy and sell and trade assets on? Does it burn 
you that they want to hold you to a different standard now that 
you are a nominee than they are held to as a member?
    Dr. Price. Well, we know what is going on here.
    Senator Burr. Well, we do. We do.
    Dr. Price. And I understand. And as my wife tells me, I 
volunteered for this.
    Senator Burr. So let us go to substance. You and I have a 
lot in common. We both spoke out in opposition to Obamacare 
early. We predicted massive premium increases. When the 
President promised, if you like your doctors, you can keep 
them, if you like your plan, you can keep it, we both said 
these promises would be broken, and, in fact, they were.
    Over the last 7 years, you and I, Senator Hatch, 
Congressman Upton, and others have actually written our own 
health-care plans because we were, I think, brave enough to say 
that, if you are going to be critical of something, then put 
your ideas on the table.
    In your opinion, was it clear to the American people that 
repeal of Obamacare was a promise that Donald Trump made before 
he was elected president?
    Dr. Price. Well, I have no doubt that it played a very 
prominent role in this past election and that the President is 
committed to fulfilling that promise.
    Senator Burr. And as the nominee and hopefully--and I think 
you will be--the Secretary of HHS, what are the main goals of 
an Obamacare replacement plan?
    Dr. Price. The main goals, as I mentioned, are outlined in 
those principles. That it is imperative that we have a system 
that is accessible for every single American, that is 
affordable for every single American, that incentivizes and 
provides the highest-quality health care that the world knows, 
and provides choices to patients so that they are the ones 
selecting who is treating them, when, where, and the like.
    So it is complicated to do, but it is pretty simple stuff.
    Senator Burr. I want to thank you for not only testifying 
here, but testifying in front of the HELP Committee when Johnny 
and I both had you over there. You are brave to go through 
this, but the country will be much better off with your 
guidance and your knowledge in this slot.
    Mr. Chairman, I yield back.
    Dr. Price. Thank you, sir.
    The Chairman. Thank you.
    Senator Cardin?
    Senator Cardin. Thank you, Mr. Chairman.
    Dr. Price, again, thank you for your willingness to serve 
in this position. And we also thank your family for being 
willing to put up with your voluntary choices.
    I want to talk about a few issues in the time that I have. 
One, yesterday the President by executive order reinstituted 
the global gag rule, but he also did it in a way that is more 
comprehensive than the previous. The new policy would prohibit 
any Federal aid to foreign organizations that provide or 
promote abortion.
    In the past, the policy only applied to organizations that 
got family planning funding; now it will apply to organizations 
that get global health funding, potentially including maternal 
health programs, anti-Zika efforts, and expansion of PEPFAR to 
stop HIV/AIDS.
    My question to you is this: if confirmed, how will you make 
sure that the U.S. can fully participate in these global health 
efforts to help with maternal health, to help in stopping of 
the spread of and ending HIV/AIDS, to make sure that the next 
Zika virus is contained so it does not cause catastrophic 
effects, if the global gag rule is enforced in a way that 
prevents us from participating in international health 
organizations?
    Dr. Price. Okay. This is really important, Senator, and I 
appreciate the question. The Department is full of all sorts of 
heroes, as you well know, and incredibly talented individuals. 
And my goal, if I am confirmed and given the privilege of 
serving as the Secretary of Health and Human Services, is to 
gather the best minds and the best talent that we have within 
the Department and without and determine what is the wisest 
policy for this Nation to have as it relates to, in this 
instance, infectious disease.
    Germs no know geographic boundaries. And we do incredible 
work, the work that the CDC does and the work that is done by 
others in our Nation, to try to work to prevent infectious 
disease, work to detect the spread of infectious disease. And 
then providing a logical and methodical and aggressive response 
to the outbreak of any infectious disease is absolutely vital 
to protect the American people, and we are committed to doing 
so.
    Senator Cardin. And I agree with that. I just hope that you 
will look at perhaps unintended consequences from these 
executive orders that could compromise our ability to be as 
effective as we need to, using all tools at our disposal.
    I want to get to tobacco regulation for one moment, an area 
that I think is now clear within the medical community, the 
impact that tobacco has, the fact that the Family Smoking 
Prevention and Tobacco Control Act of 2009 authorizes the HHS 
Secretary, through FDA, to regulate tobacco products, including 
restricting the sale of tobacco products to minors. It also has 
been expanded to include the selling of e-cigarettes, et 
cetera.
    I know initially you did not support that legislation. If 
confirmed, can you commit to us that you would rigorously 
enforce that act to make sure particularly our children are not 
subjected to the new forms of tobacco products?
    Dr. Price. If I am confirmed, the responsibility that we 
will have is to enforce the law of the land, and we will do so.
    Senator Cardin. It also requires keeping up with new 
technologies that are being used by the industry that may 
require modifications, as we see with e-cigarettes. Are you 
prepared to not only enforce the law, but to enforce our intent 
to make sure our children are protected?
    Dr. Price. Yes, I look forward to working with you, 
Senator, on just that.
    Senator Cardin. I was listening to some of the exchanges 
related to the Affordable Care Act, and we will continue to 
debate the merits of the Affordable Care Act. I am a strong 
supporter of it. I think millions of people have coverage who 
did not have it before, the quality of coverage that Americans 
now have did not exist before, and the rate of growth of our 
health-care premiums is far lower than it would have been but 
for the Act. We will debate that later.
    The question is, what is coming along? I mean, we have 
heard you say several times the principles that the President 
has articulated as to what would be in place of the Affordable 
Care Act.
    I would like just to drill down a little bit, if I could, 
on essential health benefits. We have talked about preventive 
care now being available. We know that we have now mental 
health and addiction services that are available. We also know 
we have oral health, pediatric dental, that is now available, 
which is particularly important in my State because of the 
tragic loss of Deamonte Driver in 2007.
    Can you assure us that, as you look at what will be the 
health-care system moving forward, you are prepared to make 
sure that Americans have quality insurance coverage to deal 
with issues such as preventive care, mental health services, 
addiction services, and pediatric dental?
    Dr. Price. What I can commit to you, Senator, is that we 
will do all that we can within the Department with the 
incredible knowledge and expertise that is there to define 
whether or not the program is actually working as intended or 
not, if coverage equals care. In many instances, I would 
suggest that many individuals right now have ``coverage.'' They 
have a card, but they do not have any care, because they cannot 
afford the deductible that allows them to get the care.
    So we are committed to making certain that the program 
works, not just for government, not just for the insurance 
companies, but for the patients.
    Senator Cardin. And as you know, we eliminated any copays 
on preventive care. But we can talk about the specifics going 
forward. I look forward to those discussions. Thank you, Mr. 
Chairman.
    Dr. Price. Thank you.
    The Chairman. Thank you, Senator.
    Senator Isakson?
    Senator Isakson. Thank you, Mr. Chairman.
    Tom, as Secretary-to-be, let me ask you a few ``yes'' or 
``no'' questions. You have been asked a lot of them with the 
intent of trying to get you to say ``yes'' that you are going 
to cut Medicare when you are not going to cut Medicare; you are 
going to try to improve it and reform it.
    But ``yes'' or ``no'' to these questions. Question number 
one: we have been hearing about the joint replacement program 
that Secretary Burwell launched in 2015. You and many others 
have raised concerns about this program saving money, that it 
could actually harm the quality of patient care. So in other 
words, was this an administrative action by HHS that actually 
cut a Medicare benefit?
    Dr. Price. Potentially, yes.
    Senator Isakson. Second: last year, HHS proposed a new way 
of paying for cancer drugs so as to reduce Medicare spending on 
these drugs. Many of us opposed this from our side of the aisle 
as well as the other. We were concerned it would cut cancer 
patients' benefits and, more often, it would be a cut to the 
Medicare benefit to seniors. Is that correct?
    Dr. Price. I believe that is correct. Yes.
    Senator Isakson. Last one: what about all the recent 
changes HHS has made to cut Medicare payments to Medicare 
Advantage? Nearly one-third of all Medicare beneficiaries are 
on Medicare Advantage. Would these cuts not also break the 
pledge of not cutting Medicare?
    Dr. Price. I believe so.
    Senator Isakson. My point being, any one of us can sit at 
this dais and say give me ``yes'' or ``no'' answers and 
demonstrate the point we want to make, but that all of us, 
Republican and Democrat alike, are interested in saving Social 
Security for our seniors, making Medicare work, and saving the 
taxpayers' money in the United States of America. Is that not 
true?
    Dr. Price. Absolutely.
    Senator Isakson. And one other point. Any one of us can 
take a financial disclosure, using something called disparate 
impact, where you take two facts, one over here and one over 
there, to make a wrong. Any one of us could do it to disrupt or 
misdirect people's thoughts on somebody. It has been happening 
to you a lot because people have taken things that you have 
disclosed and tried to extrapolate some evil that would keep 
you from being Secretary of HHS when, in fact, it should not be 
true.
    For example, if you go to Senator Wyden's annual report, he 
owns an interest in BlackRock Floating Rate Income Fund. The 
major holding of that fund is Valeant Pharmaceuticals. They are 
the people we jumped all over for 2,700-percent increases last 
year in pharmaceutical products. But we are not accusing the 
ranking member of being for raising pharmaceutical prices, but 
you could take that extrapolation out of that and then indict 
somebody and accuse them. Is that not true?
    Dr. Price. I think that is correct, yes, sir.
    Senator Isakson. So the point of that is, we ought to in 
the end be looking for the best person, man or woman, for the 
job and not trying to trick them into agreeing to something 
that is wrong, but in fact let them execute the programs that 
improve Medicare for the American people.
    Dr. Price. Yes, sir.
    Senator Isakson. I thank you for your time. And I reserve 
the rest of my time.
    Senator Wyden. A point of personal privilege, Mr. Chairman.
    The Chairman. Senator Wyden?
    Senator Wyden. I do not trade in health-care stocks.
    The Chairman. Okay. Did you care to----
    Senator Isakson. My only point to the Senator from Oregon 
is, you do have mutual funds like most of us have. The mutual 
funds have holdings in pharmaceuticals, many of them, one of 
them you own. But nobody should accuse somebody of holding 
pharmaceutical stocks if they have a mutual fund by pulling----
    Senator Wyden. Mr. Chairman, to continue on this point of 
personal privilege. Mutual funds in particular, by independent 
experts, ethics experts, are considered in a completely 
different category than personal trading in stocks. Even past 
Republican ethics experts make that same point, and they have 
never seen anything like what the Congressman has engaged in.
    Thank you, Mr. Chairman.
    The Chairman. Senator Brown?
    Senator Brown. Thank you, Mr. Chairman.
    And welcome, Congressman Price.
    Dr. Price. Thank you, Senator.
    Senator Brown. I was troubled by your response to Senator 
Wyden when he asked the question, if you repeal the Affordable 
Care Act, will you commit that no one will lose insurance? That 
is 22 million Americans, almost 1 million in my State.
    He asked, will you commit that no one will lose their 
insurance? And you ignored the question and responded that no 
one who lost their insurance under the Affordable Care Act--and 
to my knowledge that is 2 million to 4 million people, and 
almost all of them ended up getting reinsured--you said that no 
one who lost their insurance under the Affordable Care Act will 
basically lose it after they have been reinstated.
    So you pretty much ignored the 22 million, and that is the 
problem we all face. But I want to ask you about something 
else.
    If you are confirmed, obviously you will play a role in the 
repeal of the Affordable Care Act. I would like to ask you 
``yes'' or ``no'' questions, and they really are ``yes'' or 
``no'' questions; they are not meant as a trap.
    Marguerite is from Lyndhurst, OH. She suffers from a 
chronic condition. She was turned down by insurance companies 
for 25 years before the ACA. She will lose her insurance if the 
ban against discrimination based on existing conditions is 
weakened.
    My question is, if you are confirmed, will you maintain the 
current scope of the law and continue to vigorously enforce the 
law's ban against discriminating against individuals with 
preexisting conditions, ``yes'' or ``no''?
    Dr. Price. I commit to you that we will not abandon 
individuals with preexisting illness or disease.
    Senator Brown. Thank you. Victoria is from Buckeye Lake, 
OH. As a senior on Medicare, she relies on free preventive 
services provided by the ACA. Will you commit to ensuring 
seniors like Victoria, who rely on Medicare, continue to get 
their preventive care--no copays, no deductibles, no out-of-
pocket costs, ``yes'' or ``no''?
    Dr. Price. Preventive care and wellness care are absolutely 
vital for so many members of our population.
    Senator Brown. That is part of ACA. You will commit to 
that?
    Dr. Price. And I believe it is a part of health care and 
health coverage, and it ought to be a priority.
    Senator Brown. Yes, and we did that. Okay, I do not mean to 
be rude. We did that under the ACA.
    Grace is from Westlake, OH. She is 24. She was diagnosed 
with stage four metastatic melanoma in 2015. She is still on 
her parent's health insurance, which was purchased through the 
ACA marketplace, and she benefits from the ACA's ban on annual 
lifetime coverage maximums. Her first 3 months of treatment 
cost $800,000. As Secretary of HHS, if an insurer asks you for 
an exception to the current ban on out-of-pocket maximums as 
provided in Friday's executive order, will you commit to stand 
up for patients like Grace and refuse to grant any insurer this 
exception?
    Dr. Price. As I mentioned, I think patients ought to be at 
the center, and our goal is to make certain that every single 
patient has access to the highest-quality care.
    Senator Brown. I do not want it as your goal, I want you to 
commit that you will stand firm, as the ACA does, on this 
provision of canceling care, canceling insurance, because 
patients are too expensive.
    Dr. Price. As I said, nobody ought to lose their insurance 
because they get a bad diagnosis.
    Senator Brown. Okay. Alice is from Bethel, OH. Prior to the 
ACA, she could not afford her preferred method of birth 
control. Now thanks to the law, she benefits from covered 
contraceptive coverage. Are you able to set aside any personal 
political views and protect the doctor/patient relationship by 
committing to ensure every woman's right to access the form of 
contraception deemed best for her by her doctor at no cost, as 
currently provided in the ACA?
    Dr. Price. I think that contraception is absolutely 
imperative for many, many women. And the system that we ought 
to have in place is one that allows women to be able to 
purchase the kind of contraception that they desire, between 
their doctor and themselves.
    Senator Brown. As the law is now with the ACA. Thank you.
    President Trump said he is working with you on a 
replacement plan for the ACA, which is nearly finished and will 
be revealed after your confirmation. Is that true?
    Dr. Price. It is true that he said that, yes. [Laughter.]
    Senator Brown. So not that he has ever done this before, 
but did the President lie? Did the President lie about this, 
that he is working with you? He said he is working with you. I 
know we do not use the word ``lie'' here because we are polite 
when Presidents say statements that are not true. But did he 
lie to the public about working with you?
    Dr. Price. I have had conversations with the President 
about health care, yes.
    Senator Brown. Which is not quite an answer, so will you 
commit, with this President's plan, to maintaining the 
protections for those Ohioans you just committed to in the 
replacement plan?
    Dr. Price. Our commitment is to make certain that every 
single American has access to the highest-quality coverage and 
care possible.
    Senator Brown. I am still not sure if the President lied, 
not to you, but to us, the public, about whether he is actually 
working with you. It sounds like he did.
    Last series of questions briefly, Mr. Chairman.
    I want to find out about the Children's Health Insurance 
Program. You said last week to staff that it has been a 
remarkably successful program. You once earlier had said it 
sounds like socialized medicine to you. I do not quite know 
what that means.
    Ninety-five percent of children in America are currently 
insured. I know about the chairman's interest in CHIP, the 
Children's Health Insurance Program. Ninety-five percent of 
American children are insured now, partly because of Medicaid 
expansion, partly because of CHIP.
    You discussed the importance of using the right metrics, so 
my question is this. Funding for CHIP, I think you know, is set 
to expire in September. If confirmed, would you advise the 
President to support an extension of CHIP and the Pediatric 
Quality Measures Program beyond September of this year?
    Dr. Price. Absolutely, but I want to expand a little bit 
because, after last week's hearing in the HELP Committee, the 
same question was asked, quoting me as saying that CHIP was 
socialized medicine. And so I went back and looked at that 
article, and as so often happens, as you well know, though this 
may have never happened to you, it was a characterization in 
the article by the author of the article to push a political 
point of view.
    And I knew that was the case because I rarely, if ever, use 
that word. I talk about patients as being the focus. I do not 
talk about government being the focus.
    Senator Brown. Okay. I am sorry. That is fine. I want to 
ask you specifically on CHIP. Last week, MACPAC submitted a 
report to Congress advising we extend the current CHIP program 
and the Quality Measures Program for 5 more years. Do you agree 
with this?
    Dr. Price. I think the CHIP program, with policymakers, has 
to be looked at, and I believe it ought to be extended.
    Senator Brown. For 5 years?
    Dr. Price. Well, if we could extend it for 8, it would 
probably be better than 5.
    Senator Brown. Okay. Thank you, Mr. Chairman.
    The Chairman. Well, thank you, Senator.
    Let us go to Senator Portman.
    Senator Portman. Thank you, Mr. Chairman.
    I have a lot of questions, so I am glad you are letting 
people go a couple of minutes over, because I may need that 
time.
    Dr. Price. I am not. [Laughter.]
    The Chairman. We have been letting the other side go a 
couple of minutes over. We are not going to let our side go a 
couple of minutes over.
    Senator Portman. Okay, well I would like that time back. 
[Laughter.]
    First of all, Dr. Price, thank you very much for your 
willingness to serve. We need you.
    As you know, a couple of weeks ago Congress passed a budget 
resolution to set up a process that gives us the possibility of 
replacing the Affordable Care Act with policies that work 
better, particularly to reduce skyrocketing health-care costs 
that affect my constituents in Ohio. It is not just premiums. 
It is deductibles and copays, and also, people need more 
choices in health care.
    I did join with four of my colleagues, as you know--we 
talked about this--introducing an amendment that would have 
ensured we had enough time for the next step in the process. 
And I believe we got assurances for that to ensure that we have 
time to work with you, frankly. We need somebody at HHS in 
place who can work with us to be sure that the legislative and 
the administrative policies are working together and that this 
is done carefully.
    Prior to the Affordable Care Act, we had a very competitive 
insurance market in Ohio; now we do not. In fact, if you look 
at what has happened due to the increased regulations and 
mandates, we have a dramatically decreased competitive market. 
We went from having 17 insurers offering plans last year on the 
exchanges to 11 now. We have 20 counties now in Ohio, over one-
quarter of our counties, that only have one health-care 
insurance company offering plans. We used to have no counties 
in that situation.
    I know we are doing better than the rest of the country, 
actually, because about a third of the counties only have one 
insurer, and some of them have only one insurer in the entire 
State.
    Now that we have begun this process of replacement and the 
President has issued his executive order, what can we do, 
briefly? What actions can you take through your authority as 
Secretary to ensure that my constituents in Ohio have access to 
affordable health-care coverage with a healthy insurance 
market?
    Dr. Price. Well, what you laid out is the challenge that we 
have all across the Nation. And Ohio is doing better than other 
States, as you noted.
    But it is important to appreciate that things have gotten 
worse for the individual and small-group market, and we 
believe, I believe, that it is a direct result of policies that 
have come from Washington, DC, directly from the Affordable 
Care Act.
    So if we are honest with ourselves and honest with our 
constituents about trying to solve the challenges that they 
have to gain access to coverage that they want, then we ought 
to look at that and say, how do we fix that? And the way that 
you fix that is to make it so that individuals have the 
choices--one of the principles I mentioned--that we allow for 
pooling mechanisms that provide for individuals to have 
opportunities to recreate and reconstitute that individual and 
small-group market, which now does not exist.
    Senator Portman. And by the way, I appreciate your response 
to my colleague from Ohio about protecting people who have 
preexisting conditions. And one way you do that, obviously, is 
through those risk pools, and, again, many States had good risk 
pools that were working before the Affordable Care Act to help 
in that regard.
    As you know, Congress recently passed legislation authored 
with Senator Whitehouse called CARA, our Comprehensive 
Addiction and Recovery Act. And it is meant to address this 
opioid crisis we face--heroin, prescription drugs.
    We are now working to both fully fund--and the funding is 
there in place for this new program--and now to implement it. 
And a lot of the implementation goes through SAMHSA; almost 
half of the funding under new grant programs goes through HHS 
and SAMHSA.
    What should be done to ensure access to addiction treatment 
for those individuals currently getting insurance coverage 
through the exchanges or Medicaid expansion? And do you commit 
to us today to fully implement and implement promptly the new 
legislation?
    Dr. Price. Without a doubt. As you know, Senator, this is a 
scourge that has gone all across the country, and it is in 
communities large and small, destroying lives, destroying 
families, harming communities. And it is growing.
    And so what we must do is absolutely commit to carrying out 
the law as it was passed, but also--as I have talked about with 
some other challenges--make certain that we have the right 
metrics in place. Are we actually helping with what we are 
doing?
    There may be better things to do there, maybe things that 
we think we ought to do that in fact do not help, and we ought 
to be identifying those as much in real time as possible so 
that we can bring about a program that is actually making it 
work for the patients, for the individuals who are actually 
being harmed.
    Senator Portman. One example of that, quickly. You are 
aware, I think, of the Institution for Mental Disease rule that 
says if you have an inpatient treatment center, it has to be 
limited to 16 beds. Would you be willing to look at that rule 
to see if we can get that number up to be able to provide more 
of this treatment?
    Dr. Price. I think that is one of the rules that has to be 
looked at. I think the 3-day stay rule in facilities is 
another, where oftentimes many of these individuals have some 
mental illness as well, and the limitation on being able to 
keep folks on an inpatient basis when all of the health-care 
professionals involved in their care say they ought to, but in 
fact that is not what is covered, makes no sense. And 
therefore, they are put back out on the street, and the 
challenge is, we just get in this revolving door.
    Senator Portman. A final question, and maybe you could 
respond to this in writing, because my time is expiring based 
on the allocation here.
    With regard to the waivers, you know, Ohio applied for a 
waiver, and this was an 1115 waiver for Medicaid, to be able to 
better cover people under Medicaid. We were rejected by CMS. I 
know you have Seema Verma coming in who has worked on these 
over time.
    Do you believe that during this replacement time we should 
cover people under Medicaid expansion but then move to a 
program that is more flexible to provide better care under 
Medicaid?
    Dr. Price. I think there have to be better ways to provide 
care to the Medicaid population, because there are huge 
challenges right now, as I mentioned before. And the people 
whom we need to be listening to are the Governors and the State 
insurance commissioners and the folks on the ground actually 
providing the care. And if we listen to them, I think they will 
guide us in the right direction in terms of policy.
    The Chairman. Senator, your time is up.
    Senator Portman. Thank you, Mr. Chairman.
    The Chairman. Senator Bennet?
    Senator Bennet. Thank you, Mr. Chairman.
    I want to thank my colleague from Ohio for his graciousness 
in not going too over.
    Congressman Price, you have said a couple of times--I may 
misquote you a little, I hope not--that the goal here is access 
to the highest-quality coverage and the highest-quality health 
care for all Americans. Is that roughly where you would like to 
head? And I think that is a worthy goal.
    Dr. Price. Yes.
    Senator Bennet. And just piggybacking on what Senator 
Portman was asking you about, I am worried today--whether it is 
the Affordable Care Act or not the Affordable Care Act, whether 
it is the insurance market--that people, especially in rural 
parts of this country, in rural parts of my State, are not 
getting the access they need to high-quality health care, are 
not getting the access they need to high-quality choices in 
terms of insurance.
    I worry a little bit, and whether we are trying to repeal 
the Affordable Care Act or we are trying to fix the Affordable 
Care Act, I think it is incumbent on all of us not to make 
matters worse for rural America in doing what we are doing. And 
I know you share that goal.
    Dr. Price. Absolutely.
    Senator Bennet. And you talked about pooling as one 
solution. I wanted to talk a little bit or ask you a little bit 
about your projected quality of insurance in these markets, 
because one answer that I have heard from folks, including 
yourself, over the weeks has been making sure that people have 
the opportunity to buy coverage for catastrophic care.
    I wonder whether you also believe that it is essential that 
there be a floor for insurance providers. You know, some of the 
things that the Affordable Care Act requires for coverage 
include outpatient care, emergency services, hospitalization, 
maternity and newborn care, prescription drugs, rehab services, 
lab services, preventative care such as birth control and 
mammograms, pediatric services like vaccines, and routine 
dental exams for children younger than 19.
    I am not going to ask you to go through each one of those. 
But directionally, are we headed to a world where people in 
rural America have to settle for coverage for catastrophic 
care? Are we headed to a place where there is regulation of 
insurance providers that says if you are going to be in the 
insurance market, particularly if we are in a world where you 
are selling across State lines, there has to be a floor on the 
services you are willing to pay for?
    Dr. Price. I think there has to be absolutely credible 
coverage. And I think that it is important that individuals 
ought to be able to purchase the coverage that they want.
    Senator Bennet. I just do not want us to get to a place 
where people in America have to settle for something that no 
one else in the industrialized world has to settle for. Why 
should they have to pay out of pocket month after month after 
month for something that is not going to cover something as 
basic as a hospitalization or maternity services or, you know, 
the rest of this list? There may be certain things on the list 
we disagree with.
    But I am worried that we are heading toward a place where 
somehow that choice is accepting a world that no one else in 
the industrialized world has to accept. And I applaud your 
goal, and I hope we can work together to make it so.
    Dr. Price. As do I.
    Senator Bennet. You mentioned that we should listen to the 
Governors, which brings me to my second question and your 
answer to Senator Portman.
    In Colorado--you may have heard of this--we have something 
called the Accountable Care Collaborative that is a unique 
approach to Medicaid. It connects members with coordinated 
primary care providers while reducing barriers to access. It 
also provides coordinated care for those with dual eligibility 
for Medicare and Medicaid. I do not have it today, but I could 
show you that the cost curve there is really starting to turn 
around because of the coordinated care that is happening out 
there.
    When asked about the need for more State flexibility, which 
is an argument that is made to carry out innovative programs 
like the one in Colorado, our Governor said that, quote, 
``Greater flexibility cannot make up for the lack of funding. 
Should the Federal Government pull back its financial 
commitments, we simply cannot afford to make up the 
difference.''
    So I would ask you whether you agree with our Governor's 
assessment that while flexibility is helpful, it is not a 
replacement for critical funding needs.
    Dr. Price. I think so. And the decision for funding 
obviously is a legislative decision.
    Senator Bennet. But that is a very fundamental component of 
the Affordable Care Act, the expansion of Medicaid, would you 
not agree?
    Dr. Price. And that decision whether or not to change that 
is a decision that you and every member of the committee and 
Congress will be involved in. And if I am fortunate enough to 
serve as the Secretary of Health and Human Services, we will 
carry out the law that you pass.
    Senator Bennet. I appreciate that. In your mind, though, 
does the repeal of the Affordable Care Act include a repeal of 
the expansion of Medicaid that was part of the passage of the 
Affordable Care Act?
    Dr. Price. Any reform or improvement that I would envision 
for any portion of the Affordable Care Act would be one that 
would include an opportunity for individuals to gain coverage, 
the kind of coverage, again, that they want, the highest-
quality health care.
    Senator Bennet. But that is not the question I asked.
    And I am sorry, Mr. Chairman; I realize I am at the end of 
my time.
    Do you believe that a repeal--I mean, this is what the 
President ran on--of the Affordable Care Act includes the 
repeal of the expansion of Medicaid that was a fundamental part 
of the Affordable Care Act?
    Dr. Price. Again, that is a decision that you all would 
make.
    Senator Bennet. That is true.
    Dr. Price. What I believe is that any reform or improvement 
must include a coverage option and opportunity for every single 
American, including those who are either currently in or close 
to joining the Medicaid population in a given State, which 
changes depending on the State.
    Senator Bennet. Okay.
    Thank you, Mr. Chairman.
    The Chairman. Well, thank you, Senator Bennet.
    Let us go to Senator Toomey.
    Senator Toomey. Thank you, Mr. Chairman.
    Congressman Price, thank you for joining us.
    Dr. Price. Thank you.
    Senator Toomey. Thanks for the great work you have done in 
the House and your willingness to serve in this extremely 
important post. I appreciate it, and I enjoyed the conversation 
that we had a little while back.
    I do think it bears reminding everyone as we talk about 
Obamacare that certainly the individual market is in a classic 
death spiral. The adverse selection is destroying that market. 
It is in a freefall. In Pennsylvania, 40 percent of all 
Pennsylvanians in the Obamacare exchanges have a grand total of 
one choice, and that very typically does not include whatever 
they had before and were promised they could keep, which, of 
course, was never true.
    So we have a system that is in collapse. And what we are 
trying to do is figure out what is a better way to go forward. 
Now, when we talk about repeal, sometimes I hear people say, 
well, but we have to keep coverage of preexisting conditions 
because, you know, we have to keep that. And when I hear that, 
I think that we are missing something here.
    And here is what I am getting at. There are obviously a 
number of Americans who suffer from chronic, expensive health-
care needs. They have had these conditions sometimes all their 
lives, sometimes for some other period of time. And for many of 
them, the proper care for those conditions is unaffordable.
    I think we agree that we want to make sure those people get 
the health care they need. Now, one way to force it is to force 
insurance companies to provide health insurance coverage for 
someone as soon as they show up, regardless of what condition 
they have, which is kind of like asking the property casualty 
company to rebuild the house after it has burned down. But that 
is only one way to deal with this.
    And so am I correct, is it your view that there are other, 
perhaps more effective ways, since, after all, Obamacare is in 
a collapse, to make sure that people with these preexisting, 
chronic conditions get the health care that they need at an 
affordable price without necessarily having the guaranteed 
issue mandate in the general population?
    Dr. Price. I think there are other options. And I think it 
is important, again, to appreciate that the position that we 
currently find ourselves in with policy in this Nation is that 
those folks, in a very short period of time, are going to have 
nothing because of the collapse of the market.
    Senator Toomey. Right. The second topic is, I think you and 
I share a goal of having health care that is much, much more 
driven by individuals, families, patients, consumers--consumer-
centric rather than bureaucrat-centric, which is what Obamacare 
is.
    Do you agree with me that to get there we need to do more 
about the transparency of health-care outcomes so that informed 
consumers can evaluate among different physicians, different 
hospitals that really get the best outcomes? Do we need to do 
more there?
    Dr. Price. Absolutely. And this is an important point. And 
it is not just in outcomes. Outcomes are important, and we need 
to be measuring what actually makes sense from a quality 
standpoint and allow patients and others to see what those 
outcomes are.
    But it is transparency in pricing as well, and right now we 
do not have that. So if you are individual out there and you, 
in fact, want to know what something costs, it is virtually 
impossible to find out what that is. There are all sorts of 
reasons for that.
    But if we are honest with ourselves as policymakers and we 
want to make the system patient-friendly, not insurance-
friendly or 
government-friendly, but patient-friendly, then we would make 
that a priority. And if I am confirmed, I hope to do so.
    Senator Toomey. I think Medicare and Medicaid, CMS, can 
play a big role in advancing that. Ultimately, I think the more 
we diminish dependence on third-party payers and allow the 
evolution of a market that responds to individuals, individuals 
will demand that information the way they do in every other 
market.
    Dr. Price. Right.
    Senator Toomey. The last point I want to touch on, if I 
could, has to do with NIH research and specifically Alzheimers. 
It is my view that we ought to think of Alzheimers as a disease 
in a category of its own. And I say that because there is no 
disease like it that we know of that afflicts Americans today. 
There are 5.2 million Americans with the disease right now. It 
is 100-percent fatal. It is the sixth-leading cause of death. 
There is no cure, there is no treatment; there is nothing.
    And yet, for fiscal year 2016, NIH spending is a grand 
total of $168 per diagnosed patient. It seems to me that the 
expenditures are wildly out of line with the severity and the 
breadth and the scope of this disease. And I wonder if you 
would commit to working with me and others who share this view 
to ensure that we have a better proportionality in terms of the 
allocation of resources in the breadth and severity of 
illnesses.
    Dr. Price. I think it is absolutely imperative, Senator, 
and I look forward to working with you.
    Senator Toomey. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Senator Thune?
    Senator Thune. Thank you, Mr. Chairman.
    Dr. Price, welcome, and thank you for your willingness to 
serve in this very important capacity. We have a lot of 
challenges ahead that we need to take on.
    As I met with you a couple of weeks ago, one of the issues 
that is of particular interest to me, which I conveyed to you, 
is this issue of Indian Health Service. In 2010, there were 
some systemic problems that were uncovered in South Dakota. And 
an administrative action plan was set in motion to help remedy 
many of these findings. Similar issues popped up again 
throughout South Dakota in 2015, and they continue to this day. 
And after oversight hearings, it became abundantly clear that, 
time and again, there was a lack of follow-through by the 
agency.
    And my question is, will you commit to follow up with me in 
writing that you will designate someone at HHS to be the point 
person that my staff and I can contact to ensure, one, that 
reforms are being implemented, and two, that we continue to 
collaborate on reform in the IHS?
    Dr. Price. Absolutely, Senator. This is an area that is of 
significant concern, because it appears to me, as I know you 
shared with me, that in the Indian Health Service there are so 
many areas where we are not meeting the goal of the highest-
quality care being provided to individuals accessing that 
system.
    And so we are not doing what we ought to do in that system. 
And I am committed to making certain, should I be confirmed, to 
turn that system around.
    Senator Thune. And as I shared with you, Senator Barrasso 
and I introduced a bill last year called the IHS Accountability 
Act which we believe will bring about a lot of structural 
changes within the IHS. And as I have said many times, that 
act, although we think it addresses a lot of the problems that 
have cropped up--and it was based upon consultation that we 
received from the tribes--really is merely a first step in the 
process that is necessary to improve that agency.
    If confirmed, what types of reforms could you see yourself 
supporting when it comes to the IHS and, obviously, starting 
perhaps with our legislation? I do not know, you probably have 
not had a chance to look carefully at that yet, so I will not 
ask you to comment specifically on it. But are there thoughts 
that you have with respect to the IHS when it comes to reforms 
that you could work with us on?
    Dr. Price. Yes, I appreciate that. I have had the privilege 
of visiting some IHS facilities in the State of Wisconsin and a 
couple of facilities that were doing remarkable work. And it 
appears to me that what we have not done--and if I am 
confirmed, I look forward to getting into this area within the 
Department itself--is identified best practices within the IHS 
system itself and shared those and incentivized the ability to 
move that kind of activity that is providing high-quality care 
for individuals in that system in certain areas to make certain 
that we are able to extend that across the country in the IHS.
    Senator Thune. Okay. Well, we look forward to working with 
you on that. I think best practices is a good place to start. 
And obviously, those have not been employed in a lot of 
facilities in our State.
    In 2009, CMS issued a final rule that required all 
outpatient therapeutic services to be provided under direct 
supervision. Every year since then, the rule has been delayed, 
either administratively or legislatively, for critical access 
and small and rural hospitals.
    And I shared this with you as well. In my State, obviously, 
we have a lot of critical access hospitals, a lot of very rural 
areas, big geography to cover, and it is sometimes difficult to 
get providers out to these areas. So the question is, if 
confirmed, will you work to permanently extend the 
nonenforcement of this regulation of these hospitals in order 
to remove this regulatory burden?
    Dr. Price. Yes, I look forward to working with you on it, 
Senator. I think there are areas, from a technological 
standpoint, where we are missing the boat, especially in our 
rural areas and the critical access hospitals. In every other 
industry out there, the information technology age has arrived 
and is moving across the land with rapid speed and has done so.
    However, it seems that in health care we have put 
roadblocks up to the expansion of technology, especially into 
the rural areas. And we ought to be incentivizing that so that, 
again, the patients are able to receive the highest-quality 
care.
    It is possible now, for example, in our State, if you are 
an individual who is suspected of having a stroke, you go to a 
critical access hospital in a rural area, it is possible by 
telemedicine to be able to access one of the world's foremost 
specialists in stroke treatment by telemedicine at the 
university health center. So that is improving the lives and 
care of patients across our State.
    And I think there are so many things that we could do that 
would mirror that kind of technological expansion.
    Senator Thune. Thank you. There is one final point I will 
make, because my time is expiring. But I know you have probably 
been questioned already a good amount about what happens next 
with respect to replacing Obamacare. I would simply say that I 
hope we can work with you in beginning to shift a lot of the--
giving the States, I guess I would say, more flexibility when 
it comes to designing plans that work in our States.
    I think one of the problems that we have had with this is 
there is just too much dictation from Washington, DC and too 
much one-size-fits-all. And that is something I think that most 
States would probably agree with, and certainly, I think, most 
providers would agree with as well.
    So we look forward to working with you and designing 
programs that get that flexibility to our States and put them 
more in charge of some of these issues in a way that removes 
that power from Washington, DC, where I think too many of the 
problems have been happening.
    Thank you, Mr. Chairman.
    Dr. Price. Yes, sir. I look forward to it.
    The Chairman. Senator Casey?
    Senator Casey. Thank you, Mr. Chairman.
    Dr. Price, good to be with you again.
    Dr. Price. Thank you.
    Senator Casey. I want to ask you a couple of questions that 
center principally on children and individuals with 
disabilities.
    First, with regard to children, I think if we are doing the 
right thing, not only as a government, but as a society, if we 
are really about the business of justice and if we are really 
about the business of growing the economy, we should invest a 
lot and spend a lot of time making sure that every child has 
health care. The good news is, despite a lot of years of not 
getting to that point, not moving in the right direction, we 
have made a lot of progress.
    The Urban Institute in an April 2016 report--I will not ask 
the report to be made part of the record, but I will read a 
line from this Urban Institute report ``Uninsurance Among 
Children, 1997 to 2015,'' dated April 2016. It said as follows 
on page 3: the ``decline in children's uninsurance rate 
occurred at a relatively steady pace and includes a significant 
drop following implementation of the Affordable Care Act's key 
coverage provisions from 7.1 percent in 2013 to 4.8 percent in 
2015.''
    So that is a significant drop, 7.1 percent to 4.8. Millions 
of kids have health insurance today who would not have it 
absent the Affordable Care Act and including the Medicaid 
provisions as well. That 4.8-percent uninsured rate for kids is 
an all-time low. That means we are at a 95-percent insured rate 
across the country for children.
    Kaiser Foundation, a separate authority, tells us that even 
with that, even with all that progress made in the last couple 
of years and even some progress before that, we still have more 
than 4.1 million children uninsured.
    Would you agree with me, first of all, that we should get 
that number down, the number of uninsured children?
    Dr. Price. I think that throughout our population we ought 
to identify individuals who are uninsured and strive to make 
certain that they gain coverage.
    Senator Casey. Right. And you would agree with me with 
regard to children especially?
    Dr. Price. Everybody in the population. Children are 
precious and are our future.
    Senator Casey. Great. And just with regard to children, now 
that we have that number, we know the number that we have 
arrived at, we know the percentage, will you commit, if you are 
successful in your confirmation, to maintain or to even reduce 
that uninsured number even further--in other words, that you 
will be able to commit to us today that the number of uninsured 
children will not increase during your time as Secretary, were 
you to be confirmed, and the percentage of uninsured would not 
increase while you are Secretary?
    Dr. Price. Our goal is to decrease the number of uninsured 
individuals in the population under age 18 and over 18.
    Senator Casey. Well, I hope you maintain that, because I 
think that is going to be critically important.
    The reason I ask that question is not just to validate that 
as a critically important goal for the Nation, but your answer 
seems to be contrary or in conflict with what you have 
advocated for as a member of the House of Representatives, not 
only in your individual capacity, but as chairman of the Budget 
Committee.
    Looking at now for reference an op-ed by Gene Sperling--you 
know who Gene Sperling is. He was head of the Council of 
Economic Advisers to two Presidents, both President Clinton and 
President Obama--Chair of that National Economic Council, I 
should say, is the proper title.
    In an op-ed on Christmas Day, the fifth paragraph, here is 
what he said in a pertinent part referencing you and your 
budget proposals. He said, quote, ``Together,'' meaning the two 
areas of policy that you have a long record on, full repeal of 
ACA and block-granting of Medicaid, which we now know is Trump 
administration policy, ``they would cut Medicaid and the 
Children's Health Insurance Program funding by about $2.1 
trillion over the next 10 years, a 40-percent cut.''
    How can you answer the questions that I just asked you 
about making sure that that number of uninsured children does 
not get worse under your tenure if that is the case with regard 
to your policies, the effect of what your policies would be--
and now apparently, contrary to what was said during the 
campaign, it is now the policy of the Trump administration to 
block-grant Medicaid?
    Dr. Price. Yes. With respect to both you and to Mr. 
Sperling, it is because you all are looking at this in a silo. 
We do not look at it in a silo. We believe that it is possible 
to imagine, in fact put in place, a system that allows for 
greater coverage for individuals, in fact coverage that 
actually equals care.
    Right now, many of those individuals--the ACA actually 
increased coverage in this country. It is one of the things 
that it actually did. The problem is that a lot of folks have 
coverage, but they do not have care. So they have the insurance 
card, they go to the doctor, the doctor says, ``This is what we 
believe you need,'' and they say, ``I am sorry, I cannot afford 
that.''
    Senator Casey. A cut of a trillion dollars, a combined cut 
of a trillion dollars that would adversely impact the 
Children's Health Insurance Program and the Medicaid program, 
is totally unacceptable, I think, to most Americans, Democrat, 
Republican, or otherwise.
    Dr. Price. And you are looking at that in a silo. You are 
not looking at what the reform and improvement would be.
    Senator Casey. We will see the rebuttal to what not only 
Gene Sperling has said, but a whole long line of public policy 
advocates and experts. And I think the burden for you, sir, is 
to make sure that you fulfill your commitment to make sure that 
no children will lose health insurance coverage while you are 
Secretary.
    Dr. Price. I look forward to working with you.
    The Chairman. Okay. Senator Heller?
    Senator Heller. Thank you, Mr. Chairman.
    And, Dr. Price, thank you for being here today. And thanks 
for your patience in working with us throughout this 
confirmation process.
    Mr. Chairman, as you can imagine, I am committed to 
ensuring that all Nevadans have access to high-quality and 
affordable health insurance.
    I have a letter here that came to my attention January 10th 
from the Nevada legislature. The letter comes directly from our 
majority leader of the State Senate and our Speaker of the 
Assembly. And they are good questions, five questions. 
Obviously, they want to get the same answers that all of us 
want here.
    We have about 88,000 Nevadans who have health insurance 
through the health exchange, 77,000 Nevadans who are eligible 
for Federal tax credits, 217,000 Nevadans who receive health-
care coverage under Medicaid expansion. Basic questions.
    Mr. Chairman, if I may, can I submit this letter for the 
record, and also, if I may, ask Dr. Price if he would respond 
to this particular letter, to these legislators? Again, I think 
they are very good questions.
    The Chairman. Without objection.
    [The letter appears in the appendix on p. 89.]
    Senator Heller. Also, if I may add, if you could CC the 
Governor also. I think the Governor also would like answers to 
these questions. And I think you are in a great position to 
answer these particular questions.
    Dr. Price. Thank you, sir.
    Senator Heller. Thank you.
    If I may, can I get your opinion on the Cadillac tax?
    Dr. Price. I think the Cadillac tax is one that has made it 
such that individuals who are gaining their coverage through 
their employer--there may be a better way to make it so that 
individuals gaining their coverage through their employer are 
able to gain access to the kind of coverage that they desire.
    Senator Heller. The Cadillac tax would affect about 1.3 
million Nevadans: school teachers, union members, senior 
citizens. And there is some disagreement as to whether or not 
these individuals are wealthy or not. There are some on this 
committee who believe that the $1.1-trillion tax increase in 
Obamacare does not affect the middle class. Do you agree with 
that?
    Dr. Price. I think it does affect the middle class.
    Senator Heller. I do too. Do you believe that school 
teachers are wealthy?
    Dr. Price. Everybody has their own metric of what wealthy 
is, and some people use things to determine wealth that are not 
the greenbacks in----
    Senator Heller. I would argue that most school teachers do 
not think they are wealthy.
    Do you think most union members are wealthy?
    Dr. Price. I doubt that they think they are wealthy.
    Senator Heller. Yes, I would agree with that.
    Do you think most senior citizens are wealthy?
    Dr. Price. Most senior citizens are on a fixed income.
    Senator Heller. They would argue that they are not wealthy. 
And that is my argument on this particular tax. In fact, 
Obamacare as a whole is just another middle-class tax increase 
of $1.1 trillion.
    I guess my request and question for you is if I can get 
your commitment to work with this committee and work with 
myself and the Treasury Secretary to repeal the Cadillac tax.
    Dr. Price. Well, we will certainly work to make certain 
that those who gain their coverage through their employer have 
the access to the highest-quality care and coverage possible in 
a way that makes the most sense for individuals from a 
financial standpoint as well.
    Senator Heller. Does the Cadillac tax make the most sense?
    Dr. Price. As I mentioned, I think there are other options 
that may work better.
    Senator Heller. And do you believe it is an increase, a 
health insurance increase, to middle-class America?
    Dr. Price. I do.
    Senator Heller. Okay. I want to go to Medicaid expansion 
for just a minute. Nevada was one of 36 States that chose to 
expand eligibility for Medicaid. We went from--I think the 
enrollment went from 350,000 to over 600,000.
    And I guess the concern, and I think it is part of the 
letter that I gave to the chairman, is whether or not that will 
have an impact and what we are going to do to see that those 
individuals are not impacted. Probably the biggest question 
that we have here for you today is, what are we going to do 
about those who are part of the Medicaid expansion and how that 
is going to impact them?
    Dr. Price. Yes. Again, as I mentioned to a question on the 
other side, I believe this is a policy question that needs to 
be worked out through both the House and the Senate. We look 
forward to working with you and others, if I am able to be 
confirmed, on making certain that individuals who are currently 
covered through Medicaid expansion either retain that coverage 
or in some way have coverage through a different vehicle. But 
every single individual ought to be able to have access to 
coverage.
    Senator Heller. Dr. Price, thank you. Thank you for being 
here.
    Mr. Chairman, thank you.
    Dr. Price. Thanks, Senator.
    The Chairman. Thank you.
    Senator Warner?
    Senator Warner. Thank you, Mr. Chairman.
    Good to see you again, Dr. Price.
    Dr. Price. Thank you.
    Senator Warner. Let me start on something we discussed in 
my office. One of the issues I have been working on since I 
have been Governor, that I have been working on very closely 
with your friend, Senator Isakson, is the issue of how we as 
Americans address the end of life and sort through those 
issues. I think we both shared personal stories on that 
subject.
    Senator Isakson and I have legislation that we call the 
Care Planning Act that does not remove anyone's choices, it 
simply allows families to have those discussions with their 
health-care provider and religious faith leader if needed or 
desired in a way to prepare for that stage of life.
    This year, CMS took a step by introducing a payment code 
into the fee schedule to provide initial reimbursement for 
providers to have these conversations with, as mentioned, a 
multidisciplinary case team. It also ran a pilot program that 
allowed hospice-type benefits to be given to individuals who 
were still receiving some level of curative services, called 
the Medicare Care Choices.
    I believe it is very important that we do not go backwards 
on these issues. And as I think we talked about, we are maybe 
the only industrial nation in the world that has not had this 
kind of adult conversation about this part of life. Again, it 
is not about limiting anyone's choices.
    But would you, if you are confirmed, continue to work with 
Senator Isakson and me and others on this very important issue?
    Dr. Price. I look forward to doing so----
    Senator Warner [continuing]. And not be part of any effort 
to kind of roll back those efforts that CMS has already taken?
    Dr. Price. I think it is important to look at the broad 
array of issues here. And one of the issues is liability. And I 
cannot remember whether we discussed that in your office. But 
the whole issue of liability surrounding these conversations is 
real. We need to be talking about it openly and honestly and 
working together to try to find a solution to just that.
    Senator Warner. I would concur with that, but I also think 
this is something that more families need to take advantage of.
    On Friday, January 20th, President Trump issued an 
executive order that says Federal agencies, especially HHS, 
should do everything they can to, quote, ``eliminate any fiscal 
burden on any State or any cost, fee, tax penalty, or 
regulatory burden on individuals and providers.''
    Dr. Price, if you are confirmed in this position, will you 
use this executive order in any way to try to cut back on 
implementation or follow the individual mandate before there is 
a replacement plan in place?
    Dr. Price. Well, I think that, if I am confirmed, then I am 
humble enough to appreciate and understand that I do not have 
all the answers and that the people at the Department have 
incredible knowledge and expertise, and that my first action 
within the Department itself as it relates to this is to gain 
that insight, gain that information, so that whatever decisions 
we can make with you and with Governors and others can be the 
most informed and intelligence decisions possible.
    Senator Warner. I am not sure you answered my question. 
What I would not want to see happen as we take--I understand 
your concerns with the Cadillac tax. I know there are concerns 
you and others have raised about the individual mandate. There 
are some who are concerned about the income tax surcharges.
    It is just remarkable to me--and this is one of the reasons 
why I think so many of us are anxious to see your replacement 
plan--that the President has said he wants insurance for 
everybody, he wants to keep the prohibitions on preexisting 
conditions, he wants to keep young people on their parents' 
policies until 26, and it seems like there is at the same time 
a rush to eliminate all of the things that pay for the ability 
of Americans to have those kind of services.
    And I would just want your assurance that you would not use 
this executive order prior to a legal replacement to eliminate 
the individual mandate, which I believe helps actually shore up 
the cost coverage and the shifting of costs that are required 
in an insurance system.
    Dr. Price. Yes. No, a replacement, a reform, an improvement 
of the program, I believe is imperative to be instituted 
simultaneously or at a time----
    Senator Warner. But you will not use this executive order 
as a reason to kind of, in effect, bypass the law prior to a 
replacement being in place?
    Dr. Price. Our commitment is to carry out the law of the 
land.
    Senator Warner. I want to, in these last couple of minutes, 
go on. I know you have been in the past a strong critic of the 
Center for Medicare and Medicaid Innovation, CMMI. I believe in 
your testimony last week you saw great promise in it.
    To me, if we are going to move towards a system that 
emphasizes quality of care rather than simply quantity of care, 
we have to have this kind of experimentation. There is one such 
program, the Diabetes Prevention Program, that last year CMS 
certified saved money on a per-beneficiary basis.
    And I know my time is running out, so let me just ask these 
questions. I think they can probably be answered ``yes'' or 
``no.''
    Do you support CMMI delivery system reform demonstrations 
that have the potential to reduce spending without harming the 
quality of care?
    Dr. Price. The second clause is the most important one. I 
support making certain that we deliver care in a cost-effective 
manner. But we absolutely must not do things that harm the 
quality of care being provided to patients.
    Senator Warner. But if part of that quality of care--and I 
would agree with you--would mean bundled and episodic payment 
models that actually move us towards quality over volume, would 
you support those efforts?
    Dr. Price. For certain patient populations, bundled 
payments make a lot of sense.
    Senator Warner. And if these experiments are successful, 
would you allow the expansion of these across the whole system?
    Dr. Price. I think that what we ought to do is allow for 
all sorts of innovation, not just in this area. There are 
things I am certain that have not been thought up yet, that 
would actually improve quality and delivery of health care in 
our country, and we ought to be incentivizing that kind of 
innovation.
    Senator Warner. Well, I would simply say, Mr. Chairman, 
that CMMI seems to be one of the areas where I would like to 
have seen more, but I think it is a model and a tool we ought 
not to discard. Thank you.
    The Chairman. Well, thank you, Senator.
    Senator Scott?
    Senator Scott. Thank you, Mr. Chairman.
    Dr. Price, good to see you again.
    Dr. Price. Tim.
    Senator Scott. South Carolina launched the Nation's first 
statewide pay-for-success project with Nurse Family Partnership 
with the use of Medicaid funds. Twenty percent of the babies 
born in South Carolina are born to first-time, low-income 
mothers. We also have a much higher than average infant 
mortality rate.
    Nurse Family Partnership is evidence-based and has already 
shown real results, both in the health of the mother and the 
babies, but also in other aspects of the mother's life, such as 
high school graduation rates for teen moms and unemployment 
rates.
    What are your thoughts on incorporating a pay-for-success 
model to achieve success metrics?
    Dr. Price. Well, it sounds like a great program that 
actually has the right metric, and that is the quality of care 
and the improvement of lives. And as you state, if it is having 
that kind of success, it probably ought to be put out there 
again as a best practice for other States to look at and try to 
model.
    Senator Scott. Yes, sir. Thank you.
    I believe you were the director of the orthopaedic clinic 
at Grady Memorial Hospital in Atlanta.
    Dr. Price. I was.
    Senator Scott. You just mentioned something that I think is 
very important. I believe Grady Hospital had the highest level 
of uninsured Georgians. You talked about having coverage, but 
really not access. Can you elaborate on how your experience at 
Grady may help inform you and direct you as it relates to the 
uninsured population?
    Dr. Price. Well, it was an incredible privilege to work at 
Grady for the number of years that I did. And we saw patients 
from all walks of life and many, many uninsured individuals. 
And they come with the same kinds of concerns, the same kinds 
of challenges that every other individual has. And they have an 
additional concern, and that is, is somebody going to be caring 
for me? Is somebody going to be able to help me?
    And that is why it was so incredibly fulfilling to be able 
to have the privilege of working at Grady and assisting people 
at a time when they were not only challenged from a health-care 
standpoint, but challenged from a concern about whether or not 
people were going to be there to help them.
    Senator Scott. Yes, sir. I know that you are aware of title 
I of the Every Student Succeeds Act. It allows for the 
population of Head Start to have access to resources. It seems 
to me that it would be imperative for the Secretary of HHS and 
the Secretary of Education to look at ways to synergize your 
efforts to help the underprivileged student, the 
underprivileged child.
    Can I get your commitment that you will look for ways to 
work with the Secretary of Education where it makes sense to 
help those students? You know, we have Head Start under you and 
other programs under ESSA. It would be wonderful for us to take 
the taxpayer in one hand, the child in the other hand, and look 
for ways to make sure that they both win.
    Dr. Price. Yes, you have identified an area that is a pet 
peeve of many of us, and that is that we do not seem to 
collaborate across jurisdictional lines, not just in Congress, 
but certainly on the administrative side. And so I look forward 
to doing just that and having as a metric how the kids are 
doing.
    Senator Scott. Yes.
    Dr. Price. Are they actually getting the kind of service 
and education that they need? Are they improving? Are we just 
being custodians? Are we just parking kids in a spot, or are we 
actually assisting and improving their lives? And are we able 
to demonstrate that?
    And if we are not asking the right questions, if we are not 
looking at the right metrics, then we will not get the right 
answer that allows us to either expand what is actually working 
or to modify it and move it in a better direction.
    Senator Scott. Thank you. I think that is one of the more 
important parts of your opportunity in this position: looking 
at those kids. I know that you know as well as anyone who is a 
doctor that those ages, before you ever get into pre-K or 
Kindergarten, the development of the child between those first 
3 or 4 years is a powerful opportunity for us to direct a 
child's potential so that they maximize it.
    And sometimes we are missing those opportunities. We think 
that somehow the education system will help that child catch 
up. But there are things that have to happen before they ever 
get in the education system. So I thank you for your 
willingness to work in that direction.
    And my last question has to do with the employer-sponsored 
health-care system that we are so accustomed to in this country 
that provides about 175 million Americans with their insurance. 
In my home State of South Carolina, of course, we have about 
2.5 million people covered by their employer coverage.
    If confirmed as HHS Secretary, how would you support 
American employers in their effort to provide effective family 
health coverage in a consistent and affordable manner? Said 
differently, there has been some conversation about looking for 
ways to decouple having health insurance through your employer.
    Dr. Price. I think the employer system has been absolutely 
a remarkable success in allowing individuals to gain coverage 
that they otherwise might not gain. I think that preserving the 
employer system is imperative.
    That being said, I think that there may be ways in which 
employers--I have heard from employers who say, if you just 
give me an opportunity to provide my employee the kind of 
resources so that he or she is able to select the coverage that 
they want, then that makes more sense to them. And if that 
works from a voluntary standpoint for employers and for 
employees, then it may be something to look at.
    Senator Scott. That would be more like the HRA approach 
where the employer funds an account and the employee chooses 
health insurance, not necessarily under the umbrella of the 
employer specifically.
    Dr. Price. Exactly--and gains the same tax benefit.
    Senator Scott. Yes.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Senator McCaskill?
    Senator McCaskill. At the risk, Mr. Chairman, of being way, 
way away from you and you being someone I have worked with and 
respected greatly, I do want to gently correct something in 
your opening statement.
    The first nominee of President Trump that this Senate 
considered was confirmed by a vote of 98 to one. I would not 
consider that a partisan vote.
    The second nominee of President Trump was confirmed by a 
vote of 88 to 11. Once again, I would not consider that a 
partisan vote.
    So I really do think we are all trying to look at each 
nominee individually. And I have had a chance to review 
Congressman Price's questioning of Secretary Sebelius, and I 
can assure you, Mr. Chairman, it was no beanbag. It was tough 
stuff.
    So I think all of this looks different depending on where 
we are sitting. And I wanted to make that point.
    And as to passing Obamacare without one Republican vote, we 
are about to repeal Obamacare without one Democratic vote. This 
will be a partisan exercise under reconciliation. It will not 
be a bipartisan effort. And what we have after the repeal is 
Trumpcare. Whatever is left after the dust settles is 
Trumpcare.
    Now, I know the President likes to pay close attention to 
what he puts his name on. And I have a feeling, Congressman, 
that even though you keep saying today that Congress will 
decide, you are not really believing, are you, that your new 
boss is not going to weigh in on what he wants Congress to 
pass? We are not going to have a plan from him?
    Dr. Price. Well, I think we look forward to working with 
you and other members of the House and Senate.
    Senator McCaskill. No, my question is, are we going to have 
a plan from the President? Will he have a plan?
    Dr. Price. If I have the privilege to be confirmed, I look 
forward to working with the President and brining a plan to 
you.
    Senator McCaskill. Great. So the plan will come from 
President Trump and you will have the most important role in 
shaping that plan as his Secretary of Health and Human 
Services, correct?
    Dr. Price. I hope I have input, yes, ma'am.
    Senator McCaskill. Yes. Okay. So whatever Trumpcare ends up 
being, you will have a role in it. And I think it is really 
important to get that on the record.
    Now, when we repeal Obamacare, we are going to do a tax 
cut. Does anybody in America who makes less than $200,000--are 
any of them going to benefit from that tax cut?
    Dr. Price. It's a hypothetical, and you all are the ones 
who are going to----
    Senator McCaskill. No, no, no, no, it's not a hypothetical. 
When we repeal Obamacare, there are taxes in Obamacare. And 
when it is repealed, there is no question the taxes are going 
to be repealed. I promise you the taxes are going to be 
repealed. When those taxes are repealed, will anyone in America 
who makes less than $200,000 benefit from the repeal of those 
taxes?
    Dr. Price. I look forward to working with you on that plan, 
and hopefully that will be the case.
    Senator McCaskill. No, no, no, no, no. I am asking, the 
taxes that are in there now, does anybody who makes less than 
$200,000 pay those taxes now?
    Dr. Price. It depends how you define the taxes. There are 
many individuals who are paying much more than they did prior 
to that point. The ACA----
    Senator McCaskill. No, I am talking about taxes.
    Dr. Price. I understand.
    Senator McCaskill. Taxes, you know--the Cadillac tax has 
not been implemented, so that does not affect anybody. I am 
trying to get at the very simple question--and I do not think 
you want to answer it--that, in fact, when Obamacare is 
repealed, no one in America who makes less than $200,000 is 
going to enjoy the benefit of that.
    Dr. Price. As I say, I look forward, if I am confirmed, to 
working with you to make certain that that is the case.
    Senator McCaskill. That is not an answer, but we will go 
on.
    Okay. We talked in my office. Ending Medicare as we know 
it, your plan that you have worked on for years is converting 
Medicare to private insurance markets with government 
subsidies. Correct?
    Dr. Price. Not correct.
    Senator McCaskill. Well, we talked yesterday, and we kind 
of went through this in my office. And by the end of our 
conversation, you admitted to me, and I am going to quote you, 
that your plan for Medicare in terms of people getting either 
tax credits or subsidies or however you are going to pay for 
the Medicare recipients would be them having choices on a 
private market. And you said yes, it was pretty similar to 
Obamacare with the exception of the mandate. Did you not say 
that to me yesterday?
    Dr. Price. That's a fairly significant exception.
    Senator McCaskill. Well, but these people are old. They do 
not need to be mandated to get insurance. It is not like a 27-
year old who does not think he is going to get sick. You do not 
need a mandate for people who are elderly; they have to have 
health insurance. So the mandate is not as relevant. But did 
you not admit to me that Obamacare and the private markets are 
very similar to what you are envisioning for Medicare? Did you 
not use the phrase ``pretty similar?''
    Dr. Price. There are some similarities. I think what I 
said, though, was that the mandate was significant.
    Senator McCaskill. Well, the mandate I get in Obamacare is 
significant. But we do not need a mandate for seniors. Would 
you agree with that, that you do not have to tell seniors they 
need health insurance?
    Dr. Price. What I hope is that we do not need a mandate for 
anybody so that they are able to purchase the kind of coverage 
that they want, not that the government forces them to buy.
    Senator McCaskill. Okay. Finally, you want to block-grant 
Medicaid for State flexibility and efficiency. Correct?
    Dr. Price. I believe that Medicaid is a system that is now 
not responding necessarily to the needs of the recipients, and 
consequently, it is incumbent upon all of us as policymakers to 
look for a better way to solve that challenge.
    Senator McCaskill. Are you in favor of block-granting 
Medicaid?
    Dr. Price. I am in favor of a system that is more 
responsive to patients in the Medicaid system.
    Senator McCaskill. Are you in favor of block-granting 
Medicaid? It is a really simple question, Congressman. I mean, 
you are at your confirmation hearing for the most powerful job 
in health care in the country. I do not know why you would not 
be willing to answer whether or not you are in favor of block-
granting Medicaid. That is not complicated.
    Dr. Price. I am in favor of making certain that Medicaid is 
a system that responds to patients, not the government.
    Senator McCaskill. Okay. I do not understand why you will 
not answer that. And I do not have time. I know I am over. I 
will probably--I do not know if we are going to get another 
round, Mr. Chairman. Should I ask my last question, or are we 
going to get another chance?
    The Chairman. I am going to allow additional questions. I 
hope that not everybody will take the opportunity. [Laughter.]
    Senator McCaskill. Okay. I will disappoint you; I am sorry.
    The Chairman. I will not call it a second round, however.
    Senator McCaskill. Not many, I just have one more.
    The Chairman. Let me just on that point say that Obamacare 
raised taxes on millions of American families across income 
levels. The nonpartisan Joint Committee on Taxation analysis in 
May 2010 identified significant, widespread tax increases on 
taxpayers earning under $200,000 contained in the ACA.
    And then, for example, for 2017, 13.8 million taxpayers 
with incomes below $200,000 will be hit with more than $3.7 
billion--with a ``b''--in Obamacare tax hikes from an increase 
in the income floor for the medical expense deductions.
    Obamacare has led to middle-class tax hikes, without 
question. It has led to fewer insurance options, higher 
deductibles and higher premiums.
    So I think those are facts that cannot be denied.
    Senator McCaskill. I will look forward to looking at those 
facts, because somewhere in this mix we have alternative facts. 
[Laughter.]
    Senator Wyden. Well, and just on that----
    The Chairman. Well, I think these are right, I can tell you 
that.
    Senator McCaskill. Well, I think mine are right.
    Senator Wyden. Mr. Chairman, just a point of privilege to 
respond.
    The Chairman. Yes, sir. Yes, sir.
    Senator Wyden. On this point, no alternative facts. The 
Republicans in last year's reconciliation bill cut taxes for 
one group of people. They cut taxes for the most fortunate in 
the country. That is a matter of public record. It is not an 
alternative fact or universe. People making $200,000 and up got 
their taxes cut. That was in the reconciliation bill of the 
Republicans last year.
    The Chairman. Well, let us see who is next here. I do not 
agree with that, but we will see who is next.
    Senator Cassidy and then Senator Grassley.
    Senator Cassidy. Thank you, Mr. Chairman.
    Dr. Price, how are you?
    Dr. Price. I am well, Senator.
    Senator Cassidy. Let us talk a little about Medicaid, 
because we are getting this kind of rosy scenario of Obamacare 
and of the Republican attempt to replace it. It does seem a 
little bit odd.
    First, I want to note for the record that President Trump 
has said in various ways that he does not want people to lose 
coverage. He actually would like to cover as many people as 
under Obamacare. He wishes to take care of those with 
preexisting conditions and to do it without mandates and lower 
cost. Those will be your marching orders. Fair statement?
    Dr. Price. Absolutely.
    Senator Cassidy. Now let us go to--you and I, we talked at 
a previous meeting. We have both worked in public hospitals for 
the uninsured and for the poorly insured, folks on Medicaid.
    Now, let us just talk a little bit about Medicaid. Why 
would we see patients on Medicaid at a hospital for the 
uninsured? If they wanted to see an orthopaedist in private 
practice, does Medicaid pay a provider well enough to cover the 
cost of seeing an orthopaedic patient?
    Dr. Price. Oftentimes it does not. And in fact, as you well 
know and as mentioned before, one out of three physicians who 
ought to be able to see Medicaid patients in this Nation does 
not take any Medicaid patients. And there is a reason for that, 
whether it is reimbursement or whether it is the hassle factor 
or whether it is regulations or the like.
    But that is a system that is not working for those 
patients. And we ought to be honest about that and look at that 
and answer the question ``why?'' and then address that.
    Senator Cassidy. I will note that when the House version of 
the ACA passed, Robert Pear in The New York Times wrote an 
article about a Michigan physician, an oncologist, who had so 
many Medicaid patients from Michigan Medicaid that she was 
going bankrupt. And she had to discharge patients from her 
practice.
    Now, the ranking member said we cannot have alternative 
facts. I agree with that. We also know that a New England 
Journal of Medicine article spoke about Medicaid expansion in 
Oregon, about how when they expanded Medicaid in Oregon 
outcomes did not improve. So I suppose that kind of informs 
you--as you say, we need to make Medicaid something that works 
better for patients.
    Dr. Price. Absolutely. And we need to look at the right 
metrics. Just gaining coverage for individuals is an admirable 
goal, but it ought not be the only goal. And we must have a 
goal in health care especially to keep the patient at the 
center and realize what kind of care and coverage we are 
providing for people on the ground, for real people in real 
lives, and whether or not we are affecting them in a positive 
way or a negative way.
    If we are affecting them in a negative way, then, again, we 
need to be honest with ourselves and say, how can we improve 
that?
    Senator Cassidy. Now, a lot of times there is this kind of 
conflation of per-beneficiary payments to the States per 
Medicaid enrollee and block grants, which to me is a 
conflation.
    I will note that Bill Clinton on the left and Phil Gramm 
and Rick Santorum on the right proposed per-beneficiary payment 
some time ago. And that is actually how, would you agree with 
this, how the Federal Employees Health Benefits Program pays 
for these Federal employees? They pay a per-beneficiary payment 
to an insurer. Fair statement?
    Dr. Price. Correct.
    Senator Cassidy. Would it not be great if Medicaid worked 
as well as the Federal Employees Health Benefits Program in 
terms of improved outcomes?
    Dr. Price. It would indeed. In fact, when you talk about 
the Medicaid population, it is not a monolithic population, as 
you well know. There are four different demographic groups 
within it: seniors, disabled, and then healthy moms, and kids, 
by and large. And we treat each one of those folks exactly the 
same under the Medicaid rules.
    Senator Cassidy. So when you are pressed on whether, by 
golly, you believe in block grants, is there any nuance? I do 
not hear any of the nuances that we are discussing offered in 
that question.
    Dr. Price. Not at all.
    Senator Cassidy. But frankly, you cannot address that. Are 
you speaking about a per-beneficiary payment? Are you speaking 
about each of those four, one of those four? How do you dice 
that? New York is an older State, demographically. Utah is a 
very young State. Fair statement?
    Dr. Price. Absolutely. And those are the things that I 
think we tend not to look at, because they are more difficult 
to measure. They are more difficult to look at. But when we are 
talking about people's lives, when we are talking about 
people's health care, then it is imperative that we do the 
extra work that needs to be done to determine whether or not, 
yes, indeed, the public policy that we are putting forward is 
going to help you and not harm you.
    Senator Cassidy. Now, let me ask, because there is also 
some criticism of your proposal about Health Savings Accounts. 
I love them because they activate the patient. I think we are 
both familiar with the Healthy Indiana Plan where, on a waiver, 
they gave folks of a lower income Health Savings Accounts and 
had better outcomes, decreased ER usage. Can you comment on 
that?
    Dr. Price. Just that when people do engage in their health 
care, they tend to demand more, they tend to demand better 
services. And individuals who have greater opportunity for 
choices of who they see, where they are treated, when they are 
treated, and the like have greater opportunity to gain better 
health care.
    Senator Cassidy. So going back to not wanting to have 
alternative facts, if we contrast the experience in Healthy 
Indiana with the experience in Oregon where the National Bureau 
of Economic Research--I think, if I got that acronym correct--
published in the New England Journal of Medicine that they 
found no difference in outcomes in those who are fulfilled 
through a Medicaid expansion program in Oregon, contrast that 
absence of good effect, if you will, in outcomes with that in 
which Indiana attempted to engage patients to become activated 
in their own care. ER usage actually fell, but outcomes 
improved.
    I think in our world of standard facts, I kind of like your 
position. Thanks for bringing a nuanced, informed view to the 
health-care reform debate, Dr. Price.
    Dr. Price. Thank you, sir.
    The Chairman. Thanks, Senator.
    Senator Grassley?
    Senator Grassley. Two statements before I ask a couple of 
questions. One is, it is kind of a welcome relief to have 
somebody of your profession in this very important role, 
particularly knowing the importance of the doctor/patient 
relationship. Because in my dealing with CMS and HHS over a 
long period of time, I think that the bureaucracy has been 
short of a lot of that hands-on information that people ought 
to have.
    And secondly, when you were in my office, we discussed the 
necessity of your responding to congressional inquiries. And 
you very definitely said you would. I tongue-in-cheek said 
maybe you ought to say ``maybe'' because a lot of times 
nominees do not do it. But since you said you would, I will 
hold you to that and appreciate anything you can do to help us 
do our oversight.
    As a result of oversight, I got legislation passed a few 
years ago called the Physicians Payment Sunshine Act. And the 
only reason I bring this up is because it took Senator Wyden 
and me, last December, working hard to stop the House of 
Representatives from gutting that legislation in the Cures Act 
that passed.
    And I want to make very clear that the legislation I am 
talking about does not prohibit anything. It only has reporting 
requirements because it makes it very, very--well, it brings 
about the principle of transparency, brings accountability.
    And I have some studies here that we did and some newspaper 
reports on them, particularly one about a psychiatrist at Emory 
University who was not reporting everything that he should 
report, and even the president of Emory University came to my 
office and said, ``Thank you for making us aware of this 
stuff.''
    I want to put those in the record.
    [The studies and reports appear in the appendix beginning 
on p. 77.]
    Senator Grassley. But since you are administering this 
legislation and since Senator Blumenthal and I will think about 
expanding this legislation to include nurse practitioners and 
physician assistants, I hope that I could get your commitment 
that you will enforce this act the way it was intended to be 
enforced, because even under the Obama administration, after we 
got it passed, it was 3 years getting these regulations, 
getting it carried out. So effectively, it has only been 
working for about 2 or maybe 2\1/2\ years.
    So I would like to know, if you are confirmed, would you 
and the Department of Health and Human Services work with me to 
ensure that this transparency initiative is not weakened?
    Dr. Price. We look forward to working with you, sir. I 
think transparency in this area and so many others is vital, 
again, not just in outcomes or in pricing, but in so many 
areas, so that patients are able to understand what is going on 
in the health-care system.
    Senator Grassley. Thank you. Now, the last question deals 
with vaccine safety. You are a physician. I believe you would 
agree that immunization is very important for modern medicine 
and that we have been able to get rid of small pox way back in 
1977, worldwide polio I think in 1991, at least in the Western 
Hemisphere, and all that.
    So as a physician, would you recommend that families follow 
the recommended vaccine schedule that has been established by 
experts and is constantly reviewed?
    Dr. Price. I think that science and health care have 
identified a very important aspect of public health, and that 
is the role of vaccinations.
    Senator Grassley. Thank you very much.
    I yield back my time.
    The Chairman. Thank you, Senator.
    Senator Stabenow?
    Senator Stabenow. Thank you, Mr. Chairman.
    First, I would ask unanimous consent that a series of 
stories from individuals at a public forum that was held last 
week with my colleagues--people concerned about policies that 
our nominee has authored and about issues we are talking about 
today--be included in the record.
    The Chairman. Without objection.
    [The information appears in the appendix beginning on p. 
253.]
    Senator Stabenow. Thank you very much.
    Welcome, Congressman Price.
    Dr. Price. Senator.
    Senator Stabenow. And I appreciate our private discussion 
as well as the discussion this morning. I want to start right 
out--lots of questions--to see if we can move through some 
things quickly.
    You have said this morning that you would not abandon 
people with preexisting conditions. Is that basically what you 
are talking about with high-risk pools? Is that one of the 
strategies that you are thinking about? I have heard that 
talked about this morning.
    Dr. Price. I think high-risk pools can be incredibly 
helpful in making certain that individuals who have preexisting 
illness are able to be cared for in the highest-quality manner 
possible.
    I think there are other methods as well. We have talked 
about other pooling mechanisms. The destruction of the 
individual and small-group market has made it such that folks 
cannot find coverage that is affordable for them. And one of 
the ways to solve that challenge is to allow folks in the 
individual and small-group market to pull together. In fact, I 
think we talked about this in your office, with the Blue Shield 
model being the template for it----
    Senator Stabenow. Yes, right.
    Dr. Price [continuing]. Where individuals who are not 
economically aligned are able to pool together their resources 
solely for the purpose of purchasing coverage.
    Senator Stabenow. But let me just stress that, for about 35 
years, we have tried high-risk pools. Thirty-five States had 
them before the Affordable Care Act. And frankly, they did not 
produce great results.
    In 2011, .2 percent of the people with preexisting 
conditions--.2 percent--were actually in a high-risk pool. And 
the premiums were 150- to 200-percent higher than standard 
rates for healthy individuals, and they had lifetime and annual 
limits on coverage and cost States money. So that was the 
reality before we passed the Affordable Care Act.
    So let me also ask you, when President Trump said last 
weekend that insurance was going to be much better, do you 
think that insurance without protections for those preexisting 
conditions or without maternity coverage or without mental 
health coverage or insurance that would reinstate caps on 
cancer treatments is better?
    Dr. Price. Well, I do not know that that is what he was 
referring to. I think that----
    Senator Stabenow. Well, he said that it would be better. 
And if we in fact took away, if we went to high-risk pools 
instead of covering people with preexisting conditions, or if 
we stop the other coverage we have now, I am just wondering if 
you define that as better.
    Dr. Price. Well, I mean, you would have to give me a 
specific instance. What is better for you may not be better for 
me or somebody else. And that is the important thing that I am 
trying to get across, and that is that patients need to be at 
the center of this, not government.
    Should government be deciding these things, or should 
patients be deciding things?
    Senator Stabenow. Prior to the Affordable Care Act, about 
70 percent of the private plans that a woman could purchase in 
a marketplace did not cover basic maternity care. Do you think 
that it is better not to cover basic maternity care?
    Dr. Price. And I presume that she would purchase that 
coverage if she needed it then.
    Senator Stabenow. She would have to pay more, just as in 
general for many women. Just being a woman was a preexisting 
condition. That is the reason why we have a basic set of 
services covered under health care. So it is just a different 
way of looking at this.
    This is something where, sure, if a woman wanted to pay a 
premium, wanted to pay more, she could find maternity care. We 
said in the Affordable Care Act, that is pretty basic. And for 
over half the population who are women, maternity care ought to 
be covered.
    Let me go to another one. Do you believe that mental health 
services should be a guaranteed benefit in all health insurance 
plans?
    Dr. Price. I have been a supporter of mental health parity 
inclusion, yes.
    Senator Stabenow. So mental health should be a defined 
benefit under health insurance plans?
    Dr. Price. I think that mental health illnesses ought to be 
treated with the same model as other physical illnesses.
    Senator Stabenow. I agree with you. On Medicare, there has 
been a lot of discussion--and I have to say also, with the 
nominee for the Office of Management Budget talking today about 
Medicare and Social Security, I personally believe people on 
Medicare should be very worried right now in terms of what we 
are hearing overall.
    But I did want--and my time is up--I did want, Congressman, 
just to relay a message from my mom who is 90 years old, who 
said she does not want more choices, she just wants to be able 
to see her doctor and get the medical care that she needs. She 
is not at all supportive of the idea of Medicare in some way 
being changed into premium support, into a voucher.
    So I am conveying to you this is somebody who is getting 
great care right now and is not interested in more choices, she 
just wants to keep her care.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Dr. Price. Well, if I may, Mr. Chairman, I would just 
convey to the Medicare population in this Nation that they do 
not have reason to be concerned. We look forward to assisting 
them in gaining the care and coverage that they need.
    Senator Stabenow. Thank you.
    The Chairman. Thank you.
    Senator Cantwell?
    Senator Cantwell. Thank you, Mr. Chairman.
    Congressman Price, sorry we have not had a chance to talk.
    Dr. Price. I apologize.
    Senator Cantwell. No, I think both of us have tried, and it 
is just a myriad of consequences.
    Dr. Price. Weather.
    Senator Cantwell. But I wanted to ask you broadly, I know a 
lot of my colleagues have been asking you about Medicaid, but 
what do you think is behind the rise in Medicaid costs? What is 
it due to?
    Dr. Price. Well, I think it is multifactorial. I think that 
we have a system that has many, many controls that are creating 
greater costs to the provision of the care that is being 
provided.
    I think that, oftentimes, we are not identifying the best 
practices in the Medicaid system so that patients move through 
the system in a way that is much more economical and much more 
efficient and effective, not just from a cost standpoint, but 
from a patient standpoint. There are so many things that could 
be done for, especially the sickest of the sick in the Medicaid 
population, where we could put greater resources and greater 
individual attention to individual patients.
    As you know, in a bell curve of patients in any population, 
there are those who are the outliers on the high side, where 
the resources spent to be able to provide their care is 
significant. And if you focus on those individuals 
specifically, then you oftentimes can provide a higher level of 
care and a higher quality of care for those folks and a more 
responsive care for those folks at a lower cost to move them 
down into the mainstream of the bell curve.
    Senator Cantwell. Okay. Well, you have brought up a couple 
of interesting points, and I want to follow up on them. But 
specifically, if I started that conversation, I would start 
with two big phenomena: one, people living longer, because the 
longer they live, the more Medicaid they are going to consume. 
If they are living 10 or 15 years longer than we have had in 
the past, they are going to consume more health care. And 
second, the baby boomer population is reaching retirement age. 
Those two things are ballooning the cost of health care in 
general, and specifically for the Medicaid population.
    And I want to make sure I understand where you are, because 
I feel like the administration is creating a war on Medicaid. 
You are saying that you want to cap and control the cost. And 
what we have already established in the Affordable Care Act are 
best practice incentives and ways to give the Medicaid 
population leverage in getting affordable health care. So I 
want to understand if you are for these things.
    For example, we provided resources in the Affordable Care 
Act to rebalance Medicaid patients out of nursing home care 
into 
community-based care. Why? Because it is more affordable.
    So, do you support that rebalancing effort?
    Dr. Price. I would respectfully, Senator, take issue with 
your description of a war on Medicaid. What we desire and want 
to do is to make certain that the Medicaid population is able 
to receive the highest-quality care.
    I have cared for thousands of Medicaid patients. The last 
thing that we want is to decrease the quality of care that they 
have access to. And clearly, the system is not working right 
now. So moving toward home-based care is something that is, if 
it is right for the patient, a wonderful thing to be able to 
do, and we ought to incentivize that.
    There are so many things we could do in Medicaid that would 
provide greater quality of care that we do not incentivize 
right now.
    Senator Cantwell. We did incentivize it in the Affordable 
Care Act, and your State and about 20 other States actually did 
it. They took the money from the Affordable Care Act. In fact, 
Georgia was approved for $57 million to make sure Medicaid 
beneficiaries got care in community-based care, and it has been 
able to shift 10 percent of its long-term costs from 
institutional care to that community-based care. So it is 
working. So are you for repealing that part of the Affordable 
Care Act?
    Dr. Price. What I am for is making certain, again, that the 
Medicaid population has access to the highest-quality care 
possible. And we will do everything to improve that, because 
right now so many in the Medicaid population do not have access 
to the highest-quality care.
    Senator Cantwell. I would hope you would look at this model 
and you would also look at the Basic Health Plan model. Again, 
what I think you are proposing and what the administration is 
refusing to refute is, when the President said, ``I am going to 
protect these things,'' and my colleague, Senator Sanders, 
brought this up and asked, ``Are you going to protect this?'' 
and then senior White House staff are now saying, ``No, no, no, 
we are going to basically cap Medicaid spending,'' it is a 
problem.
    What we want to do is, we want to give these individuals 
leverage in the marketplace. That is what the Basic Health Plan 
does. That is what the community-based care plan does. It gives 
them the ability to get more affordable care and better 
outcomes, and it is saving us money.
    So if you could give us a response--I see my time is 
expired--look at those two programs and tell me whether you 
support those delivery system reforms in the Affordable Care 
Act.
    Dr. Price. I would be happy to.
    Senator Cantwell. Thank you.
    The Chairman. Well, thank you, Senator.
    That would end our first round. I would like to not go 
through a full second round, but we have some additional 
Senators here who would like to ask some more questions, so I 
guess we will start with Senator Wyden.
    Senator Wyden. Thank you, Mr. Chairman.
    Congressman, I have several ideas on how to lower the price 
of medicine. But I would like to set those aside and start with 
the President's idea: lower drug prices through bidding or 
negotiation.
    If confirmed, you are going to be the captain of the 
President's health team, and you are going to have to persuade 
Republicans to change the law so that the President can fulfill 
his pledge: more affordable prices for medicine through 
bidding.
    As captain of the health team, will you do that?
    Dr. Price. As you know, Senator, we are committed to making 
certain that drug prices are affordable for individuals so they 
can have access to the high-quality care. Right now, that 
negotiation from a Part D standpoint, which I would remind 
folks is a real success story--the cost for medications for 
seniors is about half of what it was projected to be when Part 
D passed--the Pharmacy Benefit Managers are doing that 
negotiation right now.
    I think it is important to have a conversation about 
whether or not----
    Senator Wyden. Congressman, I am asking about a specific 
idea, and it is not mine, it is the President's.
    Dr. Price. I was going----
    Senator Wyden. And the question is, will you advocate to 
Republicans for authority to negotiate? It is ``yes'' or 
``no.''
    Dr. Price. What I was going to respond, Senator, if you 
will allow me, is to say right now the PBMs are doing that 
negotiation. I think it is important to have the conversation 
and look at whether or not there is a better way to do that. 
And if there is, then I am certainly open to it.
    Senator Wyden. On Saturday, hundreds of thousands of women 
of all ages and backgrounds came to Washington to speak out in 
support of policies that you have opposed. This includes the 
Violence Against Women Act, provisions in the Affordable Care 
Act to prevent insurance companies from charging them more 
because they are women, access to no-cost contraceptive 
coverage, and the choice to see the provider they trust.
    Now, Speaker Ryan has publicly stated that no one will be 
worse off if the Affordable Care Act is repealed. But the 
nonpartisan Congressional Budget Office does not share that 
view. They have indicated nearly 400,000 women would lose 
access to care, including lifesaving cancer screenings, in the 
first year if Planned Parenthood is defunded and cut off from 
Medicaid.
    So again, Congressman, this is not my opinion as Democrat 
or Republican, this is the nonpartisan Congressional Budget 
Office.
    You are going to be the point person for health. Will you 
advise the President to reject any proposal that cuts coverage 
for or otherwise limits a woman's ability to see the provider 
she trusts?
    Dr. Price. Well, there were multiple inaccuracies in your 
premise, Senator, and I would take significant issue with the 
Congressional Budget Office conclusion because, again, as I 
mentioned to a question over here, it looks at it in a silo, 
looks at it as saying, this is what you are doing without doing 
anything else to provide coverage for individuals. And that is 
simply--that is not anybody's plan.
    Senator Wyden. Well, again, this is what is in the bill you 
wrote. And these silos--you know, we keep hearing all kinds of 
happy talk about silos and dreams and the like. What we want to 
know is one thing above everything else: is there going to be a 
replacement before there is repeal?
    And you have been asked this now by a whole host of 
members. We have not been able to get any answers on it. It 
seems to me that your own bill is out of step with what the new 
President has said. The new President said the two were going 
to be intertwined. Your own bill was repeal and run, repeal it 
now, come back some other time.
    So I want to let my other colleagues have a chance to ask 
their questions. But when you talk about silos, that is the 
view of someone--I respect your right to state it--who would 
like to be confirmed.
    The nonpartisan Congressional Budget Office says women, who 
were speaking out in communities across this country, women are 
going to lose access to those vital cancer screenings. And that 
is not a partisan statement. That is from a nonpartisan agency.
    Dr. Price. I respect----
    Senator Wyden. I hope you will reconsider your position.
    Dr. Price. I respectfully disagree with the conclusion.
    The Chairman. Okay, hopefully we can finish in the next 20 
minutes.
    Senator Cardin?
    Senator Cardin. Thank you, Mr. Chairman.
    Again, thank you, Dr. Price, for your response to our 
questions.
    One of the major objectives of the Affordable Care Act was 
to deal with the historic discrimination against minority 
communities in our health-care system. And we can give you 
chapter and verse--the medical research that was done was very 
much not directed towards the priorities in the minority 
community. The access to providers was always challenging in 
minority communities. The affordability and quality of 
insurance products were not the same in minority communities.
    So there were various provisions included in the Affordable 
Care Act to deal with that. One was an amendment that I offered 
that elevated the National Institute for Minority Health and 
Health Disparities to a full institute, as well as creating 
offices for minority health and health disparities within the 
health-related agencies.
    Are you committed to continuing progress so that we have a 
focal point, so that we draw attention to the needs of minority 
communities?
    Dr. Price. Senator, this is a really important question, 
because there are many in our society in the minority community 
who, if you look at the right metrics, are not having the same 
outcomes or same quality of health that others in society are.
    And I believe that it is incumbent upon us as individuals 
administering these programs to ask the question why, why is 
that, and then reach a plan, a strategic plan, to be able to 
help correct that. Whether that is through the current offices 
or a different mechanism, you have my commitment to look at 
that and make certain----
    Senator Cardin. I appreciate that. The National Institute 
for Minority Health and Health Disparities funded a program in 
Maryland, in Baltimore, to show disparities, and that has been 
extremely helpful. And I would just encourage you to look at 
that institute as a real, valuable resource to you to carry out 
that commitment.
    The Affordable Care Act also increased dramatically the 
funding for Qualified Health Centers that allow access to care 
in minority communities. Are you committed to maintaining the 
support for Qualified Health Centers?
    Dr. Price. Qualified Health Centers play a vital role in 
our Nation's health-care delivery system right now. And so I 
think it is imperative that we retain them or improve the 
delivery of care in that area.
    Senator Cardin. So now I am going to get to the subject 
that has been talked about by many members: Medicaid. And the 
reason I mention Medicaid--and I appreciate your response that 
you do not want to disadvantage anyone who is currently on the 
Medicaid system--is blacks, Latinos, American Indians, and 
Native Alaskans are almost twice as likely to be in Medicaid 
than the white population. In my State, 70 percent of our 
Medicaid population are people of color, so it is by far the 
dominant population that relies on Medicaid.
    So I hope you understand our concern, that when we talk 
about changing Medicaid, talk about block-granting Medicaid, 
talk about new approaches to Medicaid, it sends a signal that 
what we are going to do is cut the Federal Government's 
commitment to access for minorities. And it is a major area of 
concern.
    We have seen budget rounds where cuts to Medicaid dollar-
for-dollar would have reduced access to minority communities 
for their health-care needs. We know States have challenged 
budgets, and the more you put on the State, the more likely it 
is that many States will not be able to meet their full 
commitments to the Medicaid population.
    Can you just share with me a little bit more your vision. 
When you look at the resources we are putting into health 
care--everybody wants to do it more efficiently--but if you 
just look at the Medicaid population, what you are doing is 
taking resources away from minority communities and making the 
problem even worse.
    How can you give me a comfort level that you are committed 
to the minority communities that depend so heavily on the 
Medicaid program?
    Dr. Price. Well, Senator, let me try to assuage your 
concerns. I think, of the individuals at the dais and at this 
table, I am the only one who has ever treated a patient in the 
Medicaid system, in fact treated thousands of patients in the 
Medicaid system.
    And when we as a society use as the only major metric for 
determining whether or not we are providing care for 
individuals in the Medicaid system, the amount of money that we 
are putting into the system instead of the outcome, whether or 
not people are getting covered, whether they are able to see 
the doctor they want to see, whether they are able to get the 
kind of care that they want----
    Senator Cardin. And I agree with that. I agree with what 
you are saying, but I would just make this point----
    Dr. Price [continuing]. Then we are measuring the wrong 
thing.
    So my commitment to you is to make certain that we measure 
the right things.
    Senator Cardin. I agree with you, but if you look at the 
relative resources that are going into the Medicaid population 
versus the general population, you will find in many cases it 
is less resources. And as we said on quality education, money 
is not the only thing, but it is part of the problem.
    I just really urge us to recognize, yes, we want a better 
outcome, we all want a better outcome in our health-care 
system. But you do not do that by taking money away from our 
most vulnerable.
    Dr. Price. Thank you.
    Senator Cardin. Thank you, Mr. Chairman.
    The Chairman. Senator Nelson?
    Senator Nelson. Thank you, Mr. Chairman.
    Congressman, just to follow up our last conversation, you 
said that you did not recall having said it is a terrible idea. 
I quoted the source, Politico, and that was ``Most Republicans 
support''--and I am quoting from the Politico article of 2002, 
April the 30th, ``Most Republicans----''
    Dr. Price. 2002?
    Senator Nelson. 2012.
    Dr. Price. 2012.
    Senator Nelson. April 30th. ``Most Republicans support the 
health law's requirement that insurance companies accept all 
applicants. But the replacement plan on preexisting conditions 
put forth by the most prominent Republican ignores the idea''--
talking about preexisting conditions.
    Dr. Price. Yes, I would disagree.
    Senator Nelson. Quote, `` `It is a terrible idea,' 
Representative Tom Price, the sponsor of the plan, told 
Politico.''
    So, Mr. Chairman, I would like to insert that Politico 
article into the record for clarification.
    The Chairman. Without objection.
    [The article appears in the appendix on p. 138.]
    Senator Nelson. You and I had the opportunity yesterday to 
talk about Puerto Rico. We do not know the origin of this, but 
they are not treated like the States where the poorer of the 
population that you have, the more Federal assistance for 
Medicaid that you get. Instead it is a block grant, and the 
block grant is going to run out this year. And they are in a 
heck of problem, not only financially on the island, but now 
with a third of the population, according to the CDC, being 
infected with the Zika virus.
    Do you want to comment on what you might do going forward?
    Dr. Price. Well, as we talked about in your office 
yesterday, Senator, we absolutely need to find the resources to 
be able to make certain that they have access to the care that 
they need. These are American citizens, and it is incumbent 
upon us to take that responsibility seriously.
    Senator Nelson. I mentioned earlier, and I did so 
yesterday, that senior citizens--we have 4 million in Florida 
on Medicare, but there are almost 2 million people in Florida 
who now get their health care through the ACA.
    And on Medicare Part D, the drugs, what we have tried to do 
is close the amount of money that seniors have to pull out of 
their own pocket, otherwise known as the doughnut hole.
    Do you want to comment, Congressman, about whether or not 
seniors should have retained that Federal ability to purchase 
their drugs?
    Dr. Price. Well, in view of the fact that two of those 
senior citizens in your State are my mother-in-law and my 
father-in-law, I need to tread very carefully here.
    One of the concerns that I have about drugs being available 
for seniors is the accessibility of the drugs that they need 
and desire. So we need to make certain that formularies are not 
limited, that we are not decreasing the access and availability 
of medications that seniors have available to them for the care 
that they receive.
    Senator Nelson. And so, the part of the ACA that closed 
that doughnut hole for senior citizens, you would support that 
part?
    Dr. Price. As I say, I think it is imperative that we 
provide the greatest amount of opportunity for individual 
seniors to be able to gain access to the drugs that they need.
    So oftentimes in these discussions, we think that whatever 
we are doing right now is the only solution that is possible. 
And I just, again, I am humble enough to believe that there are 
better ideas out there. And if we find a better idea that 
actually provides greater coverage at a lower cost more 
efficiently and is more responsive to patients, then we ought 
to be able to admit to ourselves that we would embrace that if 
it were to come along.
    Senator Nelson. Congressman, as their Senator and as their 
protector of senior citizens in Florida, I cannot get away with 
an answer like that. I have to tell them that I am going to 
support their right to get drugs under Medicare Part D just 
like they are getting them now and not take that away from 
them.
    Dr. Price. And I understand that. And I would respectfully 
suggest that if we used, as a society, the line, we are going 
to maintain the kind of quality coverage that we have right now 
unless we are able to improve it, then we might just be able to 
do that for you.
    Senator Nelson. And if I gave them that answer, I would get 
run out of the room by a group of senior citizens.
    Thank you, Mr. Chairman.
    The Chairman. Senator Menendez?
    Senator Menendez. Thank you, Mr. Chairman.
    Congressman Price, one of the main policy priorities that 
you share with Speaker Ryan is to radically reform or alter, I 
should say, Medicare from its current structure to one where 
seniors would, in essence, receive a coupon to buy coverage. 
Now, despite the fact that President Trump has made repeated 
promises throughout the campaign that he will not touch 
Medicare, it seems that it is still one of your top agenda 
items.
    I have heard serious concerns about privatizing Medicare, 
not only from seniors worried about increased costs and 
decreased coverage, but also from providers in my State 
concerned about the serious negative impacts such underfunding 
will have on their ability to continue caring for Medicare 
seniors.
    So if the stated goal of Medicare privatization is to 
reduce Federal expenditures on health care for seniors, then 
does it not stand to reason that every dollar the Federal 
Government saves is going to have to come out of the pocket of 
seniors on Medicare?
    Dr. Price. Well, I disagree with the characterization of 
the program as you described it. I think it is inaccurate.
    Senator Menendez. Okay. So let us go through the specifics. 
Do you not seek to privatize Medicare?
    Dr. Price. No.
    Senator Menendez. Do you not seek to ultimately offer a 
voucher as your way of creating greater affordability?
    Dr. Price. No.
    Senator Menendez. Well, it is interesting you say that, 
because studies that have been done on your and Speaker Ryan's 
Medicare privatization plans have shown that an average 65-year 
old will pay more than twice what they pay now since the 
vouchers that you would give out are, by design, far short of 
what the current Medicare program covers.
    Dr. Price. Well, Senator, with respect, I have no reason to 
believe that the President, in his statement that he is not 
interested in modifying Medicare, that that position of the 
President has changed.
    If you want to talk about what my role as a legislator was 
in fashioning legislation and trying to solve the challenges 
that we have in Medicare, I am happy to do that. But that is 
not the role that I would play if I am given the privilege of 
being confirmed to serve as the Secretary of Health and Human 
Services; that would be to administer the changes that you all 
come up with in the Congress of the United States and the 
programs that are----
    Senator Menendez. Well, let me respond to that, because I 
know I have heard you at various times, both here and before 
the HELP Committee, say that you are going to have more of an 
administrative role, not a legislative role. And I said to you 
privately, I think that that is a little disingenuous.
    I noticed last week, the day of the hearing before the HELP 
Committee, Vice President Pence was on TV, and he said, quote, 
``I could not be more enthusiastic that someone with his 
background,'' referring to yourself, ``in medicine, but also 
his understanding of the President-elect's vision for health-
care reform and his ability to help us shape what that replace 
bill looks like once we repeal Obamacare. . . .''
    Clearly, they think, the President and the Vice President, 
that you are going to be playing a policy development role, not 
just simply the administration of whatever the Congress 
decides.
    So in your advocacy with the President as he deals with his 
desire to replace Obamacare, the reality is, you are going to 
have more than an administrative role; you are going to have a 
policy role. And if past is prologue, then your views as a 
legislator as to what you think is best for the American people 
is of concern to me because that, in essence, is a plan towards 
privatizing Medicare.
    So if that is not the case, would you commit to ensuring 
that, under your watch, Medicare will not increase costs or 
limit the coverage to current or future beneficiaries as a 
result of a change in the plan?
    Dr. Price. Senator, a couple of things. One, the comments 
that you referenced, I think, were related to the ACA, not to 
Medicare.
    Second, as I mentioned to you yesterday in our conversation 
in your office and as I have said before here, I am humble 
enough to understand and appreciate that the work that I did as 
a legislator is not necessarily the work that I would promote 
as Secretary of Health and Human Services.
    The work that has been done within the Department--the 
experts within the Department have significant knowledge and 
expertise in the work that they have done----
    Senator Menendez. Well, I appreciate that. But the essence 
of my question, then, if you dispute that your past views are 
going to be your future views, that your past views and 
legislative activity are not going to be your advocacy with the 
presidency, then I would ask you to go to the core of my 
question. Are you willing to commit that we will not see 
increased costs or less coverage for seniors under a revision 
of Medicare as you might advocate or the President might 
pursue?
    Dr. Price. What I can commit to you and will commit to you 
and have committed to you, sir, and others on this committee 
and in other conversations, is that our goal is to make certain 
that seniors have access to the highest-quality health care 
possible at an affordable price.
    Senator Menendez. Well, access without the ability to 
afford it--and I will end on this.
    Dr. Price. That is what I said: affordable price.
    Senator Menendez. Well, affordability, still a question, is 
not just an affordable price; it is your ability to have the 
wherewithal even to access an affordable price.
    Medicare guarantees as a right, it guarantees care for 
seniors, like my late mother who worked in the factories of New 
Jersey as a seamstress, was not in a unionized factory, did not 
have private insurance. After working a lifetime of hard work 
to help her family achieve what they did, she faced an enormous 
struggle with Alzheimer's that ultimately took her life. For 
her, her health-care security was Medicare. And without it, she 
would not have lived with the dignity that she deserved in the 
twilight of her life.
    So changing Medicare from a commitment and an entitlement 
to vouchers that might hope to create affordability but do not 
guarantee it, that is a fundamental shift in the nature of how 
we take care of seniors in this country. And that is why I am 
so passionate about it.
    I said this to you privately, and I just wanted to explore 
it with you publicly, but your answer does not assuage me that, 
in fact, you are committed to Medicare as we know it today in 
terms of the guarantee. Can we improve? I am always open to 
improving it, but the guarantee is what I am concerned about.
    Dr. Price. I share those concerns as well, but I disagree 
with your characterization and can also share with you a story 
of my mom, who, in the twilight of her years, had an illness 
that took her from us. And she enjoyed the benefits of Medicare 
and, without that, would not have been able to have the care 
that she received.
    Senator Menendez. Well, I hope that will be compelling to 
you in the days ahead, that it will instruct you as to how we 
should pursue Medicare.
    Thank you, Mr. Chairman.
    The Chairman. Senator Brown?
    Senator Brown. Thank you, Mr. Chairman.
    I began with the comments of Congressman Price about not 
using the word ``socialized medicine,'' the term. In 2007 in 
the Congressional Record, debating CHIP, he talked about being 
eligible for government-run socialized medicine, referring to 
CHIP. But I do not want to debate that, I just want to point 
that out. You may have forgotten--it has been 10 years--I 
certainly understand that.
    I want to follow up on what Senator Menendez said about 
Medicare, with a slightly different twist. In December, you 
said you expected lawmakers to push forward an overhaul of 
Medicare, and I quote, ``in the first 6 to 8 months of the 
Trump presidency.''
    Today, Congressman Mulvaney, the Budget Director designee, 
said that he would support raising the eligibility age for 
Social Security. He seemed to be open to raising the 
eligibility age for Medicare too, in his comments. And like 
you, he supported efforts to raise it in legislation, in 
Speaker Ryan's so-called A Better Way plan.
    That is in exact contradiction, I understand, of what 
President Trump has said; he said he opposes both cuts and 
raising the eligibility age.
    I would like you to--I asked you to clarify your position 
in a letter. I have not received a response yet. I know you are 
busy. But my question is this: if Congress passes legislation 
to raise the eligibility age for Medicare, as laid out in 
Speaker Ryan's A Better Way plan, will you advise President 
Trump to veto that legislation?
    Dr. Price. I do not anticipate a single piece of 
legislation related to just that. So we would have to look at 
the constellation, if I am confirmed.
    Senator Brown. So if something else is part of it, you 
would consider supporting raising the eligibility age? If you 
are not willing to say, no matter what else is in it--you stand 
firm on that?
    Dr. Price. If I am confirmed, it would be my responsibility 
to talk with the President about the various aspects of any 
piece of legislation, lay out the pros and cons and the 
consequences of the decisions that would be made by the 
Congress of the United States and make a recommendation.
    Senator Brown. When I think about a barber in Warren, OH or 
a factory worker in Logan, OH or a woman who works in a diner 
in Mansfield, OH or someone working construction in Troy, OH 
and saying to them, you know, I know that you think Medicare's 
eligibility age is 65, you have worked all your life, you do 
not have these jobs where we can work to older ages--you and I 
are close to the same age; unfortunately I am a bit older--but 
I just cannot imagine the morality of telling these people who 
have worked all their lives and their bodies have broken down 
more than ours do in these jobs, that we would even consider 
the possibility, as you all did in Congressman Ryan's bill, you 
did, Budget Director Mulvaney did, raising the eligibility age 
for Medicare. It is just stunning to me.
    Let me talk about something----
    Dr. Price. Senator, if I may, I struggle with the morality 
of a system that looks at Medicare, which is broken and is----
    Senator Brown. Yes, I know. I know what you are going to 
say. You have said that already. I appreciate that. I do not 
agree with that. I do not agree that Medicare is broken the way 
you say.
    Let me talk about something else. You said good things 
about innovation. I want to bring up one really quick issue and 
ask you to continue to work with us on it.
    Last summer, Secretary Burwell visited my hometown of 
Mansfield, OH to witness firsthand the effective and cost-
efficient role of community health workers in reducing infant 
mortality rates. I will talk to you more privately--and thank 
you for trying to get together in the last few days--about 
working to ensure that community health workers are recognized 
and included in new payment and delivery system reforms. They 
have been very effective at bringing down the low birth weight 
baby rate and cutting back the rate of infant mortality.
    My State is, unfortunately, maybe last in black infant 
mortality and pretty bad overall in infant mortality. I just 
want a commitment from you to at least sit and work with us on 
what Secretary Burwell and I began for dealing with community 
health workers.
    Dr. Price. Absolutely.
    Senator Brown. Okay, thank you.
    Last question--and thank you for your indulgence, Mr. 
Chairman, on this second round.
    Do you support guaranteed health care for our Nation's 
veterans?
    Dr. Price. I think the commitment that has been made by 
this Nation is that veterans should receive health care, yes.
    Senator Brown. But we do not. I mean, not all veterans 
qualify for care through the VA. On Tricare they do and there 
are a lot of them in your State as in my State. But because of 
these gaps, additional coverage options, like those provided 
through the ACA, are critical to ensure that they are covered.
    So what is the answer? The VA does not do it alone; the ACA 
complements the VA. So if we repeal the ACA, how do you 
guarantee health care for my State's thousands, your State's 
thousands of veterans who served their country, but do not have 
real health care?
    Dr. Price. Right. Well, currently, as you know, Senator, 
there are real challenges in the VA system. Again, I think I am 
the only individual on the dais here who has ever taken care of 
a patient in a VA hospital. And I know the challenges. And I 
know----
    Senator Brown. Well, but you want to repeal--thank you--but 
you want to repeal the Affordable Care Act, and we have used 
the Affordable Care Act in such a way that these veterans now 
have guaranteed health care. Almost all veterans have 
guaranteed health care, yet you are going to repeal the 
Affordable Care Act with no plans that anybody has seen yet to 
make sure these veterans have guaranteed health care.
    Dr. Price. I understand and appreciate the promise that has 
been made to veterans. And sadly, in many instances, we are not 
keeping that promise right now.
    Senator Brown. So is that part of your----
    Dr. Price. And I look forward to working with you to put 
together a better system that will----
    Senator Brown. Well, I appreciate that. I appreciate that, 
Congressman.
    Dr. Price [continuing]. Allow us to care for veterans in 
the way that we should.
    Senator Brown. Now, you had said when I asked you about 
President Trump saying he has been working with you on this 
repeal and replace plan, you said he has not really been 
working with you. So, I mean, you did not call the President a 
liar, but, you know, putting two and two together is pretty 
easy; it adds up to four.
    What does that mean? If you and he are working together, 
are you going to suggest to him that we find a way in repeal 
and replace to make sure there is guaranteed health care for 
our Nation's veterans?
    Dr. Price. Well, I think it is vital, again, as I have 
mentioned before, that every single American have access to 
affordable coverage that is of high quality. And that is our 
goal, and that is our commitment.
    Senator Brown. And so when we replace the Affordable Care 
Act after your party repeals it in this Congress, you will find 
a way for all 22 million Americans, including a lot of those 
who are veterans, to have health insurance, so they do not lose 
it with the replace part of repeal and replace?
    Dr. Price. I look forward to working with you to make that 
happen, sir.
    Senator Brown. That is not quite a ``yes,'' Congressman.
    Dr. Price. That is my answer.
    Senator Brown. Okay. Inadequate, but thank you.
    The Chairman. Okay. Thank you.
    Senator Casey?
    Senator Casey. Thank you, Mr. Chairman. Thanks for the 
additional round of questioning.
    Representative Price, I want to move to the topic I hoped I 
would have gotten to in the first round, which is individuals 
with disabilities, many of whom, I do not have the exact 
number, but many of whom rely upon Medicaid.
    One of them is actually a young child whom I just got a 
letter from his mother about--Pam Simpson, who is from 
Coatesville, PA, which is in southeastern Pennsylvania--talking 
about her son, Rowan Simpson, who was diagnosed in 2015 with 
autism. And among the things she said about the great care they 
get, that he gets in their family benefits from Medicaid, she 
says, without Medicaid, quote, ``we would be bankrupt or my son 
would go without the therapies he sincerely needs.''
    Can you guarantee today that his family is going to benefit 
from and he, Rowan Simpson, will have that kind of coverage and 
protection that Medicaid provides, that he will have that if 
you are Secretary of Health and Human Services?
    Dr. Price. We are absolutely committed to making certain 
that that child and every other child and every other 
individual in this Nation has access to the highest-quality 
care possible.
    Senator Casey. Okay, not access, he will have the medical 
care that he has right now, or better. If you can come up with 
a better level of care, that is fine. But he will have at least 
the coverage of Medicaid and all that that entails that he has 
right now? And that is either ``yes'' or ``no,'' that is not--
--
    Dr. Price. No, it is not a ``yes'' or ``no,'' because the 
fact of the matter is that, in order for the current law to 
change, you all have to change it. If I am given the privilege 
of leading at the Department of Health and Human Services----
    Senator Casey. Yes. Here is why it is ``yes''----
    Dr. Price [continuing]. And I am responsible for----
    Senator Casey. Look, you should stop talking around this. 
You have led the fight in the House, backed up by Speaker Ryan, 
for years----
    Dr. Price. To improve Medicaid.
    Senator Casey [continuing]. To block-grant Medicaid, okay?
    Dr. Price. To improve Medicaid.
    Senator Casey. To block-grant Medicaid. What that means is, 
States will have to decide whether or not this child gets the 
Medicaid that he deserves. That is what happens. So you push it 
back to the States and hope it works out.
    One estimate by the Center on Budget and Policy Priorities, 
long before you were named, said that--here is the headline of 
a chart: ``House budget chair's plan would slash Medicaid by 
one-third by 2026.'' This was not developed because you are now 
in front of this committee. That is what they were saying, that 
Medicaid would be cut by a third and by a trillion dollars.
    So let me ask you this question.
    Dr. Price. May I respond?
    Senator Casey. Let me just get this question in. Can you 
commit to us right now that no person with a disability who is 
currently covered by Medicaid, so that is everyone--that is 
Rowan and that is everyone else--that no person with a 
disability who is currently covered by Medicaid will lose 
health-care coverage, not access but coverage, under the block-
granting plan that the administration now embraces as of 
Sunday?
    Dr. Price. What I can commit to you is that in our Medicaid 
system, if I am given the privilege of service, working with 
CMS administrators, the metrics that we will use for Rowan and 
every single other patient are the quality of care that they 
are receiving----
    Senator Casey. That is fine----
    Dr. Price [continuing]. And whether or not they are 
receiving that care. The metric that you want to use----
    Senator Casey. Metrics are fine. What I am asking you again 
is, will you commit to ensure that Rowan and every other person 
in the country who has a disability, who benefits from Medicaid 
today, will they have that same coverage and the same health 
care and coverage they have today?
    Dr. Price. Our commitment is to make it so that they have 
that coverage or greater.
    Senator Casey. That is a commitment you are making.
    Dr. Price. That is a commitment.
    Senator Casey. For every person with a disability who 
benefits from Medicaid.
    Dr. Price. As I said, the goal is and our desire is to make 
sure that people have better health care, not less health care. 
And it is astounding to me----
    Senator Casey. Well, here is the problem with that. Here is 
the problem with your answer. Until Sunday, there was a 
question as to whether or not President Trump or his 
administration would fully embrace block-granting of Medicaid, 
because he said when he was campaigning that he would not cut 
Medicare and Medicaid and Social Security. As of Sunday, the 
administration has said on the record, in at least one and 
maybe two interviews, that they are going to pursue a block-
granting policy with regard to Medicaid.
    What flows from that are the following: he has a majority 
in both houses, so what you have been working on in the House 
for years that you could vote for now may become the law of the 
land. So this is a live issue; this is not theory or some 
policy among House Republicans. This is a potential enactment 
of law to block-grant Medicaid.
    And I hope you can keep your promise to make sure that no 
one with a disability suffers any diminution of care or 
coverage. That is the promise you just made, and I hope you can 
keep that in light of a trillion-dollar cut in Medicaid 
pursuant to block-granting.
    The Chairman. Senator McCaskill, you are the last one.
    Senator McCaskill. Thank you. And thank you for your 
patience in letting us have another round of questions, Mr. 
Chairman. We sincerely appreciate it.
    I would like to put in the record a table prepared by the 
Tax Policy Center on December 15, 2016 that lays out what 
happens with a repeal of all ACA taxes, including premium 
credits based on income level, if I could make that part of the 
record.
    The Chairman. Without objection, it will be placed in the 
record.
    [The table appears in the appendix on p. 91.]
    Senator McCaskill. You were chairman of the Budget 
Committee. I am going to try not to be--I get frustrated when 
people will not answer, especially when your record is so clear 
on this, Congressman. I do not really understand why you want 
to divorce yourself from your record.
    You were chairman of the Budget Committee, correct?
    Dr. Price. Yes.
    Senator McCaskill. And in that role, you had the most 
important--we all know the power of the chairman around here. 
You had incredible power to influence what was in that 
document, correct?
    Dr. Price. Which document do you refer to?
    Senator McCaskill. The budget that you prepared for 2017.
    Dr. Price. Absolutely, along with my colleagues.
    Senator McCaskill. Along with your colleagues. Was there 
anything in that document that you disagreed with on principle 
when you supported it?
    Dr. Price. Oh, absolutely.
    Senator McCaskill. Okay. What was in the document you 
disagreed with on principle when you supported it?
    Dr. Price. I would have to go back and look.
    Senator McCaskill. All right.
    Dr. Price. But it was a combined effort. But again, you 
know, as I mentioned before, if I am given the privilege of 
serving as Secretary of Health and Human Services, I appreciate 
and understand that that is a completely different role than as 
a legislator.
    Senator McCaskill. I know it is a completely different 
role. That is not what I am asking you, Congressman. I am not 
asking you about the difference.
    Dr. Price. Each of your questions refers to that role.
    Senator McCaskill. I am not asking you about the difference 
in your roles. What I am asking you is, what do you believe in? 
What do you believe in? You have been respected around these 
halls for a man of integrity because you believed in certain 
principles. And one of those was the principle that you 
embraced as chairman of the Budget Committee to block-grant 
Medicaid.
    Dr. Price. No, on the contrary. What I believe in is this 
great country and the people of this great country and the 
principles of health care that I defined earlier. And those are 
the principles that we all share, I believe, and they are that 
we need a system that is affordable for everybody, we need a 
system that is accessible for everybody.
    Senator McCaskill. I get that.
    Dr. Price. We need a system that is of the highest 
quality----
    Senator McCaskill. You have said that over and over again--
--
    Dr. Price [continuing]. That is responsive to patients, not 
to insurance companies and government.
    Senator McCaskill. I am just trying to figure out----
    Dr. Price. We need a system that incentivizes innovation, 
and a system that provides choices to patients. That is what I 
believe.
    Senator McCaskill. I understand. I understand the 
aspirational goal you have. But there is a record, Congressman. 
That is on record. And the record is that as chairman of the 
Budget Committee, controlled by your party, you put out a 
budget document, and you said over and over again that you 
favored block-granting Medicaid.
    In fact, your budget in 2017 when you were the chairman, 
you want to run away from that today as if it never happened, 
and I cannot figure out why. You are going to be influential. 
What you really believe matters. And you want to run away from 
that.
    You cut Medicaid by a trillion dollars in your 2017 budget. 
And yet today, you want to stand on some notion that, well, 
whatever you guys do is fine. And that is just not reality, 
Congressman.
    What is reality is, you have been chosen because of your 
beliefs, and your beliefs are reflected in your budget that you 
wrote as chairman of the Budget Committee. And that is the 
point I am trying to make.
    Dr. Price. Can I respond?
    Senator McCaskill. And I have a hard time understanding why 
you will not say, listen, it may not turn out the way I 
believe, but yes, I favored block grants to Medicaid.
    Dr. Price. What I believe in is a Medicaid system that is 
responsive to the patients and provides the highest-quality 
care possible.
    And I would respectfully suggest to you that that is not 
the Medicaid system that we currently have. So it is incumbent 
upon you, it is incumbent upon me, if I am given the privilege 
of serving in this capacity, to work together to find the 
solution so that we provide the highest-quality care for 
Medicaid patients and everybody else in this country.
    Senator McCaskill. And I understand. And by the way, the 
argument being made in favor of block grants is, they give more 
flexibility and efficiency to the States. That is the argument 
you have made before, that is the argument that was made around 
the budget that you crafted, that when you block-grant things 
to States, it gives them more efficiency.
    So I want to turn to a block grant that we have now, which 
is the Social Services Block Grant, which you have voted 
repeatedly to repeal. You have said that you wanted to zero it 
out. And you have voted that way as a member of Congress. And I 
want to make sure that you understand that that efficiency and 
effectiveness that you say you get with a block grant of 
Medicaid is what is happening in my State with the Social 
Services Block Grants, which, by the way, came about with 
Ronald Reagan.
    They are deciding where to use that money. And right now, 
just so you know where it is being used--in case you want to 
advise the President, the same way you voted--it is being used 
for residential treatment for detoxing off heroin, it is being 
used for daycare for seniors to keep them in their home so we 
are not paying the bill on Medicaid in a nursing home, it is 
being used for adoption services, and it is being used for case 
management to save money so that the cases are being managed 
effectively and efficiently in terms of accessing Federal 
safety net programs.
    Will you continue to advocate, as you have in Congress, for 
a repeal of the Social Services Block Grants?
    Dr. Price. Senator, with respect, I think there is likely a 
better way to provide those services in a much more efficient, 
effective, and economical way for the individuals receiving the 
care. And I would also respectfully suggest to you that another 
State flexibility model that is held up by many is the TANF 
program that has been extremely successful, and so there are 
different ways to do things.
    And again, it ought to be a collegial conversation that we 
have to lay out what the challenges are before us, working 
together to solve those challenges. And that is what I would 
like to do.
    Senator McCaskill. I just was trying to point out the 
inconsistency of saying block grants to Medicaid are good 
because of flexibility and efficiency and block grants to 
States on social services are bad. And that has been your 
record in Congress, Congressman, and that is why I brought it 
up.
    Dr. Price. And with respect, for individuals to say that 
State flexibility for Medicaid is bad, but State flexibility 
for TANF is fine, again, is a little bit inconsistent as well.
    Senator McCaskill. I understand.
    Thank you, Mr. Chairman.
    The Chairman. Well, thank you.
    Now, we are going to close this, Senator Wyden and myself, 
so we will just ask Senator Wyden to make his closing remarks, 
and then I will make mine.
    Senator Wyden. Thank you very much, Mr. Chairman.
    As we wrap up another quiet, subdued hearing in the Finance 
Committee [laughter], I just have a couple of thoughts. And the 
first is for you, Congressman. Despite our policy differences, 
I want you to know I very much respect your willingness to 
serve. As you know--we have talked about it--you and I have a 
lot of mutual friends, and I know they are very supportive of 
your career. And I want you to know I respect your willingness 
to serve.
    Here is where we are in terms of the substance. Several 
hours ago, I asked you, with respect to the executive order on 
the Affordable Care Act, will you commit that no one will be 
worse off? And you ducked it. I asked you, will you guarantee 
that no one will lose coverage? You ducked that. I asked you, 
would there be a replacement before all of this went into 
effect to avoid hurting working families? And that was ducked 
as well.
    And it just seems to me there is a big gap between the 
answers you have given on the executive order with respect to 
repealing the Affordable Care Act and what the new President 
said all through the campaign. Everybody was going to be okay, 
nobody would be worse off, there would be no gap between repeal 
and replace.
    My colleagues have gone through in great length the debate 
about the Medicaid block grant. Prediction? I think some of 
your biggest critics are going to be Republican Governors on 
this, because I think Republican Governors--and they will be 
probably more diplomatic than I--are going to see this as a 
Trojan horse to cut spending. And that is why a lot of us are 
concerned about shredding the safety net.
    I asked you about women's health care, and here the concern 
is that women all across the country are going to lose the 
choice of providers that they want and they have today and 
coverage. And you just said, ``Hey, I disagree with the 
Congressional Budget Office.''
    I asked about drugs and how we are going to lower these 
pharmaceutical prices, and you told me about pharmaceutical 
benefit managers. You told me about Part D--I voted for Part D, 
one of the relatively few Democrats who did--but you did not 
answer the question about whether you would get Republicans to 
help you fulfill the President's pledge on bargaining. So that 
is what concerns me about all of this.
    On the ethics questions, we want to correct one key point 
that was said earlier in the hearing, that the Congressman does 
not have control over his brokered accounts. First, the 
Congressman has not provided copies of the agreements that 
would clarify his level of control.
    Second, last week the Congressman told Senator Murray 
regarding the purchase of Innate, quote, ``I did it through a 
broker, I directed the broker to purchase the stock, but I did 
it through a broker.''
    And third on this point, these are not blind trusts. I just 
want the record to reflect that.
    I am also going to put an article in the record, Mr. 
Chairman, that ran this morning about investments in other 
health-care stocks, specifically in four companies that 
manufacture products in Puerto Rico.
    The Chairman. Without objection.
    [The article appears in the appendix on p. 286.]
    Senator Wyden. And so, Mr. Chairman, I will wrap up with 
just one last point. Ever since I was director of the Gray 
Panthers, the Oregon Gray Panthers--I did it for almost 7 
years--I was interested in one thing: changing a system that 
was largely for the healthy and the wealthy.
    And as you and I have talked about, I had eight Democrats 
and eight Republicans on a bipartisan bill that would do that. 
I did not get my way. But the Affordable Care Act had many, 
many good features, and one of them was, it made clear all 
across this country we were not going to go back to the days 
when health care was for the healthy and wealthy.
    And I am especially troubled as we wrap up this morning--we 
have been at it close to 4 hours--that when you take all of 
these policies together that you have described this morning, 
that is really where we are headed, that is where we are going 
to be. And that is why I am so strongly opposed to these 
positions.
    My hope is--we still have some additional questions to look 
at with the ethics issues. I can just tell the Congressman that 
George W. Bush's ethics lawyer was in the paper this morning 
talking about your stock trades, and he said ``I have not seen 
anything like this before, and I have been practicing and 
teaching about securities law for 30 years.''
    So I think there are very troubling questions that remain, 
Mr. Chairman, with respect to this. I know that we are being 
told that members have to get any written questions in by this 
evening. But with respect to what we have heard this morning 
and the lodestar that I see, that America will end up with 
health care that works for the healthy and wealthy, I am going 
to oppose it. I am very troubled by what we have heard today. 
And I appreciate the chance to make these closing remarks.
    The Chairman. Well, thank you, Senator.
    If we keep going the way we are going, there will not be 
any health care for anybody. We will not be able to afford it; 
we will not be able to provide for it. There are so many things 
that are wrong with the current system, but it is just 
pathetic, and it is gradually eating up the whole doggone 
Federal budget.
    Now, I have been around here only 40 years, but I will tell 
you I have never had a witness for any position in government 
who has performed as well as you have, who has an impeccable 
reputation in medicine and in the Congress. And to be treated 
like, if you do not agree with some concepts that some of my 
colleagues do, there is something wrong with you, is just 
beyond the pale.
    Like I say, you not only have a great deal of experience in 
medicine, but you have been a great Congressman, and you have 
been trying to get things under control around here. And you 
have found that it is almost impossible, because we have all 
these people saying we have to do everything in the world, and 
they do not care what the costs are. And that is why this 
country is broke.
    We have to find some way of delivering all these health-
care benefits to people without totally ruining the country so 
nobody gets any health-care benefits, which is where we are 
headed. I do not know how in the world we can continue to buy 
into this liberal claptrap that you do not have to pay the 
piper.
    Now, what you have said is, we are going to try, within 
this current system, to make it work and to cover everybody and 
to help people, whether they be poor or whether they be rich.
    Now, I do not know if you can say much more than that. But 
I get a kick out of how many of these people are constantly 
blathering about, we have to do everything for everybody when 
we know we are $20 trillion in debt. And this money does not 
grow on trees, and yet every one of us wants to make sure 
health care works, every one of us wants to make sure every 
deserving person in our society is cared for.
    And I say that as a person who, over the last 40 years, 
almost every health-care bill that works has my name on it, 
starting with the Orphan Drug Act. How about Hatch-Waxman that 
created the modern generic drug industry? Name it all.
    The fact of the matter is that you have been very 
forthright, very honest, and you have indicated that, in spite 
of all the problems of trying to fund health care and all the 
problems around health care, you are going to do your doggone 
level best to make sure health care is delivered to our 
American people.
    You know, I wonder how many of my colleagues on the other 
side are going to vote for you. And if they do not, it kind of 
says something about what is happening in this country.
    Now, I want to thank you for being here today. You know, I 
do not think you ducked any questions. You answered them 
forthrightly. It might not have pleased the individual 
Senators, but you did. And I look forward to Dr. Price being 
confirmed and assuming his position so he can begin working 
with us here in Congress to improve the Nation's health and the 
whole health-care system and to ensure that taxpayer dollars 
are used efficiently and effectively.
    Now, we owe that to the dedicated taxpayers and citizens of 
this great country. And to that end, several groups and 
individuals have submitted letters of support for Dr. Price. 
And I would like to ask that those be entered into the record 
at this point, without objection.
    [The letters appear in the appendix beginning on p. 82.]
    The Chairman. In closing, this committee takes its 
responsibilities very seriously. As you can see, this is a very 
intelligent committee. We have a lot of really great people on 
both sides on this committee, and they are serious about what 
goes on. But that is why we have such a thorough review process 
for nominees. This is why the committee is following and will 
continue to follow our longstanding process in the future.
    Now, I would ask that any written questions for the record 
be submitted by 8 p.m. tonight, which is 2 hours more than what 
the Democrats gave us. This is a timeline that is consistent 
with the committee's consideration of previous nominees for HHS 
Secretary. And that's a direct quote, by the way.
    Now, I want to thank you and your family for sitting 
through this and for answering these questions. I think this 
was the best I have ever heard them answered, understanding 
that there are no answers to some of these problems.
    And I just want to personally thank you. My gosh, you could 
have such a great life without doing this kind of stuff, and 
you are willing to give your life to working for the American 
people and in trying to do what really needs to be done in the 
area of health care. And I want to commend you for it, because 
I just do not think there is a justifiable reason to vote 
against you.
    Dr. Price. Thank you, sir.
    The Chairman. Well, with that----
    Senator Wyden. Mr. Chairman, just a unanimous consent 
request.
    The Chairman. Yes, sir.
    Senator Wyden. I would just like to put in a statement by 
me under this unanimous consent request----
    The Chairman. That would be fine.
    Senator Wyden [continuing]. On how important it is that 
Congressman Price respond to the questions he has been asked by 
the HELP Committee. It is a different committee, but it is 
something of great importance to me. And I appreciate it.
    The Chairman. Well, that is fine. But see, in my 
estimation, the HELP Committee should not have held a hearing 
to begin with. This is the committee of jurisdiction. This is 
the committee that has to stand up and vote on whether or not 
our congressional friend is going to serve this country in this 
great capacity. And I believe we will vote for him and get him 
out of here. And by getting him out of here, I do not mean out 
of this room, okay, we have to get him out of the Congress and 
get him up there where he can really help with all this medical 
expertise that he has.
    And it is apparent that you have it. I mean, there is no 
question about that in my mind. And it is hard for me to 
understand why anybody would give you a rough time. It is good 
to ask tough questions, and we have had a lot of tough 
questions here today, but you have answered them very, very 
well, as far as I am concerned, much better than a lot of other 
people who have held this position.
    Many of the others, even recently, could not answer these 
questions that you have been asked. And it is wonderful that we 
have a doctor who has had a long life in medical practice 
willing to give up that life, give up the freedoms that you 
have to have to repeatedly come up here and justify everything 
you do down there. I think it is a wonderful thing, and I just 
personally want to congratulate you and your wife and family 
for giving so much to this country.
    With that, we will recess, and we will reconvene again to 
vote on you promptly.
    [Whereupon, at 1:54 p.m., the hearing was adjourned.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


                    Submitted by Hon. Chuck Grassley

                The Wall Street Journal, October 3, 2008

  Grassley Says Emory Psychiatrist Didn't Report $500,000 in Payments
                           By Jacob Goldstein
For a while now, Senator Chuck Grassley has been writing to 
universities around the country to ask about ties between high-profile 
doctors and the drug industry--an interest related to a bill he's 
sponsoring that would require drug makers to report payments to 
doctors.

In the latest letter, Grassley says a prominent Emory psychiatrist 
failed to disclose a half-million dollars in payments from 
GlaxoSmithKline.

Charles Nemeroff, the chair of Emory's psychiatry department, was paid 
by Glaxo to give speeches to doctors around the country, the Grassley 
letter said. Nemeroff was also the main investigator on a federally 
funded trial of Glaxo drugs.

Emory requires its doctors to disclose potential conflicts of interest 
when they receive payments of over $10,000. In a statement to the WSJ, 
Emory said the allegations made by Senator Grassley are ``serious'' and 
that the university is ``working diligently to determine whether our 
policies have been observed consistently with regard to the matters 
cited'' by Grassley.

The New York Times posted a copy of a 2004 letter from Emory to 
Nemeroff telling him that he had to limit his Glaxo consulting fees to 
less than $10,000 a year to avoid a conflict that would violate federal 
regulations. This week's letter from Grassley says Glaxo paid Nemeroff 
more than $70,000 in 2005 and more than $30,000 in 2006, according to 
reports from the company.

Nemeroff didn't return a call from the WSJ, but the university said 
Nemerov told Emory officials that ``to the best of my knowledge, I have 
followed the appropriate university regulations concerning financial 
disclosures.'' Glaxo said it has ``rigorous guidelines governing our 
interaction with healthcare professionals who participate in GSK-
supported speaking events,'' and that it requires them to disclose 
those relationships.

Grassley has previously investigated similar issues regarding 
psychiatrists at Harvard, Stanford, the University of Cincinnati and 
the University of Texas Medical Branch. For more on Grassley's 
investigations, check out the recent interview from the HealthCare 
Channel.

The Physician Payment Sunshine Act, which Grassley sponsors, would 
require drug makers to report payments to doctors. The industry 
supports the bill--finding it preferable to a patchwork of state laws--
which has been working its way through Congress for a while now.

                                 ______
                                 

                   Money and Policy, October 3, 2008

            Top Psychiatrist Didn't Report Drug Makers' Pay
                           By Gardiner Harris
One of the nation's most influential psychiatrists earned more than 
$2.8 million in consulting arrangements with drug makers from 2000 to 
2007, failed to report at least $1.2 million of that income to his 
university and violated federal research rules, according to documents 
provided to Congressional investigators.

The psychiatrist, Dr. Charles B. Nemeroff of Emory University, is the 
most prominent figure to date in a series of disclosures that is 
shaking the world of academic medicine and seems likely to force broad 
changes in the relationships between doctors and drug makers.

In one telling example, Dr. Nemeroff signed a letter dated July 15, 
2004, promising Emory administrators that he would earn less than 
$10,000 a year from GlaxoSmithKline to comply with federal rules. But 
on that day, he was at the Four Seasons Resort in Jackson Hole, WY, 
earning $3,000 of what would become $170,000 in income that year from 
that company--17 times the figure he had agreed on.

The Congressional inquiry, led by Senator Charles E. Grassley, 
Republican of Iowa, is systematically asking some of the nation's 
leading researchers to provide their conflict-of-interest disclosures, 
and Mr. Grassley is comparing those documents with records of actual 
payments from drug companies. The records often conflict, sometimes 
starkly.

``After questioning about 20 doctors and research institutions, it 
looks like problems with transparency are everywhere,'' Mr. Grassley 
said. ``The current system for tracking financial relationships isn't 
working.'' The findings suggest that universities are all but incapable 
of policing their faculty's conflicts of interest. Almost every major 
medical school and medical society is now reassessing its relationships 
with drug and device makers.

``Everyone is concerned,'' said Dr. James H. Scully Jr., the president-
elect of the Council of Medical Specialty Societies, whose 30 members 
represent more than 500,000 doctors.

Dr. Nemeroff is a charismatic speaker and a widely admired scientist 
who has written more than 850 research reports and reviews. He was 
editor-in-chief of the influential journal Neuropsychopharmacology. His 
research has focused on the long-term mental health risks associated 
with child abuse as well as the relationship between depression and 
cardiovascular disease.

Dr. Nemeroff did not respond to calls and e-mail messages seeking 
comment. Jeffrey L. Molter, an Emory spokesman, wrote in an e-mail 
statement that the university was ``working diligently to determine 
whether our policies have been observed consistently with regard to the 
matters cited by Senator Grassley.''

The statement continued: ``Dr. Nemeroff has assured us that: `To the 
best of my knowledge, I have followed the appropriate university 
regulations concerning financial disclosures.' '' On Friday night, 
Emory announced that Dr. Nemeroff would ``voluntarily step down as 
chairman of the department, effective immediately, pending resolution 
of these issues.''

Mr. Grassley began his investigation in the spring by questioning Dr. 
Melissa P. DelBello of the University of Cincinnati after The New York 
Times reported her connections to drug makers. Dr. DelBello told 
university officials that she earned about $100,000 from 2005 to 2007 
from eight drug makers, but AstraZeneca alone paid her $238,000 during 
the period, Mr. Grassley found.

Then in early June, the Senator reported to Congress that Dr. Joseph 
Biederman, a renowned child psychiatrist at Harvard Medical School, and 
a colleague, Dr. Timothy E. Wilens, had reported to university 
officials earning several hundred thousand dollars each in consulting 
fees from drug makers from 2000 to 2007, when in fact they had earned 
at least $1.6 million each.

Then the Senator focused on Dr. Alan F. Schatzberg of Stanford, 
president-elect of the American Psychiatric Association, whose $4.8 
million in stock holdings in a drug development company raised 
concerns.

Mr. Grassley has sponsored legislation called the Physician Payment 
Sunshine Act, which would require drug and device companies to publicly 
list payments to doctors that exceed $500. Several states already 
require such disclosures.

As revelations from Mr. Grassley's investigation have dribbled out, 
trade organizations for the pharmaceutical industry and medical 
colleges have agreed to support the bill. Eli Lilly and Merck have 
announced that they would list doctor payments next year even without 
legislation.

The National Institutes of Health have strict rules regarding conflicts 
of interest among grantees, but the institutes rely on universities for 
oversight. If a university fails, the agency has the power to suspend 
its entire portfolio of grants, which for Emory amounted to $190 
million in 2005, although the agency rarely takes such drastic 
measures.

Dr. Nemeroff was the principal investigator for a 5-year $3.9 million 
grant financed by the National Institute of Mental Health for which 
GlaxoSmithKline provided drugs.

Income of $10,000 or more from the company in any year of the grant--a 
threshold Dr. Nemeroff crossed in 2003, 2004, 2005 and 2006, records 
show--would have required Emory to inform the institutes and take steps 
to deal with the conflict or to remove Dr. Nemeroff as the 
investigator.

Repeatedly assured by Dr. Nemeroff that he had not exceeded the limit, 
Emory did nothing.

``Results from N.I.H.-funded research must not be biased by any 
conflicting financial interests,'' John Burklow, a spokesman for the 
health institutes, said in the kind of tough statement that in the past 
has rarely been followed by real sanctions. ``Officials at Emory are 
investigating the concerns.''

``Failure to follow N.I.H. standards'' on conflict of interest, Mr. 
Burklow continued, ``is very serious, and N.I.H. will take all 
appropriate action to ensure compliance.''

In 2004, Emory investigated Dr. Nemeroff's outside consulting 
arrangements. In a 14-page report, Emory's conflict of interest 
committee detailed multiple ``serious'' and ``significant'' violations 
of university procedures intended to protect patients.

But the university apparently took little action against Dr. Nemeroff 
and made no effort to independently audit his consulting income, 
documents show.

Universities, too, can benefit from the fame and money the deals can 
bring--a point Dr. Nemeroff made in a May 2000 letter stamped 
``confidential'' that he sent to the dean of Emory's medical school. 
The letter, which was part of a record from a Congressional hearing, 
addressed Dr. Nemeroff's membership on a dozen corporate advisory 
boards (some of the companies' names have since changed).

``Surely you remember that Smith-Kline Beecham Pharmaceuticals donated 
an endowed chair to the department and that there is some reasonable 
likelihood that Janssen Pharmaceuticals will do so as well,'' he wrote.

``In addition, Wyeth-Ayerst Pharmaceuticals has funded a Research 
Career Development Award program in the department, and I have asked 
both AstraZeneca Pharmaceuticals and Bristol-Meyers [sic] Squibb to do 
the same. Part of the rationale for their funding our faculty in such a 
manner would be my service on these boards.''

Universities once looked askance at professors who consulted for more 
than one or two drug companies, but that changed after a 1980 law gave 
the universities ownership of patents discovered with federal money.

The law helped give birth to the biotechnology industry and led to the 
discovery of dozens of life-saving medicines. Consulting arrangements 
soon proliferated at medical schools, and Dr. Nemeroff--who at one 
point consulted for 21 drug and device companies simultaneously--became 
a national model.

He may now become a model for a broad reassessment of industry 
relationships. Many medical schools, societies and groups are 
considering barring doctors from giving lectures on drug or device 
marketing.

For all his fame in the world of psychiatry, Dr. Nemeroff has faced 
ethics troubles before. In 2006, he blamed a clerical mix-up for his 
failing to disclose that he and his co-authors had financial ties to 
Cyberonics, the maker of a controversial device that they reviewed 
favorably in a journal he edited.

The Cyberonics paper led to a bitter e-mail exchange between Dr. 
Nemeroff and Claudia R. Adkison, an associate dean at Emory, according 
to Congressional records. Dr. Adkison noted that Cyberonics had not 
only paid Dr. Nemeroff and his co-
authors but had also given an unrestricted educational grant to Dr. 
Nemeroff's department.

``I can't believe that anyone in the public or in academia would 
believe anything except that this paper was a piece of paid 
marketing,'' Dr. Adkison wrote on July 20, 2006.

Two years earlier, unknown to the public, Emory's conflict of interest 
committee discovered that Dr. Nemeroff had made more serious blunders, 
including failing to disclose conflicts of interest in trials of drugs 
from Merck, Eli Lilly and Johnson and Johnson.

His continuing oversight of a federally financed trial using 
GlaxoSmithKline medicines led Dr. Adkison to write Dr. Nemeroff on July 
15, 2004, that ``you must clearly certify on your annual disclosure 
form that you do not receive more than $10,000 from GSK.''

In a reply dated August 4, Dr. Nemeroff wrote that he had already done 
so but promised again that ``my consulting fees from GSK will be less 
than $10,000 per year throughout the period of this N.I.H. grant.''

When he sent that letter, Dr. Nemeroff had already earned more than 
$98,000 that year from GlaxoSmithKline. Three weeks later, he received 
another $3,844.56 for giving a marketing talk at the Passion Fish 
Restaurant in Woodbury, NY.

From 2000 through 2006, Dr. Nemeroff earned more than $960,000 from 
GlaxoSmithKline but listed earnings of less than $35,000 for the period 
on his university disclosure forms, according to Congressional 
documents.

Sarah Alspach, a GlaxoSmithKline spokeswoman, said via e-mail that 
``Dr. Nemeroff is a recognized world leader in the field of 
psychiatry,'' and that the company requires its paid speakers to 
``proactively disclose their financial relationship with GSK, and we 
believe that healthcare professionals are responsible for making those 
disclosures.''

http://www.nytimes.com/2008/10/04/health/policy/04drug.html

                                 ______
                                 
              Prepared Statement of Hon. Orrin G. Hatch, 
                        a U.S. Senator From Utah
WASHINGTON--Senate Finance Committee Chairman Orrin G. Hatch (R-Utah) 
today delivered the following opening statement at a hearing to 
consider the nomination of Rep. Tom Price (R-Georgia) to head the 
Health and Human Services (HHS) Department:

    Today we will consider the nomination of Dr. Tom Price to be the 
Secretary of the Department of Health and Human Services.

    I want to welcome Dr. Price to the Finance Committee. I appreciate 
his willingness to serve in a position of this magnitude, especially at 
this crucial time.

    When Obamacare was pushed through on a series of party-line votes, 
Republicans in Congress warned that the new health law would harm 
patients, families, and businesses.

    Not to put too fine a point on it, but, we were right. And, the 
next HHS Secretary will play a pivotal role as we work to repeal 
Obamacare and replace it with patient-centered reforms that will 
actually address cost. This will be an important endeavor, one that 
will and should get a lot of attention here today, but it should not be 
the sole focus of the next HHS Secretary.

    HHS has an annual budget of well over $1 trillion. Let me repeat 
that: One department, $1 trillion.

    HHS encompasses the Centers for Medicare and Medicaid Services, the 
Centers for Disease Control and Prevention, the National Institutes of 
Health, the Food and Drug Administration, and many others. It is no 
exaggeration to say that HHS touches more of the U.S. economy and 
affects the daily lives of more Americans than any other part of the 
U.S. Government.

    I firmly believe that Dr. Price has the experience and 
qualifications necessary to effectively lead this large and diverse set 
of agencies, and many people share that view.

    For example, past HHS Secretaries Mike Leavitt and Tommie Thompson 
strongly support his nomination.

    Physician organizations that know Dr. Price's work--including the 
American Medical Association and most surgical specialty groups--
enthusiastically support him. The American Hospital Association and 
other health-care stakeholder groups do as well.

    Perhaps the Healthcare Leadership Council, representing the broad 
swath of health-care providers, said it best in stating that, ``It is 
difficult to imagine anyone more capable of serving this Nation as the 
Secretary of HHS than Congressman Tom Price.''

    Unfortunately, in the current political environment, 
qualifications, experience, and endorsements from experts and key 
stakeholders don't seem to matter to some of our colleagues. At least, 
that appears to be the case, as none of those who say they oppose Dr. 
Price's nomination seem to be talking about whether he is qualified.

    Instead, we've heard grossly exaggerated and distorted attacks on 
his views and his ethics. On top of that, we've heard complaints and a 
series of unreasonable demands regarding the confirmation process 
itself.

    Of course, these tactics haven't been limited to Dr. Price. My 
Democratic friends have taken this approach with almost all of 
President Trump's cabinet nominees as Senate Democrats' unprecedented 
efforts to delay and derail the confirmation process and apply a 
radically new set of confirmation standards has continued unabated.

    To that point, let me say this: I have been in the Senate for 40 
years and I think my record for being willing to reach across the aisle 
is beyond any reasonable dispute. In fact, from time to time, I've 
taken lumps in some conservative circles for working closely with my 
Democrat colleagues.

    I have, on some occasions, voted against confirming executive 
branch nominees, but far more often than not, I have opted to defer to 
the occupants of the White House and allow them to choose who serves in 
their administrations. I've taken some lumps for that too.

    I'm not bringing any of this up to brag or to solicit praise from 
anyone in the audience. I raise all of this today so that people can 
know I'm serious when I say that I am worried about what my colleagues 
on the minority side are doing to the Senate as an institution. While 
the overriding sense of comity and courtesy among Senators has 
admittedly been in decline in recent years, I have never seen this 
level of partisan rancor when it comes to dealing with a President from 
an opposing party. I have never seen a party in the Senate--from its 
leaders on down--publicly commit to not only opposing virtually every 
nomination, but to attacking and maligning virtually every single 
nominee.

    Let me be clear: I'm not suggesting that the Senate start rubber-
stamping nominees. Nor am I suggesting that any member of the Senate 
should vote against their conscience or preferences simply out of 
respect for tradition or deference. What I am saying is that the same 
rules, processes, courtesies, and assumptions of good faith that have 
long been the hallmark of the Senate confirmation process should 
continue to apply regardless of who is President. If what we're seeing 
now is the new normal for every time control of the White House changes 
hands, the Senate, quite frankly, will be a much lesser institution.

    Unfortunately, our committee has not been entirely immune to the 
hyper-politicization of the nomination process. We saw that last week 
with the Mnuchin hearing, and I regret to say that I think we're likely 
to see more of it today.

    Case in point: I expect that, during today's hearing, we're going 
hear quite a bit about process, with claims that Dr. Price's nomination 
is being rushed and that the nominee hasn't been fully vetted.

    This is simply untrue.

    President Trump announced his intent to nominate Dr. Price just 3 
weeks after the election. Dr. Price submitted the required tax returns 
and completed questionnaire on December 21st. That was 35 days ago, 
and, by any reasonable standard, that is sufficient time for a full and 
fair examination of the nominee's record and disclosures.

    By comparison, the committee held a hearing on the nomination of 
Secretary Sebelius 16 days after she submitted her paperwork. For 
Secretary Burwell, it was 17 days. In other words, the time between the 
completion of Dr. Price's file and his hearing has been more than that 
of the last two HHS Secretaries combined. And, by the way, both of 
those nominees received at least a few Republican votes on this 
committee and on the floor.

    Outside of extraordinary process demands, Dr. Price has faced a 
number of unfair attacks on both his record as a legislator and his 
finances.

    On the questions surrounding finances, I'll defer on any 
substantive discussion and first allow Dr. Price to defend himself from 
what are, by and large, specious and distorted attacks. For now, I'll 
just say that I hope that my colleagues don't invent new standards for 
finances, ethics, and disclosure that are different from those that 
have generally applied in the past.

    There is a saying involving both stones and glass houses that might 
be applicable as well.

    With regard to Dr. Price's views and voting record, I'll simply say 
that virtually all the attempts I've witnessed to characterize Dr. 
Price's views as being ``outside of the mainstream'' have been absurd, 
unless, of course, the only ideas that are in the ``mainstream'' are 
those that endorse the status quo on healthcare and our entitlement 
programs.

    In conclusion, I just want to note that the overly partisan 
treatment of nominees and distortions of their records is a relatively 
new development on this committee. My hope is that we can begin today 
to reverse recent trends and have a fair and open discussion of the 
nominee and his qualifications.

                                 ______
                                 
              American Academy of Dermatology Association

                  1445 New York Avenue, NW, Suite 800

                       Washington, DC 20005-2134

                           Main: 202-842-3555

                           Fax: 202-842-4355

                          Website: www.aad.org

January 30, 2017

The Honorable Orrin Hatch           The Honorable Ron Wyden
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
104 Hart Senate Office Building     221 Dirksen Senate Office Building
Washington, DC 20510                Washington, DC 20510

Dear Chairman Hatch and Ranking Member Wyden:

The American Academy of Dermatology Association (Academy), which 
represents more than 13,500 dermatologists nationwide, wishes to 
express its support for the nomination of Representative Tom Price, 
M.D., for the position of U.S. Secretary of the Department of Health 
and Human Services (HHS).

Dr. Price, in his active role in health care policy in Congress as well 
as his years of service at the state level of government, has 
demonstrated a proven understanding of the intricate complexities of 
our nation's health care system. Additionally, as someone who has 
worked as a practicing physician, Dr. Price would bring to the position 
of Secretary a personal understanding of how the policies enacted in 
Washington impact the practice of medicine and delivery of care to 
patients across the country.

Specifically, Dr. Price understands the importance of the physician-
patient relationship and recognizes the critical role that physicians 
play in the delivery of care to their patients. He has often supported 
dermatology's position on integrated electronic health care records and 
the challenges of meaningful use. Dr. Price has also been a leading 
voice to reduce burdensome regulations which have limited the time 
physicians can devote to caring for and treating patients.

During his time in Congress, Dr. Price worked with colleagues on both 
sides of the aisle to enact a new Medicare physician payment system 
that streamlines multiple reporting requirements for physician 
practices within Medicare. More recently, with the roll out of the new 
Medicare Quality Payment Program (QPP), Dr. Price sought input 
regarding proposed regulations and their potential impact on physicians 
and patients, working with stakeholders and advocating with the Centers 
for Medicare and Medicaid Services (CMS), to help provide flexibility 
for physician practices both small and large.

The Academy appreciates your consideration of Dr. Price's nomination as 
Secretary of Health and Human Services, and supports his nomination as 
Secretary. At this important time in health care for our nation, Dr. 
Price's experience as a physician and his in-depth understanding of 
health care policy will provide HHS and our nation the direction needed 
to guide our health care system as it addresses the needs of a growing 
and diversifying patient population. Should you have any questions or 
need additional information, please contact Shawn Friesen, the 
Academy's Director, Legislative, Political and Grassroots Advocacy at 
[email protected] or (202) 712- 2601.

Sincerely,

Abel Torres, M.D., JD, FAAD
President, American Academy of Dermatology Association

                                 ______
                                 
             American Association of Neurological Surgeons

                 Kathleen T. Craig, Executive Director

                         5550 Meadowbrook Drive

                       Rolling Meadows, IL 60008

                          Phone: 888-566-AANS

                           Fax: 847-378-0600

                             [email protected]

                                  and

                   Congress of Neurological Surgeons

                           Regina Shupak, CEO

                  10 North Martingale Road, Suite 190

                          Schaumburg, IL 60173

                          Phone: 877-517-1CNS

                           FAX: 847-240-0804

                             [email protected]

January 4, 2017

The Honorable Orrin Hatch
Chairman
Committee on Finance
U.S. Senate
Washington, DC 20510

    SUBJECT: Rep. Tom Price Nomination for HHS Secretary

Dear Chairman Hatch:

On behalf of the American Association of Neurological Surgeons (AANS) 
and Congress of Neurological Surgeons (CNS), representing more than 
4,000 practicing neurosurgeons in the United States, we are writing in 
strong support of Representative Tom Price, M.D. (R-GA) to become the 
next Secretary of the U.S. Department of Health and Human Services 
(HHS).

Throughout his time in Congress, Dr. Price, an orthopaedic surgeon, has 
been a staunch advocate for the preservation of the doctor-patient 
relationship, a fierce protector of private practice, and a stalwart 
supporter of academic medicine. As a practicing physician, and because 
of his work on key congressional committees with jurisdiction over 
health care issues, he understands all aspects of the health care 
system, which is essential to run HHS effectively.

We have every confidence that Dr. Price will work tirelessly to create 
a health care delivery system that promotes high-quality, high-value, 
and better-coordinated care for our nation's patients. We, therefore, 
urge the Senate Finance Committee to favorably report Dr. Price's 
nomination to the full Senate vote swiftly.

Thank you for considering our views.

            Sincerely,

Frederick A. Boop, M.D., President   Alan M. Scarrow, M.D., President
American Association of 
Neurological Surgeons               Congress of Neurological Surgeons

Staff Contact:

Katie O. Orrico, Director
AANS/CNS Washington Office
725 15th Street, NW, Suite 500
Washington, DC 20005
Direct: 202-446-2024
Email: [email protected]

                                 ______
                                 
             American Podiatric Medical Association (APMA)

                        9312 Old Georgetown Road

                      Bethesda, Maryland 20814-1621

                           Tel: 301-581-9200

                           Fax: 301-530-2752

                         https://www.apma.org/

                            January 11, 2017

The Honorable Orrin Hatch
Chairman
Committee on Finance
U.S. Senate
219 Dirksen Senate Office Building
Washington, DC 20510

The Honorable Ron Wyden
Ranking Member
Committee on Finance
U.S. Senate
219 Dirksen Senate Office Building
Washington, DC 20510

Dear Chairman Hatch and Ranking Member Wyden:

The American Podiatric Medical Association (APMA) respectfully requests 
your Committee affirmatively recommend Representative Thomas Price, 
M.D., to the full Senate for Secretary of Health and Human Services 
(HHS). Founded in 1912, the APMA is the leading organization and 
represents the majority of the estimated 15,000 podiatrists in the 
country.

Dr. Price is highly qualified for this position and brings years of 
experience as a physician and the leading health policy expert in 
Congress. Dr. Price has been supportive of policies that will free 
providers of overly burdensome regulations which hinder the delivery of 
care to patients and has encouraged additional pathways for providers 
to play a more significant role in regulatory decision-making. He has 
consistently provided healthcare solutions that are patient-centered 
and emphasize consumer choice, which will be critical as Congress moves 
forward with changes to the Patient Protection and Affordable Care Act.

Again, we support the nomination of Congressman Tom Price as HHS 
Secretary and ask for your favorable consideration.

Sincerely,

R. Dan Davis, DPM
President

                                 ______
                                 
                         Corinthian Medical IPA

                        5030 Broadway, Suite 821

                           New York, NY 10034

                             T 212-740-8294

                             F 212-740-8246

                      www.corinthianmedicalipa.com

January 16, 2017

The Honorable Lamar Alexander
Chairman,
Committee on Health, Education, Labor, and Pensions
U.S. Senate
Washington, DC 20510

Re: Letter in support of Dr. Tom Price

Dear Honorable Lamar Alexander:

I have practiced medicine in the United States for 25 years. Throughout 
that time, I have focused my practices exclusively on improving 
outcomes for lower-income communities, who face extreme health 
disparities in our current system. Many of my patients are immigrants; 
and I am proudly an immigrant myself.

Today, I head a nonprofit network, Advocate Community Providers. We 
consist of over 2,000 physicians and healthcare providers and are 
responsible for over 700,000 lives across four boroughs in New York 
City. To put this population in perspective, this is larger than the 
populations of all but the seventeen largest cities in the country. 
Nearly all of our patients are Medicaid recipients; most are 
concentrated in the Hispanic and Asian communities. Our network came 
together as a result of New York's transformative Delivery System 
Reform Incentive Payment program, or DSRIP, which uses state and 
federal dollars to cut costs stemming from unnecessary hospital usage 
by lower-income patients by switching to a community-based preventative 
care system as opposed to one that depends on emergency room visits, 
and switching a value-based system instead of one based on exorbitant 
fee-for-service.

I have had the opportunity to meet with Congressman Tom Price last year 
in New York; Dr. Price was particularly interested in knowing about 
health-care issues and care-enhancing, cost-saving methods that are 
showing promise in lower-income communities in New York, especially 
regarding the DSRIP initiative.

I sincerely support his nomination and I hope that after his 
confirmation as Secretary of Health and Human Services, he will look 
closely at our work and this model and that we can work together to 
discuss support and scalability. The reforms that my network and the 24 
other similar networks in New York are pioneering can and should be 
thoughtfully considered in urban areas and rural states alike with 
heavy Medicaid populations. We stand ready to work with him.

There is no question that a new Administration taking office presents a 
key opportunity. Hopefully, it will be a historic moment for a renewed 
national dialogue on health-care reform that is apolitical and places 
patients first. The eventual outcome is uncertain, but there is no 
doubt that the Affordable Care Act will undergo significant changes. No 
matter the changes, I hope that Dr. Price and President-Elect Trump 
will be as committed to raising outcomes and creating healthier, 
stronger and more prosperous communities through better quality care 
and lower expenditures as the previous administration. I trust that 
they share that goal, and as a doctor who has worked in the Medicaid 
network, I can confirm that using this system as the place to make 
change is where the strongest potential exists.

I look forward to welcoming Dr. Price back to New York this year and 
convening a round table of providers who are leading on care-enhancing, 
cost-saving reforms that can flourish anywhere. I hope to serve as a 
laboratory for results that will have positive national implications 
and that Dr. Price and the Department of Health and Human Services will 
take every advantage of under his leadership.

With regards,

Dr. Ramon Tallaj
Chairman, Corinthian Medical IPA (CMIPA) (ACP)

                                 ______
                                 
                            State of Georgia

                         Office of the Governor

                           Atlanta 30334-0090

Nathan Deal
  Governor

The Honorable Orrin Hatch           The Honorable Ron Wyden
Chairman                            Ranking Member
Committee on Finance                Committee on Finance
U.S. Senate                         U.S. Senate
Washington, DC 20510                Washington, DC 20510

                            January 23, 2017

Dear Chairman Hatch and Senator Wyden:

    It is with great pride that I write to you to support the 
nomination of Congressman Tom Price, M.D. as the Secretary of Health 
and Human Services. As an orthopaedic surgeon, in private practice for 
twenty years, Rep. Price knows firsthand the intricacies of the 
healthcare landscape. Representative Price has served in both the State 
Senate and as a Representative for Georgia's 6th District. During this 
time, he has become a champion for healthcare. As such, he is uniquely 
situated to serve as the Secretary for Health and Human Services. 
Representative Price has been working for the past several years to 
craft a solution to the many woes of the Affordable Care Act, passed 
and signed into law in 2010.

    As a Governor, charged with balancing a state budget, I know the 
many challenges that the Affordable Care Act has brought to states like 
Georgia. Since taking office, we have seen the portion of our state 
budget consumed by health expenses continue to grow. Continued growth 
in healthcare expenses means that other critical spending areas like 
education, transportation, and public safety are put at risk.

    I look forward to the confirmation of Representative Price so that 
Georgia can craft a Medicaid program that is sustainable and best 
suited to fit the needs of our unique population.

            Sincerely,

            Nathan Deal

                                 ______
                                 
                          Grady Health System

                      80 Jesse Hill Jr. Drive, SE

                           Atlanta. GA 30303

                             (404) 616-1000

                          www.gradyhealth.org

January 20, 2017

The Honorable Orrin Hatch
Chairman
Committee on Finance
U.S. Senate
Washington, DC 20510

The Honorable Ron Wyden
Ranking Member
Committee on Finance
U.S. Senate
Washington, DC 20510

Dear Chairman Hatch and Ranking Member Wyden:

It is an honor to submit these comments as you deliberate the 
confirmation of Dr. Tom Price, M.D. as this country's next Secretary of 
Health and Human Services. I am Chairman of the Grady Health System 
Board of Directors (Grady Memorial Hospital) in Atlanta, Georgia, one 
of the largest, essential safety net health systems in the country. 
Grady has a vital stake in the future of this Nation's healthcare 
policy.

Grady was founded with a mission to care for the underserved and is 
celebrating its 125th anniversary this year. Our health system consists 
of the 953-bed Grady Memorial Hospital, 6 neighborhood health centers, 
Crestview Health and Rehabilitation Center, and Children's Healthcare 
of Atlanta at Hughes Spalding, which is operated as a Children's 
affiliate. In 2016, Grady had over 620,000 patient visits, including 
more than 130,000 emergency room visits. Over 28% of our patients are 
uninsured, 28% are covered by Medicaid, and 24% are enrolled in 
Medicare. The remainder have other forms of coverage, including 
commercial insurance.

With its nationally acclaimed emergency medical services, Grady has the 
premier level I trauma center in all of North Georgia and serves as the 
911 ambulance provider for the city of Atlanta and six rural counties. 
Grady's American Burn Association /American College of Surgeons 
verified Burn Center is one of only two in the State. And the Marcus 
Stroke and Neuroscience Center is a Joint Commission designated 
Advanced Comprehensive Stroke Center.

Other key services include Grady's Regional Perinatal Center with its 
Neonatal Intensive Care Unit, Georgia's first Cancer Center for 
Excellence, The Avon Breast Health Center, the Georgia Comprehensive 
Sickle Cell Center, and the Ponce de Leon Center--one of the top three 
HIV/AIDS outpatient clinics in the country.

As the cornerstone of healthcare in Atlanta, Grady serves Americans 
from every walk of life in every possible circumstance and does it with 
limited resources. Grady's funding, like other safety net hospitals in 
the country, is often determined by the changing priorities of 
government--local, State or Federal. And it's the place where changes 
in public policy can have an immediate and direct impact on the lives 
of our patients and the hospital's ability to meet the demand for 
services.

Dr. Price completed his residency program in orthopedics at Grady and 
later returned to serve as Medical Director of the Orthopedics Clinic. 
We believe there is no better training or opportunity to gain personal 
perspective on the health-care needs of all Americans than working at a 
safety net institution like Grady. While at Grady, Dr. Price trained 
the next generation of clinicians and provided care to the vulnerable--
particularly the uninsured and Georgia's Medicaid recipients.

No clinician has been in charge of our Nation's health-care system 
since Dr. Louis Sullivan, a former board member of Grady. With so much 
change being contemplated and considered in both houses of Congress, it 
reassures us to know that Dr. Price will view changes in policy with 
Grady and the community we serve in mind.

As our Nation continues to discuss how best to deliver health care to 
all Americans, but especially to the indigent and uninsured, we believe 
Dr. Price's experience as a physician at Grady will serve him well. We 
are grateful for Dr. Price's work with us throughout his time in public 
office. We look forward to working with him in this important role to 
improve access to care for all Americans.

Sincerely,

Francis S. Blake
Chairman

                                 ______
                                 
                National Confectioners Association (NCA)

                     1101 30th Street NW, Suite 200

                          Washington, DC 20007

                             (202) 534-1440

                       https://www.candyusa.com/

January 13, 2017

The Honorable Orrin G. Hatch        The Honorable Ron Wyden
Chairman                            Ranking Member
Committee on Finance                Committee on Finance
U.S. Senate                         U.S. Senate
219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
Washington, DC 20510                Washington, DC 20510

The Honorable Lamar Alexander       The Honorable Patty Murray
Chairman                            Ranking Member
Committee on Health, Education, 
Labor, and Pensions                 Committee on Health, Education, 
                                    Labor, and Pensions
U.S. Senate                         U.S. Senate
428 Dirksen Senate Office Building  428 Dirksen Senate Office Building
Washington, DC 20510                Washington, DC 20510

Dear Chairmen Hatch and Alexander, Senator Wyden, and Senator Murray:

I am writing to you to express support from the National Confectioners 
Association in regard to the nomination of Representative Tom Price as 
Secretary of the Department of Health and Human Services.

The National Confectioners Association is the trade organization 
representing the $35 billion U.S. chocolate, candy, gum and mints 
industry. Confectionery is manufactured in all 50 states, directly 
employing 55,000 workers in more than 1,000 facilities. In addition to 
these jobs in manufacturing, the industry supports an additional 
410,000 U.S. jobs in fields like retail, transportation and 
agriculture. The confectionery industry generates more than $10 billion 
in U.S. taxes and more than $2 billion in exports annually.

Dr. Price's experiences as a surgeon and his significant legislative 
background at the state and federal levels have uniquely positioned him 
to lead the Department. His considerable experience will also have a 
positive influence on the Food and Drug Administration, an agency with 
significant oversight on regulations that impact the confectionery 
industry. Dr. Price is a principled man and strong leader who will 
underscore the importance of making policy using the best science 
available after thorough and practical deliberation.

NCA respectfully asks for Dr. Price's prompt consideration by both of 
your committees and confirmation by the United States Senate as our 
next Secretary of the Department of Health and Human Services.

Sincerely,

John H. Downs, Jr.
President and CEO

                                 ______
                                 
       Small Business and Entrepreneurship Council (SBE Council)

                    301 Maple Avenue West, Suite 100

                            Vienna, VA 22180

                             (703) 242-5840

January 23, 2017

The Honorable Orrin Hatch           The Honorable Ron Wyden
Chairman                            Ranking Member
Committee on Finance                Committee on Finance
U.S. Senate                         U.S. Senate

The Honorable Lamar Alexander       The Honorable Patty Murray
Chairman                            Ranking Member
Committee on Health, Education, 
Labor, and Pensions                 Committee on Health, Education, 
                                    Labor, and Pensions
U.S. Senate                         U.S. Senate

Dear Chairmen Hatch and Alexander, and Ranking Members Wyden and 
Murray:

On behalf of the Small Business and Entrepreneurship Council (SBE 
Council) and our more than 100,000 members nationwide, I am writing to 
express our strong support for the confirmation of U.S. Representative 
Tom Price, M.D. as Secretary of the U.S. Department of Health and Human 
Services (HHS).

Congressman Price is a serious and successful physician, legislator, 
and policy thought leader who naturally transferred his Hippocratic 
Oath to policymaking and legislative initiatives across many areas. 
Over the course of his career in Congress, he has worked hard to 
propose and fight for policies that empower and help all Americans, 
while warning against those that do harm and undermine opportunity.

Congressman Price is a great friend of entrepreneurs and small business 
America, and understands that government policies and actions--if not 
carefully thought through--can take a disproportionate toll on the 
ability of small businesses to compete, grow, innovate and create jobs. 
Regarding health care policy, his insights and experience have been 
invaluable in developing positive solutions, while also correctly 
warning about the unintended consequences of poor policy or actions.

Congressman Price has been a leader on common sense reforms to lower 
health costs, improve quality, drive more choice and innovation in the 
market, and create true access for all health care consumers. His ``do 
no harm'' ethic is extraordinarily important now as the Congress and 
policymakers carefully unwind a health care law that has undermined 
people's health, access to health coverage, as well as their personal 
finances. Small businesses and the self-employed have especially been 
burdened by the higher costs and limited choices that have resulted 
from the Affordable Care Act.

Congressman Price is the right person, with the precise set of skills, 
experience and temperament to guide us to a system where all people 
have access to high quality, affordable care, and a system that is 
innovating for the future. This is a system--a market--that desperately 
needs more entrepreneurial ideas, but excessive regulation and 
government control are barriers that prevent the type of rapid 
innovation we are benefitting from in other industries and sectors.

SBE Council strongly supports Congressman Price's confirmation, and we 
urge the Senate to move quickly on a full vote to ensure HHS has the 
leadership it needs in many important areas, including navigating the 
type of reforms we need to make health coverage more affordable and 
competitive for the self-employed, small businesses and their 
employees. Please do not hesitate to contact me if you have questions 
about SBE Council's support for Congressman Price's confirmation as HHS 
Secretary.

Sincerely,

Karen Kerrigan
President and CEO

                                 ______
                                 
                              Scott Walker

                         Office of the Governor

                           State of Wisconsin

                             P.O. Box 7863

                           Madison, WI 53707

                         www.wisgov.state.wi.us

                             (608) 266-1212

                          Fax: (608) 267-8983

                            January 17, 2017

The Honorable Orrin Hatch           The Honorable Ron Wyden
Chairman                            Ranking Member
Committee on Finance                Committee on Finance
U.S. Senate                         U.S. Senate

The Honorable Lamar Alexander       The Honorable Patty Murray
Chairman                            Ranking Member
Committee on Health, Education, 
Labor, and Pensions                 Committee on Health, Education, 
                                    Labor, and Pensions
U.S. Senate                         U.S. Senate

Dear Chairmen Hatch and Alexander, and Ranking Members Wyden and 
Murray:

I write today in support of President-elect Trump's nomination for 
Secretary of the U.S. Department of Health and Human Services, Dr. Tom 
Price.

Secretary-designee Price is uniquely positioned to work with Wisconsin 
and other states to reform health care and help curb years of federal 
overreach. In addition to his leadership roles in congress, he spent 
more than 20 years caring for patients in Georgia as an orthopaedic 
surgeon and medical professional. If confirmed, Dr. Price will bring 
years of medical knowledge and federal lawmaking experience to the 
department.

In Wisconsin, we share Dr. Price's commitment to quality healthcare as 
we rank one of the best states in the nation for health insurance 
coverage and our reforms allowed us to cover everyone living in poverty 
under Medicaid. His decades of medical knowledge and firsthand 
experience as a licensed physician and orthopaedic surgeon, combined 
with his years as a lawmaker make him the perfect candidate to begin 
tackling critical reforms to empower the states.

Again, I strongly support the confirmation of Dr. Price as the next 
U.S. Health and Human Services Secretary. I look forward to working 
with him in this new role.

Sincerely,

Scott Walker
Governor of Wisconsin

                                 ______
                                 
       Submitted by Hon. Dean Heller, a U.S. Senator From Nevada

                           Nevada Legislature

                            January 10, 2017

The Honorable Dean Heller
324 Hart Senate Office Building
Washington, DC 20510

Dear Senator Heller:

We are writing to express our concern regarding plans to repeal the 
Affordable Care Act. Specifically, we are concerned that Republicans in 
Congress are pushing ahead with a repeal of the Affordable Care Act 
despite having no viable replacement legislation ready to enact.

Failure to immediately enact replacement legislation risks creating 
uncertainty in the insurance marketplace. Such uncertainty will likely 
result in higher out-of-
pocket costs and fewer insurance options for Nevada's families while 
simultaneously placing an increased burden on our State budget.

As you are aware, Governor Sandoval worked closely with the Legislature 
and ultimately signed legislation creating the Silver State Health 
Exchange in 2011. Subsequently, more than 300,000 Nevadans have gained 
access to health care coverage, either by purchasing it on the exchange 
or by meeting the expanded Medicaid eligibility requirements.

In light of these facts, we hope that you will address the following 
questions regarding the planned repeal of the Affordable Care Act:

    1.  What steps do you plan to take to ensure that the more than 
88,000 Nevadans who have purchased health insurance through the Silver 
State Health Exchange continue to have the ability to purchase health 
insurance with adequate coverage in a transparent marketplace?

    2.  What steps do you plan to take to ensure that the more than 
77,000 Nevadans who are eligible for Federal tax credits under the 
Affordable Care Act to help purchase private insurance will continue to 
have access to affordable health insurance options with adequate 
coverage?

    3.  What steps do you plan to take to ensure that the 217,000 
Nevadans who are receiving health care under the Medicaid expansion 
remain covered?

    4.  The Affordable Care Act guarantees coverage vital to 
preventative services for women, including cancer screenings and birth 
control. What steps do you plan to take to ensure that the Affordable 
Care Act's coverage guarantees remain intact for women's health?

    5.  The Affordable Care Act guarantees that Nevadans with pre-
existing conditions will not be denied health care and ends lifetime 
minimums on coverage. It also allows younger people, many of whom are 
saddled with college debt and cannot afford insurance, to stay on their 
parents' insurance until they are 26. What steps do you plan to take to 
preserve those coverage guarantees?

The lack of clarity regarding viable alternatives to the Affordable 
Care Act from the incoming administration and Republican congressional 
leadership is troubling. While Congress has expended considerable time 
and energy over the past several years talking about the law, hundreds 
of thousands of Nevadans have relied in good faith on the Affordable 
Care Act to obtain health insurance. Repealing the law without 
implementing an adequate replacement will put those Nevadans' health 
and well-being at risk.

Further, any congressional action that creates a large gap in insurance 
coverage will likely result in more Nevadans relying on state-funded 
social service programs. Most of these programs are already under 
resourced. Nevada cannot afford to shoulder this new financial burden 
created by politicians in Washington failing to live up to guarantees 
that the Federal Government previously made to our citizens.

We hope you will use your position as Nevada's senior U.S. Senator and 
a member of the majority party to protect the thousands of Nevada 
families who are now at risk of losing their health insurance. We also 
hope you will take steps to ensure that our State does not bear any 
unfair and unnecessary costs of caring for people who stand to lose 
that coverage in the near future.

We look forward to your prompt reply.

Sincerely,

Aaron D. Ford                       Jason Frierson
Majority Leader                     Speaker
Nevada State Senate                 Nevada State Assembly

                                 ______
                                 


                                            Submitted by Hon. Claire McCaskill, a U.S. Senator From Missouri
                                                                     Table T16-0285
                                                     Repeal all ACA Taxes, Including Premium Credits
                                                                  Baseline: Current Law
                                       Distribution of Federal Tax Change by Expanded Cash Income Level, 2017 \1\
                                                                      Summary Table
                                                             http://www.taxpolicycenter.org/
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                    Tax Units with Tax Increase or Cut \3\                                                     Average Federal Tax Rate
                           --------------------------------------------------------    Percent      Share of                              \5\
Expanded Cash Income Level         With Tax Cut              With Tax Increase        Change in       Total        Average   ---------------------------
            \2\            --------------------------------------------------------   After-Tax    Federal Tax   Federal Tax
                             Pct. of Tax                 Pct. of Tax    Avg. Tax     Income \4\      Change      Change ($)    Change  (%     Under the
                                Units     Avg. Tax Cut      Units       Increase                                                 Points)      Proposal
--------------------------------------------------------------------------------------------------------------------------------------------------------
Less than 10                         7.3        -1,150           0.0         7,140           1.6           3.5           -80          -1.5           5.3
10-20                                6.6        -1,210           4.2         3,850          -0.5          -5.8            80           0.5           2.6
20-30                                7.2          -960           9.9         4,020          -1.3         -22.1           320           1.3           4.4
30-40                               41.6          -170           9.2         4,600          -1.1         -18.2           350           1.0           7.7
40-50                               83.9           -90           6.1         5,630          -0.6         -11.2           260           0.6          10.4
50-75                               93.6          -100           3.1         6,400          -0.2          -8.3           100           0.2          13.1
75-100                              97.3          -140           1.3         5,840           0.1           3.1           -60          -0.1          15.6
100-200                             98.8          -190           0.4         6,540           0.1          14.8          -160          -0.1          18.8
200-500                             99.8          -540           0.0         8,320           0.2          18.0          -540          -0.2          23.0
500-1,000                           99.9        -4,590           0.0             0           0.9          17.9        -4,580          -0.7          28.0
More than 1,000                     99.9       -50,200           0.0             0           2.2         108.4       -50,130          -1.5          32.6
All                                 60.0          -600           3.8         4,720           0.3         100.0          -180          -0.2          19.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: Urban-Brookings Tax Policy Center Microsimulation Model (version 0516-2).
Number of AMT taxpayers (millions). Baseline: 5.5; proposal: 5.5.
* Non-zero value rounded to zero; **  Insufficient data.
\1\ Calendar year. Baseline is current law. Proposal would repeal all ACA taxes: the 3.8 percent Net Invest Income Tax, the 0.9 percent additional HI
  tax, the Cadillac Tax, the excise tax on employers offering inadequate health insurance coverage, the excise tax on individuals without adequate
  health insurance, the increase in threshold for medical expense deductions, and the excise taxes on health insurance providers, pharmaceutical
  manufacturers and importers, and medical device manufacturers and importers. Analysis includes the Premium Tax Credit which is not treated as a tax in
  the TPC baseline due to its similarity to a spending program. Simulations of Premium Tax Credit calibrated to match results from Urban Institute's
  Health Insurance Policy Simulation Model (HIPSM). For a description of TPC's current law baseline,  see http://www.taxpolicycenter.org/taxtopics/
  Baseline-Definitions.cfm.
\2\ Includes both filing and non-filing units but excludes those that are dependents of other tax units. Tax units with negative adjusted gross income
  are excluded from their respective income class but are included in the totals. For a description of expanded cash income, see http://
  www.taxpolicycenter.org/TaxModel/income.cfm.
\3\ Includes tax units with a change in federal tax burden of $10 or more in absolute value.
\4\ After-tax income is expanded cash income less: individual income tax net of refundable credits, corporate income tax, payroll taxes (Social Security
  and Medicare), estate tax, and excise taxes.
\5\ Average federal tax (includes individual and corporate income tax, payroll taxes for Social Security and Medicare, the estate tax, and excise taxes)
  as a percentage of average expanded cash income.

       Submitted by Hon. Bill Nelson, a U.S. Senator From Florida
_______________________________________________________________________
                                        Congressional Budget Office
                                                     September 2013

                A Premium Support System for Medicare: 
                    Analysis of Illustrative Options

Summary

Over the past two decades, numerous proposals have been advanced for 
the establishment of a premium support system for Medicare. Under such 
a program, beneficiaries would purchase health insurance from one of a 
number of competing plans, and the federal government would pay part of 
the cost of the coverage. The various proposals have differed in many 
respects, including the way in which the federal contribution would be 
set and how that contribution might change over time.

This Congressional Budget Office (CBO) report presents a preliminary 
analysis of the ways two illustrative options for a premium support 
system would affect federal spending and beneficiaries' choices and 
payments. The agency has developed significant new tools to analyze 
such a system in greater depth than in the past; the specifications of 
the options examined here also differ from those CBO analyzed 
previously. As the agency refines its modeling approach and considers 
alternative options for a premium support system, its findings could 
change. CBO's analysis to date indicates the following:

  Both options for premium support considered here would reduce 
federal spending for Medicare net of beneficiaries' premiums and other 
offsetting receipts.

  Under the second-lowest-bid option, the option with the greater 
reduction in net federal spending, beneficiaries' premiums and total 
payments for Medicare's Part A and Part B benefits would each be higher 
on average than they would be under current law. (Total payments 
consist of premiums and out-of-pocket costs for deductibles, 
copayments, and coinsurance.) Under the average-bid option, the option 
with the smaller reduction in net federal spending, those amounts would 
each be lower on average than they would be under current law.
---------------------------------------------------------------------------
    Notes: Unless otherwise indicated, the years referred to in this 
report are calendar years. The estimates for the next 10 years were 
generated using the Congressional Budget Office's March 2012 baseline 
projections of Medicare spending, and the analysis of longer-term 
effects was based on the agency's June 2012 long-term projections of 
Medicare spending. (Those were the most recent projections available 
when much of the analysis was performed.)

    Numbers in the text, figures, and tables may not add up to totals 
because of rounding.

  Under both options, combined spending by the federal government 
and by beneficiaries (that is, premiums and out-of-pocket costs) would 
---------------------------------------------------------------------------
be less than that if current law remained in place.

  Under both options, effects on premiums and total payments for 
some beneficiaries would differ greatly from the national averages. In 
particular, in most regions, the premiums and total payments of 
beneficiaries enrolled in the fee-for-service (FFS) program would be 
higher than they would be under current law.

  Alternative specifications for key features of a premium support 
system would yield different results.

What Premium Support Options Did CBO Analyze?

The two premium support options analyzed in this report differ in terms 
of the formula by which the federal contribution would be determined. 
Otherwise, they are very similar. The nation would be divided into 
regions within which competing private insurers would submit bids 
indicating the amounts they would accept to provide Medicare benefits 
to a beneficiary of average health. The FFS program would be part of 
the system as a competing plan, and its ``bid'' would be based on the 
projected FFS spending for an enrollee of average health in a given 
region. Insurers would bid to provide a benefit package that would 
encompass the same services covered by Part A (Hospital Insurance) and 
Part B (Medical Insurance) of Medicare under current law and that would 
have the same actuarial value as Parts A and B combined (that is, each 
package would cover the same percentage of total expenses for a given 
population that Medicare's FFS program would cover under current law). 
Beneficiaries who were eligible for the premium support system would 
not be permitted to enroll in Part C (the current Medicare Advantage 
system, offered by private insurers that contract with Medicare to 
provide Part A and Part B benefits). Part D (Medicare's prescription 
drug benefit program), which is now delivered through a competitive 
system, would continue as it is under current law and would be 
administered separately from the new program.

The federal government would pay insurers for each enrollee who was in 
average health an amount that was equal to a ``benchmark'' set for that 
region minus the standard premium paid by enrollees; insurers would 
receive larger or smaller government payments for beneficiaries whose 
health was worse or better than average. Beneficiaries who enrolled in 
a plan with a bid that equaled the benchmark would pay the plan a 
standard premium, which would equal one-quarter of the estimated cost 
of providing the Part B portion of benefits and would be the same 
across the nation (set by the same formula as that used under current 
law for the Part B premium). Beneficiaries who chose a plan with a bid 
less than the benchmark would pay a premium that was lower by the full 
amount of the difference between the bid and the benchmark, and those 
who chose a more expensive plan would pay a premium that was 
correspondingly higher.

The benchmarks that would be used to set the federal contribution are 
the defining features of the two options CBO examined:

  Under the second-lowest-bid option, the benchmark in a region 
would be the lower of a pair of bids--the region's second-lowest bid 
submitted by a private insurer and Medicare's FFS bid.

  Under the average-bid option, the benchmark in a region would be 
the weighted average of all bids, including the FFS bid. Each bid would 
be weighted by the proportion of beneficiaries enrolled in that plan in 
the year immediately preceding.

CBO assumed that no cap would be imposed on the amount or the rate of 
growth of the federal contribution and that insurers would be required 
to provide coverage to all beneficiaries who selected a particular 
plan.

The agency made detailed assumptions about many other specifications of 
the premium support system. Some were chosen to illustrate the 
potential for savings from a highly competitive system; others were 
chosen for feasibility of implementation or to simplify the analytical 
process. The specifications adopted for this analysis are not 
recommendations, and many alternative specifications are possible.

For this analysis, CBO assumed that dual-eligible beneficiaries--people 
who are simultaneously enrolled in Medicare and Medicaid--would be 
excluded from the premium support system and that federal spending for 
their health care would continue as it would under current law. Anyone 
else who was enrolled in Medicare when the premium support system was 
implemented (assumed to be 2018 for this report) would enter the system 
immediately, and anyone other than dual-eligible beneficiaries who 
became eligible subsequently would enroll in the new system. (See below 
for a brief discussion of policy alternatives that would exclude 
certain other Medicare beneficiaries from a premium support system.) 
The starting date of 2018 was chosen to allow for a period during which 
the federal government could develop the necessary administrative 
structures and beneficiaries and insurers could learn about and prepare 
for the new system.

 How Would the Premium Support Options Affect Federal Spending?

CBO estimates that the second-lowest-bid option would reduce net 
federal spending for Medicare by about $45 billion in 2020 and that the 
average-bid option would reduce such spending in that year by about $15 
billion (see Table 1). For this analysis, CBO reports those effects as 
a percentage of two different measures of spending projected under 
current law: net federal spending on Medicare as a whole and net 
federal spending on Medicare's Part A and B benefits for beneficiaries 
who would be affected by the options (that is, everyone other than 
dual-eligible beneficiaries who would have enrolled in Medicare under 
current law).

  Net federal spending for Medicare is total Medicare spending, 
including spending on dual-eligible beneficiaries and prescription 
drugs covered by Part D, minus beneficiaries' premiums and other 
offsetting receipts. The second-lowest-bid option would reduce that 
spending in 2020 by 6 percent and the average-bid option would reduce 
that spending by 2 percent, CBO estimates.

  Net federal spending on Medicare Part A and B benefits for 
affected beneficiaries includes amounts that would be paid for hospital 
and medical benefits provided by the FFS program and private plans 
under current law and the premium support options, but excludes net 
spending for dual-eligible beneficiaries, Part D benefits, and certain 
items and services that are not covered by the bids of Medicare 
Advantage plans under current law. Beneficiaries' premiums and other 
offsetting receipts are subtracted from that amount to arrive at net 
spending. The second-lowest-bid option would reduce such spending in 
2020 by 11 percent and the average-bid option would reduce such 
spending by 4 percent, CBO estimates. Those percentages are larger than 
the percentages for total Medicare spending because the savings are 
measured relative to the portion of Medicare spending that would be for 
the beneficiaries who are directly affected by the premium support 
system rather than to total Medicare spending.

Federal savings under either option would be substantially lower over 
an extended period if all current beneficiaries stayed in the existing 
Medicare system and only new enrollees participated in the premium 
support system.

The savings to the federal government would stem, in part, from greater 
price competition. Because all plans would offer a basic benefit 
package covering the same services and having the same actuarial value 
and because the government's contribution within a region would not 
vary from plan to plan (except to adjust for differences in the health 
status of enrollees), the full difference between plans' bids would be 
reflected in the premiums that enrollees would pay. Thus, the two 
options would generate more price competition among private insurers 
than would be the case under current law, which would induce insurers 
to offer plans with lower premiums as a way to attract more enrollees. 
To reduce premiums, private insurers could, for example, strengthen 
utilization management (which insurers use to control costs by 
influencing the quantity and type of services provided) or tighten 
provider networks (that is, limit the number of providers to be covered 
by a plan). In most regions, the benchmark would be lower under the 
second-lowest-bid option than under the average-bid option, so the 
federal contribution for a plan with a given bid would be lower, and 
the premium would be higher under the second-
lowest-bid option.

Heightened price competition would probably restrain the growth of 
Medicare spending over the long term by curtailing demand for costly 
new technologies and treatments and by boosting demand for technologies 
that reduced costs--although the magnitude of any such changes is 
highly uncertain. Those effects on the growth of spending would be 
larger under the second-lowest-bid option than under the average-bid 
option, CBO anticipates, because the higher premiums under the second-
lowest-bid option would cause a larger fraction of beneficiaries to 
choose private plans with lower bids.

Under current law, the growth of Medicare spending will be restrained 
in other ways during the next two decades, thus limiting the potential 
for the government to realize further savings from a premium support 
system. For example, updates to Medicare's payment rates for most 
providers in the FFS program are generally scheduled to be smaller than 
the increases in the costs of their inputs (such as labor and 
equipment), and the federal government has broad authority under 
current law to make regulatory changes to expand demonstration projects 
that successfully reduce spending for Medicare. How effective the 
various incentives and possible administrative actions under current 
law ultimately will be at restraining growth in spending, however, is 
not known.

CBO estimates that the rate of growth in Medicare spending in the 2020s 
under the two premium support options would be similar overall to the 
rate under current law. Thus, the estimated savings relative to current 
law would be roughly the same in percentage terms throughout that 
period as in 2020, although the dollar amount of the savings would 
increase. That estimate is subject to considerable uncertainty but, in 
CBO's judgment, lies in the middle of the distribution of possible 
outcomes. Beyond the next two decades, the federal savings from the 
premium support system would probably increase slightly in percentage 
terms, but CBO has not quantified the amounts because the uncertainties 
are even greater for that longer period.

How Would the Premium Support Options Affect Beneficiaries' Premiums?

CBO estimates that the premiums that affected beneficiaries would pay 
for Medicare Part A and B benefits under the second-lowest-bid option 
in 2020 would be about 30 percent higher, on average, than the current-
law Part B premium projected for that year. CBO expects that much of 
the increase would occur because many beneficiaries would remain in the 
FFS program and pay much higher premiums than would be the case under 
current law. Two-fifths of the beneficiaries who chose the FFS program 
would spend at least 6 percent of their household income on premiums 
for each beneficiary, CBO estimates. (For comparison, CBO estimates 
that under current law about one-fifth of FFS enrollees would do so.)

In contrast, under the average-bid option, affected beneficiaries would 
pay premiums that were 6 percent lower, on average, than the current-
law Part B premium in 2020. Because of the higher federal contribution, 
premiums would be substantially lower under the average-bid option than 
they would be under the second-
lowest-bid option. The impact of either option on premiums would vary 
geographically, depending on regional differences in plans' bids.

Because CBO estimates that total Medicare spending would be reduced 
under either option, and the standard premium would equal the same 
share of spending that the Part B premium equals under current law, the 
standard premium under either premium support option would be lower 
than the current-law Part B premium. In each region, beneficiaries 
would be offered at least one plan at or below the standard premium 
(given the manner in which the regional benchmarks would be 
calculated), and in most cases, at least one plan with a premium that 
is below (not just at) the standard premium would be offered, CBO 
anticipates. Beneficiaries who chose such a low-cost plan would pay a 
lower premium than they would under current law. (Beneficiaries subject 
to the income-related premium under current law--that is, the 
additional Part B premium required of beneficiaries whose income 
exceeds specified thresholds--would still be required to pay that 
additional amount.)

Under both options, most beneficiaries who wanted to remain in the FFS 
program would face higher premiums than they would for private plans. 
In addition, in many regions, the bid for the FFS program would exceed 
the benchmark, so beneficiaries who chose to remain in the FFS program 
would pay higher premiums than they would under current law. Although 
many beneficiaries would switch to lower-
bidding private plans, CBO estimates, a substantial proportion of 
beneficiaries would still prefer to remain in the FFS program.

 How Would the Premium Support Options Affect Beneficiaries' Total 
                    Payments for Medicare Services?

CBO's analysis of beneficiaries' total payments focuses on premiums and 
out-of-pocket costs for deductibles, copayments, and coinsurance for 
Medicare's Part A and B benefits for affected beneficiaries. The 
analysis accounts for the loss of the federally subsidized supplemental 
benefits that enrollees in Medicare Advantage plans would receive under 
current law (projected to average about $400 per enrollee annually in 
2020), which would not be available under the options analyzed here. In 
2020, beneficiaries' total payments would be about 11 percent higher, 
on average, under the second-lowest-bid option and about 6 percent 
lower, on average, under the average-bid option than they would be 
under current law (see Table 2).

Under the second-lowest-bid option, the premiums that beneficiaries 
would pay generally would be higher than current-law premiums, but out-
of-pocket costs generally would be lower than under current law because 
more beneficiaries would enroll in lower-bidding private plans, which 
would tend to reduce the total costs of care while maintaining the 
required actuarial value. The lower out-of-pocket costs would offset 
part, but not all, of the increase in premiums. (On average, according 
to CBO's estimates, out-of-pocket costs would account for a higher 
share of beneficiaries' total payments than premiums would, but under 
the second-lowest-bid option, they would decline by a smaller 
percentage than premiums would increase relative to amounts under 
current law.)

Under the average-bid option, the estimated reduction in beneficiaries' 
total payments results from the combination of lower average premiums 
and lower out-of-pocket costs. As with the second-lowest-bid option, 
the difference in out-of-pocket costs would be attributable primarily 
to increased enrollment in lower-bidding private plans.

Under both options, the change in total payments for particular 
beneficiaries could differ markedly from the national average. For 
example, those who chose to remain in the FFS program would generally 
face higher premiums and would not see a reduction in out-of-pocket 
costs.

 How Would the Premium Support System Affect Combined Spending by the 
                    Government and by Beneficiaries?

The sum of net federal spending for Medicare and beneficiaries' total 
payments as discussed above would be about 5 percent lower in 2020 
under the second-lowest-bid option than under current law, CBO 
estimates. Under the average-bid option, combined payments would be 
about 4 percent lower than under current law. The estimated effects 
under both options are measured as a percentage of projected net 
federal spending and beneficiaries' total payments for benefits covered 
by Parts A and B, in each case focusing on the beneficiaries who would 
be affected by the premium support system. The second-lowest-bid option 
would yield slightly more savings overall than would accrue from the 
average-bid option because the smaller federal contribution under the 
second-lowest-bid option would increase competitive pressure. The 
federal savings under the second-lowest-bid option would be much larger 
than those under the average-bid option, but beneficiaries' payments 
would be higher.

 What Are the Implications of a ``Grandfathering'' Provision in a 
                    Premium Support System?

Under some premium support proposals, all beneficiaries who became 
eligible for Medicare before the system took effect would remain in the 
current-law Medicare program and only those who became eligible after 
that time would enroll in the premium support system. Such an 
arrangement would substantially reduce federal savings relative to a 
system without a grandfathering provision--for an extended period--
because, in the early years, only a small portion of the Medicare 
population would be covered under the new system. Moreover, because 
newly eligible beneficiaries entering the system would have health care 
costs that were lower than the average for Medicare beneficiaries as a 
group, the potential savings would be limited even more.

CBO estimates that if a premium support system began in 2018 and 
existing Medicare beneficiaries remained in the current system, only 
about 25 percent of the Medicare population would be covered under the 
new system after five years (assuming dual-eligible beneficiaries were 
excluded), and those beneficiaries would account for only about 15 
percent of net Medicare spending in total for that year under current 
law (including spending for dual-eligible beneficiaries and for Part 
D). After 10 years, about 45 percent of the Medicare population would 
be covered, accounting for about 30 percent of net Medicare spending in 
total.

Although in order to simplify the modeling, CBO decided for this 
analysis not to consider grandfathering provisions, the agency expects 
to complete such a study soon. A very rough approximation (made on the 
basis of the estimated share of Medicare spending that would be covered 
each year) suggests that federal savings after five years of operation 
under a system with grandfathering would be about 15 percent of the 
savings achieved if all beneficiaries other than those with dual 
eligibility entered the new system in 2018; after a decade, about 30 
percent of those savings would be realized.

Thus, the cumulative savings would be substantially less than would be 
possible if all beneficiaries entered a premium support system 
immediately. Grandfathering also would reduce, for an extended period, 
the incentives to modify the development and adoption of new 
technologies, so the restraint in the growth of Medicare spending that 
would probably occur under a premium support system would be 
substantially smaller for many years.

 What Key Specifications of a Premium Support System Would Affect 
                    Federal Spending and Beneficiaries' Payments?

On the basis of its preliminary analysis, CBO identified several 
important features of premium support proposals that would 
significantly affect federal spending and beneficiaries' payments:

  A smaller federal contribution would yield greater federal 
budgetary savings; on average, beneficiaries' premiums would be higher, 
however.

  Including the FFS program as a competing plan would boost 
federal savings, both because the rates the program pays providers 
(which generally are below rates paid by commercial plans) would serve 
to hold down the rates paid by competing private insurers and because 
in some regions the FFS program would be the 
lowest-bidding plan and therefore could lower the benchmark relative to 
what it would be otherwise.

  Excluding some groups of beneficiaries from the premium support 
system--say, people born before a particular year or dual-eligible 
beneficiaries--would reduce federal savings; however, including certain 
groups could pose additional challenges for administering the system 
and could have unintended consequences for members of those groups. 
(Dual-eligible beneficiaries, for example, might face limited provider 
networks and complex issues of care coordination.)

  Features that make beneficiaries more responsive to differences 
in premiums would boost enrollment in plans with lower bids and thus 
increase the incentive for plans to submit lower bids.

Many other aspects of a premium support system also would significantly 
affect federal spending and enrollees' payments. CBO will continue to 
develop its capacity to estimate the effects of varying those features.

 Two Illustrative Options for a Premium Support System for Medicare

In designing a premium support system for Medicare, lawmakers would 
confront many choices affecting federal costs, beneficiaries' payments, 
and, perhaps, beneficiaries' access to care and the quality and nature 
of the care that they would receive--both in the short term and over 
the longer term. To project the potential effects of such a system, CBO 
developed detailed illustrative specifications regarding eligibility 
for the program and the timing of its implementation, the structure of 
the market for Medicare benefits, and the determination of federal 
contributions and beneficiaries' payments.

CBO analyzed two illustrative options, both of which would require 
insurers to submit bids specifying the payment they would accept to 
provide a basic package of Medicare benefits for an enrollee of average 
health. Under each option, the federal contribution toward 
beneficiaries' health care costs would be determined on the basis of a 
benchmark set for each region of the country. The two options differ in 
that under the first, determination of the benchmark would involve the 
second-
lowest bid in each region; under the second, the benchmark would be set 
on the basis of a weighted average of bids in the region. For this 
analysis, CBO adopted a variant of the second-lowest-bid approach that 
is similar to those included in several recent proposals.\1\ Under such 
an approach, the benchmark would equal the lower of two bids: the 
second-lowest bid from a private insurer and Medicare's FFS bid. Thus, 
in any region, the benchmark could be no higher than the bid of the FFS 
program. (For a summary of the program's operations under the second-
lowest-bid option, see Figure 1. The operations under the average-bid 
option would be the same except for the determination of the 
benchmark.)
---------------------------------------------------------------------------
    \1\ See House Committee on the Budget, The Path to Prosperity: A 
Responsible Balanced Budget: Fiscal Year 2014 Budget Resolution (March 
2013), http://go.usa.gov/bAAV (PDF, 7 MB); Pete Domenici and Alice 
Rivlin, Domenici-Rivlin Protect Medicare Act (Bipartisan Policy Center, 
June 2012), http://tinyurl.com/nherwb4; and Ron Wyden and Paul Ryan, 
Guaranteed Choices to Strengthen Medicare and Health Security for All: 
Bipartisan Options for the Future (House Committee on the Budget, 
December 15, 2011), http://go.usa.gov/bAsz.

Medicare would continue to be divided into Parts A, B, and D under both 
options, and financing for federal outlays would come mostly from the 
---------------------------------------------------------------------------
same sources as under current law (see Box 1).

The specifications outlined in this report are not recommendations. 
Some were chosen to illustrate the potential for savings from a premium 
support framework; others were chosen for feasibility of implementation 
or to simplify the modeling approach. Many other variants of these 
options are possible. (For additional discussion, see the section 
``Implications of Key Specifications and Alternatives.'')

Eligibility and Timing

CBO assumed that dual-eligible beneficiaries would be excluded from the 
premium support system and that gross federal spending for their health 
care would continue as it would if current law remained in place. (In 
2009, those beneficiaries made up 19 percent of the Medicare population 
and accounted for 29 percent of total spending for Medicare's Part A 
and Part B benefits.) \2\ CBO made that assumption because of the 
additional complexity of specifying how the system would work if such 
beneficiaries were included, although alternative systems could be 
designed to include them. CBO did not make any explicit assumptions 
about the system of care that would be in place for dual-eligible 
beneficiaries, and it assumed that their exclusion from the premium 
support system would not affect the number of Medicare beneficiaries 
who enrolled simultaneously in Medicaid.
---------------------------------------------------------------------------
    \2\ See Congressional Budget Office, Dual-Eligible Beneficiaries of 
Medicare and Medicaid: Characteristics, Health Care Spending, and 
Evolving Policies (June 2013), www.cbo.gov/publication/44308.

Everyone else who was enrolled in Medicare when the premium support 
program took effect in 2018 would enter the new system at once, and 
people who reached eligibility after 2018 (other than dual-eligible 
beneficiaries) would enter the new system when they became eligible. 
The Medicare Advantage program would not be available as an option 
after 2017 for beneficiaries in the premium support system.

The Structure of the Market for Medicare Benefits

CBO made several assumptions about the structure of the market for 
Medicare coverage, including the required scope of benefits, the 
bidding process, and the process by which beneficiaries would choose a 
plan.

Scope of Benefits. Under each premium support option, insurers would 
offer a basic package of benefits with services and an actuarial value 
that matched those provided by Medicare's FFS program under Parts A and 
B. CBO assumed that hospice services and certain services provided to 
beneficiaries with end-stage renal disease would not be included in the 
basic benefit package and that spending for those services would 
continue as it would under current law. Those services were excluded so 
that the plans' benefits would be identical to those that are included 
in the bids of Medicare Advantage plans under current law. That 
assumption simplified CBO's modeling.

Insurers would be permitted to offer an additional package with 
enhanced benefits, however, and would submit separate bids for 
providing prescription drug benefits through Medicare's Part D, as 
under current law. Enrollment in Part D would remain voluntary.

Bids. To simplify the choices for beneficiaries (and thereby heighten 
competition based on differences in premiums), private insurers would 
be allowed to submit bids for just one or two plans for the basic 
Medicare package in each region. (The two plans could have different 
features--offering a larger or smaller provider network, for example--
but both would need to have the same actuarial value.) Insurers would 
submit bids reflecting their costs for a combined package of Part A and 
Part B benefits (as insurers do for Medicare Advantage) and not 
separate bids for Parts A and B. Bids would be the amount that insurers 
would charge to provide care for a beneficiary of average health. 
Insurers also could offer one package of enhanced benefits (with a 
single, fixed higher actuarial value that would be the same for all 
insurers) to go along with each basic package offered. Enrollees would 
pay the full additional cost of the enhanced packages through higher 
premiums. Under such rules regarding packages with enhanced benefits, 
beneficiaries would find it easier to compare plans, and thus 
competition would be heightened.

Bidding Regions. Regional boundaries would be determined by the 
government and designed to coincide with health care markets within 
states. Regions would be the same for all prospective bidders, and 
insurers would be required to serve the entire regions for which they 
submitted bids.

Fee-for-Service Medicare. Medicare's FFS program would act as a 
competing plan. Its bid in each region would be based on the amount it 
would cost the program in that region to provide care for a beneficiary 
with average health as projected by the Medicare program. Support for 
disproportionate-share hospitals (whose share of low-income patients 
exceeds a specified threshold) and spending for medical education, 
hospice benefits, and certain benefits for patients with end-stage 
renal disease would be excluded from that projection. CBO assumed that 
such spending would continue outside the premium support system at the 
amounts projected under current law. The government's administrative 
costs for the FFS program, however, would be included in the bid. The 
FFS program would be required to maintain a contingency reserve fund 
equal to a specified percentage of projected expenses, and if the 
program's actual expenses differed from its projected expenses, future 
bids would be adjusted to maintain adequate reserves. CBO assumed that 
there would be no changes to current law concerning either the 
mechanisms for setting the rates paid to providers or the tools 
available to the FFS program to help it contain costs. As under current 
law, enrollees in the program could purchase supplemental (medigap) 
coverage from private insurers. CBO assumed that the same standard 
medigap plans that are currently available would be available under the 
two premium support options.

Coverage for Retirees. CBO assumed that employers and unions that 
provide coverage for retirees who are Medicare beneficiaries would make 
cash payments to their retirees to be applied toward the purchase of a 
basic package offered in the bidding region, an enhanced-benefit 
package (on top of a basic package) from any of the private plans in 
that region, or supplemental coverage for the FFS program. In that way, 
the choices of beneficiaries with retiree coverage would be the same as 
those of other beneficiaries, and they would have no additional 
incentives to select a particular plan (as typically occurs now when 
employers pay part of the premium if retirees enroll in a plan offered 
by the employer). CBO assumed that the premium support system would be 
implemented so as to not affect the percentage of beneficiaries with 
retiree coverage. Those assumptions simplified CBO's modeling.

Requirement Regarding Issuance. Insurers would be required to issue 
insurance to all Medicare beneficiaries who applied and to charge the 
same premium for all enrollees in a particular plan within a bidding 
region.

Plan Selection. Beneficiaries would receive information about premiums, 
cost sharing, and other plan attributes to help them compare plans. 
Enrollees would choose a plan during an annual enrollment period and 
would be required to remain in that plan for a year. Once beneficiaries 
chose a plan, they would automatically remain in that plan in 
subsequent years unless they chose a different one.

Initial Choice. Beneficiaries would not automatically remain in their 
current plan when the premium support system began in 2018. In 2018 and 
later years, beneficiaries who entered the premium support system and 
did not make an affirmative choice for enrollment would be assigned 
(with equal probability) to plans that presented bids at or below the 
benchmark, including the FFS program if it met that criterion. (If more 
than four plans in a region did so, beneficiaries would be assigned to 
one of the four lowest-bidding plans.) After their first year in the 
system, beneficiaries who were initially assigned to a plan would 
remain in that plan unless they chose a different plan during a future 
enrollment period or the plan to which they were assigned was no longer 
one of the lowest-bidding plans in their region (in that case, the 
beneficiaries would be assigned to one of the new low-bidding plans in 
their region). Beneficiaries who had been assigned to a plan and then 
subsequently chose another plan, as well as beneficiaries who 
affirmatively chose a plan when they entered the premium support 
system, would remain in that plan in subsequent years unless they chose 
a different one.

Enrollment in Part A and Part B. For this analysis, CBO assumed that 
enrollment in Part B would remain voluntary and that beneficiaries with 
coverage under Part A or Part B (or both) could enroll in any plan 
within a bidding region. Federal payments to plans for enrollees with 
Part A coverage only would be reduced proportionately on the basis of 
the share of total Medicare spending nationally for Part A services, 
and federal payments to plans for people covered under Part B only 
would be reduced in a similar manner.\3\
---------------------------------------------------------------------------
    \3\ That approach to enrollment of beneficiaries who are not 
enrolled in both Parts A and B of Medicare was adopted to simplify the 
modeling for this analysis. In fact, including such beneficiaries in a 
premium support system would raise complex issues that are not 
addressed in this report.
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Federal Contributions and Beneficiaries' Payments

CBO also made assumptions about the determination of the amounts the 
federal government would pay insurers for providing Medicare coverage 
and the amounts beneficiaries would pay for that coverage under the 
illustrative premium support options.

Federal Contributions and Risk Adjustment. The benchmarks for setting 
the federal contribution would be based on the bids for the basic 
package of benefits. A benchmark would be calculated in each bidding 
region for a beneficiary of average expected health. For each enrollee 
of average health, the federal government would pay insurers an amount 
that was equal to the regional benchmark minus the standard premium. To 
compensate for a higher or lower cost implied by an individual 
beneficiary's ``risk score,'' insurers would receive a larger or 
smaller payment for a beneficiary whose health was worse or better than 
average--as is the case under current law for Medicare Advantage and 
Part D.\4\ Neither the amount nor the rate of growth in federal 
payments would be capped.
---------------------------------------------------------------------------
    \4\ CBO assumed that a risk adjustment mechanism comparable to that 
used for the Medicare Advantage program would be used for a premium 
support system. That mechanism assigns each beneficiary a risk score, 
based on the person's medical conditions and demographic 
characteristics, that represents the expected spending in the FFS 
program relative to the national average for the Medicare population. A 
beneficiary with a risk score of 1.0 has average expected spending. To 
simplify the discussion, this report refers to beneficiaries with risk 
scores that are less than or greater than 1 as being in better or worse 
than average health--although personal characteristics other than 
health also influence spending for Medicare services.

Beneficiaries' Payments. Medicare beneficiaries who joined plans with 
bids that equaled the regional benchmark and were enrolled in Parts A 
and B would pay the insurer a standard premium, which would be set at 
25 percent of total costs for covered services in Part B (physicians' 
services, hospital outpatient care, durable medical equipment, and 
other services, including some home health care)--using the same 
formula as that for the standard Part B premium under current law. The 
premium for beneficiaries with Part A coverage only would be 
proportionately smaller than the standard premium based on the share of 
total Medicare spending nationally for Part A services (about half); a 
similar calculation would be used to set the premium for enrollees in 
---------------------------------------------------------------------------
Part B only.

Beneficiaries who joined plans with bids that were higher than the 
benchmark would pay the insurers the standard premium plus the 
difference between the bid and the benchmark. Those who selected plans 
below the benchmark would pay the insurers the standard premium minus 
the difference between the benchmark and the bid. In contrast to the 
rules for the current Medicare Advantage program, insurers with bids 
below the benchmark could not use such differences to enhance benefits 
or reduce premiums for Part D prescription drug insurance and the 
result would be heightened competition based on differences in premiums 
for the basic benefit package.

For the most part, premiums would be paid directly to insurers, as is 
generally the case for Part D, rather than withheld from Social 
Security benefits, as is generally the case under current law for Parts 
A and B. Income-related premiums for Part B specified in current law 
would continue and would be withheld from Social Security benefits.

Hypothetical Examples of Determining Premiums

Several examples show how premiums would be determined under the 
illustrative premium support options considered here. The hypothetical 
bids for regions with high and low levels of FFS spending per 
beneficiary are roughly consistent with the bids CBO has projected for 
such regions under the two options. In regions where FFS spending is 
high, premiums under the second-lowest-bid option would generally be 
higher than those under the average-bid option because the benchmark 
would be set at a low bid rather than at the average bid, and low bids 
would be much lower than the average bid. In regions where FFS spending 
is low, the low bids and the average bid would be closer and premiums 
under the two options would be more similar.

The Second-Lowest-Bid Option. Consider a region with high FFS spending 
in which the FFS program's bid in 2020 was $14,000 and the bids from 
the region's five private plans were in the range of $11,000 to $11,800 
(see Table 3). Under the second-lowest-bid option, the regional 
benchmark would be $11,200, equal to the bid of the second-lowest-
bidding private plan. The annual premium for enrollees in that plan 
would be $1,500, the standard premium nationwide. Premiums for the 
other plans would differ from that amount depending on how the bids 
compared with the benchmark. Because the FFS bid would be $2,800 more 
than the benchmark, the premium for FFS enrollees would be $4,300 
($1,500 plus $2,800). The annual premium for the lowest-bidding private 
plan would be $1,300.

Next, consider a low-spending region in which the FFS program's bid was 
$9,900 and the bids of the five private plans ranged from $9,300 to 
$10,100. The regional benchmark would equal that of the second-lowest-
bidding private plan ($9,500), and enrollees in that plan would pay the 
standard premium of $1,500. Because the bid of the FFS program would be 
$400 more than the benchmark, FFS enrollees would pay an annual premium 
of $1,900.

The Average-Bid Option. Consider again the high-spending region in 
which the FFS bid was $14,000. The private plans' bids would be 
slightly higher in this region--ranging from $11,200 to $12,000--
because the share of income that beneficiaries would spend on premiums 
would be lower, on average, thus reducing the sensitivity of 
beneficiaries' choice to differences in premiums and reducing 
competition among plans to lower bids. As a simple example, assume 
that, in the previous year, 25 percent of the people in the region 
enrolled in the FFS program and 75 percent enrolled in private plans, 
with an equal number enrolled in each private plan. Then the benchmark 
(the enrollment-weighted average bid) would be $12,200. Under this 
option, the standard premium would be $1,500 nationwide. Because the 
FFS program's bid would be $1,800 more than the benchmark, the FFS 
premium would be $3,300. The annual premium for the lowest-bidding 
private plan would be $500 because that plan's bid would be $1,000 less 
than the benchmark.

Finally, consider the low-spending region in which the FFS program's 
bid would be $9,900. The bids of private plans would be about the same 
as that for the second-lowest-bid option in this region, ranging from 
$9,500 to $10,300. Assume that, because FFS spending is low, in the 
previous year 75 percent of the region's beneficiaries enrolled in the 
FFS program and 25 percent enrolled in private plans, with an equal 
number enrolled in each private plan. The benchmark would be the 
enrollment-weighted average bid of $9,900. Because the FFS bid would be 
the same as the benchmark, the FFS premium would be the standard 
premium of $1,500. The annual premium for the lowest-bidding private 
plan would be $1,100.

Comparison With the Current Medicare Program

Although some aspects of a premium support system would make it similar 
to the current Medicare program, there also would be significant 
differences. Under both illustrative options analyzed here, insurers 
would be required to provide a benefit package that encompassed the 
same services that were covered under Parts A and B of Medicare (with 
the few exceptions noted above) and that had the same actuarial value 
as Parts A and B combined. However, under both options, the federal 
contribution per beneficiary in each bidding region would be determined 
prospectively each year on the basis of the bids submitted by 
participating insurers. In contrast, except for Part D, federal 
spending for Medicare under current law is either on a fee-for-service 
basis or, in the case of Medicare Advantage enrollees, is tied to 
spending in the FFS program.

Under current law, the premium paid by enrollees in the FFS program is 
the same regardless of where a beneficiary lives. That premium has two 
components, both for enrollment in Part B: the standard amount 
(referred to in this report as the Part B premium), and the income-
related amount. Under either illustrative option, by contrast, the FFS 
program would be one of the bidders, and its premium would vary by 
region depending on how its bid compared with the benchmark.

Although the current Medicare Advantage program is similar in some ways 
to a premium support system, several features limit the extent of price 
competition among private insurers, and the FFS program is not a bidder 
in Medicare Advantage. For example, benchmarks for Medicare Advantage 
(which determine the maximum federal payment for an enrollee) are set 
by law as a specified percentage of the average FFS spending in a given 
county and are announced before insurers submit bids (see Box 1).\5\ In 
contrast, benchmarks for the premium support options would be 
determined from plans' bids. Another difference concerns the incentives 
offered to beneficiaries to enroll in plans with lower bids. Under 
Medicare Advantage, beneficiaries who enroll in a plan with a bid below 
the benchmark receive some of the difference between the two, generally 
in the form of additional benefits. Under the two premium support 
options, by contrast, beneficiaries who enrolled in a plan with a bid 
below the benchmark would receive the entire difference between the two 
in the form of a lower premium.
---------------------------------------------------------------------------
    \5\ This description reflects the method of determining Medicare 
Advantage benchmarks that will be fully phased in by 2017. The 
benchmark for each county will be set at a specified share (ranging 
from 95 percent to 115 percent) of local FFS costs.
---------------------------------------------------------------------------

Effects on Federal Spending

Projecting the effects of a premium support system in the first several 
years after implementation is difficult, given the substantial changes 
to the Medicare program that such a system would entail, the lack of 
historical experience with similar systems, the rapid evolution of 
health care and health insurance, and the significant changes in the 
Medicare program occurring under current law. (For additional details 
about the methods used in the analysis, see Appendix A.) Projections 
are even more uncertain for the period following the first several 
years of implementation. One reason is that growth in Medicare 
spending--and for health care more generally--has slowed markedly over 
the past several years, although it is not clear how much of the 
slowdown is attributable to persistent changes in the health care 
system.\6\ Moreover, spending for Medicare is projected to be 
restrained by provisions of the Affordable Care Act that will change 
the ways and amounts that health care providers and insurers are 
paid.\7\ The implications of those changes for long-term growth in 
Medicare spending are difficult to assess, thus adding to the 
uncertainty concerning the difference in spending that might occur as a 
result of policy changes--including the adoption of a premium support 
system.
---------------------------------------------------------------------------
    \6\ See Michael Levine and Melinda Buntin, Why Has Growth in 
Spending for Fee-for-Service Medicare Slowed? Working Paper 2013-06 
(Congressional Budget Office, August 2013), www.cbo.gov/publication/
44513.
    \7\ The Affordable Care Act comprises the Patient Protection and 
Affordable Care Act and the health care provisions of the Health Care 
and Education Reconciliation Act of 2010.
---------------------------------------------------------------------------

Effects in the First Several Years

CBO assumed that the premium support system would be implemented in 
2018. This analysis reflects the assumption that dual-eligible 
beneficiaries would be excluded from the premium support system and 
that federal spending for their health care would continue as projected 
under current law. Everyone else enrolled in Medicare in 2018 would 
enter the new system in that year, and people who became eligible for 
Medicare subsequently (other than dual-eligible beneficiaries) would 
enter the new system. For this analysis, CBO chose 2020 as an 
illustrative year shortly after implementation for which to report 
results about federal spending. Additional information--both about the 
bids of private plans and about the uncertainty in the estimates--
provides context for understanding those results.

In 2020, the second-lowest-bid option would reduce net federal spending 
for Medicare by about $45 billion, or 6 percent, from the approximately 
$700 billion projected under current law, CBO estimates (see Figure 2). 
The average-bid option would reduce net spending in that year by about 
$15 billion, or 2 percent, the agency estimates.\8\ Those percentage 
savings were estimated relative to net federal spending on all services 
covered by Parts A, B, and D, including spending on benefits for dual-
eligible beneficiaries. (The estimated savings in percentage terms were 
generated using CBO's March 2012 baseline projections of Medicare 
spending--because the agency's work on the estimates in this report 
began in earnest in early 2012--and the estimated savings in dollar 
terms were obtained by applying the percentages to the agency's latest 
baseline projections of Medicare spending, which were released in May 
2013.) \9\
---------------------------------------------------------------------------
    \8\ This analysis presents estimated changes in net federal 
spending because the allocation of financial flows to the budget 
categories of gross outlays and offsetting receipts would differ from 
those under current law in complicated ways. The two options would 
eliminate withholding of basic premiums from Social Security benefits; 
instead, beneficiaries would pay the basic premium directly to a plan. 
The reduction in gross spending attributable to that change in the way 
premiums were collected would be accompanied by a corresponding 
reduction in the government's collections of offsetting receipts. 
However, the proposals also would establish a new source of offsetting 
receipts consisting of the premiums paid by beneficiaries who enrolled 
in the FFS program--that is, the basic premiums plus the amount by 
which the FFS program's bid exceeded the benchmark (or minus the amount 
by which the benchmark exceeded the FFS program's bid).
    \9\ See Congressional Budget Office, ``Medicare--March 2012 
Baseline'' (March 13, 2012), www.cbo.gov/publication/43060, and 
``Medicare--May 2013 Baseline'' (May 14, 2013), www.cbo.gov/
publication/44205.

The second-lowest-bid option would reduce net federal spending on Parts 
A and B of Medicare in 2020 by about 11 percent for beneficiaries who 
would be affected and the average-bid option would reduce such spending 
by about 4 percent, CBO estimates. Those savings are larger than the 
savings for net federal spending on all of Medicare because the amount 
of spending to which the savings are compared is restricted here to 
include only the beneficiaries and the portions of Medicare that would 
be covered by the new system. (The ratios of the two estimates for each 
premium support option are nearly identical, and the difference 
reported here is attributable primarily to rounding.) \10\
---------------------------------------------------------------------------
    \10\ The ratios also differ because of small effects on net 
spending for dual-eligible beneficiaries. Although CBO assumed that 
gross federal spending for dual-eligible beneficiaries would not 
change, net spending would increase by a small amount relative to that 
under current law because premiums for dual-eligible beneficiaries 
would decrease. Those premiums would be linked to total Part B spending 
in Medicare, which would decline under the premium support options.

For either option, during the first several years of a premium support 
system, Medicare savings would be similar in percentage terms to the 
savings estimated for 2020, with one main exception. Under the average-
bid option, the federal savings estimated for 2018 would be much 
smaller than the amount estimated for 2020 in percentage terms because 
the FFS bid would receive a greater weight in constructing benchmarks 
in the first year of the new system than it would in later years. (CBO 
assumed that the weight would equal the proportion of enrollment in the 
FFS program under current law in 2017.) Thus, under the average-bid 
option, most regions would have higher benchmarks in 2018 than they 
---------------------------------------------------------------------------
would later.

Federal savings would be greater under the second-lowest-bid option 
than under the average-bid option because the benchmarks that determine 
the federal contribution would be lower. Under either option, CBO 
projects, the benchmarks in most regions would be lower than the FFS 
program's bid.

Although federal costs would decrease if more people declined Medicare 
coverage under either option than did so under current law, CBO 
projects that few people would do so. Beneficiaries would have plans 
available that cost less than, or about the same as, Medicare under 
current law. Also, beneficiaries who did not actively choose a plan 
would be assigned to one, and CBO expects that few would choose to drop 
out of the Medicare program rather than remain in an assigned plan for 
the required one-year period.

Effects on Private Plans' Bids. The options' effects on federal 
spending would be determined in part by how they influenced the bids of 
private plans. Various factors, such as competition and the reduced 
importance of the administratively determined payment rates of the FFS 
program, would affect the bids that determined the benchmarks. CBO used 
its projection of the bids that Medicare Advantage plans would submit 
under current law as a starting point in estimating the bids of private 
insurers under premium support. On net, CBO's analysis indicates that 
private insurers' bids in 2020 under the two options would be below the 
current-law bids for Medicare Advantage by about 4 percent, on average, 
and that the differences between those types of bids would vary 
regionally. That outcome would be the net result of different types of 
downward and upward pressures on bids.

On the one hand, CBO expects, both options would create more 
competitive pressure than the Medicare Advantage program, encouraging 
insurers to reduce their costs (primarily by constraining the volume 
and intensity of health care services provided and to a lesser extent 
by reducing administrative costs and profits) and thus to be able to 
lower their bids. The greater competition relative to the current 
Medicare program would arise because insurers with lower bids would 
expect to achieve larger increases in enrollment, because more Medicare 
beneficiaries would choose plans affirmatively and those beneficiaries 
would face larger differences in premiums among different plans. The 
specification adopted for this report that insurers could submit no 
more than two bids for the basic benefit package per bidding region 
also would increase competitive pressure to submit lower bids, in CBO's 
view. (Under the Medicare Advantage program, insurers often submit more 
than two bids in their service areas.) Given the competitive structure 
of the two premium support options, CBO expects that restricting 
insurers to a maximum of two bids would cause insurers to eliminate 
some of the higher-bidding plans that would exist under the current-law 
Medicare Advantage program. Another smaller but notable force also 
would tend to lower private plans' bids: The enrollees in private plans 
would be healthier (on average, after accounting for characteristics 
included in the risk adjustment mechanism) than enrollees in the FFS 
program, and such ``favorable selection'' would occur to a greater 
extent in a premium support system than under current law, CBO expects. 
That relatively greater favorable selection would occur because private 
plans would face greater pressure under premium support to contain 
costs (for example, by narrowing provider networks), and as a result, 
they would be less attractive to beneficiaries who use more health care 
services than do other beneficiaries with the same risk score.

On the other hand, reductions in the share of Medicare beneficiaries 
enrolled in the FFS program would cause private insurers participating 
in a premium support system to pay higher rates to health care 
providers. Two main mechanisms would be at work. First, although the 
rates private insurers pay now under the Medicare Advantage program are 
similar to those for Medicare's FFS program, CBO expects that a lower 
FFS market share would reduce the importance of the FFS program's rates 
in determining how much private insurers would pay providers for 
treating Medicare enrollees. Second, to accommodate an influx of 
enrollees, some private plans might need to expand their networks to 
include health care providers who would be more costly, on average. 
(CBO assumed in this preliminary analysis that all plans would be 
required to serve all beneficiaries who wished to enroll.) The 
resulting payment rates negotiated between insurers and health care 
providers would probably rise toward commercial rates for people under 
age 65 (which, adjusted for differences in average health status by 
age, are generally higher than Medicare's rates), especially where the 
market share of the FFS program declined substantially. However, even 
in areas where the FFS market share would be very low, CBO expects, the 
rates private insurers paid providers for their premium support 
enrollees would be somewhat lower than the rates they would pay for 
commercial enrollees under current law for several reasons: The FFS 
provider payment rates would serve as a reference point for 
negotiations, the competitive structure of a premium support system 
would tend to constrain rates, and the commercial rates existing 
alongside a premium support system would be lower because the extent to 
which relatively low Medicare FFS rates led providers to charge more to 
treat privately insured enrollees would abate as the FFS market share 
declined.

Although CBO projects that bids would be similar under the two premium 
support options, the agency expects that they would be just slightly 
lower under the second-lowest-bid option than under the average-bid 
option because private insurers would have a stronger incentive to bid 
low under the former. However, factors that would tend to increase 
private plans' bids--the reduced importance of the provider payment 
rates in the FFS program and the broadening of provider networks--also 
would be stronger under the second-lowest-bid option than under the 
average-bid option and would partially offset the stronger incentive to 
bid low.

Uncertainty in the Estimates. CBO's estimates of the effects on 
Medicare spending of the two illustrative premium support options 
depend on numerous parameters and other factors used in predicting the 
responses of insurers, health care providers, and beneficiaries--all of 
which are subject to considerable uncertainty. To characterize that 
uncertainty, the agency specified ranges of values for five key 
parameters in its analysis and determined the effects of varying those 
parameters, focusing on estimates for 2020.\11\ The ranges for the 
parameters' values were chosen to represent CBO's judgment that, 
accounting not only for uncertainty about those parameters but for many 
other sources of uncertainty, there would be about a two-thirds chance 
that the effect on federal spending would be within the range reported 
(under an assumption that the premium support system was implemented as 
specified here).
---------------------------------------------------------------------------
    \11\ CBO varied the following parameters to construct the ranges: 
bids of Medicare Advantage plans relative to FFS spending as projected 
under current law, the amount by which private insurers would reduce 
their bids relative to Medicare Advantage bids under current law in 
response to the increased competitive pressure created by the premium 
support system, the higher rates that private insurers would need to 
pay providers (with corresponding increases in bids) that CBO projects 
would result if the market share of the FFS program fell significantly, 
the responsiveness of beneficiaries to differences in premiums when 
choosing among plans, and the percentage of beneficiaries who would not 
actively choose a plan in the first year of premium support and that 
therefore would be assigned to a plan with a bid at or below the 
benchmark.

The results indicate that for the second-lowest-bid option, net federal 
spending in 2020 on Parts A and B for beneficiaries who would be 
covered under the premium support system analyzed would probably be 
reduced by between 9 percent and 14 percent (CBO's central estimate is 
11 percent), and for the average-bid option, federal spending would 
probably be reduced by some amount between 1 percent and 7 percent (the 
central estimate is 4 percent). (See Table 2.) \12\ The range is 
smaller for the second-lowest-bid option mainly because a higher or 
lower proportion of beneficiaries enrolled in lower-bidding plans under 
that option would not directly affect the benchmarks that determined 
the federal contribution. By contrast, spending under the average-bid 
option would be directly sensitive to the fraction enrolled in lower-
bidding plans, and the range of estimates incorporates the greater 
uncertainty from that additional factor. (For additional discussion of 
factors affecting the ranges, see Appendix B.)
---------------------------------------------------------------------------
    \12\ For the second-lowest-bid option, the reported range is not 
symmetric about the central estimate because of rounding.
---------------------------------------------------------------------------

Effects After the First Several Years

After the initial years of a premium support system, the percentage 
savings from either illustrative option would remain roughly constant 
for about a decade, CBO estimates. At that point, heightened price 
competition would probably reduce the growth of Medicare spending over 
the long term relative to that under current law, and that effect would 
probably be larger under the second-lowest-bid option than under the 
average-bid option. However, the longer-term effects are even more 
uncertain than are the short-term effects of a premium support system 
on Medicare spending. And if other health care or health insurance 
policies changed as well, the effects of such a system on spending 
could differ significantly from those presented here.

Effects of the Two Illustrative Options. During the decade following 
the first several years of implementation, CBO expects that the growth 
in bids of private plans under either option would be close to the 
growth in per capita costs in the FFS program under current law, 
contributing to the roughly constant percentage savings over that 
period. Over the longer term, CBO expects that the growth in Medicare 
spending under the options would probably be somewhat less than the 
growth of Medicare spending under current law.

The increased competition created by either option would tend to 
restrain growth in Medicare spending by reducing demand for costly new 
technologies and treatments and by increasing demand for cost-reducing 
technologies. A crucial factor underlying the rise in spending for 
health care in recent decades has been the emergence, adoption, and 
widespread diffusion of new medical technologies and services.\13\ 
Although such advances can sometimes reduce costs, in medicine they and 
the accompanying changes in clinical practice have generally had the 
opposite effect. By strengthening price-based competition in Medicare, 
a premium support system could change that dynamic within the program 
and perhaps in the broader health care system. Moreover, relative to 
outcomes under current law, the potential for cost savings from 
managing utilization and limiting provider networks would be greater 
under a premium support system with a larger share of Medicare 
beneficiaries enrolled in private plans that have the flexibility to 
manage care. The magnitude of that effect is highly uncertain, however, 
and it would take a number of years before it became fully apparent. 
CBO anticipates that the effect on spending would be larger under the 
second-lowest-bid option--because of greater competitive pressure--than 
under the average-bid option.
---------------------------------------------------------------------------
    \13\ See Congressional Budget Office, Technological Change and the 
Growth of Health Care Spending (January 2008), www.cbo.gov/publication/
41665.

However, the provisions of current law that will restrain growth in 
Medicare spending limit the potential for additional savings to result 
from a premium support system. In particular, CBO anticipates, private 
insurers would not be able to hold down payments to health care 
providers to the extent required in the FFS program under the 
sustainable growth rate mechanism for physicians or under the 
provisions of the Affordable Care Act that apply to other providers 
(the consequences of those provisions are discussed below). More 
generally, current law offers incentives to providers and beneficiaries 
to help reduce growth in federal spending, and it allows some 
flexibility for the Centers for Medicare and Medicaid Services in 
managing the program. Beneficiaries' demand for Medicare services will 
be constrained as the program's premiums and cost sharing consume a 
larger portion of their income. For providers, whose updates to 
Medicare's payment rates are generally scheduled to be smaller than the 
increases in the costs of inputs, the pressure to adopt cost-reducing 
procedures and technologies will be significant. Other changes in the 
structure of Medicare payments to providers--such as financial 
incentives to reduce hospital-
acquired infections and readmissions--also might help to constrain 
federal spending.\14\ The Centers for Medicare and Medicaid Innovation, 
like many state Medicaid agencies and private insurance companies and 
providers, is hoping to achieve cost savings by testing promising ideas 
for modifying rules and payment methods and by expanding the use of 
ideas that prove effective.\15\ Whether any of the several 
demonstrations currently in process will succeed and be applied more 
widely is still uncertain.
---------------------------------------------------------------------------
    \14\ For example, see Sarah L. Krein and others, ``Preventing 
Hospital-Acquired Infections: A National Survey of Practices Reported 
by U.S. Hospitals in 2005 and 2009,'' Journal of General Internal 
Medicine, vol. 27, no. 7 (July 2012), pp. 773-779, http://go.usa.gov/
DbQC; and Centers for Medicare and Medicaid Services, ``Readmissions 
Reduction Program,'' http://go.usa.gov/DbQW.
    \15\ A list of ongoing demonstration projects is available at 
Centers for Medicare and Medicaid Services, ``Innovation Models,'' 
http://go.usa.gov/DbQd.

Another factor limiting the potential for cost savings under a premium 
support system is that the Medicare program is required by law to cover 
items and services that are judged to be medically necessary and 
reasonable. Private insurers participating in the premium support 
options analyzed for this report would be required to cover the same 
services as those covered by the FFS program. The options would cause 
less restraint on the development of costly new technologies than would 
be the case if private insurers (or the Medicare program as a whole) 
had the authority to refuse coverage for certain services if, for 
example, less costly alternatives were available that were at least as 
effective. Under the options analyzed in this report, however, private 
insurers would have some flexibility to reduce beneficiaries' use of 
costly services through tools such as utilization management, higher 
cost sharing, and exclusion of providers from an insurer's network on 
the basis of practice style. By contrast, the FFS program does not have 
the authority to apply such methods to influence beneficiaries' use of 
services but, rather, must pay for any services that are used as long 
as they meet Medicare's criteria for coverage. That feature of the FFS 
program would remain in place under the two premium support options and 
might limit the extent to which either option could reduce the growth 
in Medicare spending. (Removing the FFS program as a competitor in the 
premium support system would tend to push up Medicare spending in other 
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ways, as discussed earlier.)

In quantifying the effects of the illustrative premium support options 
relative to outcomes under current law, CBO recognized that current law 
provides for three approaches to restraining cost growth in Medicare 
that could be difficult to sustain over the long term: the ongoing 
reductions in payment updates for most providers in the FFS program, 
the sustainable growth rate mechanism for payment rates for physicians, 
and the process associated with the Independent Payment Advisory 
Board.\16\ It is unclear whether the long-term restraint of Medicare 
spending envisioned to occur through those provisions can be 
accomplished through greater efficiency in the delivery of health care 
or whether it would lead to reductions in beneficiaries' access to care 
or the quality of care they received. Accordingly, CBO's extended 
baseline reflects the assumption that the growth rate of Medicare 
spending after 2029 will not be affected by those provisions but that 
the percentage reduction in Medicare spending in 2029 achieved through 
those provisions will continue in later years.\17\ In the analysis in 
this report, CBO anticipates that beneficiaries will respond to 
concerns regarding access and quality in the FFS program by showing 
some additional preference for private plans relative to the FFS 
program when payment rates for providers in private plans increase 
relative to those paid by the FFS system.
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    \16\ Before the enactment of the Affordable Care Act, payment 
updates for most providers (except for physicians, whose payments have 
been controlled by the sustainable growth rate mechanism since 1998) 
generally were set to equal the estimated percentage change in the 
average cost of providers' inputs. Under current law, however, the 
updates will equal those percentage changes in costs minus the 10-year 
moving average of growth in productivity in the economy overall--a 
measure that seeks to capture, for the economy as a whole, how much 
more output is produced from a given amount of inputs. Under current 
law, payment rates for physicians' services in Medicare will be reduced 
by about 25 percent in January 2014 and, CBO projects, will be 
increased by small amounts in most subsequent years. The Independent 
Payment Advisory Board will be required to submit a proposal to reduce 
Medicare spending in certain years if the rate of growth in spending 
per enrollee is projected to exceed specified targets.
    \17\ For more discussion, see Congressional Budget Office, The 2012 
Long-Term Budget Outlook (June 2012), pp. 56-57, www.cbo.gov/
publication/43288.

Under the assumptions of its extended baseline, CBO anticipates that 
growth in Medicare spending per beneficiary (after removing the effects 
of demographic changes on health care spending--in particular, changes 
in the population's age distribution) would exceed growth in spending 
per beneficiary for all forms of private health insurance combined 
because the private sector has more flexibility to respond to the 
pressures created by rising health care spending than administrators of 
Medicare have under current law. The growth rate of federal spending 
for Medicare under the two illustrative premium support options--which 
involve a mixture of features of Medicare and private health 
insurance--would probably be lower than that for the existing Medicare 
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program but above that for private health insurance.

Uncertainty in the Estimates. Estimates of the longer-term effects of 
the premium support options on Medicare spending are subject to the 
same sources of uncertainty that are described above for the shorter-
term effects, but the magnitude of the uncertainty is increased by the 
longer time horizon. Uncertainty in projecting federal spending for 
Medicare over the long term under current law adds to the uncertainty 
of such estimates.

In particular, CBO's assessment--that the growth rate of federal 
spending for Medicare under the two options would probably be lower 
than that for the existing Medicare program but above that for private 
health insurance--is highly uncertain. It is possible, for instance, 
that over the long term, the bargaining power of health care providers 
relative to private insurers could increase to such an extent that 
spending growth under the options would exceed that for the existing 
Medicare program. Alternatively, private health insurers could be more 
successful than CBO projects in developing processes for delivering 
care in ways that would reduce costs, in which case spending growth 
under the options could be further below that for the existing Medicare 
program than CBO anticipates.

Effects of Modifying the Illustrative Premium Support Options or of 
Combining a Premium Support System With Other Changes to Medicare. The 
longer-term effects of the two illustrative options on Medicare 
spending could differ significantly from the estimates presented here 
if either option was modified or if policies for setting payment rates 
in the FFS program were revised. For example, imposing a cap on federal 
contributions under a premium support system could have an important 
effect on federal savings, and changes in the way provider payment 
rates in the FFS program were set could have complex interactions with 
a premium support system. Although CBO has not estimated the 
consequences of such policies, the following observations provide some 
relevant information.

Effects of a Cap on Federal Contributions. The effects of a cap on 
federal contributions under a premium support system would depend in 
part on how the cap was specified. CBO expects that if a premium 
support system limited the growth rate of federal contributions per 
beneficiary to match the growth of gross domestic product (GDP) per 
capita plus, say, 1.5 percentage points per year, in most years such a 
cap probably would not be binding. Under last year's extended baseline, 
which largely follows current law and which CBO used for the analysis 
in this report, the agency projected that the growth rate of Medicare 
spending per beneficiary between 2020 and 2032 (after adjusting for 
demographic changes) would be, on average, 0.8 percentage points 
greater than the growth rate of GDP per capita.\18\ As a result of the 
offsetting factors just described, CBO estimates that the growth rate 
for Medicare spending during those years under both premium support 
options would be similar to that under current law.
---------------------------------------------------------------------------
    \18\ See Congressional Budget Office, The 2012 Long-Term Budget 
Outlook (June 2012), www.cbo.gov/publication/43288.

A cap of per capita GDP plus 1.5 percentage points could be binding 
regularly, however, if CBO's long-term projection underestimates growth 
in Medicare spending. And that cap could be binding in some years but 
not in others even if the projection is generally accurate because of 
volatility in the growth of health care costs and GDP. Moreover, the 
prospect of a cap's taking effect could alter the behavior of insurers 
in any year, thus increasing or decreasing the likelihood that such a 
cap would take effect. The effects of a cap would also depend on the 
details of how it was specified and enforced. For the current report, 
CBO has not attempted to estimate the effects of imposing a cap on 
---------------------------------------------------------------------------
federal contributions.

Effects of Alternative Policies for Setting Payment Rates for Providers 
in Fee-for-Service Medicare. Under CBO's extended alternative fiscal 
scenario (included in The 2012 Long-Term Budget Outlook), the reduced 
payment updates would expire and the Independent Payment Advisory Board 
process would cease to be effective after 2022, and payments to 
physicians would be maintained at 2012 rates rather than declining as 
scheduled. Under that scenario, CBO projected, net Medicare spending in 
2030 would be about 0.5 percent of GDP higher than it would be under 
CBO's extended baseline. CBO has not estimated the effects of combining 
a premium support system with the changes to current law that are 
assumed under its extended alternative fiscal scenario.

Instead, if current-law policies restraining cost growth were retained 
through the 2030s or longer, then spending in the existing Medicare 
program would be below that projected under CBO's extended baseline. 
CBO has not estimated the long-term effects of a premium support system 
under such restraints either.

Effects on Beneficiaries' Premiums

The premiums that beneficiaries would pay under the two premium support 
options would depend on the premiums charged by the plans in their 
region and on the beneficiaries' choice of plan. Under each option, at 
least one plan would be available in every region that charged the 
standard premium or less, and in most regions other plans would be 
available that charged premiums that were higher or lower than that 
amount (depending on whether the bid was above or below the benchmark). 
For each option, CBO estimated the premiums that would be charged by 
the array of plans offered, and the agency summarized that information 
by estimating the average premiums charged by three plans--the second-
lowest-bidding private plan in the region, the median-bidding private 
plan (that is, the plan with a bid in the middle of the distribution 
among private plans), and the FFS program. To arrive at the average 
premium charged by each plan, CBO computed a weighted average of 
region-specific premiums, with each region weighted by the proportion 
of affected beneficiaries.

CBO next estimated the premiums that beneficiaries would pay under each 
option by estimating their choice of plan, based on the differences in 
the premiums charged and on beneficiaries' sensitivity to those 
differences. For that analysis, CBO computed a weighted average of the 
premiums charged, weighting plans by the number of beneficiaries each 
one enrolled. CBO compared average premiums charged by plans and 
average premiums paid by beneficiaries with the Part B premium under 
current law.

Background on Premium Determination

Under either premium support option analyzed in this report, 
beneficiaries would pay the standard premium if they chose a plan with 
a bid that was equal to the regional benchmark. That premium would be 
the same everywhere in the country and would be determined by the same 
formula used under current law for the Part B premium: The federal 
government allocates spending under Medicare Advantage to Parts A and B 
on the basis of the share of total spending in the FFS program for Part 
B services and then sets the Part B premium equal to 25 percent of all 
Part B spending, divided by the number of beneficiaries. In this 
report, the standard premium equals 25 percent of the estimated amount 
of total Medicare spending attributable to Part B services under a 
premium support system.

Under current law, the Part B premium will be $1,600 in 2020, CBO 
projects. Because total Medicare spending would be slightly less than 
it would be under current law under either premium support option, CBO 
estimates, the standard premium for each would be slightly lower than 
the Part B premium under current law--$1,500 per year under either 
option. (All estimates of annual premiums in this report are rounded to 
the nearest $100; although CBO projects that the standard premium under 
the average-bid option would be higher than that under the second-
lowest-bid option, those amounts round to the same number.)

If a beneficiary chose a plan with a bid that differed from the 
regional benchmark, the premium would depend on the plan chosen. 
Someone who enrolled in a plan with a bid above the benchmark would pay 
the standard premium plus the amount by which the plan's bid exceeded 
the benchmark, and someone who enrolled in a plan with a bid below the 
benchmark would pay a correspondingly lower premium. CBO expects that, 
depending on how bidding regions were defined, there might be some 
sparsely populated regions in which no private plans would participate 
under either option. In those regions, the FFS program would be the 
only plan available, and beneficiaries who enrolled in the program 
would pay the standard premium.

CBO focused on standard premium amounts that did not include income-
related adjustments. In addition, the agency analyzed premiums only for 
the basic package of Medicare benefits, excluding additional amounts 
that enrollees in private plans might pay for enhanced benefits or that 
enrollees in the FFS program might pay for supplemental coverage.

Enrollees in private plans under the options would forgo the federal 
subsidies for supplemental benefits that would be provided by many 
Medicare Advantage plans under current law. CBO estimates that the 
annual value of those supplemental benefits (under current law) will be 
about $400, on average, per Medicare Advantage enrollee in 2020. The 
loss of those subsidies would make private plans less attractive under 
the options, all else being equal. For this analysis, CBO compared 
premiums for both options with the $1,600 current-law premium projected 
for Part B. The agency did not make any adjustment in that analysis for 
the loss of supplemental benefits under the Medicare Advantage program. 
Those forgone benefits are included in the analysis presented below 
concerning the effects of the two options on beneficiaries' total 
payments.

Premiums by Region. The range of premiums around the standard premium 
would vary geographically. CBO's analysis focused on four groups of 
regions--ranked from highest to lowest average FFS spending--with equal 
numbers of beneficiaries in each group. In regions with high FFS 
spending, CBO estimates, the bid for the FFS program would be higher 
than the private plans' bids and higher than the benchmark under either 
option. Medicare beneficiaries enrolled in the FFS program in such 
regions tend to use certain health care services at a higher-than-
average rate, so private plans would have greater potential to achieve 
savings relative to the FFS program by reducing that use. In contrast, 
CBO estimates, the FFS program's bid would be similar to or lower than 
the bids of private plans in many regions with low FFS spending. People 
enrolled in the FFS program in those regions tend to use less care, so 
private plans would have less potential to achieve savings by reducing 
the quantity of care; savings from reducing the price of care also 
would be difficult to achieve because of the restraints in provider 
payment rates that are scheduled for the FFS system under current law. 
Thus, the range of premiums would be narrower in regions with low FFS 
spending.

Premiums for Beneficiaries Who Do Not Actively Choose a Plan. CBO 
projects that many beneficiaries would not actively choose a plan in 
the first year of a premium support system--perhaps because they were 
unaware of the new system, did not understand how to enroll, were 
hampered by a health problem, or for some other reason. Under the 
options considered for this report, beneficiaries who did not choose a 
plan would be assigned to a plan with a bid at or below the benchmark. 
CBO projects that about 15 percent of beneficiaries would not choose a 
plan in the first year of premium support under the second-lowest-bid 
option and about 20 percent would not choose a plan in the first year 
under the average-bid option.\19\ Those beneficiaries would pay 
premiums less than or equal to the standard premium, but there would be 
no guarantee that the assigned plan would include all of their current 
providers.
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    \19\ CBO expects that some beneficiaries who were assigned to a 
low-bidding plan in the first year would later switch to the FFS 
program or to another plan that would have, on average, a higher 
premium.

Under an alternative approach, which CBO has not yet analyzed, 
beneficiaries who did not make a choice would remain in the plan most 
similar to their current plan (or be transferred to the FFS program if 
a similar plan was no longer available). In particular, beneficiaries 
who had been in the FFS program when the premium support system began 
would remain in that program unless they chose a private plan. In that 
sort of system, FFS beneficiaries would retain access to their current 
providers but, depending on the region, their premiums could be 
substantially higher. In addition, insurers would have less incentive 
to reduce their bids because they would anticipate that being a lower-
bidding plan would result in a smaller gain in enrollment than they 
would achieve if all beneficiaries were required to affirmatively 
choose a plan.

Premiums Charged by Plans in 2020

Under either illustrative premium support option, CBO anticipates, 
beneficiaries would be offered at least one plan at or below the 
standard premium and most people would have access to at least one 
other plan with a premium below that amount. In most regions, the plans 
with premiums at or below the standard amount would be private. 
Overall, CBO estimates, the premiums charged by plans would generally 
be lower under the average-bid option than under the second-lowest-bid 
option because the benchmarks would be higher under the average-bid 
option, so the federal government would contribute more for each plan.

The Second-Lowest-Bid Option. Under this option, CBO estimates, the 
average premium for the second-lowest-bidding private plan across all 
regions would be about $1,500 per year in 2020, or 6 percent below the 
Part B premium projected under current law for that year (see Table 4). 
In regions with low FFS spending, however, the premium for the second-
lowest-bidding private plan would tend to be higher than in other 
regions because of the role of FFS spending in determining the 
benchmark. Specifically, in some regions with low FFS spending, the bid 
for the FFS program would be lower than that of the second-lowest-
bidding private plan, so the FFS program's bid would become the 
benchmark, and the premium for the second-lowest-bidding private plan 
would be above the standard amount. CBO estimates that the average 
premium for the second-lowest-bidding private plan would be $1,600 in 
regions with the lowest FFS spending (see Figure 3).

The average premium for the median-bidding private plan available would 
be $1,800 in 2020 under the second-lowest-bid option, CBO estimates. 
That amount would be 13 percent above the current-law Part B premium.

The average premium for the FFS program under the second-lowest-bid 
option would be about $3,100, or almost twice the projected Part B 
premium under current law, CBO estimates. That increase would occur 
because, in most regions, the FFS program's bid would be substantially 
above that of the second-lowest-bidding private plan, and thus the bid 
for the latter would become the benchmark. The premium for the FFS 
program would be highest in regions with the highest average FFS 
spending. CBO estimates that in those regions, the average premium for 
the FFS program would be $4,600, or almost triple the projected 
current-law Part B premium. Even in regions with the lowest FFS 
spending, the average FFS premium would be $1,900, or almost 20 percent 
above the projected current-law Part B premium. (In some regions, the 
FFS program's bid would be lower than that of the second-lowest-bidding 
private plan, and the premium would equal the standard premium.)

The Average-Bid Option. Premiums would generally be lower under the 
average-bid option than under the second-lowest-bid option. For the 
second-lowest-bidding private plan, the national average premium in 
2020 would be $900 under the average-bid option, CBO estimates--more 
than 40 percent below the projected current-law Part B premium for that 
year. That amount would be less than the premium for that plan under 
the second-lowest-bid option because, in most areas, the benchmark 
would be higher and the plan's bid would be below the benchmark, which 
determines the government's contribution. Under the average-bid option, 
the average premium of the second-lowest-bidding private plan would be 
the smallest (at $600) in regions with the highest FFS spending because 
that plan's bid would be lower relative to the benchmark (which would 
be influenced by the bids of the FFS program and the higher-bidding 
private plans). The average premium of the second-lowest-bidding 
private plan would be substantially greater (at $1,400) in regions 
where FFS spending is lowest because, in most of those areas, that 
plan's bid would be close to the bid of the FFS program.

For the median-bidding private plan, CBO estimates that the average 
premium would be $1,200. That amount would be 25 percent below the 
current-law Part B premium in 2020.

The FFS program's bid under the average-bid option would be above the 
benchmark in most areas. CBO estimates that the national average 
premium for the FFS program would be $2,400, 50 percent higher than the 
projected current-law Part B premium.

Premiums Paid in 2020

The average premiums that beneficiaries would pay under a premium 
support system would depend not only on the premiums charged by plans 
as just discussed, but also on the plans beneficiaries chose to enroll 
in. Under the second-lowest-bid option, CBO estimates, the average 
annual premium paid by beneficiaries in 2020 would be $2,100--about 30 
percent higher than the current-law Part B premium for that year (see 
Figure 4). Under the average-bid option, CBO estimates, the average 
premium paid by beneficiaries in 2020 would be $1,500, or 6 percent 
below the 
current-law Part B premium.

The Second-Lowest-Bid Option. CBO estimates that about half of the 
beneficiaries included in the premium support system would enroll in 
private plans under the second-lowest-bid option and about half would 
enroll in the FFS program. The average premium paid by beneficiaries 
for private plans across all regions would be $1,800 and the average 
premium paid for the FFS program would be $2,500. The percentage of 
household income that beneficiaries would spend on the premium for the 
FFS program would vary substantially. The premium for the FFS program 
would amount to less than 2 percent of household income for about one-
fourth of enrollees in that plan and to 6 percent or more for about 
two-fifths of the plan's enrollees. In comparison, under current law 
that premium would amount to less than 2 percent of household income 
for about two-fifths of beneficiaries in the FFS program and to 6 
percent or more of household income for about one-fifth of 
beneficiaries in that program. (Those estimates focus on the standard 
premium and, in the case of premium support, on any reduction or 
increase in that premium that would result when a beneficiary enrolled 
in a plan with a bid below or above the benchmark. The estimates do not 
include amounts paid for the income-related premium.)

Under the second-lowest-bid option, average premiums would vary 
regionally. Beneficiaries in regions with the highest FFS spending 
would pay an average of $2,300 (compared with the nationwide average of 
$2,100). The higher average premium estimated for the regions with 
highest FFS spending is largely a reflection of CBO's estimate that 
about one-fifth of the beneficiaries would enroll in the FFS program. 
In those regions, roughly half of all beneficiaries enrolled in the FFS 
program would spend at least 6 percent of their household income on the 
FFS premium. Beneficiaries in regions with the lowest FFS spending 
would pay an average premium of $1,800, according to CBO's estimates. 
About 80 percent of beneficiaries in regions with the lowest FFS 
spending would enroll in the FFS program.

The Average-Bid Option. CBO estimates that slightly fewer than half of 
all beneficiaries would enroll in private plans under the average-bid 
option in 2020 and slightly more than half would enroll in the FFS 
program--proportions that are similar to those CBO projects for the 
second-lowest-bid option.\20\ For all regions combined, the average 
premium paid by beneficiaries in the FFS program would be $2,000 and 
the average premium paid by enrollees in private plans would be $1,000, 
compared with $2,500 and $1,800, respectively, under the second-lowest-
bid option.
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    \20\ Two opposing considerations led CBO to project similar--but 
not identical--enrollment patterns for the two options. In most 
regions, the FFS premium would be higher relative to private plans' 
premiums under the second-lowest-bid option than under the average-bid 
option. That difference would arise because the second-lowest bid would 
be lower than the average bid, resulting in a larger gap between the 
federal contribution and FFS costs under the second-lowest-bid option. 
As a result, enrollment would tend to be higher in private plans under 
the second-lowest-bid option. CBO expects, however, that the prospect 
of paying higher premiums under the second-lowest-bid option would 
prompt more beneficiaries to choose a plan in the first year of the 
program. Thus, a smaller proportion of beneficiaries would be assigned 
to a plan at or below the benchmark, and that would tend to decrease 
enrollment in private plans under the second-lowest-bid option.

Under the average-bid option, the average premium would be 
approximately equal for beneficiaries in all four groups of regions 
classified by FFS spending, CBO estimates. Where FFS spending is 
highest, the estimated $1,500 average premium reflects the anticipated 
choice of some beneficiaries to enroll in private plans with bids below 
the benchmark (about three-fourths of that group; their average premium 
would be less than $1,500) and of others to enroll in the higher-
bidding FFS program (about one-fourth; their average premium would be 
more than $1,500). In areas with the lowest FFS spending, the $1,500 
average premium reflects much smaller differences between the bids of 
private plans and the FFS program. In those regions, about three-
fourths of beneficiaries would enroll in the FFS program, by CBO's 
estimate.

Effects on Beneficiaries' Total Payments

CBO has estimated the effects of the two illustrative premium support 
options on beneficiaries' total payments for covered services. The 
total consists of premiums and out-of-pocket payments for deductibles, 
coinsurance, and copayments. In this analysis, out-of-pocket payments 
include all such obligations for beneficiaries, whether paid directly 
by beneficiaries or covered by supplemental insurance.\21\ The premiums 
included in CBO's estimates are the average premiums that beneficiaries 
would pay as presented above and are based on CBO's projections of the 
distribution of beneficiaries among plans. Income-related premiums for 
Part B also were included in the total payments the agency estimates 
under current law and for both options. In addition, the estimates 
account for the value of the forgone federally subsidized supplemental 
benefits that would have been available to enrollees in Medicare 
Advantage plans under current law but that would not be available under 
the two options. As discussed below, the estimated effects of the two 
premium support options on beneficiaries' total payments are subject to 
considerably greater uncertainty than are the estimated effects on 
federal spending and the premiums charged by plans.
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    \21\ This report does not provide estimates of the total effects of 
the premium support options on beneficiaries' payments for Medicare 
services because the analysis did not include premiums that 
beneficiaries would pay for supplemental coverage. (CBO has not yet 
modeled such coverage as part of a premium support system.) However, by 
including total out-of-pocket costs for Medicare services, whether paid 
by the beneficiary or by supplemental insurance, the analysis captures, 
in the aggregate, most of the costs beneficiaries would incur for 
premiums for supplemental insurance.
---------------------------------------------------------------------------

Effects in 2020

CBO estimates that beneficiaries' total payments in 2020 would be about 
11 percent higher, on average, under the second-lowest-bid option than 
they would be under current law. The premiums paid by beneficiaries 
would be higher, on average, than under current law, but beneficiaries' 
out-of-pocket costs would be lower--even though the actuarial value of 
the Medicare benefit would be unchanged--because of a decline in the 
total cost of covered services, which would be a result primarily of 
greater enrollment in lower-bidding private plans.\22\ (On average, a 
larger share of beneficiaries' total payments is in out-of-pocket costs 
than in premiums, so, in the calculations of the change in total 
payments, the percentage change in out-of-pocket costs receives a 
greater weight than the corresponding change in premiums.) The 
projected savings in out-of-pocket costs would offset part, but not 
all, of the increase in premiums.
---------------------------------------------------------------------------
    \22\ CBO expects that lower-bidding plans would generally have 
lower rates of health care utilization. As a result, enrollees would 
pay less out of pocket than they would with higher-bidding plans. Under 
the options in this report, the actuarial value of all plans would 
match the value of current-law Medicare; that is, every plan would 
cover the same percentage of the total expenses of a given population 
that is covered by the current Medicare benefit package. For general 
information on the actuarial value of health plans, see Chris L. 
Peterson, Setting and Valuing Health Insurance Benefits, Report for 
Congress R40491 (Congressional Research Service, April 6, 2009).

CBO's analysis implies that beneficiaries' total payments would be 
about 6 percent lower, on average, under the average-bid option than 
under current law. That reduction results from the combination of the 
lower average premiums paid discussed above and a reduction in average 
out-of-pocket costs, which would result primarily from higher 
---------------------------------------------------------------------------
enrollment in lower-bidding private plans.

Under both options, the effect on total payments for particular 
beneficiaries could differ greatly from the nationwide average and 
would depend partly on the region and the choice of plan. In 
particular, beneficiaries who chose to remain in the FFS program would 
generally face higher premiums and would not experience a reduction in 
out-ofpocket costs.

Uncertainty in the Estimates

To characterize the uncertainty of the estimated effects of the options 
on beneficiaries' total payments, CBO applied the same type of analysis 
reported above for the effects of the premium support options on 
federal spending. Specifically, it varied the same five parameters, 
with ranges chosen to generate lower and higher estimates of the 
effects on beneficiaries' payments for each option. In CBO's judgment, 
there is a two-thirds chance under the second-lowest-bid option that 
beneficiaries' total payments in 2020 would, on average, be within a 
range extending from a reduction of 2 percent to an increase of 24 
percent relative to payments under current law (CBO's central estimate 
is that total payments would increase by 11 percent). For the average-
bid option, the corresponding range of likely average effects on 
beneficiaries' total payments extends from no effect to a reduction of 
12 percent (the central estimate is a reduction of 6 percent.) (See 
Table 2.) The range under the average-bid option is narrower than that 
under the second-lowest-bid option mainly because the changes in 
beneficiaries' premiums from varying those parameters are smaller under 
the average-bid option and because the variation in responsiveness to 
smaller changes in premiums results in a smaller range of effects on 
total payments. (For additional discussion of factors affecting the 
ranges, see Appendix B.)

Beneficiaries' total payments would be unlikely to rise, on average, 
under the 
average-bid option relative to those under current law, for two main 
reasons. First, because use of health care services tends to be higher 
for enrollees in the FFS program than for those in private plans, out-
of-pocket costs would probably be lower under the average-bid option 
than they would be under current law as long as the percentage of 
beneficiaries in the FFS program did not increase. According to CBO's 
central estimates, the share of beneficiaries in private plans would be 
about 20 percentage points greater than under current law, and a 
reduction in that share would be unlikely. Second, average premiums 
paid under the option would be closely tied to the standard premium, 
which would be set using the same formula as the Part B premium under 
current law, so those average premiums would not differ greatly from 
the Part B premium. And even if premiums were slightly higher under the 
average-bid option than under current law, the effect probably would 
not offset the decline in out-of-pocket costs.

 Effects on Combined Federal Spending and Beneficiaries' Total Payments

The combined payments of the federal government and beneficiaries 
constitute the total amount paid for health care services covered by 
Medicare. They consist of the federal government's payments to plans, 
beneficiaries' premiums, and beneficiaries' out-of-pocket payments. CBO 
estimates that those payments would be about 5 percent lower under the 
second-lowest-bid option and about 4 percent lower under the average-
bid option than they would be under current law. Those percentages are 
a combination of the effects on net Medicare spending and on 
beneficiaries' total payments discussed above.

CBO expects that the decrease in combined payments would probably be 
slightly larger under the second-lowest-bid option than under the 
average-bid option mainly because the former would result in lower bids 
by private plans and a larger share of beneficiaries enrolled in those 
plans. CBO did not quantify the uncertainty of those estimates but it 
did reach two conclusions about ranges that would cover two-thirds of 
the possible outcomes for the two options: First, such ranges would 
clearly overlap; that is, CBO is not confident that combined payments 
under the second-lowest-bid option would be lower than combined 
payments under the average-bid option. Second, based on the separate 
ranges for federal spending and for beneficiaries' total spending, 
ranges for combined payments would extend only over reductions in 
payments; that is, it is likely that either option would result in 
reductions in combined federal spending and beneficiaries' total 
payments.

The sum of federal spending and beneficiaries' payments examined here 
is a significant component of total national spending on health care, 
and this analysis suggests that total national spending would probably 
decline under either of the two illustrative premium support options. 
However, a premium support system would interact with other parts of 
the health care system in complex ways that CBO has not quantified.

 Comparison With CBO's Previous Analyses of a Premium Support System

CBO has previously estimated the budgetary effects of revamping 
Medicare as a premium support system.\23\ But those earlier analyses 
were limited in at least two key respects: They did not include 
detailed modeling of beneficiaries' choices among alternative insurance 
plans, and they did not include detailed modeling of insurers' behavior 
regarding bids or payments to health care providers. Thus, none of 
those analyses captured the full effects of a competitive system on 
federal spending or payments by beneficiaries. The analysis in this 
report incorporates such modeling. In addition, this report differs 
from some previous analyses by CBO in considering different 
illustrative options for a premium support system instead of a specific 
proposal.
---------------------------------------------------------------------------
    \23\ For example, see Congressional Budget Office, The Long-Term 
Budgetary Impact of Paths for Federal Revenues and Spending Specified 
by Chairman Ryan (March 2012), www.cbo.gov/publication/43023; Long-Term 
Analysis of a Budget Proposal by Chairman Ryan (attachment to a letter 
to the Honorable Paul Ryan, April 5, 2011), www.cbo.gov/publication/
22085; Budget Options, Volume 1: Health Care (December 2008), pp. 120-
121, www.cbo.gov/publication/41747; and Designing a Premium Support 
System for Medicare (December 2006), www.cbo.gov/publication/18258.

The treatment in this report is substantially different from the rough 
analysis of a specific premium support proposal published by CBO in 
April 2011. Not only have there been substantial improvements in CBO's 
modeling of the behavior of beneficiaries and insurers, but the options 
examined in this report differ in important ways from that earlier 
proposal. For example, the earlier proposal included a grandfathering 
provision, and CBO estimated that only 4 percent of Medicare spending 
in 2022 would be accounted for by premium support payments under that 
proposal. The proposal also specified a federal contribution that was 
initially fixed (rather than determined through bidding) and that would 
keep pace with the consumer price index for all urban consumers (at a 
rate that CBO estimated would be substantially slower than the rate of 
growth in Medicare spending under current law). Moreover, because of 
the simple formula for determining federal spending in that proposal, 
CBO projected such spending over a longer period than it does in this 
---------------------------------------------------------------------------
report.

CBO's estimates of the total payments by beneficiaries and of combined 
federal spending and beneficiaries' payments for the 2011 proposal were 
much higher than the estimates for the two options in this report 
primarily because CBO projected for that earlier report that health 
care spending covered by private plans would be much higher initially 
and would grow faster than the agency currently estimates. The 
difference arose from two main factors: First, the earlier proposal did 
not include the Medicare FFS program as a bidding plan in the premium 
support system. Because that program was not present to put downward 
pressure on the rates paid to providers by private insurers, CBO 
projected, the premiums of private plans would be substantially higher 
than they would be under the premium support options discussed in this 
report. Second, more recent information has led CBO to make a downward 
revision in its projections of the future growth rate of private health 
insurance premiums.\24\
---------------------------------------------------------------------------
    \24\ See Congressional Budget Office, Updated Estimates for the 
Insurance Coverage Provisions of the Affordable Care Act (March 2012), 
www.cbo.gov/publication/43076.
---------------------------------------------------------------------------

Implications of Key Specifications and Alternatives

Although policymakers would need to determine many specific 
characteristics of a premium support system, several choices would be 
particularly important from a federal budgetary perspective: setting 
the formula for the government's contributions, determining whether the 
traditional FFS program would be included as a competing plan, setting 
rules of eligibility for the system, delineating bidding regions, and 
designing the program features that would influence beneficiaries' 
choice of a plan. Policymakers would also need to address many other 
design and operational issues to implement such a system.

Note again that the illustrative premium support options analyzed here 
are anchored in basic features of the current Medicare system: Both 
would guarantee insurance for all beneficiaries; adjust payments to 
private insurers to account for the health of their enrollees (that is, 
use risk adjustment); and, under what is called community rating, 
require that insurers charge everyone in a region the same premium for 
the same coverage. Changes to those features also could have important 
consequences for a premium support system.

In addition, changes in the broader health care and health financing 
systems would affect a premium support system and change the way it 
affected federal spending and beneficiaries' payments. For example, if 
more people outside of the Medicare market purchased health insurance 
plans with narrower networks of providers and lower premiums than CBO 
expects under current law, the willingness of Medicare beneficiaries to 
purchase similar plans in a premium support system would probably 
increase--although the opposite could occur if people's experiences 
with those plans left them dissatisfied. Legislative changes affecting 
the broader health care market also could have consequences for the 
effects of a premium support system in Medicare. For instance, 
repealing the tax exclusion for employment-based health insurance would 
heighten pressure to restrain the growth of health care costs outside 
of Medicare. The resulting changes in practice patterns of health care 
providers would probably decrease private plans' bids under a premium 
support system, although CBO has no basis for estimating the magnitude 
of such an effect.

Federal Contributions

In this analysis, CBO focused on two possible approaches to determining 
federal contributions, but many other methods could be used. For 
example, capping the growth rate of federal contributions could 
generate additional federal savings relative to an uncapped proposal, 
although CBO has not yet estimated the effects of such a cap. In 
general, federal budgetary savings would increase as federal 
contributions declined, but beneficiaries' premiums would be higher.

The Fee-for-Service Program

CBO assumed that Medicare's FFS program would continue to be offered 
within the premium support options analyzed here. If, instead, the FFS 
program was eliminated, the savings produced for the government under a 
premium support system would be less (or federal spending could be even 
more than under current law) because the rates that private insurers 
would pay health care providers for treating Medicare enrollees would 
probably be higher than CBO estimates for either premium support 
option. In general, the rates that private insurers now pay providers 
for Medicare Advantage enrollees are similar to those Medicare pays 
under the FFS program but substantially below the rates paid for 
enrollees who are in commercial plans and are not Medicare 
beneficiaries.

CBO anticipates that competition from the FFS program within a premium 
support system would constrain the rates that private insurers paid for 
premium support enrollees in the same way that the FFS program now 
appears to constrain the rates that insurers pay for Medicare Advantage 
enrollees. If a system did not offer the FFS program as a choice, the 
result probably would be higher payment rates, higher bids, and higher 
costs for the government. CBO also expects that, under the options 
analyzed here, in some regions the FFS program would submit the lowest 
bid, so eliminating the program would directly reduce federal savings 
by raising the benchmark in those regions.

Eligibility

If fewer people were included in a premium support system, federal 
savings generally would be lower, all else being equal. For this 
analysis, CBO assumed that the premium support systems would not 
include a grandfathering provision (thus including more beneficiaries 
than if such a provision were part of the system) and would exclude 
dual-eligible beneficiaries.

A Grandfathering Provision. Under some premium support proposals, all 
beneficiaries who became eligible for Medicare before the system took 
effect would remain in the current-law Medicare program and only those 
who became eligible after that time would enroll in the premium support 
system. Several important questions would arise about the structure of 
such a program (see Box 2). Clearly, however, grandfathering some 
beneficiaries would limit the savings that could be achieved over an 
extended period because only a subset of the Medicare population would 
enroll in the new system and (because the grandfathered beneficiaries 
would be older) the cost of health care for the eligible population 
would tend to be lower than average.

CBO estimates that if a premium support system implemented in 2018 
excluded beneficiaries who entered the program before 2018 and dual-
eligible beneficiaries, only about 25 percent of the Medicare 
population would be covered under the new system after 5 years, and 
spending for those beneficiaries would represent only about 15 percent 
of net Medicare spending in total in that year under current law (where 
such spending includes that for dual-eligible beneficiaries and for 
Part D). After a decade, approximately 45 percent of the Medicare 
population would be covered, and spending for that group would 
represent about 30 percent of net Medicare spending in total under 
current law.

Because the share of the Medicare population and the share of Medicare 
spending covered would rise gradually under a grandfathering provision, 
federal savings would be substantially smaller over an extended period 
than would be the case if all beneficiaries entered the new system 
immediately. A very rough approximation (made on the basis of the 
estimated share of Medicare spending covered each year) for a system 
that also excluded dual-eligible beneficiaries suggests that of the 
total savings achieved if all eligible beneficiaries entered in 2018, 
federal savings would be about 15 percent as much after 5 years and 
about 30 percent as much after 10 years.

Moreover, the savings under a grandfathering provision could be 
slightly smaller than the rough estimates would suggest, for two 
reasons. First, CBO anticipates that the gradual rise in the proportion 
of Medicare beneficiaries and Medicare spending covered under such a 
system would give private insurers less incentive to reduce their bids, 
over an extended period, than would be the case if all eligible 
beneficiaries entered the system immediately. Second, the reduction in 
the growth of Medicare spending likely to occur under a premium support 
system as a result of changes in the demand for new technologies would 
be substantially smaller for many years if that system included a 
grandfathering provision.

Dual-Eligible Beneficiaries. Medicare covers some services for dual-
eligible beneficiaries and Medicaid covers others, thus creating 
conflicting financial incentives for the federal and state governments 
and for health care providers.\25\ Recent federal and state efforts 
have focused on integrating the Medicare and Medicaid funding streams 
and coordinating the often-complex care of many of those 
beneficiaries--and including that group in a premium support system 
would pose substantial additional challenges. For instance, it would be 
difficult to give dual-eligible beneficiaries incentives to choose low-
bidding plans in a premium support system while also minimizing their 
total payments for medical services. Despite that, excluding such 
beneficiaries would reduce the potential savings that could be achieved 
from a premium support system. In addition, that exclusion might create 
incentives for private plans to encourage lower-income beneficiaries 
with higher health care costs than predicted by their risk scores to 
seek Medicaid eligibility and thereby leave the plan.\26\
---------------------------------------------------------------------------
    \25\ See Congressional Budget Office, Dual-Eligible Beneficiaries 
of Medicare and Medicaid: Characteristics, Health Care Spending, and 
Evolving Policies (June 2013), www.cbo.gov/publication/44308.
    \26\ Such effects are not included in CBO's estimates in this 
report.

Bidding Regions

CBO assumed that bidding regions for both options would reflect health 
care markets within states. The precise definition of those markets 
would involve trade-offs. For example, defining regions to include 
large numbers of beneficiaries would make insurers' projections of 
average spending within the region more reliable. However, regions that 
included areas that varied greatly in their spending would make it more 
difficult for insurers to project spending for their enrollees because 
those enrollees could be concentrated in certain areas within the 
region. As another example, because CBO assumed that a premium support 
system would require any insurer that submitted a bid for a region to 
serve the entire region, some local and regional insurers might decline 
to participate if a region included areas they could not serve 
effectively, thus reducing competition. And in some regions, those 
firms could be among the insurers offering the lowest-cost health care, 
the highest-quality health care, or both. However, if regions were 
small, some insurers might decline to participate even though they 
would have served those same areas if they had been included in larger 
regions. That result could occur, say, if the costs to carriers of 
developing networks of providers in those areas were higher than in 
nearby areas and if those costs would have been worth incurring to 
serve a larger region.

Features of a System That Could Influence Enrollment

Features of a premium support system that made beneficiaries more 
sensitive to differences in plans' premiums would tend to reward plans 
that bid low with higher enrollment and thus encourage more plans to 
submit lower bids.

In the illustrative premium support options analyzed here, CBO assumed 
that differences in bids would be translated dollar for dollar into 
differences in premiums. If, instead, the government retained some of 
the difference between the benchmark and bids below that amount, two 
effects would occur: First, the government would reduce its spending by 
the amount retained, all else being equal. Second, however, by 
retaining some of the difference between the benchmark and the bids, 
the government would reduce the incentive for beneficiaries to enroll 
in low-bidding plans and thus reduce the incentive for plans to submit 
low bids--which would increase the benchmark and federal spending. The 
net effect of those two factors on government spending would depend 
partly on beneficiaries' responsiveness to premiums and partly on the 
extent to which private insurers raised their bids. Moreover, if the 
difference between the benchmark and bids below that amount was 
provided as additional benefits rather than as cash, beneficiaries 
would tend to have more difficulty comparing plans.

CBO assumed that beneficiaries who did not choose a plan when they 
entered the premium support system would be assigned to a plan that 
submitted a bid that was at or below the benchmark (or assigned to one 
of the four lowest-bidding plans if more than four were at or below the 
benchmark). If, instead, beneficiaries were automatically placed into 
their original plan (if they had already been enrolled in Medicare) or 
into the FFS program, insurers would probably have less incentive to 
submit low bids, and beneficiaries' total payments would be higher 
because low-bidding plans would have lower enrollment. Conversely, if 
those beneficiaries were assigned to plans that had especially low bids 
(rather than being assigned equally to all plans bidding at or below 
the benchmark), insurers would probably have a greater incentive to 
submit low bids, and beneficiaries' total payments would be lower. 
Alternatively, if beneficiaries were required to choose a plan if they 
wished to enroll in the premium support system and thus to maintain or 
obtain Medicare coverage, some would not do so and the fraction of the 
eligible population not covered by Medicare would increase--
particularly in the first few years after implementation.

In this analysis, CBO assumed that the basic packages that plans would 
be required to offer would consist of health care services and an 
actuarial value that matched those provided by Medicare's FFS program 
under Parts A and B--although the plans could vary in other dimensions, 
such as the breadth of provider networks or the structure of 
coinsurance. If that basic package was only a minimum requirement and 
plans could supplement a package in unrestricted ways without offering 
the basic package itself, comparisons would be more difficult for 
beneficiaries, enrollment in low-bidding plans would be reduced, and 
plans' bids would rise. Conversely, if the deductibles and copayments 
of the basic package were made standard, comparisons would be simpler. 
The drawback of standardization, however, is that it could dampen the 
ability of insurers and providers to develop more cost-effective 
approaches to providing health care and for beneficiaries to choose 
those approaches rather than more expensive ones.

                                 ______
                                 

                              Appendix A: 
                        Basis for CBO's Findings

The preliminary findings presented in this report regarding the effects 
of two illustrative options for a premium support system for Medicare 
(one called the second-lowest-bid option and the other called the 
average-bid option) are based on detailed modeling of the behavior of 
buyers and sellers of health insurance policies. In its analysis, the 
Congressional Budget Office (CBO) focused particular effort on 
estimating private insurers' bids under those options.

CBO reviewed the research literature and consulted a variety of experts 
who represented a broad span of views about premium support systems. In 
addition, some insights about the potential responses of beneficiaries 
and insurers are possible from observing current experience with the 
Medicare Advantage program (which provides benefits through private 
insurance), Medicare Part D (the prescription drug program), the 
Federal Employees Health Benefits program, and various employment-based 
insurance plans. The usefulness of those systems to inform the analysis 
of a premium support system is limited, however, because the 
competitive structure of a premium support system would be quite 
different from that of Medicare Advantage or the federal employees' 
program, and the array of health care services covered would be broader 
than that under Part D. Moreover, information about the small number of 
employers whose experiences with similar systems have been studied in 
depth may not be broadly generalizable--particularly to the Medicare 
population, which is likely to be less responsive than the nonelderly 
population to differences in health insurance premiums. Finally, the 
changes that are occurring in private health care and in health 
insurance could affect federal spending on Medicare in complicated and 
unpredictable ways--either under current law or under a premium support 
system. And the adoption of a premium support system for Medicare could 
have spillover effects on private health care and health insurance 
systems.

The current analysis incorporates a range of significant improvements 
in the modeling of a premium support system for Medicare compared with 
CBO's earlier analyses of such systems.\27\ The agency has devoted 
considerable time and effort to strengthening its analytical 
capabilities in this area. Nonetheless, it is extremely difficult to 
know how beneficiaries or insurers would respond to a premium support 
system for Medicare, and the actual outcomes would surely differ from 
the estimates presented in this report--which, according to CBO's 
current judgment, represent the middle of the distribution of possible 
outcomes. The agency's modeling effort is not complete; further 
analysis and additional consultation with outside experts may alter the 
findings, perhaps in significant ways. One potential area of inquiry 
that CBO has not analyzed concerns the ways a premium support system 
might affect the coordination of care or the quality of care that 
beneficiaries receive; the agency does not currently have the tools 
necessary to study such effects, nor does it anticipate having them in 
the near future.
---------------------------------------------------------------------------
    \27\ For examples of earlier analyses, see Congressional Budget 
Office, Long-Term Analysis of a Budget Proposal by Chairman Ryan 
(attachment to a letter to the Honorable Paul Ryan, April 5, 2011), 
www.cbo.gov/publication/22085, and Designing a Premium Support System 
for Medicare (December 2006), www.cbo.gov/publication/18258.
---------------------------------------------------------------------------

Estimating Private Insurers' Bids

To estimate the bids that private insurers would submit in 2020 under 
the two illustrative premium support options considered in this report, 
CBO analyzed insurers' 2012 bids for Medicare Advantage, projected 
those bids to 2020, and adjusted them to account for the differences in 
competition that CBO anticipates private insurers would face under the 
two options as compared with the current Medicare Advantage program.

In adjusting the projected Medicare Advantage bids to develop estimates 
of what private insurers would bid under a premium support system, CBO 
concluded that some factors would tend to lower bids and others would 
tend to raise them (see Figure A-1). The net effect is that the 
projected bids under the two premium support options considered in this 
report are lower, by an average of about 4 percent under each option, 
than those projected for the current-law Medicare Advantage program. 
(Bids would be slightly lower under the second-lowest-bid option than 
under the average-bid option, but the differences relative to bids 
under the Medicare Advantage program are rounded to the nearest 
percentage point.) The difference between private insurers' bids under 
the two options and average spending in Medicare's fee-for-service 
(FFS) program would remain fairly constant in the decade after the 
first few years of implementation, CBO anticipates.

Projecting Medicare Advantage Bids

Under current law, each Medicare Advantage plan generally can define 
its service area as consisting of one or more counties.\28\ CBO based 
its estimates on the bids submitted by insurers for their service 
areas, using the county as the unit of analysis. The agency developed 
simulated distributions of bids for counties based on the view that 
insurers would participate in a premium support system and would offer 
insurance plans with a range of prices, just as is the case for the 
current Medicare Advantage program.
---------------------------------------------------------------------------
    \28\ This discussion applies to local Medicare Advantage plans, 
which account for the bulk of enrollment in the Medicare Advantage 
program. By contrast, the federal government defines service areas for 
regional preferred provider organizations--or PPOs--as consisting of 
one or more states; each PPO must serve one or more of those designated 
service areas.

CBO estimated benchmarks for counties under the two premium support 
options on the basis of the agency's projected distributions of private 
insurers' bids, which were combined with projected per capita Medicare 
FFS spending for each county. The use of the county as the unit of 
analysis simplified the modeling and provides a foundation for 
subsequent analyses of a system with other types of bidding regions. 
The results of the analysis could change if different types of regions 
---------------------------------------------------------------------------
were specified.

Under current law, Medicare Advantage insurers submit a bid for a 
beneficiary in average health (defined as a beneficiary with a risk 
score of 1.0). CBO projects that the average bid from current-law 
Medicare Advantage plans in 2020 will be 6 percent below the average 
FFS spending for a beneficiary with the same reported risk score. For 
the one-quarter of the nation's counties with the highest average FFS 
spending, CBO estimates, the average Medicare Advantage bid will be 12 
percent below that amount.\29\ For the one-quarter of counties with the 
lowest average FFS spending, CBO projects that the average Medicare 
Advantage bid will be 6 percent above that amount.\30\
---------------------------------------------------------------------------
    \29\ For this analysis, CBO divided counties into quartiles on the 
basis of average FFS spending in the county, with the same number of 
counties in each quartile. This differs from the approach elsewhere in 
the report for the analysis of beneficiaries' premiums, which divides 
groups of regions into quartiles constructed such that the same number 
of beneficiaries is in each quartile.
    \30\ Those estimates incorporate factors affecting bids that are 
related to the risk adjustment mechanism, discussed below. For this 
analysis, CBO excluded three types of Medicare Advantage plans that 
differ substantially from plans that would probably be offered under a 
premium support system: private FFS plans, special needs plans, and 
employment-based group plans. The FFS program's costs used for the 
comparisons in this report exclude certain types of spending because it 
is not covered by the bids that Medicare Advantage plans submit under 
current law--namely, the additional payments to disproportionate-share 
hospitals (whose share of low-income patients exceeds a specified 
threshold) and spending for medical education, hospice benefits, and 
certain benefits for patients with end-stage renal disease. CBO 
included in its calculations the government's cost of administering the 
FFS program. The analysis was based on CBO's projections of Medicare 
expenditures and Medicare Advantage enrollments in March 2012. See 
Congressional Budget Office, ``Medicare--March 2012 Baseline'' (March 
13, 2012), www.cbo.gov/publication/43060.

CBO expects that Medicare Advantage bids will be higher relative to 
average FFS spending in the same areas in 2020 than in 2012 because 
Medicare Advantage plans will be able to achieve some--but not all--of 
the restraint in provider payment rates that is scheduled for the FFS 
system under current law. As a result, the agency projects higher 
growth in the bids of Medicare Advantage plans than it does for growth 
in per capita spending under the FFS system.

Factors That Would Tend to Reduce Bids

CBO anticipates that two main mechanisms would tend to lower bids under 
either option relative to Medicare Advantage bids under current law: 
increased competition that would result from stronger incentives for 
beneficiaries and insurers to focus on reducing health care costs and 
the slightly greater favorable selection for private plans than exists 
under the Medicare Advantage program.

Increased Competition. Differences in the plans' bids under either 
option would translate directly into differences in beneficiaries' 
premiums. Under current law, a Medicare Advantage plan with a bid below 
the benchmark receives a federal payment that equals the bid plus a 
rebate that is a percentage of the difference between the bid and the 
benchmark. (Beginning in 2014, the rebate will range from 50 percent to 
70 percent, depending on the plan's performance on certain measures of 
quality.) Plans now return most of that difference in the form of 
supplemental benefits (rather than as reduced premiums), which 
consumers generally find harder to evaluate than a cash amount. Under 
the illustrative premium support options, plans with bids below the 
benchmark would return the entire difference between the two in the 
form of lower premiums. Beneficiaries would therefore be more sensitive 
to differences in plans' bids in deciding on a plan than they would be 
under the Medicare Advantage program, so the insurers would have more 
incentive to lower their bids under the two premium support options.

Insurers also would face more competition under both options because of 
changes in market structure. Under the Medicare Advantage program, the 
benchmarks are announced before insurers submit their bids. Under the 
two premium support options, the benchmarks would be determined from 
the bids themselves. Some evidence suggesting that competition among 
Medicare Advantage plans is limited under the current approach comes 
from a study that concluded that a $1.00 increase in a benchmark, with 
all other factors (including health care costs) held constant, results 
in a $0.49 increase in the average bid.\31\ In a highly competitive 
system (for example, one in which each dollar that a bid was below the 
bid of another plan within a region would correspond to a dollar's 
difference in the premiums between the two plans), the insurers' bids 
would primarily reflect their costs rather than the benchmarks.
---------------------------------------------------------------------------
    \31\ Zirui Song, Mary Beth Landrum, and Michael E. Chernew, 
``Competitive Bidding in Medicare: Who Benefits From Competition?'' 
American Journal of Managed Care, vol. 18, no. 9 (September 2012), pp. 
546-552, http://tinyurl.com/odtwf87.

Insurers would be expected to respond to increased competition by 
reducing their costs and lowering their bids.\32\ The reductions might 
occur partly as a result of reduced administrative costs or smaller 
profit margins. But they also could result from cuts in spending for 
services, perhaps made possible by insurers' combining improvements in 
management of care with development of more restrictive provider 
networks, slower adoption of expensive technological advances, faster 
adoption of methods to compensate providers that demonstrated cost-
effective care, or changes in benefit design (for example, tying cost-
sharing requirements to evidence of the cost-effectiveness of specific 
services).
---------------------------------------------------------------------------
    \32\ For related research, see Thomas C. Buchmueller, ``Consumer-
Oriented Health Care Reform Strategies: A Review of the Evidence on 
Managed Competition and Consumer-Directed Health Insurance,'' Milbank 
Quarterly, vol. 87, no. 4 (December 2009), pp. 820-841, http://
tinyurl.com/nsaff32, and ``Does a Fixed-Dollar Premium Contribution 
Lower Spending?'' Health Affairs, vol. 17, no. 6 (November 1998), pp. 
228-235, http://tinyurl.com/puwqjaz; David M. Cutler and Sarah J. 
Reber, ``Paying for Health Insurance: The Trade-Off Between Competition 
and Adverse Selection,'' Quarterly Journal of Economics, vol. 113, no. 
2 (May 1998), pp. 433-466, http://tinyurl.com/ mycqvem; and Steven C. 
Hill and Barbara L. Wolfe, ``Testing the HMO Competitive Strategy: An 
Analysis of Its Impact on Medical Care Resources,'' Journal of Health 
Economics, vol. 16, no. 3 (June 1997), pp. 261-286, http://tinyurl.com/
nvvz76c.

Under the specification of the two options that restricts insurers to 
submitting a maximum of two bids for the basic benefit package in any 
bidding region, CBO also expects that insurers would eliminate some of 
the higher-bidding plans that would exist under the Medicare Advantage 
program--reducing average bids. (Under the Medicare Advantage program, 
---------------------------------------------------------------------------
insurers often submit more than two bids in their service areas.)

Increased Favorable Selection. Under both premium support options, all 
private insurers in a region would submit bids indicating the payment 
they would accept to provide Medicare benefits for a beneficiary of 
average health, and those standardized bids would be used to establish 
regional benchmarks. Payments to insurers would be adjusted to reflect 
the health status of their enrollees, using a risk adjustment mechanism 
that CBO assumed would be comparable to that of the Medicare Advantage 
program.

It is difficult to adjust payments to reflect health status, and the 
system used for Medicare Advantage is unavoidably imperfect. Medicare 
beneficiaries in poor health tend to prefer to enroll in the FFS 
program because it generally places fewer restrictions on the use of 
health care services. That tendency is in evidence even among 
beneficiaries with the same risk scores because risk scores incorporate 
only limited information about health status. When a beneficiary who 
enrolls in a private plan is healthier than someone with the same risk 
score enrolled in the FFS program, the private plan experiences 
``favorable selection'' beyond that captured by risk scores. Some 
research indicates that current Medicare Advantage enrollees who have a 
given risk score would have had lower costs, on average, under the FFS 
program than people enrolled in the FFS program with that same 
score.\33\
---------------------------------------------------------------------------
    \33\ Estimates of the difference vary considerably, however. For 
example, see Joseph P. Newhouse and others, ``Steps to Reduce Favorable 
Risk Selection in Medicare Advantage Largely Succeeded, Boding Well for 
Health Insurance Exchanges,'' Health Affairs, vol. 31, no. 12 (December 
2012), pp. 2,618-2,628, http://tinyurl.com/naps2jl; Medicare Payment 
Advisory Commission, Report to the Congress: Medicare and the Health 
Care Delivery System (June 2012), pp. 100-101, http://go.usa.gov/DXbF; 
Gerald F. Riley, ``Impact of Continued Biased Disenrollment From the 
Medicare Advantage Program to Fee-for-Service,'' Medicare and Medicaid 
Research Review, vol. 2, no. 4 (2012), pp. E1-E17, http://go.usa.gov/
DXbd; and Jason Brown and others, How Does Risk Selection Respond to 
Risk Adjustment? Evidence From the Medicare Advantage Program, Working 
Paper 16977 (National Bureau of Economic Research, April 2011), 
www.nber.org/papers/w16977.

CBO expects that, under either premium support option, private plans 
would experience greater favorable selection (beyond that captured by 
risk scores) than they will experience under the Medicare Advantage 
program. That is, people who enrolled in private plans--under either 
option--would use fewer health care services, on average, than people 
with the same risk score enrolled in Medicare Advantage. CBO 
anticipates that outcome because increased competition would prompt 
insurers to take more aggressive steps to control costs (by enhancing 
utilization management or using tighter provider networks, for 
example), thus rendering private insurers less attractive to 
beneficiaries who would, on average, use more health care services than 
---------------------------------------------------------------------------
would other beneficiaries with the same risk score.

Because of the increased favorable selection, costs per enrollee would 
be lower for private plans under a premium support system than for 
Medicare Advantage plans under current law if the average risk scores 
in the two sets of plans were the same. Reflecting those lower costs, 
private plans competing for additional enrollees under either option 
would tend to reduce their bids for a beneficiary of average health 
relative to those of Medicare Advantage plans, CBO anticipates.

Factors That Would Tend to Raise Bids

CBO estimates that in most counties the percentage of beneficiaries 
enrolled in the FFS program would decline once either premium support 
option took effect. In CBO's assessment, the reduced market share of 
the FFS program would tend to boost the rates that private insurers 
paid to health care providers and thereby lead them to raise their 
bids. That reduction in market share, and thus the effect on private 
insurers' bids, would be greater in areas where average FFS spending 
was high. (CBO's methodology for estimating the proportion of 
beneficiaries who would select the FFS program is discussed below.)

Declines in the FFS program's market share would affect payment rates 
for private insurers through two main mechanisms. First, the importance 
of payment rates from the FFS program would diminish as a determinant 
of the amounts private insurers would pay health care providers for 
treating Medicare enrollees (those FFS payment rates are generally a 
good deal lower than the rates private insurers pay to providers of 
health care for people with commercial insurance--that is, employment-
based coverage). Second, some private insurers would need to broaden 
their provider networks to accommodate additional enrollees. Both 
mechanisms would cause insurers to raise their bids to cover additional 
costs, CBO projects.

The Reduced Importance of FFS Provider Payment Rates. CBO's assessment 
of the importance to private plans of FFS payment rates is based on the 
observation that, on balance, the rates paid for Medicare Advantage 
enrollees are similar to or slightly above those that Medicare pays for 
FFS patients' care--even though providers receive substantially higher 
amounts when they offer the same services to patients in commercial 
plans focused on the under-65 population.\34\ The exact cause of the 
difference is not known, but it appears to arise in part because 
private insurers that offer Medicare Advantage plans can exclude from 
their networks any providers who are unwilling to accept Medicare's 
rates, thus reducing those providers' volume of Medicare patients; 
those same providers would generally end up being paid the lower rates 
for treating Medicare patients in the FFS system. Moreover, when 
Medicare Advantage enrollees go outside their plan's provider network 
to obtain care that the plan either must cover by law (emergency care, 
for example) or that it covers as a matter of choice (such as certain 
highly specialized services), federal law requires providers to accept 
Medicare's FFS rates as payment in full.\35\ Thus, a hospital that 
might anticipate providing a certain amount of emergency care to 
enrollees in a Medicare Advantage plan would not receive higher 
commercial rates for treating those patients simply because it refused 
to join the plan's network.
---------------------------------------------------------------------------
    \34\ Information about those rates is based on interviews conducted 
by CBO staff with industry sources and is consistent with reports in 
the research literature. See Robert A. Berenson and others, ``The 
Growing Power of Some Providers to Win Steep Payment Increases From 
Insurers Suggests Policy Remedies May Be Needed,'' Health Affairs, vol. 
31, no. 5 (May 2012), pp. 973-981, http://tinyurl.com/ntyyudv.
    \35\ Sections 1866(a)(1)(O) and 1876(i)(1) of the Social Security 
Act contain the relevant provisions for hospitals and physicians, 
respectively.

The relationship between private insurers and providers is much 
different for plans that serve commercial enrollees. Although there are 
dominant insurers in many commercial markets, they appear to have less 
leverage than the Medicare FFS program has with providers--in part, at 
least, because FFS payment rates are established by law and are not 
subject to negotiation. If providers are unwilling to accept rates for 
their commercial enrollees that are similar to Medicare's rates, they 
can be reasonably confident that other insurers will pay them more--
particularly because private insurers typically try to satisfy 
consumers' desire for broad provider networks. In addition, when 
enrollees in commercial plans go outside the plan's network to receive 
care, the providers who treat them generally charge more than they 
would have charged had they been in the plan's network. Insurers often 
limit their payments for such care to predetermined amounts, but 
patients are often responsible for some or all of the differences 
---------------------------------------------------------------------------
between those payments and the provider's charges.

In regions where the role of the FFS program diminished under a premium 
support system, CBO expects, the relationship between private insurers 
and health care providers would become less similar to the relationship 
in Medicare Advantage under current law and more similar to the 
relationship in the commercial market for people under age 65.

Broadening of Provider Networks. Another reason bids would increase as 
the share of beneficiaries in the FFS program fell is that private 
insurers, on average, would need to expand their networks to 
accommodate increased enrollment. As a result, private insurers would 
probably need either to pay higher rates or to contract with providers 
with higher-cost practice styles. Bids would rise as a result of 
including higher-cost health care providers that private insurers would 
tend to have excluded when their networks could be narrower. The 
expansion would be greater for lower-bidding plans, CBO projects, 
because those plans would experience greater increases in enrollment.

The Magnitude of the Resulting Adjustments to Bids. CBO did not adjust 
its projections of private insurers' bids in counties in which it 
expects that the FFS program would maintain the share that it currently 
holds (or its nationwide market share, if that is lower). The agency 
anticipates that, in those counties, the forces that now allow private 
insurers to obtain payment rates for their Medicare Advantage plans 
that are similar to those for Medicare's FFS program would continue to 
prevail under a premium support system.\36\ However, where the market 
share of the FFS program is projected to fall below its current level--
and where that share would be below the current national market share--
CBO expects that private insurers would pay higher rates to providers 
for their premium support enrollees than they would pay under current 
law for Medicare Advantage enrollees. CBO adjusted its projections for 
insurers in those counties, and the adjustment was greater for counties 
where larger reductions are anticipated in the FFS program's market 
share. CBO also adjusted the bids upward slightly for plans at or near 
the bottom of the bid distribution to account for the expected 
broadening of provider networks.
---------------------------------------------------------------------------
    \36\ CBO expects that the rates private insurers will pay providers 
under Medicare Advantage plans will rise over time relative to 
Medicare's FFS rates because private insurers are not likely to obtain 
all of the reductions in payment updates that are scheduled for the FFS 
program under current law. The adjustments to bids discussed in this 
section were applied to projected Medicare Advantage bids, developed 
under the expectation that private insurers' payment rates would be 
higher relative to Medicare FFS rates than they are now.

The size of the adjustment for private plans' bids was made partly on 
the basis of the agency's assessment of the average difference between 
the rates paid by Medicare and the rates paid by private insurers to 
hospitals, physicians, and other providers for enrollees in commercial 
plans. However, the adjustment was smaller than that average difference 
---------------------------------------------------------------------------
as a way to account for four main factors:

  The observed difference in payment rates now is more informative 
about the rise in rates that might occur under a premium support system 
in which the FFS program was eliminated; rates would generally rise 
much less under a system in which the FFS program was a competing 
plan--particularly in regions where the FFS program retained a 
significant market share.

  Medicare's FFS payment rates would be used as a reference point 
in negotiations between private plans and providers for their premium 
support enrollees, which would tend to keep those rates below 
commercial rates even in regions where the FFS program had a very low 
market share.

  The competitive structure of a premium support system would tend 
to push rates below commercial rates. In particular, current tax-based 
subsidies to health insurance for commercial enrollees result in less 
competitive pressure on provider payment rates than would occur under 
the premium support options analyzed here.

  A reduction in the FFS market share would lower commercial 
rates, reducing the difference between FFS rates and commercial rates. 
Because of the reduction in the FFS market share, fewer health care 
services would be paid for at relatively low Medicare FFS rates. As a 
result, fewer costs associated with Medicare beneficiaries would 
probably be shifted to private insurers through higher rates for 
hospital services, thus reducing commercial rates.

After considering all of those factors, CBO made separate adjustments 
to its estimates of the bids in each county, depending on the projected 
changes in the FFS program's market share. The relationship between the 
FFS market share and private plans' bids is subject to considerable 
uncertainty, but CBO regards its estimates as being in the middle of 
the distribution of possible outcomes.

Differences Between the Options' Effects on Bids

The combined effects of the factors that would tend to lower bids would 
be slightly larger under the second-lowest-bid option than under the 
average-bid option. In 2020, those effects would reduce bids by about 7 
percent, on average, under the 
second-lowest-bid option and by about 6 percent under the average-bid 
option. In either case, the amount by which bids were reduced would 
vary considerably from one region to another.

The effects of the factors that tended to increase bids also would be 
slightly larger under the second-lowest-bid option than under the 
average-bid option because the increased competition, and the resulting 
changes in enrollment among the plans, would be greater. In 2020, that 
effect would boost bids by about 3 percent, on average, under the 
second-lowest-bid option and by about 2 percent under the average-bid 
option.

The largest difference in the effects of the two options on bids by 
private insurers would result from a difference in the degree of 
competition. That difference would occur for two main reasons.

First, and more important, the benchmark would be lower under the 
second-lowest-bid option than under the average-bid option in most 
regions, so the premiums for a plan with a given bid would be higher. 
In CBO's judgment, insurers would expect those higher premiums to 
increase beneficiaries' sensitivity to differences in costs because 
premiums would consume a greater share of enrollees' discretionary 
income.

Second, bids for plans that wanted to attract automatically assigned 
beneficiaries would tend to be lower under the second-lowest-bid option 
than under the average-bid option. Under either option, according to 
specifications outlined in this report, beneficiaries who made no 
affirmative choice would be assigned with equal probability to an 
available plan that had submitted a bid that was at or below the 
regional benchmark (or to one of the four lowest-bidding plans if more 
than four met that criterion). Although such beneficiaries would be 
comparatively less attractive to plans than those who made an active 
enrollment choice, some plans would nevertheless seek to obtain them 
through assignment. Because no more than two plans would receive 
automatically assigned beneficiaries under the second-lowest-bid option 
in most instances, compared with as many as four under the average-bid 
option, the plans that wanted to enroll such beneficiaries would have 
greater incentives to submit lower bids under the second-lowest-bid 
option.

Changes Over Time in Effects on Bids

Under either option, the combined effects of the factors that tended to 
reduce bids would increase over time, as would the combined effects of 
the factors that tended to increase bids. On balance, CBO anticipates, 
the difference between private insurers' bids under the two options and 
average FFS costs would remain fairly constant for the decade following 
the first few years of implementation.

CBO expects that the increased competition in particular would lead 
insurers to reduce costs even more after 2020 so they could keep their 
bids as low as possible in subsequent years. However, for three 
reasons, the incremental reductions would probably be smaller than the 
initial drop: First, one assumption of this analysis is that the 
legislation that created a new premium support system would provide 
private insurers with several years to determine how to reduce their 
costs before the system was implemented with the result that many 
changes would probably be undertaken in the first few years. Second, 
because many beneficiaries would probably remain in the first plan they 
chose without thoroughly evaluating their options in subsequent years, 
insurers would have an especially strong incentive to submit low bids 
in the first year of the new system. Third, insurers would tend to 
undertake the easier reductions first, and additional reductions would 
probably involve more difficult actions.

However, CBO also projects that Medicare Advantage bids under current 
law will rise more rapidly than average spending in the FFS program. As 
a result, greater cost reduction under the premium support options 
would be necessary in future years to maintain the percentage savings 
relative to FFS spending projected for 2020. By CBO's estimate, the 
additional cost reductions would roughly offset the trends in Medicare 
Advantage bids projected under current law through the 2020s.

 Estimating Federal Spending for Medicare and Beneficiaries' Total 
                    Payments

The methods for estimating combined federal spending and beneficiaries' 
total payments were similar for both options CBO analyzed. CBO 
projected bids for a given year as described in the previous section. 
The agency used those bids (and, for the average-bid option, past 
enrollment) to estimate benchmarks in each county and premiums for each 
plan in each county. It then simulated the enrollment of a large sample 
of beneficiaries in different plans on the basis of premiums and 
previous patterns of enrollment, calculated federal spending as the sum 
of the risk-adjusted federal contribution for each beneficiary, and 
compared total federal spending with the baseline projection. To 
project beneficiaries' total payments, CBO used claims data to estimate 
cost-sharing payments by each beneficiary for the services covered by 
Medicare and combined those estimates with the plans' premiums.

The estimates incorporated data from administrative records for a 
sample of about 600,000 Medicare beneficiaries, along with county-level 
projections of the FFS program's bid and the bids of private plans. CBO 
adjusted the estimates of out-of-pocket spending to match the actuarial 
value of the plans and current distributions of health spending by age, 
health risk, and other factors.

The enrollment simulations were based in part on estimates of two 
especially important aspects of beneficiaries' choices of plans: their 
sensitivity to premiums and the likelihood that they would actively 
choose to enroll in a plan. The analysis also incorporated the effects 
of CBO's expectation that patients who enrolled in private plans would 
have their diagnoses coded more intensively than would patients in the 
FFS program. Possible spillover effects on Medicare FFS spending from 
increased enrollment in private plans were not considered in the 
estimates.

Sensitivity to Premiums

To develop its projections of the plans that Medicare beneficiaries 
would choose under different premium support proposals, CBO conducted 
its own analysis and it examined findings from the research literature 
concerning beneficiaries' sensitivity to premiums in selecting health 
plans.\37\ In the agency's judgment, there are two main reasons that 
beneficiaries' sensitivity under either option would be greater than is 
generally reported in the literature for the Medicare population. 
First, they would face larger differences in premiums under the options 
than those that have been studied previously. Second, beneficiaries 
would receive information on the features of available plans--including 
premiums--in ways that would make comparison among plans simpler than 
is generally the case under current law. Moreover, CBO anticipates, 
beneficiaries who are new Medicare enrollees in the future will be more 
sensitive, on average, than current beneficiaries are to differences in 
premiums. CBO expects those beneficiaries to be healthier generally 
(and thus less likely to have strong ties to providers who might not be 
in some plans' networks) and, because of their experience in the health 
insurance marketplace, to be more conversant than many current 
enrollees are with the process of choosing among plans that offer 
different premiums and packages of benefits.
---------------------------------------------------------------------------
    \37\ See, for example, Thomas C. Buchmueller and others, ``The 
Price Sensitivity of Medicare Beneficiaries: A Regression Discontinuity 
Approach,'' Health Economics, vol. 22, no. 1 (January 2013), pp. 35-51, 
http://tinyurl.com/oo2rrk4; Steven D. Pizer, Austin B. Frakt, and Roger 
Feldman, ``Nothing for Something? Estimating Cost and Value for 
Beneficiaries From Recent Medicare Spending Increases on HMO Payments 
and Drug Benefits,'' International Journal of Health Care Finance and 
Economics, vol. 9, no. 1 (March 2009), pp. 59-81, http://tinyurl.com/
p7xjtvh; Thomas C. Buchmueller, ``Price and the Health Plan Choices of 
Retirees,'' Journal of Health Economics, vol. 25, no. 1 (January 2006), 
pp. 81-101, http://tinyurl.com/m6p93dz; Adam Atherly, Bryan E. Dowd, 
and Roger Feldman, ``The Effect of Benefits, Premiums, and Health Risk 
on Health Plan Choice in the Medicare Program,'' Health Services 
Research, vol. 39, no. 4 (August 2004), pp. 847-864, http://
tinyurl.com/o4wl339; Bryan E. Dowd, Roger Feldman, and Robert Coulam, 
``The Effect of Health Plan Characteristics on Medicare+Choice 
Enrollment,'' Health Services Research, vol. 38, no. 1, part 1 
(February 2003), pp. 113-135, http://tinyurl.com/p34m69r; Anne Beeson 
Royalty and Neil Solomon, ``Health Plan Choice: Price Elasticities in a 
Managed Competition Setting,'' Journal of Human Resources, vol. 34, no. 
1 (Winter 1999), pp. 1-41, http://tinyurl.com/o2m3br7; David M. Cutler 
and Sarah J. Reber, ``Paying for Health Insurance: The Trade-Off 
Between Competition and Adverse Selection,'' Quarterly Journal of 
Economics, vol. 113, no. 2 (May 1998), pp. 433-466, http://tinyurl.com/
mycqvem; and Thomas C. Buchmueller, ``The Health Plan Choices of 
Retirees Under Managed Competition,'' Health Services Research, vol. 
35, no. 5, part 1 (December 2000), pp. 949-976, http://tinyurl.com/
lajxa4w.

In most regions, under either option, beneficiaries would be able to 
choose from several private plans that are likely to be more similar to 
one another than to the FFS program in terms of the size of provider 
networks and approaches to utilization management. Therefore, CBO 
anticipates, beneficiaries would be more sensitive to premiums when 
choosing among private plans than they would be when choosing between 
any private plan and the FFS program. Additionally, CBO expects, 
beneficiaries would become somewhat less sensitive to the cost of 
premiums after the first few years; once beneficiaries are in a plan, 
they generally do not seem to switch readily.\38\ Nevertheless, the 
possibilities of attracting new enrollees each year and of losing 
existing enrollees to competitors would provide incentives for private 
plans to continue to keep bids low.
---------------------------------------------------------------------------
    \38\ For related discussion, see Benjamin R. Handel, ``Adverse 
Selection and Inertia in Health Insurance Markets: When Nudging 
Hurts,'' working paper (University of California at Berkeley, March 
2013, http://emlab.berkeley.edu/bhandel/index.shtml; Peter J. 
Cunningham, Few Americans Switch Employer Health Plans for Better 
Quality, Lower Costs, Research Brief 12 (National Institute for Health 
Care Reform, January 2013), www.nihcr.org/Health-Plan-Switching; 
Jonathan D. Ketcham and others, ``Sinking, Swimming, or Learning to 
Swim in Medicare Part D,'' American Economic Review, vol. 102, no. 6 
(October 2012), pp. 2639-2673, http://tinyurl.com/ow8luxd; Keith M. 
Marzilli Ericson, Consumer Inertia and Firm Pricing in the Medicare 
Part D Prescription Drug Insurance Exchange, Working Paper 18359 
(National Bureau of Economic Research, September 2012), www.nber.org/
papers/w18359; and Kathleen Nosal, ``Estimating Switching Costs for 
Medicare Advantage Plans,'' working paper (University of Arizona, June 
2012), www.u.arizona.edu/nosal/research.html.

The constraints on Medicare payment rates for providers embodied in 
current law may result in diminished access to care and in reduced 
quality of care for beneficiaries in the FFS program, although the 
timing and extent of such changes are very difficult to predict. In 
this analysis, CBO anticipates that beneficiaries would respond to the 
possibility of reduced access or quality by being somewhat more 
inclined to choose a private plan than to choose the FFS program when 
the FFS rates for health care providers fell relative to those of 
private plans.

Active Choice of a Plan

In CBO's assessment, a significant proportion of beneficiaries would 
not actively choose a plan in the first year that a premium support 
system was implemented. Under the specifications adopted for this 
report, beneficiaries who did not make a choice would be assigned 
randomly to a plan with a bid at or below the benchmark (or to one 
among the four lowest-bidding plans, if more than four bid at or below 
the benchmark). To project that share of beneficiaries, CBO analyzed 
the behavior of Medicare Advantage enrollees whose plans had left the 
market, and it reviewed research on enrollment in the Part D program.

CBO expects that a higher percentage of beneficiaries would choose a 
plan under the second-lowest-bid option than under the average-bid 
option because the higher average premiums would be more likely to 
impel beneficiaries to learn about the new program and choose a plan. 
CBO projects that, on average, about 15 percent of beneficiaries would 
not choose a plan in the first year of premium support under the 
second-lowest-bid option and about 20 percent would not choose a plan 
in the first year under the average-bid option. The percentages would 
be expected to vary according to certain demographic characteristics 
and health status identified in CBO's analyses and in its review of 
related research. The agency also projects that most beneficiaries who 
were assigned to a plan in 2018 would still be in that plan by 2020 
(the reference year for the analysis of beneficiaries' premiums) but 
that some beneficiaries who did not choose a plan in the first year 
would switch from the low-bidding plan to which they were assigned to a 
higher-bidding plan later.

More Intensive Diagnostic Coding by Private Insurers

Evidence suggests that private insurers in the Medicare Advantage 
program record a larger number of diagnoses than FFS providers do, so a 
given beneficiary would be expected to have a higher risk score in a 
Medicare Advantage plan than in the FFS program. Because higher risk 
scores result in larger payments, private insurers have a financial 
incentive to ensure that every appropriate diagnosis is coded for each 
enrollee; such an incentive does not generally exist in the FFS sector. 
Although the Medicare program adjusts the risk scores of Medicare 
Advantage enrollees downward to attempt to account for the difference--
and that adjustment was incorporated in the risk scores used in this 
analysis--there is recent evidence that the adjustment is probably 
insufficient.\39\ CBO expects that under the two options private 
insurers would code diagnoses more intensively than providers treating 
FFS patients to the same extent that they would do so in the Medicare 
Advantage program under current law and that the Medicare program would 
adjust the risk scores of enrollees in private plans to the same extent 
that is projected for Medicare Advantage under current law. Thus, no 
adjustments to plans' projected bids in Medicare Advantage were needed 
to account for those practices.
---------------------------------------------------------------------------
    \39\ The Centers for Medicare and Medicaid Services has estimated 
that reported risk scores for Medicare Advantage enrollees are 3.4 
percent higher than they would have been in the FFS sector, and the 
agency adjusts the reported risk scores downward by 3.4 percent when it 
calculates payments to the plans. Under current law, beginning in 2014 
and continuing until 2018, the agency must increase the adjustment 
until the downward adjustment reaches at least 5.9 percent. The 
Government Accountability Office has estimated that the difference in 
coding boosts risk scores for Medicare Advantage enrollees by between 5 
percent and 6 percent relative to likely scores in the FFS system and 
that the difference has widened over time. See Government 
Accountability Office, Substantial Excess Payments Underscore Need for 
CMS to Improve Accuracy of Risk Score Adjustments, GAO-13-206 (January 
2013), www.gao.gov/products/GAO-13-206.

However, CBO expects that the more intensive coding of diagnoses would 
affect federal spending under a premium support system even though it 
would not affect the bids of private plans relative to those under 
current law. In particular, under both options, a larger fraction of 
the Medicare population would be covered by private plans, and thus 
more of the population would be subject to more intensive coding, on 
average, than is the case under current law. Therefore, CBO accounted 
for differences in coding in its projections of payments to insurers. 
CBO expects that beneficiaries who switched from the FFS program to a 
private plan would end up with higher risk scores and that the Medicare 
program would adjust for only part of that difference in calculating 
payment amounts for the insurers. As a result, the federal government 
would pay more for such beneficiaries under a premium support system, 
all else being equal, than it would if there was no difference in 
coding or if the Medicare program adjusted the risk scores of private 
plans to completely remove the effects of coding differences.

Possible Spillover Effects on Medicare FFS Spending

There is evidence that increases in the proportion of beneficiaries 
enrolled in Medicare Advantage plans lead to lower federal spending for 
beneficiaries in the FFS program and in a lower intensity of their 
treatment.\40\ Such spillover effects could occur through at least two 
pathways: Increased managed care penetration could change the way 
physicians treat all of their patients, not just those enrolled in 
managed care plans, and it could influence investment decisions and the 
adoption of new technology in local markets. For this report, CBO did 
not incorporate such spillover effects on the FFS program.
---------------------------------------------------------------------------
    \40\ See Katherine Baicker, Michael Chernew, and Jacob Robbins, The 
Spillover Effects of Medicare Managed Care: Medicare Advantage and 
Hospital Utilization, Working Paper 19070 (National Bureau of Economic 
Research, May 2013), www.nber.org/papers/w19070; Michael Chernew, 
Philip DeCicca, and Robert Town, ``Managed Care and Medical 
Expenditures of Medicare Beneficiaries,'' Journal of Health Economics, 
vol. 27, no. 6 (December 2008), pp. 1,451-1,461, http://tinyurl.com/
qxfh4h9; and Laurence C. Baker, ``The Effect of HMOs on Fee-for-Service 
Health Care Expenditures: Evidence From Medicare,'' Journal of Health 
Economics, vol. 16, no. 4 (July 1997), pp. 453-481, http://tinyurl.com/
kf28hus. The study of Baicker and others presented estimates of the 
effects of Medicare Advantage plans' market share on hospitals' 
resource costs of treating Medicare beneficiaries, which do not 
directly determine Medicare's payments for FFS beneficiaries under the 
prospective payment system. The two other studies estimated the effects 
of Medicare Advantage plans' market share on Medicare spending for FFS 
beneficiaries.

In CBO's estimation, such effects would be very small or even 
negligible in 2020, although the agency will explore the issue more in 
future analyses. The sustainable growth rate mechanism for physicians 
and the provisions of the Affordable Care Act that restrain payment 
updates for most other FFS providers also will restrain federal 
spending in Medicare's FFS program, suggesting that any additional 
reductions in Medicare spending on the FFS program that might result 
from a spillover effect would be smaller than has been estimated in the 
past.\41\
---------------------------------------------------------------------------
    \41\ The Affordable Care Act comprises the Patient Protection and 
Affordable Care Act and the health care provisions of the Health Care 
and Education Reconciliation Act of 2010.

Over the longer term, the size of spillover effects would depend in 
part on whether the restraints on payment updates in the FFS program 
specified under current law are maintained. However, as discussed in 
the section of the text on ``Effects After the First Several Years,'' 
stronger price-based competition under a premium support system would 
probably affect the emergence and diffusion of new technology and 
services in ways that might reduce FFS spending (for a beneficiary of 
---------------------------------------------------------------------------
average health, relative to that under current law) in the longer term.

                                 ______
                                 

                              Appendix B: 
                Analysis of Uncertainty in the Estimates

To characterize uncertainty in the estimated effects of the two 
illustrative options for a premium support system (one called the 
second-lowest-bid option and the other called the average-bid option) 
on federal spending for Medicare and on beneficiaries' total payments, 
the Congressional Budget Office (CBO) determined ranges of values for 
five key parameters and estimated the effects of varying those 
parameters. Those estimates focused on results for 2020, which CBO used 
as a reference year in the analysis. The ranges for the parameters' 
values were chosen to represent CBO's judgment that, accounting not 
only for uncertainty about those parameters but also about most of the 
sources of uncertainty in the analysis (assuming that a premium support 
system was implemented as specified here), there would be about a two-
thirds chance that CBO's central estimate for the effect on federal 
spending would be within the range reported.

CBO varied the following parameters to construct the ranges:

  Bids of Medicare Advantage plans relative to Medicare fee-for-
service (FFS) spending as projected under current law,

  The amount by which private insurers would reduce their bids 
relative to Medicare Advantage bids under current law in response to 
the increased competitive pressure created by the premium support 
system and other factors,

  The higher rates that private insurers would need to pay 
providers (with corresponding increases in bids) that CBO projects 
would result if the market share of the FFS program fell significantly,

  The responsiveness of beneficiaries to differences in premiums 
when choosing among plans, and

  The percentage of beneficiaries who would not actively choose a 
plan in the first year of premium support and who therefore would be 
assigned to a plan with a bid at or below the benchmark.

Effects on Federal Spending

CBO estimated a range of effects on federal spending by simultaneously 
varying all five key parameters in ways that would result in higher or 
lower spending under the premium support options. To do so, the agency 
examined how varying each parameter would affect spending.

 Bids by Medicare Advantage Plans Relative to Fee-for-Service Spending

If Medicare Advantage bids under current law were lower than those in 
CBO's projections and FFS spending was as CBO projects, then federal 
savings under both options would be greater, according to CBO's 
estimates, because the benchmarks under the options would be lower than 
projected. Conversely, if Medicare Advantage bids under current law 
were higher than those in CBO's projections and FFS spending was as CBO 
projects, federal savings would be smaller than projected. Although 
CBO's estimates of the effects of a premium support system are 
sensitive to changes in the bids of Medicare Advantage plans relative 
to FFS spending, those estimates are not directly sensitive to equal 
percentage changes in Medicare Advantage bids and FFS spending--that 
is, to an across-the-board increase or decrease in Medicare spending 
relative to the amounts that CBO projects--because the difference 
between the benchmarks under the options and federal spending for 
Medicare under current law would not be affected. However, if such an 
across-the-board change occurred, it could affect the amount by which 
private insurers under a premium support system reduced their bids 
relative to Medicare Advantage bids (as discussed below).

 Reduction of Bids of Private Plans in Response to Increased 
                    Competitive Pressure and Other Factors

If private insurers responded to increased competitive pressure by 
reducing their bids by more than the amounts in CBO's central 
estimates, federal savings would be correspondingly greater under both 
options because the benchmarks would be lower than estimated. But 
federal savings would be lower if private insurers reduced their bids 
by less than the central estimates.

In addition, if FFS and Medicare Advantage costs were higher across the 
board (because of greater systemwide growth in costs), there might be 
more opportunity for cost savings, depending on the underlying drivers 
of that growth, and the amounts by which private insurers reduced their 
bids under the premium support options would probably be greater than 
they are in the agency's central estimates. Similarly, if costs were 
lower across the board, the amounts by which private insurers reduced 
their bids under the premium support options would probably be smaller 
than they are in the agency's central estimates.

Rates That Private Insurers Would Pay to Providers

If the decline in the market share of the FFS program under a premium 
support system resulted in higher payment rates for health care 
providers and therefore in higher bids from private insurers than in 
CBO's central estimates, federal savings would be correspondingly 
smaller because both those bids and the benchmarks would be higher, all 
else being equal. If that effect was smaller than in the central 
estimates, however, federal savings would be correspondingly greater.

Beneficiaries' Sensitivity to Premiums

Departures from the central estimates in beneficiaries' responsiveness 
to differences in premiums would influence federal spending both 
through the effects on plans' bids and through the effects on the share 
of beneficiaries enrolled in private plans. If beneficiaries were more 
responsive to differences in premiums than is predicted in CBO's 
central estimates, private insurers' bids would be lower than they are 
in those estimates (because insurers would have a stronger incentive to 
reduce their bids if such reductions led to larger increases in 
enrollment); those lower bids would result in greater federal savings. 
Conversely, if beneficiaries were less responsive to differences in 
premiums than in the central estimates, the private insurers' bids 
would be higher and federal savings would be lower. Regarding 
enrollment shares, if beneficiaries were more responsive to differences 
in premiums than in the central estimates, a larger proportion would 
switch to lower-bidding plans under premium support, causing several 
indirect effects on federal savings (as discussed below). If they were 
less responsive, the opposite would occur.

Active Choice of a Plan

If a larger percentage of beneficiaries did not actively choose a plan 
in the first year of premium support than is predicted in CBO's central 
estimates and if those beneficiaries were assigned to plans with bids 
at or below the benchmark, a larger percentage of beneficiaries would 
be enrolled in low-bidding plans, all else being equal. Conversely, if 
a smaller percentage of beneficiaries did not actively choose a plan, a 
smaller percentage would be enrolled in low-bidding plans. The 
implications for federal savings under the two premium support options 
would be similar to the indirect effects (discussed below) that would 
occur through changes in the shares of enrollment in private plans when 
beneficiaries were more, or less, sensitive to differences in premiums 
than is predicted in the central estimates. (Although one might expect 
that having a higher share of beneficiaries not actively choosing a 
plan would have effects similar to beneficiaries' being less sensitive 
to premiums, that is not the case because the beneficiaries who did not 
choose a plan would be assigned to a low-bidding plan.)

 Effects of Changes in the Proportion of Beneficiaries in Lower-Bidding 
                    Plans

A greater responsiveness of beneficiaries to differences in premiums 
when choosing among plans and a larger percentage of beneficiaries not 
actively choosing a plan in the first year would both lead to a larger 
proportion of beneficiaries being enrolled in lower-bidding plans. 
Similarly, less responsiveness to differences in premiums and a smaller 
percentage of beneficiaries not actively choosing a plan would lead to 
a smaller proportion of beneficiaries being enrolled in lower-bidding 
plans. Those differences in enrollment would have indirect effects on 
federal savings through three main mechanisms:

  Under the average-bid option, having a greater proportion of 
beneficiaries in lower-bidding plans would result in lower benchmarks 
(because benchmarks are constructed by weighting each plan's bid by its 
enrollment in the prior year) and thus would result in greater federal 
savings. And if a smaller proportion were enrolled in lower-bidding 
plans, higher benchmarks and lower federal savings would result. Under 
the second-lowest-bid option, however, having a higher or lower 
proportion of beneficiaries enrolled in lower-bidding plans would not 
directly affect benchmarks.

  In most regions, the lower-bidding plans would be private plans, 
and higher enrollment in those plans would be accompanied by a lower 
market share for the FFS program, which would increase bids of private 
plans for reasons discussed above, all else being equal. Lower 
enrollment in private plans would have the opposite effect.

  For any given set of bids, CBO expects, greater enrollment in 
private plans would result in smaller federal savings because 
diagnostic coding by private insurers would be more intensive than that 
by FFS providers under a premium support system (as is now the case 
under the Medicare Advantage program) and federal payments to private 
plans would be adjusted to account for only part of that difference in 
coding. Again, lower enrollment in private plans would have the 
opposite effect.

Effects on Beneficiaries' Total Payments

CBO estimated a range of effects on beneficiaries' total payments by 
simultaneously varying all five key parameters in ways that would 
result in higher and lower payments under the premium support options. 
In CBO's assessment, the uncertainty of the estimated effects on 
beneficiaries' total payments is greater than that concerning the 
estimated effects on federal spending because there are especially 
broad ranges of plausible values for the two parameters that would 
affect beneficiaries' payments the most: their sensitivity to premiums 
and the percentage who would not initially choose a plan. Varying other 
parameters also affects the estimates.

If beneficiaries were more sensitive to premiums than CBO's central 
estimates indicate, more of them would enroll in lower-bidding plans, 
and their total payments would be lower, on average, than the central 
estimates indicate (because enrollees in low-bidding plans would pay 
lower premiums and use fewer medical services and therefore pay less 
out of pocket for services). The opposite also is true: If 
beneficiaries are less sensitive to premiums, fewer would enroll in 
lower-bidding plans, and their total payments would be higher, on 
average.

By the same logic, if the proportion of beneficiaries who did not 
choose a plan in the first year of a premium support system was larger 
than that indicated by the central estimates, their total payments 
would be lower, on average, than predicted (because those who did not 
choose a plan would be assigned to one with a bid at or below the 
benchmark). And if the proportion of beneficiaries who did not choose a 
plan was smaller than in the central estimates, their total payments 
would be higher, on average.

Beneficiaries' payments under the premium support options also would 
depend on other factors that contribute to the uncertainty of CBO's 
estimates. Private plans' bids could differ from the agency's central 
estimates if the current-law bids for Medicare Advantage were higher or 
lower than they are in CBO's estimates, if private insurers reduced 
their bids under a premium support system by more or less than the 
amounts in those estimates, or if the adjustment to plans' provider 
payment rates (and thus their bids) reflected a decline in the FFS 
market share that was smaller or larger than that in the estimates. For 
example, if the bids of private plans were below the central estimates, 
then payments would be lower for enrollees in those plans (because of 
lower premiums and reduced cost sharing) and higher for those who 
enrolled in the FFS program (because the lower cost of private plans 
would reduce benchmarks and raise FFS premiums). As a result, 
beneficiaries would have a greater incentive to switch from the FFS 
program to private plans, and beneficiaries' total payments would be 
lower than CBO's central estimates would indicate (assuming that the 
number of beneficiaries enrolled in the FFS program was not so large 
that the increase in payments for those beneficiaries outweighed the 
reduction in payments for enrollees in private plans and the reduction 
in the standard premium for all beneficiaries as a result of the lower 
benchmarks). If private plans' bids were higher than predicted by the 
central estimates, beneficiaries' total payments would rise relative to 
the central estimates.

                                 ______
                                 

                          About This Document

This Congressional Budget Office (CBO) report was prepared in response 
to interest expressed by Members of Congress. In keeping with CBO's 
mandate to provide objective, impartial analysis, the report makes no 
recommendations.

Jessica Banthin, James Baumgardner, Tom Bradley, Melinda Buntin 
(formerly of CBO), Holly Harvey, Paul Jacobs, Jeffrey Kling, Paul Masi, 
Eamon Molloy, Lyle Nelson, Romain Parsad, and Andrew Stocking 
contributed to the analysis and prepared the report with guidance from 
Linda Bilheimer and Peter Fontaine. Additional assistance was provided 
by numerous analysts in CBO's Budget Analysis Division and in its 
Health, Retirement, and Long-Term Analysis Division.

Henry Aaron of the Brookings Institution, Joseph Antos of the American 
Enterprise Institute, Thomas Buchmueller of the University of Michigan, 
Michael Chernew of Harvard University, Mark Duggan of the University of 
Pennsylvania, Alain Enthoven of Stanford University, Roger Feldman of 
the University of Minnesota, Amy Finkelstein of the Massachusetts 
Institute of Technology, Paul Ginsburg of the Center for Studying 
Health System Change, Mark McClellan of the Brookings Institution, Mark 
Miller of the Medicare Payment Advisory Commission, Joseph Newhouse of 
Harvard University, Patricia Neuman of the Kaiser Family Foundation, 
and Robert Reischauer of the Urban Institute provided comments about 
CBO's analytical approach. (The assistance of external experts implies 
no responsibility for the final product, which rests solely with CBO.)

Kate Kelly edited the report, and Maureen Costantino and Jeanine Rees 
prepared it for publication. An electronic version is available on 
CBO's website (www.cbo.gov/publications/44581).

Douglas W. Elmendorf
Director

September 2013

                                 ______
                                 

                                Table 1.
 Change in Net Federal Spending for Medicare Under Illustrative Premium
        Support Options, Relative to That Under Current Law, 2020
------------------------------------------------------------------------
                      Second-Lowest-Bid Option     Average-Bid Option
------------------------------------------------------------------------
In Billions of                            -45                       -15
 Dollars a
 
As a Percentage of                         -6                        -2
 Net Federal
 Spending for
 Medicare
 
As a Percentage of                        -11                        -4
 Net Federal
 Spending for Parts
 A and B for
 PAffected
 Beneficiaries b
------------------------------------------------------------------------
Source: Congressional Budget Office.
 
Note: Although estimates of percentage changes are based on CBO's March
  2012 baseline projections (which are the projections underlying the
  analysis in this report), the dollar savings are based on applying
  those percentages to CBO's most recent projections (see Updated Budget
  Projections: Fiscal Years 2013 to 2023, May 2013, www.cbo.gov/
  publication/44172).
 
a Rounded to the nearest $5 billion.
 
b Affected beneficiaries include everyone who would have enrolled in
  Medicare under current law, except dual-eligible beneficiaries (people
  who are simultaneously enrolled in Medicare and Medicaid). Spending
  for affected beneficiaries includes all spending for Part A (Hospital
  Insurance) and Part B (Medical Insurance) except spending that was
  excluded because it is not covered by the bids that Medicare Advantage
  plans submit under current law--namely, the additional payments to
  disproportionate-share hospitals (whose share of low-income patients
  exceeds a specified threshold) and spending for medical education,
  hospice benefits, and certain benefits for patients with end-stage
  renal disease. Spending for Part D prescription drug insurance is
  excluded.



                                Table 2.
    Change in Net Federal Spending for Medicare and in Beneficiaries'
Payments Under Illustrative Premium Support Options, Relative to Amounts
                         Under Current Law, 2020
------------------------------------------------------------------------
      (Percent)       Second-Lowest-Bid Option     Average-Bid Option
------------------------------------------------------------------------
Net Federal Spending
 for Parts A and B
 for Affected
 Beneficiaries a
    Central Estimate                      -11                        -4
    Range                           -9 to -14                  -1 to -7
 
Total Payments by
 Affected
 Beneficiaries b
    Central Estimate                       11                        -6
    Range                            -2 to 24                  0 to -12
 
Net Federal Spending
 for Parts A and B
 for Affected
Beneficiaries Plus
 Total Payments by
 Affected
 Beneficiaries a, b,
  c
    Central Estimate                       -5                        -4
 
Memorandum:
Premiums Paid by
 Affected
 Beneficiaries c, d
    Central Estimate                       31                        -6
------------------------------------------------------------------------
Source: Congressional Budget Office.
 
Note: Affected beneficiaries include everyone who would have enrolled in
  Medicare under current law, except dual-eligible beneficiaries (people
  who are simultaneously enrolled in Medicare and Medicaid).
 
a The reported range for the second-lowest-bid option is not symmetric
  around the central estimate because of rounding. Spending for affected
  beneficiaries includes all spending for Part A (Hospital Insurance)
  and Part B (Medical Insurance) except spending that was excluded
  because it is not covered by the bids that Medicare Advantage plans
  submit under current law--namely, the additional payments to
  disproportionate-share hospitals (whose share of low-income patients
  exceeds a specified threshold) and spending for medical education,
  hospice benefits, and certain benefits for patients with end-stage
  renal disease. Spending for Part D prescription drug insurance is
  excluded.
 
b Payments include premiums and out-of-pocket costs for deductibles,
  copayments, and coinsurance for services and supplies covered by Part
  A and Part B. Payments include the standard Part B premium and the
  income-related premium (applicable for beneficiaries whose income
  exceeds specified threholds) but exclude any additional amounts paid
  for enhanced benefits or supplemental (medigap) coverage.
 
c Range has not yet been estimated.
 
d Under current law and under the options, premiums are for the basic
  package of Medicare benefits covered under Parts A and B. They exclude
  any additional amounts paid for enhanced benefits or supplemental
  (medigap) coverage and any amounts paid for the incomerelatedpremium.


  [GRAPHIC] [TIFF OMITTED] T12417.001
  

  [GRAPHIC] [TIFF OMITTED] T12417.002
  


                                 Box 1.
------------------------------------------------------------------------
 
-------------------------------------------------------------------------
The Medicare Program
------------------------------------------------------------------------
In 2013, Medicare will provide federal health insurance for 52 million
 people who are elderly (age 65 or older) or disabled or who have end-
 stage renal disease. Of that group, about 85 percent are elderly.
 Medicare's Part A (Hospital Insurance) primarily covers inpatient
 hospital, skilled nursing facility, and hospice care. Part B (Medical
 Insurance) mainly covers services provided by physicians and other
 practitioners and by hospital outpatient departments. Home health care
 may be covered by Part A or by Part B. Medicare's Part D is the
 prescription drug program. Nearly 30 percent of Medicare beneficiaries
 receive care through the Medicare Advantage program, or Part C, in
 which private health insurers assume responsibility for, and the
 financial risk of, providing Medicare benefits. Almost all of the
 remaining beneficiaries receive care in the traditional fee-for-service
 (FFS) program. In 2012, gross spending for Medicare was $557 billion.
 Net of offsetting receipts (mostly premiums paid by beneficiaries),
 federal spending for the program was $472 billion.
 
 
 
Medicare's Financing
The various parts of Medicare are financed in different ways. Part A is
 financed primarily by a payroll tax. Beneficiaries' premiums (including
 income-related adjustments paid by higher-income beneficiaries) cover
 just over one-quarter of the outlays for Part B, and general funds from
 the U.S. Treasury cover nearly all of the rest. The government's
 payments to Medicare Advantage plans are financed by funds from Parts A
 and B. For Part D, enrollees' premiums cover about one-quarter of the
 cost of the basic prescription drug benefit, the federal government
 receives payments from states for dual-eligible beneficiaries (who are
 enrolled simultaneously in Medicare and Medicaid), and general funds
 cover most of the remaining cost. In fiscal year 2012, payroll taxes
 financed about 37 percent of Medicare outlays, beneficiaries' premiums
 covered about 13 percent, and most of the rest came from general funds
 of the Treasury.
 
Medicare's Traditional Fee-for-Service Program
Enrollees in the traditional FFS program are covered for services
 delivered by any participating provider, and both the package of
 benefits and the rates paid to providers are set by law. Medicare
 beneficiaries share those costs through deductibles and coinsurance,
 but because cost-sharing liabilities can be substantial (in part
 because traditional Medicare does not include an annual cap on what
 beneficiaries spend), about 90 percent of beneficiaries in the FFS
 program have supplemental insurance that covers most or all of their
 cost sharing, often through retiree plans offered by former employers
 or through individual insurance policies (known as medigap plans) or
 Medicaid.
 
Medicare Advantage
In most places in the United States, Medicare beneficiaries may choose
 among competing private insurers--through the Medicare Advantage
 program--instead of the traditional FFS program. Participating
 insurance companies submit bids indicating the per capita payment they
 are willing to accept for providing Part A and B benefits to a
 beneficiary of average health. (A separate bidding process determines
 payments for Part D.) The federal payment per enrollee then depends on
 what the insurance company bids and on how that amount compares with a
 ``benchmark'' that is announced by the federal government before those
 bids are submitted. Under a system set to be fully phased in by 2017,
 benchmarks will be based on per capita spending in the FFS program at
 the county level, and they will range from 95 percent of FFS spending
 per capita in the one-quarter of counties where such spending is
 highest to 115 percent of FFS spending per capita in the one-quarter of
 counties where such spending is lowest. Plans with quality ratings
 above a specified threshold will have bonus amounts added to their
 benchmarks.
 
Plans that submit a bid below the benchmark for a service area receive
 federal payments that equal their bid plus a rebate that is a
 percentage of the difference between the bid and the benchmark.
 (Beginning in 2014, the rebate will range from 50 percent to 70
 percent, depending on the plan's performance on certain quality
 measures.) Plans must return the rebate to enrollees in the form of
 reduced cost sharing for benefits, coverage for items not covered by
 Medicare, or reduced Part B or Part D premiums. Plans with a bid that
 equals or exceeds the benchmark receive federal payments that equal the
 benchmark and must charge enrollees a premium for their Medicare
 coverage equal to the amount by which their bid exceeds the benchmark.
 Plans' payments from Medicare are larger or smaller, respectively, for
 enrollees who are in worse- or better-than-average health.
------------------------------------------------------------------------



                                                    Table 3.
    Examples of Determining Premiums Under Illustrative Premium Support Options, Using Hypothetical Bids and
                                                   Enrollment
----------------------------------------------------------------------------------------------------------------
                                  Region With High Fee-for-Service      Region With Low Fee-for-Service Spending
                                              Spending                 -----------------------------------------
                             ------------------------------------------
                                               Annual      Proportion        Bid         Annual      Proportion
                                   Bid         Premium      Enrolled                     Premium      Enrolled
----------------------------------------------------------------------------------------------------------------
                                            Second-Lowest-Bid Option
 
Fee-for-Service Program            14,000         4,300          0.25         9,900         1,900          0.75
 
Private Plans
    A                              11,800         2,100          0.15        10,100         2,100          0.05
    B                              11,600         1,900          0.15         9,900         1,900          0.05
    C                              11,400         1,700          0.15         9,700         1,700          0.05
    D                              11,200         1,500          0.15         9,500         1,500          0.05
    E                              11,000         1,300          0.15         9,300         1,300          0.05
 
Benchmark                          11,200          n.a.          n.a.         9,500          n.a.          n.a.
Standard Premium                     n.a.         1,500          n.a.          n.a.         1,500          n.a.
 
                                               Average-Bid Option
 
Fee-for-Service Program            14,000         3,300          0.25         9,900         1,500          0.75
 
Private Plans
    A                              12,000         1,300          0.15        10,300         1,900          0.05
    B                              11,800         1,100          0.15        10,100         1,700          0.05
    C                              11,600           900          0.15         9,900         1,500          0.05
    D                              11,400           700          0.15         9,700         1,300          0.05
    E                              11,200           500          0.15         9,500         1,100          0.05
 
Benchmark                          12,200          n.a.          n.a.         9,900          n.a.          n.a.
Standard Premium                     n.a.         1,500          n.a.          n.a.         1,500          n.a.
Enrollment-Weighted Average        12,200         1,500          n.a.         9,900         1,500         n.a.
----------------------------------------------------------------------------------------------------------------
Source: Congressional Budget Office.
 
Notes: Under the second-lowest-bid option, the benchmark would equal the lower of the second-lowest bid from a
  private plan and the bid of the fee-for-service program. Under the average-bid option, the benchmark would
  equal the enrollment-weighted-average bid among all plans, including the fee-for-service program.
 
      Proportion enrolled is for the previous year. Equal proportions among private plans are used to simplify
  the example. (According to CBO's estimates, enrollment would be higher in low-bidding plans.)
 
      Under both options, premiums would equal the standard premium plus the bid minus the benchmark, and
  federal contributions for a beneficiary of average health would equal the benchmark minus the standard
  premium. Those federal contributions would be $9,700 and $8,000 under the second-lowest-bid option in regions
  with high and low fee-for-service spending, respectively, and $10,700 and $8,400 under the average-bid option
  in such regions, respectively.
 
      n.a. = not applicable.


[GRAPHIC] [TIFF OMITTED] T12417.003



                                                    Table 4.
 Average Annual Premiums Charged by Plans for Medicare Part A and B Benefits Under Illustrative Premium Support
                                      Options, Weighted by Population, 2020
----------------------------------------------------------------------------------------------------------------
                                         Second-Lowest-Bid Option                   Average-Bid Option
                                 -------------------------------------------------------------------------------
                                                       Change From  Part                       Change From  Part
                                    Annual Premium     B Premium  Under     Annual Premium     B Premium  Under
                                       (Dollars)          Current Law          (Dollars)          Current Law
                                                           (Percent)                               (Percent)
----------------------------------------------------------------------------------------------------------------
Second-Lowest-Bidding Private                 1,500                  -6                 900                 -44
 Plan
 
Median-Bidding Private Plan                   1,800                  13               1,200                 -25
 
Fee-for-Service Program                       3,100                  94               2,400                 50
----------------------------------------------------------------------------------------------------------------
Source: Congressional Budget Office.
 
Note: Premiums charged by plans are averages weighted by the Medicare population in each region. (Those averages
  differ from the average premiums paid by beneficiaries, which are based on CBO's projections of enrollment in
  plans.) Under current law and under the options, premiums are for the basic package of Medicare benefits
  covered under Part A (Hospital Insurance) and Part B (Medical Insurance). They exclude any additional amounts
  paid for enhanced benefits or supplemental (medigap) coverage and any amounts paid for the income-related
  premium (applicable for beneficiaries whose income exceeds specified threholds). Under current law, for most
  beneficiaries, Part A will have no premium and the premium for Part B (excluding income-related adjustments)
  will be $1,600 in 2020, CBO projects. Amounts are rounded to the nearest $100.


  [GRAPHIC] [TIFF OMITTED] T12417.004
  

  [GRAPHIC] [TIFF OMITTED] T12417.005
  


                                 Box 2.
------------------------------------------------------------------------
 
-------------------------------------------------------------------------
Grandfathering of Beneficiaries Under a Premium Support System
------------------------------------------------------------------------
Under one type of proposal for a premium support system, current
 beneficiaries and those who became eligible for Medicare before the new
 system took effect would continue to receive coverage under the
 existing Medicare program; only those beneficiaries who became newly
 eligible on or after a specified date would enroll in the premium
 support system. Such an arrangement would require the federal
 government to address several important design questions-some are
 unique to such a system and others are relevant for any premium support
 system but have added significance if grandfathering is part of the
 design. Although policymakers might also consider changing the existing
 Medicare program if it remained in operation, this discussion focuses
 on design issues specifically related to a grandfathering provision in
 a premium support system, and it assumes that beneficiaries who
 remained in the existing system could choose Medicare's fee-for-service
 (FFS) program or a Medicare Advantage plan and that private insurers
 could participate in the premium support system, the Medicare Advantage
 program, or both.
 
Enrollment in Part B
An important question for any premium support system is whether
 enrollment in Medicare's Part B (Medical Insurance) would remain
 voluntary, and if so, how beneficiaries who declined that coverage
 would be treated by the system. About 8 percent of Medicare
 beneficiaries are not enrolled in Part B currently, generally because
 either they or a spouse are still working and have employment-based
 coverage as primary insurance with Medicare as a secondary insurer.
 
Among the Medicare population age 65 or older, younger beneficiaries are
 more likely to decline Part B coverage, and the percentage that does so
 has increased as more people have stayed in the workforce past age 65.
 (The late-enrollment penalty for Part B is waived for active workers in
 larger companies that offer employment-based coverage. If such workers
 were to enroll, Medicare would be a secondary payer for their health
 care costs, which would reduce the value of the coverage.) Some 19
 percent of 65-year-old Medicare beneficiaries were not enrolled in Part
 B in 2011, up from 15 percent in 1999. If a premium support program
 included grandfathering, the question of whether Part B enrollment
 would remain voluntary would be especially important because the
 younger segment of the retirement-age population would constitute a
 substantial fraction of the beneficiaries covered in the first few
 years.
 
Bidding Regions
Depending on how the regions were defined, in many regions the number of
 beneficiaries in a premium support system with a grandfathering
 provision could initially be very small. If dual-eligible beneficiaries
 also were excluded from the new system, the Congressional Budget Office
 (CBO) projects, just 5 percent of the Medicare population would be
 covered by the system after the first year, and only 25 percent would
 be covered after the fifth year.
 
Some proposals would have bidding regions correspond to health care
 markets within states. In that case, grandfathering would result in
 some regions' enrolling very small numbers of people in the new system
 in the first few years. Because personal health care expenditures vary
 widely, the actual costs of enrollees in private plans and the FFS
 program could differ greatly from those plans' bids for their regions.
 That uncertainty could make participation less attractive to private
 insurers, cause them to raise their bids if they chose to participate,
 and create significant year-to-year variation in the amounts of the
 bids. In regions with few beneficiaries, private insurers also would
 have less incentive to modify health care plans to contain costs.
 
Bids and Risk Adjustment
Under the illustrative premium support options analyzed for this report,
 insurers would submit a bid for a beneficiary with average expected
 health care costs (that is, a beneficiary with a risk score of 1.0),
 and federal payments to insurers would be adjusted to account for
 differences between their enrollees' expected costs and those of the
 average beneficiary. CBO assumed that the risk adjustment would be
 comparable to that for the Medicare Advantage program, in which federal
 payments to insurers are adjusted on the basis of enrollees' medical
 conditions and demographic characteristics.
 
In the initial years of a system with grandfathering, a substantial
 proportion of covered beneficiaries would not have the history of past
 Medicare claims data necessary to compute a risk score. For those
 beneficiaries, payments to plans could be adjusted using a version of
 the risk adjuster based entirely on demographic characteristics. That
 approach lacks the completeness of the standard risk adjuster, which
 includes information on medical conditions, so pursuing it would raise
 questions about the adequacy of risk adjustment in the first few years.
 
Under a grandfathering provision, the bidding and risk adjustment
 mechanism could reflect average expected costs for a beneficiary in the
 premium support system. That approach would necessitate ``rescaling''
 the risk adjustment factors to correspond to the segment of the
 Medicare population enrolled in the premium support system or
 reestimating those factors (because particular risks are associated
 with costs in ways that would differ between that segment and the
 Medicare population as a whole). If the existing risk adjustment
 mechanism was used instead, insurers would base their bids on a
 population that differed from the population served under the premium
 support system. An analogous set of issues would confront the Medicare
 Advantage program. Once the premium support system began, the
 proportion of beneficiaries eligible to enroll in a Medicare Advantage
 plan would decline each year as new people entered the premium support
 system.
 
Beneficiaries' Premiums
For both illustrative options, CBO assumed that beneficiaries who
 enrolled in a plan with a bid equal to the benchmark would pay a
 standard premium determined using the same formula used to calculate
 the Part B premium under current law. With grandfathering, that premium
 could be determined in various ways. One approach would be to compute a
 single standard premium for the entire Medicare population that would
 apply both to beneficiaries in the premium support system and to those
 who were grandfathered into Medicare in its current-law form. In a
 second approach, separate computations could be made for a standard
 premium under the premium support system and for the Part B premium
 that would apply to the grandfathered population; a standard premium
 could be computed as one amount, or standard premiums could differ by
 beneficiaries' age. Each approach would involve a different
 distribution of health care costs and of potential savings from a
 premium support system among age groups.
------------------------------------------------------------------------


 [GRAPHIC] [TIFF OMITTED] T12417.006
 

                                 ______
                                 

                        Politico, April 30, 2012

                   GOP Split on Reforming Health Care
                         By Jennifer Haberkorn
Ask the 242 House Republicans what kind of health policy they'd like to 
enact instead of President Barack Obama's health care reform law and 
you might get 242 different answers.

Even after 3 years of railing against Obama's plan, Republicans have 
coalesced around only a few basic tenets of health policy--let alone a 
full replacement plan.

They are even divided over whether some of the popular pieces of 
Obama's health law are a good idea. For example, most Republicans 
support the health law's requirement that insurance companies accept 
all applicants--but the replacement plan put forward by the most 
prominent Republican ignores that idea.

``It's a terrible idea,'' Rep. Tom Price (R-GA), the sponsor of the 
plan, told Politico. He said Democrats only enacted the provision in 
order to require exactly what kinds of insurance Americans must have. 
He would rather expand coverage voluntarily.

The wide range of GOP opinions could make it hard for the party to come 
together behind a single plan to replace Obama's health care law if 
it's overturned by the Supreme Court this summer.

A ruling against all or part of the legislation has the potential to 
reopen the health care wars of 2009, putting the differences among 
Republicans on full display. It's a divide Democrats would try to 
exploit as they press Republicans on how they're going to solve the 
country's health care problems.

``If the Supreme Court throws out the president's plan, we're going to 
have to have something on the table,'' said Rep. Paul Broun (R-GA), a 
physician.

House Republicans won't be the only ones with replacement plans. Gov. 
Mitt Romney's health agenda relies more on state-level reforms and 
private competition than Obama's law.

On Capitol Hill, there are a handful of pending Republican health 
bills.

Days before the Supreme Court heard oral arguments over the health law, 
Broun introduced a plan that allows Americans to deduct all of their 
health care costs; encourages the use of health savings accounts; 
converts Medicare to a ``premium support'' model that subsidizes 
private coverage; allows consumers to buy insurance across state lines; 
and encourages the use of association health plans, which allow groups 
of people or co-workers to buy health care together.

Broun said he's trying to drum up support among lawmakers and outside 
groups and already has the backing of FreedomWorks, the conservative 
group led by Dick Armey.

The plan that's likely to get the closest look from Republicans is 
sponsored by Price, an orthopedic surgeon and one of the House's 
leading voices on health care. He released a video on Wednesday touting 
the plan, which he originally introduced in 2009.

                                 ______
                                 
    Prepared Statement of Hon. Thomas Price, M.D., Nominated to be 
           Secretary, Department of Health and Human Services
    Thank you, Chairman Hatch, Ranking Member Wyden, and all the 
members of this committee, for the opportunity to speak with you today 
and engage in a discussion about the road ahead for our great Nation. 
These proceedings, and this entire process, would not be possible 
without the work of your staff, and so I want to extend my appreciation 
to them as well for the great service they provide. Thanks so much to 
Senator Johnny Isakson for his generous introduction. We've known each 
other for nearly 30 years--and I'm so grateful for his friendship and 
kindness, and our State is blessed to have had his service and 
leadership. I wish also to especially thank my wife of 33 years, Betty. 
Her support, encouragement and advice (which is always correct) mean 
more than I could ever say.

    Over the past few weeks, I have had the chance to meet with many of 
you individually and have gained a real appreciation for the passion 
you all have about the critical work of the Department of Health and 
Human Services. Please know that I share that passion. That is why I am 
here today--and why I'm honored to have been nominated by the President 
to serve as the next Secretary of HHS.

    We all come to public service in our own unique ways that inform 
who we are and why we serve. My first professional calling was to care 
for patients. That experience as a physician and later as a legislator 
has provided a holistic view of the complex interactions that take 
place every day across our communities and across this country that, 
when done correctly, are in service to the greater good we seek to 
achieve. Today, I hope to share with you how my experience has helped 
shape my understanding of and appreciation for the work of the 
department and its team, which I hope to lead.

    From an early age, I had an interest in medicine. My earliest 
memories are of a farm in Michigan where my family and I lived before 
moving to suburban Detroit at the age of five. I spent most of my 
formative years being raised by a single mom--and I assumed a lot of 
responsibility since there were 5 of us. Some of my fondest memories 
were spending time with my grandfather--a physician--as he made house 
calls to see patients. Having both a father and grandfather as 
physicians surely influenced my path toward medicine. And it was very 
likely that the orthopedist who treated my many broken bones in my 
youth gave me a particular fascination for fixing things--and not just 
broken bones.

    After graduating with a medical degree from the University of 
Michigan, I went south to Atlanta, GA--which I've called home for 
nearly 40 years. It's where I met my wife Betty and where we raised our 
son. I did my residency at Emory University and Grady Memorial Hospital 
in downtown Atlanta. I would return to Grady later in my career to 
serve as Medical Director of the Orthopedic Clinic. Throughout my 
professional career I treated patients of every age--from all walks of 
life--including many children. Anyone who has ever treated a child 
knows how fulfilling it is to look into the eyes of a parent and tell 
them our team has helped heal their son or daughter--to give them peace 
of mind. My memories of Grady are filled with the gracious comments 
from parents and patients for the team of health care specialists with 
whom I had the privilege of working. I cherished my time there.

    After 25 years of school and training, I hung out my shingle to 
start a solo private orthopedic practice. Over the years, this practice 
grew and eventually became one of the largest, non-academic orthopedic 
groups in the country--a group I would eventually serve as Chairman of 
the Board. Whether as part of that team or on staff at a hospital, it 
was apparent early on that every person involved in the delivery of 
care, no matter their role--doctors, nurses, lab techs, orderlies--all 
had one goal in mind--and that was to get our patients well again, to 
heal them. It was always a team effort and wherever you fit into that 
team, you appreciated the value of those working with you.

    During 20 years as a practicing physician--both in office and 
hospital setting--I learned a good bit about not just treating patients 
but about the broader health care system and where it intersects with 
government--local, State and Federal. A couple of lessons stand out. 
One--many patients I knew or treated were never more angry and 
frustrated than when they realized that there was someone other than 
themselves and /or their physician making medical decisions on their 
behalf--when there was someone not involved in the actual delivery of 
care that was standing between them and their doctor or treatment.

    Another lesson came the day I noticed that there were more 
individuals within our office who were dealing with paperwork, 
insurance filings, and government regulations than there were 
individuals actually seeing and treating patients. It was in those 
moments that it became crystal clear that our health care system was 
losing focus on the number one priority--the individual patient. Having 
had no greater joy than taking care of patients, I felt compelled to 
broaden my role in public service, and help solve the issues harming 
the delivery of medicine--so I ran for the State Senate in Georgia.

    Anyone here who has ever served at the State level knows that State 
government has a different feel to it--a different pace. In Georgia, I 
found the State Senate to be a remarkably bipartisan place where 
collegial relationships were the norm. This is the environment in which 
I learned to legislate--reaching across the aisle to get the work 
done--needing the buy-in and the support of more than just one party. I 
worked with Democrats including then State senator, now-Atlanta Mayor, 
Kasim Reed. He and I did not see eye to eye on everything, for sure, 
but we were successful in finding our way together through some really 
challenging issues for our State.

    In Congress, I have been fortunate to have been a part of 
collaborations that broke through party lines to solve problems 
including those pertaining to health care. Early in my congressional 
career, I was privileged to work alongside then-
representative, now Senator, Tammy Baldwin to introduce legislation 
that would have empowered States to come up with new ideas to provide 
health care coverage to their uninsured populations. Just this past 
Congress, it was a bipartisan, bicameral effort that actually succeeded 
in ridding Medicare of a broken physician payment system and which has 
now begun the creation of a new system that, if implemented properly, 
will help ensure that seniors have better access to higher quality 
care.

    If confirmed, my obligation will be to carry to the Department of 
Health and Human Services both an appreciation for bipartisan, team-
driven policymaking and what has been a lifetime commitment to work to 
improve the health and well-being of the American people. That 
commitment extends to what I call the six principles of health care--
six principles that, if you think about it, all of us hold dear: 
affordability, accessibility, quality, choices, innovation, and 
responsiveness. We all want a health care system that's affordable, 
that's accessible to all, of the highest quality, with the greatest 
number of choices, driven by world-leading innovations, and responsive 
to the needs of the individual patient.

    But HHS is more than just health care. There are real heroes at 
this department doing incredible work to keep our food safe, to develop 
new drugs and treatment options--driven by scientists conducting truly 
remarkable research. The Centers for Disease Control and Prevention--
which we in Atlanta are proud to have headquartered in our city--is the 
first place the world turns to when there's a health care threat that 
requires the greatest, most capable minds to solve.

    There are heroes among the talented, dedicated men and women 
working to provide critical social services--helping families and, 
particularly, children have a higher quality of living and the 
opportunity to rise up and strive to achieve their American Dream--
something we all want for ourselves and our loved ones.

    The role of HHS in improving lives means it must carry out its 
responsibilities with compassion. It also must be efficient, effective 
and accountable, as well as being willing to partner with those in our 
communities already doing remarkable work. In every aspect of the 
department, across the spectrum of issues and services it handles, 
there is embedded a promise that has been made to the American people. 
Governor Michael Leavitt, during his confirmation hearing in 2004 to 
take on this task, spoke of our highly regarded ``brands''--the CDC, 
FDA, NIH, and others--and how they must be preserved and strengthened 
because they guarantee that those promises are kept.

    Today's challenges make it even more important that we strengthen 
our resolve to keep the promises we, as a society, have made to our 
senior citizens and to those among us who are most in need of care and 
support. That means saving, strengthening, and securing Medicare for 
today's beneficiaries and future generations. It means ensuring that 
our Nation's Medicaid population has access to quality care. It means 
maintaining, and expanding, America's leading role in medical 
innovation and the treatment and eradication of disease.

    As I noted at the outset, I share your passion for these issues--
having spent my life in service to them. And yet, there's no doubt that 
we do not all share the same point of view when it comes to addressing 
each and every one of them. Our approaches to policies may differ, but 
there surely exists a common commitment to public service and 
compassion for those we serve. We all hope, by our actions, to help 
improve the lives of the American people, to help heal individuals and 
whole communities. With a healthy dose of humility and appreciation for 
the scope of the challenges before us, with your assistance and with 
God's will, we can make it happen. I look forward to working with you 
to do just that.

    Thank you very much for the privilege of appearing before you 
today.

                                 ______
                                 

                        SENATE FINANCE COMMITTEE

                  STATEMENT OF INFORMATION REQUESTED 
                               OF NOMINEE

                      A. BIOGRAPHICAL INFORMATION

 1.  Name (include any former names used): Thomas Edmunds Price, M.D.

 2.  Position to which nominated: Secretary of the Department of Health 
and Human Services.

 3.  Date of nomination: January 20, 2017.

 4.  Address (list current residence, office, and mailing addresses):

 5.  Date and place of birth: October 8, 1954, Lansing, Michigan.

 6.  Marital status (include maiden name of wife or husband's name):

 7.  Names and ages of children:

 8.  Education (list secondary and higher education institutions, dates 
attended, degree received, and date degree granted): Dearborn High 
School, 1969-1972, Diploma; University of Michigan, 1972-1979, 
Bachelor's Degree and Doctor of Medicine.

 9.  Employment record (list all jobs held since college, including the 
title or description of job, name of employer, location of work, and 
dates of employment): Surgical Intern, Emory University School of 
Medicine/Grady Health System, Atlanta, GA, 1979-1980; Orthopaedic 
Surgical Resident, Emory University School of Medicine/Grady Health 
System, Atlanta, GA, 1980-1984; Orthopaedic Surgeon, solo and group 
practice (North Fulton Orthopaedic Clinic, Compass Orthopaedics, 
Resurgens Orthopaedics), Roswell/Atlanta, GA, 1984-2002; Assistant 
Professor, Orthopaedic Surgery, Emory University School of Medicine/
Grady Health System, Atlanta, GA 2002-2004; Georgia State Senator, 
State of Georgia, Atlanta, GA, 1997-2005; Member of Congress, GA06, 
House of Representatives, Washington DC, 2006-present.

10.  Government experience (list any advisory, consultative, honorary, 
or other part- time service or positions with Federal, State, or local 
governments, other than those listed above): See Appendix A.

11.  Business relationships (list all positions held as an officer, 
director, trustee, partner, proprietor, agent, representative, or 
consultant of any corporation, company, firm, partnership, other 
business enterprise, or educational or other institution): Founder/
owner, North Fulton Orthopaedic Clinic, Roswell, GA; co-
founder/president, Compass Orthopaedics, Roswell, GA; Director/chairman 
of board, Resurgens Orthopaedics, Atlanta/Roswell, GA; managing 
partner, Chattahoochee Associates, Roswell, GA (owns medical office 
building); member and co-owner, Diagnostic Ventures of Roswell, LLC, 
Roswell, GA (owns medical office building); member and co-owner, RMC3, 
LLC, Roswell, GA (owns stake in Diagnostic Ventures of Roswell, LLC, 
which owns medical office building); limited partner, Carolina 
Properties, Ltd., (owns apartment buildings in North Carolina, South 
Carolina, and Virginia).

12.  Memberships (list all memberships and offices held in 
professional, fraternal, scholarly, civic, business, charitable, and 
other organizations): Roswell Rotary Club, 1985-present, president 
1996-1997; American Academy of Orthopaedic Surgeons; American Medical 
Association; Medical Association of Georgia; Medical Association of 
Atlanta; Atlanta Orthopaedic Society; Kelly Orthopaedic Society; 
Georgia Orthopaedic Society; American College of Surgeons; 
Chattahoochee Nature Center; Georgia Ensemble Theatre; Georgia 
Arthritis Foundation.

13.  Political affiliations and activities:

    a.  List all public offices for which you have been a candidate.

      Georgia State Senate District 56; U.S. House of Representatives 
GA06.

    b.  List all memberships and offices held in and services rendered 
to all political parties or election committees during the last 10 
years.

      Member of Congress, GA06, Republican.

    c.  Itemize all political contributions to any individual, campaign 
organization, political party, political action committee, or similar 
entity of $50 or more for the past 10 years.

      See Appendix B.

14.  Honors and awards (list all scholarships, fellowships, honorary 
degrees, honorary society memberships, military medals, and any other 
special recognitions for outstanding service or achievement):

     See Appendix C.

15.  Published writings (list the titles, publishers, and dates of all 
books, articles, reports, or other published materials you have 
written):

     Saving the American Miracle: The Destruction and Restoration of 
American Values. Paperback--self-published, January 20, 2011.

     In addition, a listing of all requested Op-Eds authored by Dr. 
Price has been attached as Appendix D.

16.  Speeches (list all formal speeches you have delivered during the 
past 5 years which are on topics relevant to the position for which you 
have been nominated):

     See Appendix E.

17.  Qualifications (state what, in your opinion, qualifies you to 
serve in the position to which you have been nominated):

     My strengths are commitment, passion, and expertise. My entire 
adult life has been dedicated to service--professionally as an 
orthopaedic surgeon, politically as a State Senator and member of 
Congress, and in our community through numerous volunteer and charity 
activities. As a third-generation physician, I am well aware of the 
challenges of caring for patients and the societal needs of 
populations. For over 20 years, I had the privilege of practicing 
orthopaedic surgery in both private and public settings, training in an 
urban medical center including service in a veterans hospital, and 
treating folks of all ages and all walks of life. I founded North 
Fulton Orthopaedic Clinic and over time co-founded Resurgens 
Orthopaedics--reputed to be the largest private group practice of 
orthopaedic surgeons in the country. While serving as a Georgia State 
Senator, I was responsible for training students, interns, and 
residents in a large, major urban hospital in Atlanta. Those 
experiences coupled with being a legislator at both the State and 
Federal levels has given me a comprehensive understanding of the 
complex interactions taking place every day between patients and their 
families, physicians, providers, insurers, as well as local, State, and 
Federal Governments. It is a perspective that has reinforced my belief 
that the individual patient must always be at the center of health-care 
policy decisions. Having examined many systems and collaborated with 
many individuals and groups to bring improvements to our health-care 
financing and delivery, my breadth of experience and understanding has 
uniquely qualified me for this post. I have a deep passion for finding 
positive solutions to improve the human condition and allowing each 
member of our society to realize their full potential. I am not daunted 
by the challenge before us and have confidence in the promise that HHS 
may bring with its many agencies and broad jurisdiction to assist our 
communities and citizens. As a student of scientific principles, I have 
a profound appreciation for the role of basic scientific research, for 
the development of innovative treatments and cures, and for the 
imperative that America remains a leader in those pursuits.

                   B. FUTURE EMPLOYMENT RELATIONSHIPS

 1.  Will you sever all connections with your present employers, 
business firms, associations, or organizations if you are confirmed by 
the Senate? If not, provide details.

    Yes, any and all necessary.

 2.  Do you have any plans, commitments, or agreements to pursue 
outside employment, with or without compensation, during your service 
with the government? If so, provide details.

    No.

 3.  Has any person or entity made a commitment or agreement to employ 
your services in any capacity after you leave government service? If 
so, provide details.

    No.

 4.  If you are confirmed by the Senate, do you expect to serve out 
your full term or until the next presidential election, whichever is 
applicable? If not, explain.

    Yes.

                   C. POTENTIAL CONFLICTS OF INTEREST

 1.  Indicate any investments, obligations, liabilities, or other 
relationships which could involve potential conflicts of interest in 
the position to which you have been nominated.

     None. The nominee will comply with all Office of Government Ethics 
recommendations for current and future personal investment holdings.

 2.  Describe any business relationship, dealing or financial 
transaction which you have had during the last 10 years, whether for 
yourself, on behalf of a client, or acting as an agent, that could in 
any way constitute or result in a possible conflict of interest in the 
position to which you have been nominated.

     None. The nominee will comply with all Office of Government Ethics 
recommendations for personal business relationships, dealings, and 
financial transactions.

 3.  Describe any activity during the past 10 years in which you have 
engaged for the purpose of directly or indirectly influencing the 
passage, defeat, or modification of any legislation or affecting the 
administration and execution of law or public policy. Activities 
performed as an employee of the Federal Government need not be listed.

     Only as a member of Congress.

 4.  Explain how you will resolve any potential conflict of interest, 
including any that may be disclosed by your responses to the above 
items.

     I intend to operate as I always have during all of my years in 
public service: by making ethical compliance a cornerstone of my public 
service and operating without reproach. Any personal holdings or 
positions which could conceivably present a potential conflict of 
interest have been disclosed to the Office of Government Ethics, and 
appropriate resolution of any potential conflict of interest will be 
resolved prior to my confirmation.

 5.  Two copies of written opinions should be provided directly to the 
committee by the designated agency ethics officer of the agency to 
which you have been nominated and by the Office of Government Ethics 
concerning potential conflicts of interest or any legal impediments to 
your serving in this position.

 6.  The following information is to be provided only by nominees to 
the positions of United States Trade Representative and Deputy United 
States Trade Representative:

     Have you ever represented, advised, or otherwise aided a foreign 
government or a foreign political organization with respect to any 
international trade matter? If so, provide the name of the foreign 
entity, a description of the work performed (including any work you 
supervised), the time frame of the work (e.g., March to December 1995), 
and the number of hours spent on the representation.

    N/A.

                       D. LEGAL AND OTHER MATTERS

 1.  Have you ever been the subject of a complaint or been 
investigated, disciplined, or otherwise cited for a breach of ethics 
for unprofessional conduct before any court, administrative agency, 
professional association, disciplinary committee, or other professional 
group? If so, provide details.

     The nominee was the subject of an investigation by the Office of 
Congressional Ethics in 2010 for matters involving fundraising 
activities associated with his principal campaign committee. Although 
the matter was referred for further consideration by the House 
Committee on Standards of Official Conduct, the committee dismissed the 
matter finding no wrongdoing and recommending that no further action 
was necessary. The public record associated with this investigation is 
available at the following link: https://oce.house.gov/january-26-2011-
oce-referral-regarding-rep-tom-price/.

 2.  Have you ever been investigated, arrested, charged, or held by any 
Federal, State, or other law enforcement authority for a violation of 
any Federal, State, county or municipal law, regulation, or ordinance, 
other than a minor traffic offense? If so, provide details.

    No.

 3.  Have you ever been involved as a party in interest in any 
administrative agency proceeding or civil litigation? If so, provide 
details.

    No.

 4.  Have you ever been convicted (including pleas of guilty or nolo 
contendere) of any criminal violation other than a minor traffic 
offense? If so, provide details.

    No.

 5.  Please advise the committee of any additional information 
favorable or unfavorable, which you feel should be considered in 
connection with your nomination.

    N/A.

                     E. TESTIFYING BEFORE CONGRESS

 1.  If you are confirmed by the Senate, are you willing to appear and 
testify before any duly constituted committee of the Congress on such 
occasions as you may be reasonably requested to do so?

    Yes.

 2.  If you are confirmed by the Senate, are you willing to provide 
such information as is requested by such committees?

    Yes.

                               APPENDIX A

        Leadership Positions and Standing Committee Assignments

1997-1998--Georgia Senate
     Health and Human Services
     Insurance and Labor
     Reapportionment
     Special Judiciary
     Youth, Aging, and Human Ecology

1999-2000--Georgia Senate
     Minority Whip
     Consumer Affairs
     Education
     Health and Human Services
     Reapportionment
     Special Judiciary

2001-2002--Georgia Senate
     Minority Whip
     Education
     Health and Human Services
     Reapportionment
     Rules
     Veterans and Consumer Affairs

2003-2004--Georgia Senate
     Majority Leader
     Appropriations
     Economic Development and Tourism, Vice-chair
     Education, ex-officio
     Ethics
     Health and Human Services
     Insurance and Labor ex-officio
     Reapportionment and Redistricting, Secretary
     Rules, Secretary

2005-2009--U.S. House of Representatives
     Financial Services
     Education and Workforce/Labor

2009-2011--U.S. House of Representatives
     Chair--Republican Study Committee
     Financial Services
     Education and Labor
     Ranking Member--Workforce Protections Subcommittee
     Ranking Member--HELP Subcommittee
     Franking Commission

2011-2013--U.S. House of Representatives
     Chair--Republican Policy Committee
     Ways and Means
     Budget
     Franking Commission

2013-2015--U.S. House of Representatives
     Ways and Means
     Vice-Chair--Budget Committee
     Education and Workforce
     Franking Commission

2015-2017--U.S. House of Representatives
     Chair--Budget Committee
     Ways and Means

                               APPENDIX B

            Contributions Made By Thomas and Elizabeth Price
------------------------------------------------------------------------
  Contributor Name    Committee Name     Transaction Date       Amount
------------------------------------------------------------------------
Clark-Price,         Norwood, Charlie       August 23, 2000         $250
 Elizabeth            via Norwood for
                      Congress
------------------------------------------------------------------------
Clark-Price,         Gingrey, J.              July 27, 2002       $1,000
 Elizabeth            Phillip via
                      Gingrey for
                      Senate Inc.
------------------------------------------------------------------------
Clark-Price,         Isakson, John             June 6, 2003         $200
 Elizabeth            Hardy via
                      Georgians for
                      Isakson
------------------------------------------------------------------------
Price, Elizabeth     Handel, Karen            June 29, 2013       $1,000
                      Christine via
                      Handel for
                      Senate Inc.
------------------------------------------------------------------------
Price, Elizabeth     Handel, Karen        December 18, 2013       $1,000
                      Christine via
                      Handel for
                      Senate Inc.
------------------------------------------------------------------------
Price, Elizabeth     Georgia                 March 21, 2013         $250
                      Republican
                      Party, Inc.
------------------------------------------------------------------------
Price, Elizabeth     Georgia                 March 10, 1999         $200
                      Republican
                      Party, Inc.
------------------------------------------------------------------------
Price, Elizabeth     Georgia                   June 9, 1997         $500
                      Republican
                      Party, Inc.
------------------------------------------------------------------------
Price, Elizabeth     Gingrey, J.            August 28, 2002       $1,000
                      Phillip via
                      Gingrey for
                      Senate, Inc.
------------------------------------------------------------------------
Clark-Price,         Romney, Mitt/            June 28, 2012       $1,000
 Elizabeth            Paul D. Ryan
                      via Romney for
                      President, Inc.
------------------------------------------------------------------------
Price, Thomas E.,    Georgia                    May 4, 1999         $295
 M.D.                 Republican
                      Party, Inc.
------------------------------------------------------------------------
Price, Thomas E.,    Gingrey, J.              July 27, 2002       $1,000
 M.D.                 Phillip via
                      Gingrey for
                      Senate, Inc.
------------------------------------------------------------------------
Price, Thomas E.,    Gingrey, J.            August 28, 2002       $1,000
 M.D.                 Phillip via
                      Gingrey for
                      Senate, Inc.
------------------------------------------------------------------------
Price, Thomas E.,    Republican            October 23, 2000         $250
 M.D.                 National
                      Committee
------------------------------------------------------------------------
Price, Thomas E.,    Bush, George W.       January 22, 2004       $2,000
 M.D.                 via Bush-Cheney
                      '04 (Primary)
                      Inc.
------------------------------------------------------------------------
Price, Thomas E.,    Republican            October 23, 2000         $250
 Mrs.                 National
                      Committee
------------------------------------------------------------------------
Price, Thomas E.,    Political Action          June 6, 2002         $250
 M.D.                 Committee of
                      the American
                      Association of
                      Orthopaedic
                      Surgeons--PAC
                      of AAO
------------------------------------------------------------------------
Price, Thomas E.,    Dole, Elizabeth        August 24, 1999       $1,000
 M.D.                 via Elizabeth
                      Dole for
                      President
                      Exploratory
                      Committee Inc.
------------------------------------------------------------------------
Price, Thomas E.,    Georgia                   May 24, 2000         $300
 M.D.                 Republican
                      Party, Inc.
------------------------------------------------------------------------
Price, Thomas E.,    Biggert, Judy       September 23, 2012       $2,000
 M.D.                 via Judy
                      Biggert for
                      Congress
------------------------------------------------------------------------
Price, Thomas E.,    NRCC                 December 11, 2008         $220
 M.D.
------------------------------------------------------------------------
Price, Thomas E.,    Gingrich, Newton      January 22, 1998       $1,000
 M.D.                 L., via Friends
                      of Newt
                      Gingrich
------------------------------------------------------------------------
Price, Thomas E.,    Price, Thomas            July 28, 2004      $99,000
 M.D.                 Edmunds via
                      Price for
                      Congress--Loan,
                      since repaid
------------------------------------------------------------------------
Price, Thomas E.,    Price, Thomas           August 6, 2004     $150,000
 M.D.                 Edmunds via
                      Price for
                      Congress--Loan,
                      since repaid
------------------------------------------------------------------------



                     Joint Fundraising Contributions
    These are contributions to committees who are raising funds to be
                    distributed to other committees.
   The breakdown of these contributions to their final recipients may
                              appear below.
------------------------------------------------------------------------
  Contributor Name    Committee Name     Transaction Date       Amount
------------------------------------------------------------------------
Price, Mrs.          Trump Make          September 15, 2016       $1,000
 Elizabeth            America Great
                      Again Committee
------------------------------------------------------------------------


               Recipient of Joint Fundraiser Contributions
   These are the Final Recipients of Joint Fundraising Contributions.
------------------------------------------------------------------------
  Contributor Name    Committee Name     Transaction Date       Amount
------------------------------------------------------------------------
Price, Mrs.          Trump, Donald J./   September 15, 2016         $800
 Elizabeth            Michael R.
                      Pence via
                      Donald J. Trump
                      for President,
                      Inc.
------------------------------------------------------------------------



                          Georgia Contributions
------------------------------------------------------------------------
                                    PAC
              Contributor's    Affiliation/      Date
 Recipient         Name         Occupation/    Received    Type   Amount
                                 Employer
------------------------------------------------------------------------
Georgia      Hon. Thomas E.   Physician Self- April 25,   Monet   $4,863
 Republican   Price            Employed        2006        ary
 Party,                                                    Gene
 Inc.                                                      ral
------------------------------------------------------------------------
Georgia      Hon. Thomas E.   Physician Self- April 25,   Monet   $4,956
 Republican   Price            Employed        2008        ary
 Party,                                                    Gene
 Inc.                                                      ral
------------------------------------------------------------------------
Georgia      Hon. Thomas E.   Physician Self- April 27,   Monet   $5,220
 Republican   Price            Employed        2010        ary
 Party,                                                    Gene
 Inc.                                                      ral
------------------------------------------------------------------------
Georgia      Hon. Thomas E.   Physician Self- January 5,  Monet   $5,220
 Republican   Price            Employed        2010        ary
 Party,                                                    Gene
 Inc.                                                      ral
------------------------------------------------------------------------
Karen        Elizabeth Price  Councilwoman,   January 5,  Monet   $1,000
 Handel for                    City of         2010        ary
 Governor,                     Roswell                     Prim
 Inc.                                                      ary
------------------------------------------------------------------------
Georgia      Elizabeth Price  Physician       March 21,   Monet     $250
 Republican                    Compass         2013        ary
 Party,                        Orthopedics                 Gene
 Inc.                                                      ral
------------------------------------------------------------------------
Keep Judge   Elizabeth Price  Physician       April 16,   Monet     $500
 Tom                           Compass         2014        ary
 Campbell;                     Orthopedics                 Gene
Thomas                                                     ral
 Ralph
 Campbell
 Jr.
------------------------------------------------------------------------
Fulton       Elizabeth Price  Homemaker  N/A  January     Monet     $150
 County                                        22, 2009    ary
 Republican                                                Gene
 Party,                                                    ral
 Inc.
------------------------------------------------------------------------
Fulton       Elizabeth Price  Homemaker  N/A  February    Monet      $50
 County                                        13, 2009    ary
 Republican                                                Gene
 Party,                                                    ral
 Inc.
------------------------------------------------------------------------
Fulton       Elizabeth Price  Homemaker  N/A  April 29,   Monet     $150
 County                                        2010        ary
 Republican                                                Gene
 Party,                                                    ral
 Inc.
------------------------------------------------------------------------
Fulton       Elizabeth Price  City            October 7,  Monet      $10
 County                        Councilman,     2011        ary
 Republican                    City of
 Party,                        Roswell
 Inc.
------------------------------------------------------------------------
Fulton       Elizabeth Price  City            October 7,  Monet     $180
 County                        Councilman,     2011        ary
 Republican                    City of
 Party,                        Roswell
 Inc.
------------------------------------------------------------------------
Friends to   Thomas E.        Congressman     October     Monet   $1,000
 Elect Todd   Price, MD        United States   25, 2013    ary
 Tyson,                                                    Spec
 Inc., Todd                                                ial
 Tyson
------------------------------------------------------------------------
Georgia      Thomas E.        Physician Self- December    Monet     $250
 Medical      Price, MD        Employed        3, 2014     ary
 Political                                                 Prim
 Action                                                    ary
 Couunittee
 (GAMPAC)
------------------------------------------------------------------------

                               APPENDIX C

                  Awards Received by Dr. Thomas Price

1988  In  Appreciation--Chairman, Bylaws Committee--North Fulton 
Regional Hospital 1988
       In Appreciation--American Cancer Society

1990  In  Appreciation--Chairman, Department of Surgery--North Fulton 
Regional Hospital

1993   President's Award--``Rx for Georgia''--Medical Association of 
Georgia
      Pr esident's Award--Medical Association of Atlanta--Chairman, 
Health Care Reform Committee

1994  Pr esident's Award--Medical Association of Atlanta--Chairman, 
Health Systems Reform Committee
      Pr esident's Award--Medical Association of Atlanta--Chairman, 
Health Care Reform Committee

1996   Partners in Education--Fulton County Schools
       In Appreciation--1st Vice President--Medical Association of 
Georgia

1997   In Appreciation--Northside Alliance for Mentally Ill
      Re cognition--Support of Georgia Rotary Student Program--Georgia 
Rotary Student Endowment
       Distinguished Service Award--Medical Association of Atlanta

1998   Rotarian of the Year--Roswell Rotary Club
      Outstanding Rotarian--Past Service--Roswell Rotary Club
      Legislative Service Award--Association of County Commissioners of 
Georgia
      Certificate of Achievement--Georgia Emergency Management Agency

1999  Ou tstanding work as a friend of medicine and demonstrating 
dedication to patients of Georgia--Medical Association of Georgia
       In Appreciation--Kiwanis Club of Historic Roswell
       Senator of the Year--Georgia Republican Party
       Legislative Leadership Award--Georgia Hospital Association
      In  Appreciation--Honorable and Holy Calling to Public Service--
Presbytery of Greater Atlanta

2000   Will Watt Fellow--Rotary International
      In  Appreciation--Member of Governing Council--Organized Medical 
Staff Section, American Medical Association
       In Appreciation--Medical Team--Roswell High School
       Legislative Leadership Award--Georgia Hospital Association

2001   In Appreciation--Georgia Alcohol Policy Partnership
       In Appreciation--North Georgia Community Action, Inc.
       In Appreciation--Coalition for Hospital Choice
       In Appreciation--Friends of Scouting, North Fulton Team
      Fa mily Practice Legislator of the Year--Leadership in Health 
Care--Georgia Academy of Family Physicians

2002   Aven Citizenship Cup--Medical Association of Atlanta
      Na than Davis Award--Outstanding State Senator--American Medical 
Association
       In Appreciation--Keep Roswell Beautiful

2003   President's Award--National Republican Legislators Association
      Ch ampion of 2003 Legislative Session--Perimeter Community 
Improvement Districts
       Cottage School--commencement speaker
       In Appreciation--Northside Baptist Church dedication

2005   NWYC Constituent Communication Award
       Rotary Club of Roswell East
       Civil Air Patrol
       University of Phoenix Award
       Consulate General of Israel--Friend of Israel Award
       New South Energy Award
       Governor's Office of Highway Safety
       National Health Museum Charter Membership Award
       College of American Pathologists Award
       Americans for Tax Reform--2005 Hero of the Taxpayer Award
       Spirit of Enterprise Award--U.S. Chamber of Commerce

2006   U.S. Chamber--Spirit of Enterprise Award
       Tommy Nobis Center--Award Presentation
       Adopt a Road Award
       ATR Hero of the Taxpayer Award
       60 Plus Association of the Guardian of Senior's Rights Award
       Association of Builders and Contractors--Champion of Merit Shop
       JWOD Congressional Champion Award
       Club for Growth Defender of Economic Freedom Award
       National Tax Limitation Committee Tax Fighter Award
       National Museum of Patriotism--Patriotism Award
       All Saints Catholic Church--Community Fellowship Award
       Cobb Chamber Award
       National Society of Sons of the American Revolution
       Armor Troops Foundation, Inc. Award
       National Hemophilia Foundation Award
       National Taxpayers Union--Taxpayers' Friend
       International Foodservice Distributors Association--Thomas 
Jefferson Award

2007   U.S. Chamber--Spirit of Enterprise Award
       Georgia Ensemble Theater--Legacy Award
       National Taxpayers Union--Taxpayers' Friend
       NAPUS Georgia Chapter Award

2008   North Fulton Chamber of Commerce Pioneer Award
        U.S. Chamber of Commerce Spirit of Enterprise Award
       U.S. English Award
       Medicare Choices Award
        A in English Award
       Americans for Tax Reform Award--Hero of the Taxpayer
      Na tional Association of Mutual Insurance Companies--Benjamin 
Franklin Public Policy Award
       Club for Growth's Defender of Economic Freedom Award
       American Legion--Certificate of Appreciation
       Oglethorpe Student Body and Phi Delta Epsilon's Thank You Award
       GA Civilian Aide to Secretary of Army--Appreciation Award
       Coalition for Medicare Choices--The Medicare Choices Leadership 
Award
       IFDA--Thomas Jefferson Award
       National Taxpayers Union Taxpayers' Friend

2009  Na tional Association of Manufacturers--Manufacturing Legislative 
Excellence
      Na tional Orthopedic Leadership Conference--leadership on 
musculoskeletal diseases and conditions
       American Conservative Union Defenders of Liberty Award
       National Taxpayers Union--2008 Taxpayers' Friend Award
      60  Plus Association--Ben Franklin Award to thank you for working 
against the death tax
       AAOS--Congressional Leadership Award
       Club for Growth Defender of Economic Freedom Award
       Weyrich Awards Reception--You are receiving an award
       U.S. Chamber--Spirit of Enterprise Award
       Fulton County Republican Party--Leadership and Service Award
       Cherokee County Volunteer Aging Council Award
       FHL Bank--Key to Homeownership Award
      Am erican Academy of Orthopedic Surgeons--Congressional 
Leadership Award
       Doctors for Patient Freedom--Ed Annis Award for Medical 
Leadership
       Logisticare Appreciation Award for Presentation to Logisticare 
Operations

2010   National Taxpayers Union--Friend of the Taxpayer Award
       U.S. Chamber of Commerce Spirit of Enterprise Award
       AAOS Advocacy Communications Award
      Na tional Association of Mutual Insurance Companies--Benjamin 
Franklin Public Policy Award
       American Conservative Union Defenders of Liberty Award
       U.S. English Award
       ProEnglish--American Unity Award
       GM Executive Retirees Club of GA
       GA GOP 6th District--Ronald Reagan Freedom Fighter Award
      Am erican Academy of Orthopedic Surgeons Advocacy--Communications 
Award
      International Foodservice Distributors Association--Thomas 
Jefferson Award
       Club for Growth's Defender of Economic Liberty Award

2011   Institute for e-Health Policy--leadership award on HIT policy 
issues
      Na tional Association of Manufacturers--Manufacturing Legislative 
Excellence
       National Taxpayers Union's--Taxpayers' Friend Award
       Emory Board of Trustees--GA Delegation Award
       60 Plus Association's Guardian of Seniors' Rights Award
       American Conservative Union Defender of Liberty Award
       Club for Growth's Defender of Economic Liberty Award
       Health Care Leadership Council--Champion of Healthcare 
Innovation
       GA Association of Physicians of Indian Heritage Award

2012   Cobb County Republican Women--Trumpet Award
       U.S. Chamber of Commerce Spirit of Enterprise Award
       Rotary International's Polio Eradication Champion Award
       Healthcare Leadership Council--Champion of Healthcare Innovation
       Small Business Council of America's 2012 Congressional Award
       IFDA--Thomas Jefferson Award
       RetireSafe--2012 Standing Up for America's Seniors Award
       Freedomworks Award
       NFIB Guardian of Small Business Award
       Fulton County JRTOC's Coin of Excellence Award
       National Society of Daughters of the American Revolution
       NASA-Space Shuttle Discovery GA flag
       American Congress of Obstetricians and Gynecologists--Public 
Service Award

2013   National Association of Manufacturers--Award for Excellence
       American Conservative Union Foundation Award
       American Congress of Obstetricians and Gynecologists--Public 
Service Award
       U.S. Chamber of Commerce Spirit of Enterprise Award
       Dearborn High School Hall of Fame
       Senior Connections--Summer 2013 Champion of Senior Award
       America's Essential Hospitals Essential Physician Leader Award
       National Taxpayers Union--2012 Taxpayers' Friend Award
       Doctors for Patient Freedom--Ed Annis Award for Medical 
Leadership
       Southern Ortho Association's Award
       American Urological Association--Presidential Lecturer Award

2014   U.S. Chamber of Commerce Spirit of Enterprise Award
       America's Essential Hospital Essential Physician Leader Award
       ACU Annual Award
       Association of Builders and Contractors--Champion of Merit Shop
       National Retail Federation--Hero of Main Street Award
       International Foodservice Distributors Association--Thomas 
Jefferson Award
       Virginians for Quality Healthcare--Healthcare Freedom Guardian 
Award
       National Association of Manufacturers--Award for Excellence
      Na tional Taxpayer Union--National Taxpayers Union's Taxpayers' 
Friend Award for 2013
       Association of Mature American Citizens--Friend of AMAC Award
       National Active and Retired Federal Employees Award
       Rx Drug Abuse Summit
      Am erican College of Cardiology--President's Award for 
Distinguished Public Service Award
       ACC President's Award for Distinguished Public Service
       International Foodservice Distributors Association--Thomas 
Jefferson Award

2015   FRC Action True Blue Award
       National Association of Manufacturers--Award for Excellence
      Am erican Society of Transplantation--Organ Transplantation and 
Donation Legislative Leaders of the Year Award
       American Academy of Ophthalmology--Academy's Visionary Award
       American Conservative Union--Award for Conservative Excellence
       60 Plus Association--Member Tax Reform Award
       U.S. Chamber of Commerce Spirit of Enterprise Award
      Al liance for Patient Access and National Association of 
Nutrition and Aging Services Programs--2015 Medicare Part D Patient 
Access Champion Award
       ACU Annual Award
       Rotary Club of Dunwoody--Certificate of Appreciation
       GA Ortho Society--James Funk Distinguished Service Award
       GA Association of College Republicans--Order of Reagan
       FRC Action True Blue Award

2016   AMRPA Chairman's Award
       ACU--Award for Congressional Excellence
       American Medical Rehab Providers Association--Chairmen's Award
       American Transaction Processor Coalition--Legislative Champion 
Award
       ATPC Friend of Industry Award
       U.S. Chamber of Commerce Spirit of Enterprise Award
      He althcare Leadership Council--Champion of Healthcare Innovation 
IFDA--Thomas Jefferson Award
       Campaign to Fix the Debt--Fiscal Hero Award
       National Retail Federation--Heroes of Main Street Award
       GA Life Alliance--Advocate for Life Award
       HME--Congressional Leadership Award
       World Harvest Church Award
       Campaign to Fix the Debt Fiscal Hero Award
       National Retail Federation--Heroes of Main Street Award

No Year   Coalition for Medicare Choices--Leadership Award
       SIRPAC
      Al liance for Patient Access Medicare Part D--Patient Access 
Champion Award
       Veterans Issues--William Cobb VFW of Roswell Award
       Republic of Korea
       Naval Academy--Certificate of Appreciation
       American's Essential Hospital--Essential Physician Leader
       NFIB Guardian of Small Business (111th Congress)
       NFIB Guardian of Small Business (113th Congress)
       NFIB Guardian of Small Business (114th Congress)
      As sociated Builders and Contractors Champion of the Merit Shop 
(111th Congress)
       Theodore Roosevelt American Unity Award (111th Congress)
      As sociated Builders and Contractors Champion of the Merit Shop 
(110th Congress)
       NFIB Guardian of Small Business (112th Congress)
      As sociated Builders and Contractors Champion of the Merit Shop 
(112th Congress)

                               APPENDIX D

       Op-Eds Authored by Dr. Tom Price--May 2011 to the Present

        The listing of pertinent Op-Eds begins on the table below and 
        contains website addresses for direct access to the specified 
        publications. In instances where a particular Op-Ed is not 
        available via an internet source, a copy of the actual 
        publication is attached for the committee's reference.


------------------------------------------------------------------------
    Date         Publication        Title                 Link
------------------------------------------------------------------------
May 13, 2011  Health Reform     Empowering     http://tomprice.house.gov/
               Report            America's      op-ed/empowering-
                                 Seniors        americas-seniors
------------------------------------------------------------------------
May 14, 2011  The Daily Caller  Debt Limit     http://tomprice.house.gov/
                                 and Spending   op-ed/debt-limit-nnd-
                                 Reforms are    spending-reforms-are-
                                 Inextricably   inextricably-linked
                                 Linked
------------------------------------------------------------------------
June 28,      TownHall.com      Cutting What   http://tomprice.house.gov/
 2011                            Washington     op-ed/cutting-what-
                                 Has Yet to     washington-has-yet-spend-
                                 Spend and      and-cannot-afford
                                 Cannot
                                 Afford
------------------------------------------------------------------------
October 10,   Human Events      Empowering     http://tomprice.house.gov/
 2011                            Patients       op-ed/empowering-
                                 First Act:     patients-first-act-
                                 The Solution   solution-obamacare
                                 to Obamacare
------------------------------------------------------------------------
November 15,  Cobb Medical      H.R. 3000--    Attached
 2011          Society           Empowering
                                 Patients Not
                                 Government
------------------------------------------------------------------------
November 16,  Big Government    Patient        http://tomprice.house.gov/
 2011                            Centered       op-ed/patient-centered-
                                 Healthcare     healthcare-possible
                                 is Possible
------------------------------------------------------------------------
November 26,  The Washington    PRICE:         http://tomprice.house.gov/
 2011          Times             Preserving     op-ed/price-preserving-
                                 the promise    promise-patients
                                 to patients
------------------------------------------------------------------------
December 1,   Reporter          Republicans,   http://tomprice.house.gov/
 2011          Newspapers        Democrats      op-ed/republicans-
                                 see            democrats-see-different-
                                 different      fixes-fiscal-stalemate
                                 fixes to
                                 fiscal
                                 stalemate
------------------------------------------------------------------------
December 12,  Chicago Tribune   Getting        http://tomprice.house.gov/
 2011                            America out    op-ed/getting-america-
                                 of deep debt   out-deep-debt
------------------------------------------------------------------------
December 16,  The Oregonian/    Medicare pro:  http://www.oregonlive.com/
 2011          McClatchy         Reasonable     opinion/inPdex.ssf/2011/
                                 reforms can    12/
                                 provide fair   medicare_pro_reaPsonable
                                 fees for       _reform.html
                                 physicians
                                 and ensure
                                 patients
                                 receive
                                 quality
                                 treatment
------------------------------------------------------------------------
February 15,  The Hill          President      http://tomprice.house.gov/
 2012                            obviously      op-ed/president-
                                 doesn't        obviously-
                                 grasp the      doesn%E2%80%99t-grasp-
                                 seriousness    seriousness-fiscal-
                                 of fiscal      situation
                                 situation
------------------------------------------------------------------------
May 31, 2012  The Daily Caller  Obamacare      http://tomprice.housc.gov/
                                 Medical        op-ed/obamacare-medical-
                                 Device Tax:    device-tax-hazardous-
                                 Hazardous to   america%E2%80%99s-health
                                 America's
                                 Health
------------------------------------------------------------------------
June 5, 2012  The Hill          IPAB is not    http://tomprice.house.gov/
                                 the way to     op-ed/ipab-not-way-lower-
                                 lower          medicare-costs
                                 Medicare
                                 costs
------------------------------------------------------------------------
July 1, 2012  Marietta Daily    Try            http://tomprice.house.gov/
               Journal           Principled     op-ed/try-principled-
                                 Solutions to   solutions-health-care-
                                 Health Care    fix
                                 Fix
------------------------------------------------------------------------
July 26,      USA Today         Plenty of      http://tomprice.house.gov/
 2012                            Alternatives   op-ed/plenty-
                                 to             alternatives-government-
                                 Government     health-care
                                 Health Care
------------------------------------------------------------------------
Fall 2012     Jewish Policy     A Principled   https://
               Center            Health Care    www.jewishpolicycenter.o
                                                rg/2012/08/31/health-
                                                care-empower-patients/
------------------------------------------------------------------------
July 30,      The Washington    Regulations    http://tomprice.house.gov/
 2012          Times             Are Choking    op-ed/regulations-are-
                                 Small          choking-small-business-
                                 Business       engine-growth
                                 Engine of
                                 Growth
------------------------------------------------------------------------
December 6,   AJC               House          http://tomprice.house.gov/
 2012                            Republicans    op-ed/house-republicans-
                                 Stand by       stand-taxpayers
                                 Taxpayers
------------------------------------------------------------------------
February 6,   Red State         Require A      http://tomprice.house.gov/
 2013                            Plan           op-ed/require-plan
------------------------------------------------------------------------
March 12,     FoxNews.com       Introducing a  http://tomprice.house.gov/
 2013                            responsible,   op-ed/introducing-
                                 reasonable     responsible-reasonable-
                                 plan to        plan-balance-federal-
                                 balance the    budget
                                 federal
                                 budget
------------------------------------------------------------------------
April 19,     The Hill          President's    http://origin-
 2013                            budget         nyi.thehill.com/blogs/
                                 ignores the    congress-blog/economy-a-
                                 will of the    budget/295025-presidents-
                                 people         budget-ignores-the-will-
                                                of-the-people
------------------------------------------------------------------------
May 20, 2013  Real Clear        The Unserious  http://tomprice.house.gov/
               Politics          Senate         op-ed/unserious-senate-
                                 Budget         budget
------------------------------------------------------------------------
May 30, 2013  Washington        President      http://tomprice.house.gov/
               Examiner          Obama is       op-ed/president-obama-
                                 Responsible    responsible-his-
                                 for His        administration
                                 Administrati
                                 on
------------------------------------------------------------------------
May 31, 2013  AJC               Stop the       http://tomprice.house.gov/
                                 Obamacare      op-ed/stop-obamacare-
                                 train wreck    train-wreck
------------------------------------------------------------------------
July 17,      The Hill          How to         http://tomprice.house.gov/
 2013                            Replace        op-ed/how-replace-
                                 Obamacare      obamacare
------------------------------------------------------------------------
July 31,      The Daily Caller  We can't       http://tomprice.house.gov/
 2013                            trust the      op-ed/we-can%E2%80%99t-
                                 IRS to         trust-irs-enforce-
                                 enforce        obamacare
                                 Obamacare
------------------------------------------------------------------------
October 8,    Marietta Daily    All            http://tomprice.house.gov/
 2013          Journal           Republicans    op-ed/all-republicans-
                                 want is        want-fairness-all-
                                 fairness for   americans-and-thats-why-
                                 all            we-fight
                                 Americans,
                                 and that's
                                 why we fight
------------------------------------------------------------------------
December 5,   National Review   Empowering     http://tomprice.house.gov/
 2013                            Patients       op-ed/empowering-
                                 First          patients-first
------------------------------------------------------------------------
February 10,  ConservantiveUSA  Let's Begin    http://
 2014          .org              Again--Patie   www.conservativeusa.org/
                                 nts First      updates/lets-begin-again-
                                                patients-first-rep-tom-
                                                price-md-ga-06-
                                                reptomprice-feb-10-2014
------------------------------------------------------------------------
February 19,  Red Alert         A Better       http://tomprice.house.gov/
 2014          Politics          Prescription   op-ed/better-
                                 for            prescription-millenials
                                 Millenials
------------------------------------------------------------------------
March 7,      Maryland State    There's No     Attached
 2014          Medical Journal   Code for
                                 Quality Care
------------------------------------------------------------------------
March 20,     AMA SE            New            Attached
 2014                            Challenges
                                 Mean New
                                 Opportunitie
                                 s
------------------------------------------------------------------------
March 24,     Medical           Modernizing    Attached
 2014          Association of    Medicare to
               Georgia E-        Protect
               Newsletter        Seniors
------------------------------------------------------------------------
August 11,    Roll Call         Save           http://tomprice.house.gov/
 2014                            Medicare's     op-ed/save-medicares-
                                 Home Health    home-health-benefit
                                 Benefit
------------------------------------------------------------------------
January 23,   Real Clear        A Healthy      http://tomprice.house.gov/
 2015          Politics          Economy for    op-ed/healthy-economy-
                                 All            all
------------------------------------------------------------------------
March 17,     USA Today         Balance the    http://tomprice.house.gov/
 2015                            budget for a   op-ed/balance-budget-
                                 prosperous     prosperous-america
                                 America
------------------------------------------------------------------------
April 1,      AMA SE            Prepared to    Attached
 2015                            Act on
                                 Patient-
                                 Centered
                                 Reform
------------------------------------------------------------------------
April 6,      SC Times          House budget   http://www.sctimes.com/
 2015                            plan would     story/opinion/2015/04/05/
                                 set U.S. on    house-budget-plan-set-us-
                                 right fiscal   right-fiscal-path/
                                 path           25277905/
------------------------------------------------------------------------
July 30,      Independent       Medicare and   http://tomprice.house.gov/
 2015          Journal PReview   Medicaid       op-ed/medicare-and-
                                 Turn 50        medicaid-turn-50-today-
                                 Today. Let's   let%E2%80%99s-keep-them-
                                 Keep Them      healthy
                                 Healthy
------------------------------------------------------------------------
February 2,   Medical           A Step in the  Attached
 2016          Association of    Right
               Georgia E-        Direction
               Newsletter
------------------------------------------------------------------------
March 10,     Medical           Keep the       Attached
 2016          Association of    focus on the
               Georgia E-        patient
               Newsletter
------------------------------------------------------------------------
April 5,      AMA SE            Focused on     Attached
 2016                            Solutions
------------------------------------------------------------------------
April, 13,    Real Clear        How and Why    http://tomprice.house.gov/
 2016          Politics          We Budget      op-ed/how-and-why-we-
                                                budget
------------------------------------------------------------------------
September 7,  Roll Call         Obamacare      http://tomprice.house.gov/
 2016                            Agency         op-ed/obamacare-agency-
                                 Escapes        escapes-congressional-
                                 Congressiona   oversight
                                 l Oversight
------------------------------------------------------------------------
October 13,   JAMA Forum        Three          http://tomprice.house.gov/
 2016                            Congressmen'   op-ed/3-
                                 s Views on     congressmen%E2%80%99s-
                                 ACA's Flaws,   views-aca%E2%80%99s-
                                 Alternatives   flaws-alternatives-
                                 for Health     health-system-reform
                                 System
                                 Reform
------------------------------------------------------------------------
October 17,   FoxNews.com       Reps.          http://www.foxnews.com/
 2016                            Burgess,       opinion/2016/10/17/reps-
                                 Price, Roe:    burgess-price-roe-our-
                                 Our            diagnosis-as-doctors-
                                 diagnosis as   obamacare-is-about-to-
                                 doctors--Oba   collapse.html
                                 maCare is
                                 about to
                                 collapse
------------------------------------------------------------------------
November 1,   TownHall.com      Obamacare is   http://tomprice.house.gov/
 2016                            failing.       op-ed/obamacare-failing-
                                 Let's try a    let%E2%80%99s-try-better-
                                 Better Way     way
------------------------------------------------------------------------


                                 ______
                                 
                     A Step in the Right Direction
                 By Congressman Tom Price, M.D. (GA-06)
On December 28th of last year, President Obama signed into law the 
Patient Access and Medicare Protection Act (S. 2425)--legislation that 
included several health-care reforms that had bipartisan support in 
Congress. Included in that package of reforms was a provision 
addressing electronic health record (EHR) meaningful use requirements--
specifically hardship exceptions for physicians who would be unable to 
comply with the Centers for Medicare and Medicaid Services' (CMS) final 
Stage 2 modification rule. At issue was the fact that CMS released its 
rule with less than the requisite 90 days left to comply in 2015.

The hardship exceptions provisions in S. 2425 are based on a bill that 
I had introduced, the Meaningful Use Hardship Relief Act (H.R. 3940), 
almost 2 months prior. We acted because it was clear that many 
physicians would likely be unfairly penalized due to CMS's failure to 
offer health-care providers adequate time to comply with new 
requirements pertaining to the electronic health records program. Under 
the new law, physicians are able to more easily obtain a hardship 
exception due to insufficient time in the 2015 reporting period. 
Additionally, CMS is now also able to batch process hardship exception 
applications for groups of physicians, rather than strictly on a more 
burdensome individual case-by-case basis.

On January 22nd, CMS released guidance on the updated hardship 
exception application, and our office is continuing to closely monitor 
this issue as well as the meaningful use and electronic health records 
program. We would encourage you to apply for the hardship exemption. 
You can do so by going to CMS.gov. This is a small step but a step 
nonetheless toward protecting the critical doctor-patient relationship. 
Patients and physicians face many challenges in today's health-care 
system. Anything that can be done to allow physicians to focus more of 
their time and energy on the practice of medicine ought to be done so 
that we can further improve the quality and responsiveness of care.

                                 ______
                                 
                    There's No Code for Quality Care
                 By Congressman Tom Price, M.D. (GA-06)
Physicians are used to dealing with complex systems--the human body 
being the most obvious example. They devote their years of education 
and their craft to finding answers to tough questions, solutions to 
difficult and--for patients and their families--very personal 
challenges. The eagerness of physicians, scientists, and other health-
care providers to tackle the complex and at times unknown is driven by 
the knowledge that their time and commitment is in service to the 
health and well-being of others. Providing the best care for patients 
is the motivation.

So it is with particular concern and consternation that today 
physicians are being inundated with a new set of complex problems to 
solve. The purveyor of these new challenges is, generally speaking, the 
regulatory state. It's the folks who are not so much in charge of 
actually caring for patients but the ones who have taken it upon 
themselves to be in charge of telling physicians more and more how to 
care for patients.

Their more widely known mandates and regulations center most recently 
on the implementation of electronic health records (EHRs) and 
meaningful use requirements. The sorts of items that can justifiably be 
applied to improving quality care if physicians have the flexibility, 
the time and the resources to comply in an orderly fashion. That's a 
big ``if.''

But then you have the complexities being handed down from upon high 
that have at best a tangential relationship to serving the needs of 
patients. Perhaps none will be more frustrating and costly to the 
delivery of care than the new ICD-10 diagnosis coding system that 
American physicians, hospitals, and other health-care providers are 
being told to adopt.

The ICD-10 system has already earned a reputation as a bridge a bit too 
far--a sign that the regulatory state has become far too prescriptive 
to the point of being comical. You've likely heard of some of the more 
humorous new diagnosis codes. ICD-10 applies specific codes to injuries 
related to burning water skis, injuries sustained through an accident 
with a military vehicle while riding an animal, or being struck by any 
number of different animals for example, an orca.

Could those examples and any of the others listed in the ICD-10 system 
occur? One supposes almost anything is possible. But the ``more is 
better'' mentality that sits behind the drafting and implementation of 
this system portends a very arduous and in many cases financially 
perilous environment for physicians and their practice.

Resources that might be applied to new innovative technologies, 
expanded capacity to serve new patients, or even charitable payment 
scenarios will be diverted to pay for the adoption and implementation 
of ICD-10. Those most likely to be squeezed are the private practices--
particularly those caring for patients in rural or under-served 
communities--that operate on narrow margins. That shifts the delivery 
of care to hospitals where the quality can be equal but the costs 
disproportionately higher.

As an orthopaedic surgeon who practiced medicine for over 20 years in 
the Metro Atlanta area, I know firsthand about practicing medicine both 
in a private and hospital setting. There are benefits and drawbacks to 
both. But what makes our health-care system most beneficial to patients 
is the flexibility and diversity of care. The regulators are on 
schedule to continue destroying that flexibility and diversity of care.

We see it in the manner in which the Affordable Care Act (ACA) is 
defining quality care based on a Washington-centric point of view. And, 
we see it with the unwillingness on the part of the Centers for 
Medicare and Medicaid Services (CMS) to consider a delay in the 
implementation of ICD-10 coding requirements. CMS Director Marilyn 
Tavenner recently confirmed that Washington would consider no more 
delays and that it was ``time to move on.''

Thankfully, Congress has taken action--albeit in a limited capacity. 
Legislation recently signed into law included a 1-year delay of the 
ICD-10 deadline. It pushes back the date at which medical providers 
must adopt the new coding system from October 1st of this year to 
October 1, 2015.

So where does that leave physicians trying to practice their profession 
and care for patients? According to a February 2014 report commissioned 
by the American Medical Association (AMA), a small medical practice 
will be on the hook for anywhere between $56,639 to over $226,000 in 
costs associated with the transition. For a medium size practice, AMA 
estimates pre- and post-implementation costs rising to as high as 
$824,735. And, the ``typical large practice'' can expect to pay 
anywhere in the range of $2 million to $8 million.

Perhaps in Washington that's not considered a lot of money. But in the 
real world where the cost of health-care delivery is already rising due 
to any number of other forces--including innovation and other 
regulations--adding hundreds of thousands to millions of dollars to the 
cost of care is incredibly troubling.

It should come as no surprise that an overwhelming majority of 
physicians were not ready for this year's October 1st deadline. A 
survey by the Medical Group Management Association found that slightly 
fewer than 10 percent of medical practices claim to have made 
significant progress on implementing the overhaul of the ICD system. In 
other words, if you were to put aside the argument about whether or not 
shifting to the new coding system was wise or necessary, folks still 
are not ready.

In Congress, there's a broader effort underway to avoid this coming 
train wreck altogether. H.R. 1701, the Cutting Costly Codes Act of 
2013--of which I'm a co-
sponsor--would prohibit the Secretary of Health and Human Services from 
moving forward with the ICD-10 implementation.

What happens if a year passes, no action is taken to prohibit the 
implementation, and further delays are not forthcoming? If Washington 
ignores the facts and the frustration shared by many in the medical 
community? The initial costs associated with adopting ICD-10 will 
likely seem like a drop in the bucket over the longer term as medical 
practices struggle to familiarize themselves with the new litany of 
codes. It is expected that the number of codes will grow from roughly 
20,000 to over 150,000.

Any failures to properly apply the right diagnostic label may be met 
with rejection or withholding of payment for services already rendered. 
Furthermore, fines and other costly legal proceedings could be incurred 
by physicians and medical practices whose only crime may be that they 
had unwittingly failed to comply properly with this complex new system.

Were the new ICD-10 diagnosis codes coming online in otherwise 
relatively calm waters in the Nation's health-care system, the 
disruption could perhaps have been contained. But that's not the 
reality physician's face today. With the implementation of the 
Affordable Care Act, America's health-care system and those 
participating in it have been thrown one curve ball after another--told 
to get on board or get out of the way.

Far too often that's how a bureaucracy functions, and it is the 
strongest argument against endowing regulators with the type of 
prescriptive power they are now preparing to wield. For the sake of 
patient access to quality, affordable care, we must continue to search 
for solutions that will let physicians do what they are trained to do--
care for those in need. To be successful, physicians must engage in the 
public debate.

                                 ______
                                 
                 New Challenges Mean New Opportunities
                 By Congressman Tom Price, M.D. (GA-06)
There is no shortage of issues these days competing for our attention. 
We have turmoil and upheaval around the world. There are long-running 
disagreements and troubles here at home. And while it can all be a tad 
overwhelming, it's important to find within these challenges the 
opportunity to affect positive change. Of note right now are five key 
areas that do deserve our focus--all of which, coincidentally, have 
emerged either from action or inaction on the part of your government.

As a physician, I have watched with particular concern the troubled 
rollout or unraveling of the President's health-care law. Frankly, what 
we have is the expected outcome of truly disastrous policymaking. The 
law is not working--at least not as advertised. It is not working for 
patients, families or physicians. And, its failures are not merely the 
result of incompetence on the part of the Obama administration. They 
are the product of a fundamental conflict between the law and those 
principles of health care we hold dear: affordability, accessibility, 
choices, innovation, quality, and responsiveness.

Premiums are rising. Provider networks made available through the new 
exchange plans are smaller. Folks are losing the coverage they had and 
access to the doctors they trusted. Less access and less affordability 
mean choices are being taken away from Americans. The law taxes 
innovation--literally a tax on life-saving medical devices. All of this 
will contribute to diminished quality of care as the system becomes 
more responsive to the needs of bureaucrats and less so to the needs of 
patients, families and doctors.

So what can be done? Anyone who has taken care of patients knows that 
the status quo that existed prior to the passage of Obamacare was not 
working either. So no one should pretend we can simply uproot the 
current law and that will solve everything. We need a set of reforms 
that serve patients and those who care for them. Patient-centered 
solutions--like those I've introduced in H.R. 2300, the Empowering 
Patients First Act--would expand access to more health care choices by 
making it financially feasible for folks to purchase the coverage they 
want.

We'd solve the insurance challenges of portability and pre-existing 
conditions by allowing folks to own their coverage no matter who's 
paying for it and to pool together and gain the purchasing power of 
millions. That way we can make sure no one is priced out of the 
insurance market due to a pre-existing injury or illness.

To go after the rising costs of care in America, H.R. 2300 would enact 
medical malpractice reforms. Our plan would deter the practice of 
defensive medicine by giving physicians an affirmative defense in a 
court of law built on standards agreed upon and established by 
physicians--not Washington.

Just as we need broader health-care reform, we also need to once and 
for all rid Medicare of its current payment formula. The sustainable 
growth rate (SGR) formula is not working for patients or doctors. The 
effort to repeal and replace it with one that does work has gone on too 
long. Thankfully, some encouraging steps have been taken in recent 
weeks.

In the House of Representatives, we have passed a bill to repeal the 
SGR and modernize the payment system--giving physicians time to adjust 
to new rules that will hopefully provide the type of certainty and 
flexibility needed to increase the quality of care. The ball is now in 
the Senate's court. Our hope is that they will work with us so that 
there is a credible plan to move forward. We need to get this specific 
issue resolved in a way that protects seniors and respects American 
taxpayers.

It is out of respect for American taxpayers that we must also keep our 
eye on the tremendous fiscal challenges we are facing as a Nation right 
now. As vice-chairman of the House Budget Committee, I've had the 
opportunity to work with many of my colleagues on different budget 
proposals over the years--plans that would balance the Federal 
Government's books, save and strengthen critical programs like Medicare 
and Social Security, and enact pro-growth policies like fundamental tax 
reform to get this economy moving. A budget is a blueprint for the 
positive direction we can take our Nation if we have the courage to 
make real, tough decisions on behalf of this generation and the next. 
Right now the committee is working on the next budget for fiscal year 
2015. With the President offering his plan that taxes more in order to 
spend more, there's a real opportunity and obligation to provide that 
better, alternative vision.

Another pro-growth area we ought to be focused on is America's ongoing 
energy revolution. Whether one is talking about the growth in our 
ability to safely harvest more and more of America's abundant natural 
resources or the growth in new energy technologies, there are exciting 
opportunities here that will truly benefit our Nation. A robust energy 
market means more direct and indirect jobs and economic freedom. 
Internationally, a lessening of dependence on foreign sources of energy 
and a growing of America's impact on the global energy markets means we 
have greater influence in diplomatic and national security affairs.

One doesn't have to look farther than the recent events in Ukraine to 
see an opportunity to leverage an all of the above energy strategy. 
With Russia exercising power in that part of the world thanks to their 
prolific energy production and distribution we can directly undermine 
their coercive powers by expanding our production and sale of energy 
resources to allies in the region.

Lastly, what contributes to the disgust many feel watching Russia 
invade and annex a piece of another country is that this action flies 
in the face of democratic values we hold sacred here in America. Those 
values were written into our Constitution and made explicit when our 
founders declared our rights came from God, not man. Chief among them 
is the First Amendment's right to freedom of speech.

Unfortunately, that fundamental freedom has been under assault from an 
overactive regulatory environment in Washington. We know that the IRS 
unfairly targeted and abused certain Americans whose only crime was 
attempting to speak up for their beliefs. Now, the IRS is attempting to 
codify that level of abuse through new regulations affecting groups--
including veterans' organizations and those engaged in civic 
education--that file as nonprofits under the tax code's 501(c)(4) 
designation.

Under that section of the code, activities by these nonprofits that are 
for the purposes of ``social welfare'' are tax exempt. The IRS wants to 
rewrite the rules after 55 years to essentially force these 
nonprofits--many of which hold political views in conflict with the 
current administration--to re-classify under a different section of the 
code or become subject to taxation. Either way, the end result would be 
to silence voices and expose more Americans to further abuse and unfair 
treatment.

All of these issues--whether foreign, domestic or both--impact our 
lives in some form or another. We should not shy away from these 
challenges because with them comes opportunity to improve our lives and 
that of our families, friends, and neighbors. If we can find a way to 
bridge differences, reinforce time-honored principles, and show 
leadership, I'm confident we will find positive solutions that build a 
stronger future for our Nation.

                                 ______
                                 
                Modernizing Medicare to Protect Seniors
                 By Congressman Tom Price, M.D. (GA-06)
The Medicare program is a vital life-line for millions of American 
seniors. Unfortunately, the current program is not working as well as 
it should for either those in retirement or the physicians who care for 
them. In addition to the real financial challenges the program as a 
whole faces in the next few years--challenges that ought to be 
addressed with broader reforms to Medicare--we have an even more 
immediate concern as it relates to Medicare's current payment formula.

Efforts to address the broken sustainable growth rate formula (SGR) 
have been underway for years. In the meantime, Congress has acted to 
avoid the SGR's looming large cuts in physician reimbursements by 
enacting a series of delays--some longer than others. This has been 
done to buy time for policymakers to coalesce around a responsible 
solution that will repeal the SGR permanently and replace it with a 
system that makes sense. The cost of those delays has been substantial, 
but it has also been necessary in order to protect access to care for 
seniors.

Thankfully, promising steps have been made in the last several months 
to forge a consensus on a real plan to modernize the Medicare payment 
system. Introduced in February, the SGR Repeal and Medicare Provider 
Payment Modernization Act of 2014 (H.R. 4015) enjoys bipartisan, 
bicameral support. On March 14th the House of Representatives passed 
the bill and sent it to the Senate for its consideration.

In order to ensure these solutions both protect seniors and respect 
taxpayers, the legislation endorsed by the House of Representatives 
included a delay in the Affordable Care Act's individual mandate to 
offset the costs associated with a repeal of the SGR. The Obama 
administration has already implemented a de facto delay to this 
provision of the President's health-care law through executive fiat. We 
thought it better to do so through the normal and constitutional 
lawmaking process.

The latest projections show cuts to physician reimbursement rates in 
the range of 24% if nothing is done. Temporary patches will continue to 
buy more time but in the aggregate over the years they also prove more 
costly than a full repeal and replace scenario. More importantly, the 
level of uncertainty and anxiety that will persist so long as this 
issue remains unresolved exacts its own costs on physicians and seniors 
that cannot be measured in dollars and cents.

It is rare in Washington these days that you can find an issue that 
secures both bipartisan support and action. We should not miss this 
opportunity to enact a positive set of solutions that will modernize 
Medicare's payment system. Our hope is that the Senate will come to the 
table with the House of Representatives so we can work together to 
protect seniors' access to health care.

                                 ______
                                 
               Prepared to Act on Patient-Centered Reform
                 By Congressman Tom Price, M.D. (GA-06)
This summer the Supreme Court of the United States will render a 
verdict in the case of King v. Burwell, which could have a lasting 
impact on whether the Affordable Care Act or ``Obamacare'' remains the 
law of the land. The fundamentals of the case are fairly 
straightforward: should the Obama administration be allowed to offer 
subsidies to help Americans purchase health-care coverage through 
Obamacare exchanges established by the Federal Government? The text of 
the law states that subsidies are to be made available to those who 
have enrolled in an insurance plan through an exchange established by 
the State. Since the enactment of Obamacare, 37 States have chosen not 
to establish their own exchanges or have partnered with the Federal 
Government in some fashion--meaning millions of Americans have gained 
health-care coverage with the help of subsidies through a Federal 
exchange.

If the Court rules in favor of the actual text of the law, which does 
not explicitly provide financial assistance to those purchasing 
coverage through the Federal exchange, those millions of Americans who 
purchased that insurance coverage would lose access to subsidies and 
face even higher health-care costs. For its part, the Obama 
administration has claimed it has no strategy in place to handle the 
aftermath of such a ruling--despite being complicit in the creation of 
the law itself and its, quite possibly soon to be ruled illegal, 
interpretation.

Conversely, in March, I introduced the Medical Freedom Act (H.R. 
1234)--legislation to allow States the freedom to offer within their 
jurisdiction health plans, health savings accounts, and other 
arrangements that are currently restricted under Obamacare, and the 
Medicare Patient Empowerment Act (H.R. 1650)--allowing patients and 
physicians to voluntarily contract for a service outside of the 
dictates from CMS. This type of flexibility within States to regulate 
their markets and ensuring doctors may practice as they see most 
appropriate would be strong first steps toward mitigating the fallout 
from the King v. Burwell ruling. At the same time, committees of 
jurisdiction in the House of Representatives and the Senate have been 
hard at work putting together policy proposals of their own that would 
be needed to respond should the court rule that the Federal exchange 
subsidies are indeed illegal. No matter the makeup of our response, 
Congress is aiming to be prepared so that the American people are not 
made to suffer any more than they already have from Obamacare.

Even if the Court rules in favor of the Obama administration's 
interpretation and keeps the subsidies flowing on the Federal 
exchanges, there still remains real, fundamental concerns with how this 
law has been implemented, the impact it is having on the quality and 
affordability of health care in America, on access to physicians and on 
innovation.

Those of us who believe we ought to have a health-care system less 
geared toward Washington and more in the hands of patients, families 
and physicians have to continue to push our colleagues and Congress and 
take our case to the American people. We have to keep the conversation 
going, and make clear that there are positive, patient-centered 
solutions out there that are far better for the health of our Nation 
than what Obamacare has to offer.

For several years now, I have introduced legislation each Congress 
called the Empowering Patients First Act--a set of solutions that would 
expand access to quality affordable health-care choices and put 
patients, families and doctors in charge of health-care decisions, not 
Washington, DC. We have offered patient-centered reforms like 
Individual Member Associations so folks can pool together for the 
purpose of purchasing affordable coverage; lawsuit abuse reform to end 
the practice of defense medicine that adds hundreds of billions of 
dollars to America's health-care bill each year; health-care tax 
credits so folks have the financial wherewithal and incentive to 
purchase the sort of coverage that meets their individual needs.

There are many other aspects of the Empowering Patients First Act that 
would enhance the quality, affordability and accessibility of care in 
our country. Indeed, there are a myriad of positive, promising ideas 
that my colleagues in Congress have put forward and each of those ideas 
should continue to be a part of an honest and open debate on a broader 
reform effort.

Depending on its decision, the Supreme Court's ruling later this year 
may initiate an unraveling of Obamacare or it may have no real impact. 
Either way, policymakers need to be prepared to respond. Physicians and 
other health-care practitioners across the country need to be ready as 
well to play a constructive role in ensuring that not only in the near 
term but in the long run, we protect and preserve the sanctity of the 
doctor-patient relationship.

                                 ______
                                 
                          Focused on Solutions
                 By Congressman Tom Price, M.D. (GA-06)
America's Founding Fathers wisely chose to give Congress--the branch of 
government closest and most accountable to the people--the power to 
write laws, determine how many hard-earned tax dollars are necessary to 
administer those laws, and to ensure the executive branch is faithfully 
carrying out those laws. For our Nation's experiment in self-government 
to work, those roles and responsibilities must be respected.

At the Committee on the Budget in the U.S. House of Representatives--on 
which I am honored to serve as chairman--we have been hard at work 
doing just that. The House Budget Committee is tasked with putting 
together an annual budget. We provide lawmakers a blueprint for how 
Congress can assert the spending and oversight authorities given it 
under the Constitution and do so in a responsible, responsive manner.

In March, the House Budget Committee introduced and approved our fiscal 
year 2017 budget resolution which we call A Balanced Budget for a 
Stronger America. This proposal would balance the Federal budget within 
10 years without raising anyone's taxes. It keeps the Federal 
Government's books in balance beyond the coming decade which puts us on 
a path to pay off the national debt. If the policies we advocate were 
enacted, we would achieve over $7 trillion in deficit reduction through 
a combination of savings and economic growth. Those savings come from 
common sense reforms we propose to make government more efficient, 
effective, and accountable.

Some of the more critical reforms are in the area of health care. We 
put forward a plan to save and strengthen the Medicare program. We 
advocate for an improved system that enhances quality, gives seniors 
more choices, and ensures that traditional Medicare is always available 
to Americans when they reach retirement age.

Under current law, if nothing is done, Medicare will go insolvent in 
2030. This will result in a significant reduction in benefits for 
seniors' health care. We believe this would be irresponsible. Our plan 
would prevent this from happening with patient-centered reforms, and 
ensure this program, which millions have paid into, will be there for 
them when they need it.

For the brave men and women of our armed forces, for our veterans, and 
for our military families, our budget encourages additional health-care 
reforms at both the Department of Veterans Affairs (VA) and the 
Department of Defense (DoD). Those who protect and defend our Nation 
must have access to the care they need when they need it.

For those Americans who are struggling to afford health-care coverage, 
our budget rejects the broken status quo and calls for innovative 
solutions. We would give States the flexibility to design and implement 
their Medicaid programs to meet the unique needs of their communities. 
At the same time, we would get rid of the top-down, Washington-knows-
best model that is currently in place in private-sector health care and 
implement patient-centered solutions to ensure every American has 
access to the health coverage they want, not the one Washington forces 
them to buy.

What these solutions ultimately comprise is part of a conversation 
currently being held in Congress and, specifically, among those of us 
on the House Task Force on Health Care Reform. We are developing a 
package of reforms that would create a patient-centered health-care 
system where Americans have access to quality, affordable choices, the 
doctor-patient relationship is respected, and real insurance challenges 
like pre-existing conditions are solved through policies that protect 
and empower individuals, not government mandates.

The task force is committed to building these solutions from the ground 
up. However, we do not come to this challenge empty handed. Numerous 
health care policy ideas--including H.R. 2300, the Empowering Patients 
First Act which I have introduced for the past several congresses--have 
been circulating for years, both before and after passage of the 
President's health-care law.

The Task Force on Health Care Reform is one pillar of a larger effort 
to advance a positive, proactive agenda. A perfect partner in that 
effort is the annual budget resolution which is why the House Budget 
Committee has been committed to bringing this positive proposal 
forward. We are focused on getting results and solving the numerous 
challenges facing our country--from the economy to national security--
so we have a more secure and more prosperous Nation.
                                 ______
                                 
                   Empowering Patients Not Government
                 By Congressman Tom Price, M.D. (GA-06)
While practicing orthopaedic surgery for over 20 years, my focus was, 
as it should be, on the patients and serving their needs to the best of 
my ability. Unfortunately, during the early 1990s under then-President 
Clinton's attempt to overhaul America's health-care system, it became 
clear that policy decisions were continuing to be made in Washington 
that would have a profound, and oftentimes, negative impact on the 
practice of medicine. Many of those decisions were being made by 
individuals, probably with good intentions, but who knew little to 
nothing about the practice of medicine--who had never cared for 
patients or understood what it took to do so.

While President Clinton's efforts were unsuccessful, last year 
President Obama signed into law a massive health reform law that is 
destructive and fails to protect and promote the principles of health 
care we cherish, including affordability, accessibility, quality, 
responsiveness, innovation, and choices. The challenge to improve our 
health-care system and make it accessible to more Americans still 
stands; i.e., the status quo is unacceptable, which makes it incumbent 
upon those of us who disagree with the overhaul enacted in the previous 
congress to propose positive solutions in line with health-care 
principles that protect the rights of patients and doctors.

In order to ensure health-care choices in America, Congress must repeal 
the President's health-care law first and foremost and then reform the 
system in a common sense manner. As one of a growing number of 
physicians in the House of Representatives, we understand that changes 
must be made. In order to move the debate forward, I recently 
introduced legislation to repeal and replace the President's health-
care law.

The Empowering Patients First Act (H.R. 3000) encourages individuals to 
obtain health coverage and makes it financially feasible for 
individuals and families to do so. It addresses the issue of lawsuit 
abuse and defensive medicine, which was completely ignored in last 
year's health-care law, and it keeps Washington out of the way of 
health-care decisions. At its core, it advances patient-centered 
solutions to the challenges we face.

Many of us in the medical profession have seen firsthand the 
distortions and disruptions that defensive medicine and excessive 
bureaucracy have on the practice of medicine. Inserting misguided 
government controls and regulations will lead to the denial of care and 
the elimination of health-care choices and personal decision-
making. Under current law, there is even an unaccountable, unelected 
board of 15 bureaucrats--the Independent Payment Advisory Board 
(IPAB)--that will have the power to deny health care to America's 
seniors. That is wrong and does not have to happen in order to make our 
health-care system stronger. It will only weaken the quality of 
medicine for seniors and all Americans.

Since physicians know the best care for their patients, the Empowering 
Patients First Act establishes doctor-led quality measures. And we 
encourage healthier lifestyles by allowing employers more flexibility 
in offering discounts to their employees through wellness and 
prevention programs.

The health-care system in America needs to be reformed and improved--
there is no doubt about that--but this must be done without handing 
over greater authority to the Federal Government. As a physician and 
someone who spent years caring for patients, the damage that can be 
done to the health of our great Nation by government interference is 
clear and unacceptable. The current situation demands that we advance a 
plan not only to halt that interference, but also one to improve access 
to quality, affordable health care. That solution is H.R. 3000!

                                 ______
                                 
                     Keep the Focus on the Patient
                 By Congressman Tom Price, M.D. (GA-06)
A patient-centered health-care system is built upon six principles: 
accessibility, affordability, quality choices, responsiveness, and 
innovation. Today, there are many instances where those principles are 
being violated--more often than not through rules and regulations 
handed down from bureaucratic agencies in Washington, DC. For an 
example, we need only look at how physicians and hospitals have had to 
go about adopting electronic health records (EHR).

As part of the economic stimulus package that became law in the early 
days of the Obama administration, there was a concerted effort to help 
spur adoption of EHR among physicians and hospitals. The law states 
``the Secretary [of Health and Human Services] shall seek to improve 
the use of electronic health records and health-care quality over time 
by requiring more stringent measures of meaningful use.''

From this text was born a complex and burdensome set of requirements 
known as Meaningful Use (MU) Stage 1, 2, and 3. Although well-
intentioned, the MU requirements have chiefly missed the mark by 
focusing more on data entry and less on patients and their doctors.

Physicians face a number of impediments to meeting the MU requirements, 
many of which are outside of their control. These include the lack of 
usability and interoperability among EHR, significant data exchange 
fees, interference with face-to-face patient care, time-consuming data 
entry, the degradation of clinical documentation, and in inflexible 
metrics.

A total of 209,000 physicians will face penalties in 2016 for failing 
to meet EHR MU criteria. While 80 percent of physicians have adopted 
EHR in their practices, less than 10 percent of physicians have 
successfully participated in MU Stage 2 so far. If we want higher 
quality care, healthier patients, and a more efficient use of time and 
resources, then the MV program needs to be reevaluated so it moves in 
the direction of our health-care principles.

This past October, the Centers for Medicare and Medicaid Services (CMS) 
released its modified Stage 2 rule of the MU program. CMS issued its 
directive with less than the requisite 90 days remaining in the 2015 
program year. That meant it was virtually impossible for doctors to 
meet the requirement deadlines.

Anticipating this challenge, I introduced H.R. 3940--the Meaningful Use 
Hardship Relief Act--to provide physicians with much-needed relief by 
ensuring they would be granted a hardship exception to avoid penalties 
stemming from the delayed rulemaking. Working with colleagues in 
Congress, physicians and various stakeholders, we were able to get 
language based on the solutions that we introduced included in a larger 
package of reforms--S. 2425, the Patient Access and Medicare Protection 
Act--which was signed into law just prior to the new year.

On January 22, CMS released a hardship application for physicians and 
hospitals to use when filing an exception to the MU penalty for the 
2015 program year. In the past, providers and hospitals had separate 
application forms. Under the new law, the application is now 
streamlined and can be used by both. Providers may file as individuals 
or in groups--while before each individual provider would have had to 
submit a separate application to be considered by CMS on a case-by-case 
basis. This new streamlined process also allows CMS to process hardship 
applications more efficiently in batches.

All physicians are encouraged to go to CMS.gov and apply for a hardship 
exception under the category ``EHR Certification/Vendor Issue (CEHRT 
Issues),'' which references ``insufficient time'' in accordance with 
CMS's delayed rulemaking. Applications must be submitted to CMS by 
March 15.

Sadly physicians know all too well that the work of defending the 
principles of patient-centered care never ends. While MU penalties 
affect physicians and hospitals nationwide, here in Georgia our 
laboratories and physician groups were facing a more unique threat at 
the beginning of this year. Under a blatantly prejudiced reimbursement 
policy related to new codes for drug testing. CMS was threatening a 33 
percent cut from the national payment rate for Georgia labs and 
doctors. Thanks to the Medical Association of Georgia and others, we 
were able to get this serious discrepancy repaired and ensure that 
Georgia health-care providers were treated fairly.

With solutions to improve our health-care system that adhere to our 
principles, we can protect the doctor-patient relationship from undue 
influence and interference, and put patients, families, and doctors in 
charge.

                                 ______
                                 

                               APPENDIX E

    Speeches and Remarks Made by Dr. Tom Price--2012 to the Present

------------------------------------------------------------------------
     Date              Name              Topic             Location
------------------------------------------------------------------------
               2016 Speeches and Remarks by Dr. Tom Price
 
January 13,     REMARKS:           What, If Anything  DC
 2016            Brookings Event    Congress is
                                    Likely to
                                    Accomplish in
                                    This Election
                                    Year
 
January 23,      REMARKS: Georgia  Washington Update  GA
 2016            Medical
                 Directors
                 Association
                 Winter Symposium
 
January 30,     REMARKS:           Healthcare         GA
 2016            Conservative       Update, Emphasis
                 Policy             on H.R. 2300
                 Leadership
                 Institute
 
February 24,    REMARKS: NAHU      Health Care--ACA   DC
 2016            Meeting            replacement
 
March 1, 2016   REMARKS: AMRPA     Congressional      DC
                 Leadership Forum   Update and
                                    Gratitude for
                                    the AMRPA
                                    Chairman's Award
 
March 22, 2016  REMARKS: Pete      General            DC
                 Sessions Medical   Healthcare
                 Professionals      Overview
                 Fly-in
 
March 24, 2016  REMARKS: Emory     The State of the   GA
                 College            GOP and H.R.
                 Republicans        2300
 
April 11, 2O16  REMARKS:           Issues of          GA
                 Healthcare         Healthcare
                 Symposium with     Economics and
                 Berry College      Policy in the
                                    U.S.
 
April 13, 2016  REMARKS: Idea      No topics listed   DC
                 Forum on
                 Healthcare
                 Reform
 
April 14, 2016  REMARKS: Georgia   Washington Update  DC
                 Society of
                 Ophthalmology
                 Breakfast
 
April 19, 2016  REMARKS: NASS      General/Broad      DC
                 Event              Update on
                                    Healthcare as it
                                    Stands in the
                                    House and From
                                    his Perspective
                                    as Chairman of
                                    the Budget
                                    Committee
 
May 4, 2016     REMARKS: Emory     Federal Funding    GA
                 Science Advocacy   for Biomedical
                 Network            Research,
                                    Particularly for
                                    the National
                                    Institutes of
                                    Health (NIH) and
                                    National Science
                                    Foundation (NSF)
 
June 27, 2016   REMARKS:           Washington Update  NY
                 Roundtable Lunch   With a Focus on
                 Event with         Budget Committee
                 Market News        Activity and Dr.
                 International      Price's Work on
                 Connect            Health Care
 
July 13, 2016   REMARKS: Health    Your Perspective   DC
                 on Wednesday       as a Leader in
                                    the House on
                                    Finalizing
                                    Health
                                    Initiatives in
                                    the 2nd Session
                                    of Congress;
                                    Standard
                                    Healthcare
                                    Speech
 
July 21, 2016   REMARKS:           Future of Health   OH
                 Washington Post    Care and Health
                 Panel on           Policy Issues
                 Healthcare         the Next
                                    President Will
                                    Face
 
August 7, 2016  REMARKS: GPLA;     Perspectives on    GA
                 Perspectives on    Physician
                 Physician          Leadership
                 Leadership         Communication
                 Communication
 
August 13,      REMARKS:           The Current State  GA
 2016            Concierge          of Healthcare
                 Medicine           and Emerging
                 Conference         Entrepreneurial
                                    Forms of
                                    Healthcare
                                    Delivery in
                                    America
 
August 25,      REMARKS: MVP Vets  Your Work in       GA
 2016            Event With         Washington and
                 Elekta and         How It's
                 AdvaMed            Essential to the
                                    Medical
                                    Technology
                                    Community
                                    (Medical Device
                                    Tax or Even the
                                    Breakthrough
                                    Pathways
                                    legislation,
                                    e.g.)
 
August 25,      REMARKS: AARP      Social Security    GA
 2016            Financial Forum    (Challenges to,
                 With Senator       the Future of,
                 Isakson            Possible
                                    Solutions) and
                                    any Other
                                    Financial
                                    Initiatives at
                                    the Federal
                                    Level You Would
                                    Like to
                                    Highlight
 
September 10,   REMARKS: AKSM      Washington/        GA
 2016            Medical Director   Healthcare
                 Meeting            Update
 
September 13,   REMARKS: PhRMA     CMMI and 2017      DC
 2016            Board              Agenda
 
September 20,   REMARKS: AAMC      Present            DC
 2016                               Information
                                    About Mr.
                                    Trump's
                                    Platform,
                                    Especially as it
                                    Related to
                                    Health Care
 
September 28,   REMARKS: U.S.      Better Way Health  DC
 2016            Chamber's E8       Care Plan
                 Committee
 
October 10,     REMARKS: Emory     Future of Health,  GA
 2016            School of          Healthcare, and
                 Business's         Congressional
                 Speaker Series:    Roll
                 Medical
                 Technology
                 (Health IT and
                 Medical Devices)
 
October 17,     REMARKS: Seniors   Senior's           Call
 2016            for Trump          Healthcare
                 Conference Call    (Medical and
                                    Supplementary
                                    Coverage)
 
October 20,     REMARKS: Eastern   Federal            LA
 2016            Orthopedic         Healthcare and
                 Society            How it Affects
                                    Orthopaedic
                                    Surgeons
 
November 1,     REMARKS:           Healthcare         PA
 2016            Healthcare Event
                 With Trump
 
November 2,     REMARKS: Medtrade  AAHomecare         GA
 2016            Conference         Washington
                                    Update
 
November 12,    REMARKS: RIPON:    National Health    DC
 2016            PANEL 4            Service vs.
                                    Obamacare
 
November 21,    REMARKS: Panel     Importance of      GA
 2016            Discussion With    U.S. Global
                 U.S. Global        Leadership and
                 Leadership         to Highlight the
                 Coalition          Positive Impacts
                                    America's
                                    Development and
                                    Diplomatic
                                    Programs Have on
                                    Georgia
 
                2015 Speeches and Remarks by Dr.Tom Price
 
January 12,     REMARKS: Heritage  Vision for the     DC
 2015            Action Policy      House Budget
                 Summit             Committee +
                                    Upcoming Fiscal/
                                    Economic
                                    Deadlines (ex:
                                    SGR)
 
January 30,     REMARKS: American  Affordable Care    DC
 2015            Society of         Act Update
                 General Surgeons
                 Conference
 
January 31,     REMARKS:           Empowering         GA
 2015            Conservative       Patients First
                 Policy             Act
                 Leadership
                 Institute
 
February 9,     REMARKS: MASA      SGR, ICD-10 and    DC
 2015            Conference         How the Doctor's
                                    Caucus Can Have
                                    More Influence
                                    in Congress as
                                    Far as Medical
                                    Issues
 
February 12,    REMARKS: ASCO      SGR Reform and     DC
 2015            Oncology Meeting   How it is
                                    Impacted by the
                                    Budget Process
 
February 18,    REMARKS: Panel     Obamacare/         GA
 2015            Discussion With    Healthcare
                 Senator Isakson:   Reform
                 NFIB/GA Small
                 Business Day
 
February 24,    REMARKS: AMA       Budget, Medicare,  DC
 2015            National           etc.
                 Advocacy
                 Conference
 
February 28,    REMARKS: CPAC      What Have His      MD
 2015                               Former
                                    Colleagues in
                                    Medicine Told
                                    Him About How
                                    Obamacare is
                                    Affecting Their
                                    Practices, and
                                    What Effect
                                    Might This Have
                                    on Federal
                                    Spending?
 
March 2, 2015   REMARKS: American  General Update on  DC
                 Academy of         Healthcare
                 Neurology
                 Reception
 
April 16, 2015  REMARKS: American  Medicare Payment   DC
                 Academy of         Outlook
                 Ophthalmology
 
April 27, 2015  REMARKS: GNFCC's   Your Health Care   GA
                 Healthcare         Plan and
                 Technology         Obamacare Repeal
                 Roundtable         and Replacement
 
April 27, 2015  REMARKS:           Repeal of the SGR  FL
                 Emergency          and Interested
                 Department         in What Will
                 Practice           Happen Moving
                 Management         Forward
                 Association's
                 Solutions Summit
 
April 28, 2015  REMARKS: Big       Opening Remarks--  DC
                 Cities Health      Share Your
                 Coalition          Personal Story
                 Breakfast
                 Briefing With
                 John Lewis
 
April 30, 2015  REMARKS: Laffar    Discuss What Your  DC
                 Associates 55th    View Is as to
                 Washington         the Most
                 Conference         Important
                                    Economic
                                    Legislative
                                    Agenda Items and
                                    Current Events
 
May 1, 2015     REMARKS: American  What It's Like to  DC
                 Association of     Be a Member of
                 Orthopaedic        Congress and
                 Surgeons           Former Surgeon;
                                    Budget Outlook;
                                    Healthcare
                                    Landscape--Post-
                                    SGR
 
May 6, 2015     REMARKS: Lecture   A Balanced Budget  NJ
                 With the           for a Stronger
                 Princeton Tory     America: Federal
                                    Spending,
                                    Obamacare, and
                                    Other Washington
                                    Updates
 
May 13, 2015    REMARKS: American  H.R. 23OO          DC
                 Tax Reform
                 Meeting
 
May 19, 2015    REMARKS: National  Primary Focus:     DC
                 Association of     Dr. Price's
                 Spine              Patient Shared
                 Specialists:       Billing
                 (NASS) Capitol     Legislation--H.R
                 Hill Day 2015      . 1650, Medicare
                                    Patient
                                    Empowerment Act
 
June 8, 2015    REMARKS: SE        Healthcare         IL
                 Breakfast at AMA
 
June 15, 2015   REMARKS: American  H.R. 2300          GA
                 Society of
                 Actuaries
 
June 23, 2015   REMARKS:           Brief Overview of  DC
                 Healthcare         Work in the Ways
                 Leadership         and Means
                 Council Luncheon   Committee
 
July 20, 2015   REMARKS: Town      Meaningful Use--   GA
                 Hall Meeting       Town Hall Is
                 With AMA           Focused on
                 President Stack    Electronic
                                    Health Records
                                    and Looming
                                    Regulations
 
August 1, 2015  REMARKS:           Current State of   GA
                 Concierge          Healthcare and
                 Medicine           Emerging
                 Conference         Entrepreneurial
                                    Forms of
                                    Healthcare
                                    Delivery in
                                    America
 
August 9, 2015  REMARKS: GPLA      Perspectives on    GA
                                    Physician
                                    Leadership
 
August 14,      REMARKS: South     Policy and the     GA
 2015            Atlantic Region    Impact on
                 Architecture for   Healthcare
                 Health Annual      Delivery
                 Conference
 
August 17,      REMARKS: UCB       Healthcare         GA
 2015            Politics and       Related Topics--
                 Pizza Luncheon     Vision for the
                                    U.S. Healthcare
                                    System--FDA
                                    Reform, etc.
 
August 21,      REMARKS: WellStar  Healthcare/Budget  GA
 2015            Board Meeting--    Update
                 Reception and
                 Dinner
 
September 24,   REMARKS:           Your Specialty in  MI
 2015            University of      Medicine and
                 Michigan Young     Perhaps Touch on
                 Americans for      Some Important
                 Freedom            Legislative
                                    Issues
                                    (Obamacare)
 
September 28,   REMARKS:           Health Reform and  DC
 2015            Chairman's         Budget
                 Council Policy
                 Conference
 
October 3,      REMARKS: GOS       No topics listed   GA
 2015
 
November 16,    REMARKS: AMA       Personal           GA
 2015            Southeastern       Experience in
                 Delegation         Medicine and
                 Breakfast          Transition to
                                    Government
 
December 3,     REMARKS: First     Health Policy and  DC
 2015            Quality Forum      Related Budget
                                    Issues
 
December 9,     REMARKS: AEI       No topics listed   DC
 2015            Speech
 
               2014 Speeches and Remarks by Dr. Tom Price
 
January 15,     REMARKS:           MMP Bill           DC
 2014            Healthcare         Completive
                 Policy Briefing    Bidding (They
                                    May Bring Up
                                    SGR, ACA, etc.)
 
February 10,    REMARKS: Heritage  H.R. 2300          DC
 2014            Action Panel
 
February 22,    REMARKS: Tea       Healthcare         GA
 2014            Party Patriots     Update--H.R.
                 Healthcare Event   2300
 
February 27,    REMARKS: Lone      Healthcare         DC
 2014            Star Leadership    Roundtable--E&C,
                 PAC Breakfast      W&M Perspective
 
February 27,    REMARKS: Galen     Healthcare Reform  DC
 2014            Institute Health   Proposals
                 Solutions
                 Conference
 
February 28,    REMARKS: AEI       Healthcare Reform  DC
 2014            Symposium
 
March 6, 2014   REMARKS: CPAC      The New Medical    MD
                 Panel              Realities We All
                                    Face: Rationing,
                                    Denial of Care,
                                    Doctor Shortages
                                    and a Loss of
                                    Religious
                                    Liberty Under
                                    Obamacare
 
March 7, 2014   REMARKS: AEI       The Health of      DC
                 Panel              America's Health
                                    Policy
 
March 9, 2014   REMARKS: RJC--     Healthcare         GA
                 Atlanta            Update, Emphasis
                                    on H.R. 2300
 
March 12, 2014  REMARKS: The       Affordable Care    DC
                 Commonwealth       Act, its
                 Fund's Harkness    Prospects for
                 Fellows            Expanding
                                    Coverage,
                                    Transforming the
                                    U.S. Health Care
                                    System and
                                    Containing Costs
 
March 24, 2014  REMARKS: American  Current Major      DC
                 Psychiatric        Healthcare
                 Association        Issues in
                 Advocacy           Congress
                 Leadership
                 Conference
                 (annual fly-in)
 
March 27, 2014  REMARKS: American  Healthcare: SGR,   DC
                 Association of     ACA, etc.
                 Physicians of
                 Indian Origin
                 (AAPI)
 
March 27, 2014  REMARKS: NASS      Importance of      DC
                 Washington         Physician
                 Conference         Advocacy and
                                    Visiting
                                    Washington, DC,
                                    to SGR
 
April 1, 2014   REMARKS:           Health Care and    DC
                 Obamacare: What    the Economy
                 to Watch in 2014   Between Now and
                                    November
 
April 3, 2014   REMARKS: Tax       Your Thoughts on   DC
                 Council            the
                                    Comprehensive
                                    Reform Process,
                                    SGR, Highways,
                                    and Other Items.
 
April 9, 2014   REMARKS: Las       Healthcare and     DC
                 Vegas              the Impact on
                 Metropolitan       American
                 Chamber of         Employers Both
                 Commerce           Large and Small
                 Conference
 
April 10, 2014  REMARKS: PDMA      Healthcare in      MD
                                    2014 and Beyond
 
April 11, 2014  REMARKS: Heritage  If You Like This   DC
                 Conference         Session, You Can
                                    Keep it--Real
                                    Health Care
                                    Solutions As
                                    Obamacare
                                    Unravels
 
April 14, 2014  REMARKS: Forsyth   The Un-Affordable  GA
                 County Tea Party   Care Act/
                 Tax Day Rally      Obamacare--``0ne
                                    Giant Tax''
 
April 23, 2014  REMARKS: National  Drug-Related       GA
                 Rx Abuse Summit    Legislation He
                                    Has Supported
                                    and any Stories
                                    He Could Tell
                                    About the
                                    Epidemic in
                                    Georgia
 
April 23, 2014  REMARKS: St.       The Future of      MO
                 Louis              Health Care
                 Orthopaedic        Reform: A
                 Society Dinner     Physician's
                                    Perspective on
                                    Policy Making
 
April 26, 2014  REMARKS: Alabama   Navigating the     AL
                 Orthopaedic        ACA and the
                 Society Meeting    Battle for
                                    PPatient-
                                    Centered
                                    Solutions
 
May 8, 2014     REMARKS:           Concern That is    VA
                 Virginians for     Percolating
                 Quality            Among the
                 Healthcare Forum   Republican Base
                                    and the Media
                                    That the
                                    Leadership
                                    Actually Has no
                                    Intention to
                                    ``Repeal and
                                    Replace''
 
May 12, 2014    REMARKS: St.       Healthcare Update  GA
                 Joe's General
                 Medical Staff
                 Meeting
 
May 17, 2014    REMARKS: Atlanta   Healthcare Update  GA
                 International      from DC--
                 Trauma Symposium   Emphasis on
                                    Reform
 
June 17, 2014   REMARKS:           Crafting Health    DC
                 Government         Innovation That
                 Health             Works for
                 Information        Patients and
                 Technology         Doctors
                 Conference
 
June 17, 2014   REMARKS: ASCA      An Update on       DC
                 Dinner             Healthcare
 
August 12,      REMARKS: Medical   Healthcare         NC
 2014            Forum: ``Federal   Problems
                 Issues Facing      Confronting
                 the Medical        Doctors, Nurses,
                 Community in       Administrators,
                 NC's 3rd           and Patients
                 Congressional
                 District''
 
August 13,      REMARKS:           Federal Issues     NC
 2014            Roundtable Lunch   that Will Affect
                 with Congressman   Eastern NC's
                 Walter Jones and   Medical
                 Special Guest      Community
                 Congressman Tom
                 Price
 
August 17,      REMARKS:           Perspectives on    GA
 2014            Leadership         Physician
                 Session--GPLA      Leadership
 
September 30,   REMARKS: Keynote   Sustaining         DC
 2014            Speaker, AHIP      Medicare for
                 Medicare and       Future
                 Medicaid           Generations:
                 Conference         Views From the
                                    Hill
 
November 20,    REMARKS: Speech/   General            DC
 2014            Panel With         Discussion on
                 Benjamin Rush      How One Goes
                 Institute,         From Medicine to
                 Georgetown         Congress
                 Chapter
 
               2013 Speeches and Remarks by Dr. Tom Price
 
January 10,     REMARKS: Florida   Update on What is  FL
 2013            Healthcare         Happening in DC
                 Reception          on the Health
                                    Care Front Since
                                    Election Day--
                                    Federal
                                    Viewpoint
 
February 27,    REMARKS: Call      Reintroduction of  Call
 2013            With Coalition     the Medicare
                 or State Medical   Patient
                 and National       Empowerment Act.
                 Specialty          (Dr. Price)--
                 Societies          Medicare Patient
                                    Empowerment Act
                                    in the New
                                    Congress and
                                    Strategies to
                                    Get it Passed
 
March 4, 2013   REMARKS: AWARD     Physician          DC
                 American           Payments: Cuts,
                 Congress of        Bumps, and
                 Obstetricians      Bruises
                 and
                 Gynecologists
                 (ACOG) 31st
                 Annual
                 Congressional
                 Leadership
                 Conference
 
March 4, 2013   REMARKS: AAMC      Current Climate    DC
                 Government         on Capitol Hill
                 Relations          as it Relates to
                 Conference         Federal Health
                                    Care Spending
                                    (Particularly,
                                    Medicare,
                                    Medicaid, Public
                                    Health Service
                                    Programs Like
                                    the National
                                    Health Service
                                    Corps, and the
                                    NIH)
 
March 6, 2013   REMARKS: Meeting   U.S. Health        DC
                 With               Reform and the
                 Commonwealth       Sustainability
                 Fund's Fellows     of Medicare and
                                    Medicaid, the
                                    Challenge of
                                    Improving the
                                    Quality of Care
                                    and Access to
                                    the Latest
                                    Technologies and
                                    Medications
                                    While Containing
                                    Spiraling Health
                                    Care Costs
 
March 17, 2013  REMARKS: American  Impact of the      VA
                 Urological         Affordable Care
                 Association        Act on
                                    Physicians
 
April 7, 2013   REMARKS: Self-     Perspectives on    DC
                 Insurance          Implementation
                 Institute of       of the ACA and
                 America, Inc.      any Future
                 (SIIA)             Actions Being
                                    Taken by the
                                    House Affecting
                                    Healthcare
                                    Reform
 
May 3, 2013     REMARKS: National  Entitlement        DC
                 Orthopaedic        Reform: Long-
                 Leadership         Term Economic
                 Conference         Projections and
                 (AAOS)             the Outlook for
                                    Medicare Reform
 
May 6, 2013     REMARKS: RADPAC    Specifics on       DC
                                    Healthcare and
                                    Comments on
                                    Radiology Bill--
                                    H.R. 846--and
                                    H.R. 3269 Last
                                    Congress That
                                    Had More Than
                                    270 Co-Sponsers
 
May 15, 2013    REMARKS: PPO       Impact of          DC
                 Capital Caucus     Obamacare and
                                    the Next Steps
                                    as We Look Ahead
                                    to 2014
 
May 22, 2013    REMARKS: American  Problems With      DC
                 Association for    Medicare's
                 Homecare           Competitive
                 Washington         Bidding Program
                 Legislative        and Benefits of
                 Conference         the Market
                                    Pricing Program
                                    (MPP) HME
                                    Provider
                                    Compliance and
                                    Audit Issues;
                                    Power Mobility
                                    Issues; and
                                    Efforts to
                                    Eliminate
                                    Medicare Fraud
                                    and Abuse
 
June 15, 2013   REMARKS: Becker's  Orthopaedic,       IL
                 ASC Review Panel   Spine, and Pain
                                    Management
                                    Practices and
                                    ASCs--6 Defining
                                    Issues
 
June 17, 2013   REMARKS: AMA SE    Status of          IL
                 Delegation         Obamacare
                 Breakfast
 
June 24, 2013   REMARKS: National  Obamacare and      GA
                 Association of     Your Plan on
                 Health             Reducing Costs,
                 Underwriters'      From the
                 Annual             Provider Side of
                 Convention         Business
 
July 9, 2013    REMARKS: Alliance  Healthcare         DC
                 of Specialty
                 Medicine
 
July 16, 2013   REMARKS: 2013      What               DC
                 Health Care        Representative
                 Payments and       Price Thinks
                 Policy             About Emerging
                 Conference         Health Reform
                                    Issues in the
                                    113th Congress
 
July 20, 2013   REMARKS: Southern  Obamacare Current  ..................
                 Orthopaedic        Perspective
                 Association
 
August 10,      REMARKS: GA        Perspectives on    GA
 2013            Physicians         Physician
                 Leadership         Leadership
                 Academy
 
August 17,      REMARKS: American  How Will The       MD
 2013            Society of         Affordable Care
                 General Surgeons   Act Influence
                                    the Practice of
                                    Surgery in the
                                    Near Future?
 
August 20,      REMARKS: GNFCC's   ACA                GA
 2013            Healthcare Panel
 
September 23,   REMARKS: Elekta    Importance of      GA
 2013            Learning and       Elekta to
                 Innovation         Georgia and the
                 Center (LINC)      Health Care
                 Grand Opening/     Industry
                 Ribbon Cutting
 
October 9,      SPECIAL GUEST:     Talk About SGR,    DC
 2013            U.S. Oncology      Government
                 Network PAC        Shutdown, and
                 Board              Thoughts of What
                                    Happens Over the
                                    Next Couple of
                                    Months; Anything
                                    Physician
                                    Related
 
October 21,     REMARKS: GA/Cobb   Affordable Care    GA
 2013            Chamber            Act--The Story,
                 Healthcare         The Politics and
                 Summit             Policy, and the
                                    Future
 
October 24,     REMARKS: CA        Panel of GOP       ..................
 2013            Lincoln Club Fly-  members Who Are
                 in                 Working on a GOP
                                    Plan/Alternative
                                    to Obamacare--
                                    Very Casual/
                                    Informal
                                    Discussion
 
November 16,    REMARKS: Keynote   As the Largest     DC
 2013            address Medical    Medical Student
                 Student Section    Organization in
                 at the AMA-MSS     the Country the
                 Interim Assembly   AMA-MSS is
                 Meeting            Dedicated to
                                    Representing
                                    Medical
                                    Students,
                                    Improving
                                    Medical
                                    Education,
                                    Developing
                                    Leadership, and
                                    Promoting
                                    Activism for the
                                    Health of
                                    America
 
November 16,    REMARKS: 4th       Current            MD
 2013            Edward Annis       Republican
                 Medical Freedom    Health Reform
                 Awards Dinner/     Proposals
                 Give Award to
                 Dr. Carson
 
November 17,    REMARKS:           Physicians as      MD
 2013            International      Leaders and
                 Medical            Legislators
                 Graduates
                 Section
 
November 18,    REMARKS: AMA SE    Developments on    DC
 2013            Delegation         ACA and Some on
                 Breakfast          SGR
 
December 4,     REMARKS: Ripon     The Health Care    DC
 2013            Society            Debate: Reform
                 Breakfast          vs. Reality
 
December 11,    REMARKS: ATR       H.R. 2300          DC
 2013            Wednesday
                 Meeting to Roll
                 Out H.R. 2300
                 Score
 
               2012 Speeches and Remarks by Dr. Tom Price
 
January 23,     REMARKS: 39th      March for Life     DC
 2012            Annual March for
                 Life
 
February 21,    REMARKS: Cushman   Healthcare Update  GA
 2012            and Wakefield
                 Healthcare CFO
                 Roundtable
 
February 23,    REMARKS:           Healthcare         GA
 2012            Southeast          Update,
                 Permanente         Including the
                 Medical Group      Revolving Status
                 Board of           of the ACA
                 Directors          Legislation and
                 Meeting            What SPMG Can Do
                                    to Best Position
                                    Itself for the
                                    Future
 
February 29,    REMARKS: Luncheon  Physician Payment  DC
 2012            for the American   Reform and the
                 Association of     Prospects of
                 Clinical           Passing H.R.
                 Endocrinologists   1700 Given the
                                    Inability of
                                    Congress Thus
                                    Far to Enact
                                    Permanent
                                    Medicare
                                    Physician
                                    Payment Reform
 
March 5, 2012   REMARKS: American  Perspective on     DC
                 Urological         Where Medicine
                 Association        is Going,
                                    Implementation
                                    of the Health
                                    Reform Bill,
                                    etc.
 
March 7, 2012   REMARKS: Academic  Conference         DC
                 Health Centers     Committee
                 Fly-in             Outcome; What
                                    Will the 2012
                                    Election Mean
                                    for Teaching
                                    Hospitals,
                                    Payroll Tax
                                    Conference, and
                                    SGR?
 
March 13, 2012  REMARKS: Colorado  The Nexus of       CO
                 School of          Medicine and
                 Medicine           Politics . . .
                 Benjamin Rush      Closer Than you
                 Society            Think!
 
March 16, 2012  REMARKS: RPA       Future of          DC
                 Reception          Healthcare
 
March 22, 2012  REMARKS: Townhall  Athena's           DC
                 Meeting With       Innovative
                 Athena Health      Approach to
                                    Incentivizing
                                    Meaningful
                                    Health
                                    Information
                                    Exchange and a
                                    Recent OIG
                                    Opinion the
                                    Company
                                    Successfully
                                    Obtained That
                                    Has the
                                    Potential to at
                                    Last Unleash the
                                    Technological
                                    Innovation in
                                    the Health Care
                                    Sector That Has
                                    Eluded Policy
                                    Makers for
                                    Decades
 
March 22, 2012  REMARKS: National  Medication         DC
                 Association of     Adherence: How
                 Chain Drug         Important it Is
                 Stores             for Patients to
                                    Take Their
                                    Medications, and
                                    Take Them
                                    Correctly; One
                                    of the Items in
                                    our MTM Bill
                                    That We Stress
                                    is That Patients
                                    in Transition of
                                    Care Need Extra
                                    Help to Make
                                    Sure They Take
                                    Their Meds, Take
                                    Them Properly,
                                    and Continue to
                                    Take Them Until
                                    the Physician
                                    Has Determined
                                    They Stop
 
March 27, 2012  REMARKS: Hands     Hands Off My       DC
                 Off My             Healthcare
                 Healthcare Rally
 
April 12, 2012  REMARKS: Lunch     Health Care        DC
                 With AMA           Reform From the
                 Students           Perspective of a
                                    Physician in
                                    Congress
 
April 12, 2012  REMARKS: Speaking  Healthcare in      DC
                 at the Commons     America: Where
                 Seminar            Have We Come
                                    From and Where
                                    Are We Going?
 
April 13, 2012  REMARKS: Medical   Physician          AL
                 Association for    Leadership:
                 State of Alabama   Critical for
                 Annual Meeting     Preserving the
                                    Profession; Why
                                    Physicians
                                    Should be More
                                    Involved in the
                                    Political
                                    Process
 
April 23, 2012  REMARKS: North     A Washington/      GA
                 Fulton Hospital    Healthcare
                 (Semi- Annual      Update
                 Medical Staff
                 Meeting)
 
April 26, 2012  REMARKS: National  Discussion on How  DC
                 Journal Keynote    Congress Can Act
                 Interview          in the Interest
                                    of the American
                                    Public and the
                                    Policy Issues
                                    Americans Want
                                    Their Elected
                                    Officials to
                                    Focus on for the
                                    Remainder of the
                                    112th Congress
 
April 26, 2012  REMARKS: American  No Topic Listed    DC
                 Association of
                 Orthopaedic
                 Surgeons
 
April 30, 2012  REMARKS: To        A Principled       ..................
                 Hilldale           Prescription for
                 Students           America's
                                    Health: The
                                    Perspective of
                                    Doctor-Turned-
                                    Lawmaker
 
May 8, 2012     REMARKS: College   Outlook in         DC
                 of American        Congress for the
                 Pathologists       Rest of the
                 Breakfast          Year; What's the
                                    GOP View on
                                    Health Care and
                                    Medicare Reform?
                                    What Happens
                                    Next in Health
                                    Care if ACA is
                                    Repealed or is
                                    Not Repealed?
 
May 21, 2012    REMARKS:           Health Care        MO
                 University of      Financing in
                 Missouri Medical   General and
                 School             Financing of
                                    Graduate Medical
                                    Education
 
May 22, 2012    REMARKS: Richmond  Healthcare         GA
                 County Medical     Update; Status
                 Society            of Healthcare
                                    Reform
                                    Legislation
 
June 3, 2012    REMARKS: GA/SC     Our Bill, H.R.     SC
                 Radiology          3269; How We Can
                 Societies Joint    Get it Into End
                 Chapter Meeting    of Year Package,
                                    etc.; SGR; Your
                                    Bill to Repeal
                                    and Replace ACA
 
June 15, 2012   REMARKS: Faith     Panel: Obamacare:  DC
                 and Freedom        Repeal, Replace,
                 Coalition          and Reform
 
June 18, 2012   REMARKS: AMA       No topic listed    IL
                 Southeastern
                 Breakfast
 
June 22, 2012   REMARKS: Stand Up  Your/House         GA
                 for Religious      Perspective on
                 Liberty Rally      HSS Mandate;
                                    Role the Federal
                                    Government is
                                    Playing to
                                    Infringe on the
                                    Rights of
                                    Religious
                                    Organizations;
                                    Any Updates From
                                    the House on
                                    These Issues
 
June 26, 2012   REMARKS: American  Personal Story of  MD
                 Orthopaedic        How You Got
                 Association        Involved in
                                    Politics
 
July 10, 2012   REMARKS: American  Repealing and      DC
                 Action Network     Replacing
                 and Crossroads     Obamacare
                 GPS Healthcare
                 Panel
 
July 10, 2012   REMARKS: American  Price/Boustany     DC
                 Association of     Medicare
                 Neurological       Physician
                 Surgeons Fly-in    Payment Bill and
                                    Private
                                    Contracting
 
July 20, 2012   REMARKS: Smart     Healthcare, Next   VA
                 Girl Politics      Steps
 
July 27, 2012   REMARKS: Lincoln   Obamacare          FL
                 Day Dinner with
                 Ross
 
July 31, 2012   REMARKS: B26       Healthcare         NC
                 Romney Breakfast
 
August 3, 2012  REMARKS: ASCRS/    Medicare           Call
                 ASOA Retreat       Physician
                 (via               Payment Reform,
                 teleconference)    the SGR, IPAB
                                    Repeal
 
August 7, 2012  REMARKS: GAMES     Healthcare: Home   GA
                 Legislative        Health Care:
                 Breakfast          Medicare
                                    Competitive
                                    Bidding and the
                                    Current Audit
                                    Environment
 
August 7, 2012  REMARKS:           Healthcare/        GA
                 Brunswick          Washington
                 Medical            Update
                 Community Event
 
August 12,      REMARKS: Georgia   Perspective on     GA
 2012            Physicians         Physician
                 Leadership         Leadership
                 Academy
 
August 24,      REMARKS:           The Opportunity    CA
 2012            Strathspey         for Reforms to
                 Crown: A New       the ACA
                 Model for
                 Healthcare
 
August 25,      REMARKS:           No topic listed    CA
 2012            Government
                 Affairs Panel:
                 Creating a New
                 Era in
                 Healthcare
 
August 28,      REMARKS:           Healthcare Panel   FL
 2012            Bipartisan
                 Conversation on
                 Healthcare
 
August 29,      REMARKS: The Hill  No topic listed    FL
 2012            Healthcare Panel
 
September 9,    REMARKS: Docs 4    U.S.               VA
 2012            Patient Care       Congressional
                                    Solutions for
                                    Obamacare
 
September 10,   REMARKS: American  The Outlook for    DC
 2012            Academy of         Health Care
                 Dermatology        Legislation and
                                    Legislation
                                    Impacting
                                    Physicians
                                    Broadly and,
                                    More
                                    Specifically,
                                    Dermatologists
 
September 13,   REMARKS: American  Providing an       Call
 2012            Congress of        Assessment of
                 Obstetricians      the Post-SCOTUS
                 and                Health Reform
                 Gynecologists      Landscape
                 Government
                 Relations
                 Committee
 
September 13,   REMARKS: SC-04     Healthcare,        DC
 2012            Chambers of        General Ideas
                 Commerce           and Thoughts
                 National Issues    About PPACA, the
                 Fly-in             Supreme Court
                                    Ruling on PPACA,
                                    and Healthcare
                                    Issues in
                                    General as it
                                    Relates to the
                                    Business
                                    Community
 
November 10,    REMARKS: Mount     Obamacare's        GA
 2012            Vernon Towers      Impact on
                 Retirement         Seniors
                 Facility
 
November 11,    REMARKS: Emory     Healthcare         GA
 2012            Johns Creek        Update; H.R.
                 Hospital           3000
 
November 16,    REMARKS: Medtrade  H.R. 6490--Why     GA
 2012            Expo (Power for    That Would be
                 Funding Welcome    Better Than the
                 Reception)         Current
                                    Competitive
                                    Bidding
                                    Methodology
 
November 22,    REMARKS: SCI       Healthcare Update/ GA
 2012            Solutions          Legislative
                 Healthcare         Trends in
                 Meeting            Healthcare
                                    Policy
 
November 24,    REMARKS: National  Health Policy      TX
 2012            Association of     Issues Facing
                 Spine              Congress
                 Specialists
------------------------------------------------------------------------


                                 ______
                                 
     Questions Submitted for the Record to Hon. Thomas Price, M.D.
                 Questions Submitted by Hon. Ron Wyden
                    brokerage account documentation
    Question. In the hearing, you were asked to reaffirm that trades in 
your brokerage accounts were controlled by your stock broker and not by 
yourself.

    Please provide the management and brokerage agreements for all 
accounts that hold individual health-care stocks including but not 
limited to the Morgan Stanley account labeled Morgan Stanley #1 in your 
2015 House of Representatives Financial Disclosure and the Morgan 
Stanley account labeled Morgan Stanley #2 in your 2015 House of 
Representatives Financial Disclosure.

    Answer. I previously provided the Senate Finance Committee 
(``SFC'') with substantial information regarding the nature of the 
brokerage accounts described in this inquiry and have no further 
information to provide at this time. Additional information regarding 
Morgan Stanley's management and brokerage policies is also readily 
available in the public domain.
           management of shares in innate immunotherapeutics
    Question. As discussed in the disclosure memo, which was made part 
of the record of the hearing, you purchased shares in Innate 
Immunotherapeutics in private placements in 2016.

    In what account and in what form were those shares held at the time 
you filed your financial disclosures, as a nominee, with Federal ethics 
officials and your response to the committee's questionnaire? In what 
account and in what form are those shares currently held? If shares 
were transferred between accounts, when were they transferred and at 
whose direction?

    Answer. I previously provided the SFC with substantial information 
regarding the issues raised in this question. As the committee is fully 
aware, the shares of Innate Immunotherapeutics (``Innate'') purchased 
in 2016 through private placement were held with the company in 
electronic certificate format up until recently. In the process of 
gathering information to respond to committee questions (posed on 
January 17, 2017) in the wake of due diligence meetings with committee 
staff, I learned that these electronic certificate holdings have now 
been transferred to his Wells Fargo Joint Brokerage Account #1. The 
desire to transfer this holding from electronic certificate form to a 
brokerage account was discussed during the due diligence meeting with 
SFC staff. Both the SFC and OGE were appropriately notified of the 
transfer upon its completion.
                            brokerage trades
    Question. In testimony to the Senate HELP Committee, you stated 
that you directed your broker to purchase shares in Innate 
Immunotherapeutics.

    During your time in Congress, have you ever directed your broker to 
make any other transactions in stock of specific companies? If so, 
please identify the companies, the date, and volume of the transaction.

    Answer. To the best of my knowledge, I have not undertaken such 
actions. Throughout my time as a member of the U.S. House of 
Representatives, I have abided by and adhered to all ethics and 
conflict of interest rules applicable to me.
                 trans-pacific partnership negotiations
    Question. Did you or your staff consult with the House Ethics 
Committee at any time concerning the possibility or appearance of a 
conflict of interest or other ethics concern arising from your 
ownership of shares in Innate Immunotherapeutics and your role as a 
member of the House Ways and Means Committee concerning negotiations 
related to the Trans-Pacific Partnership, or the receipt of any 
information that you received in that capacity or as a member of the 
House concerning such negotiations?

    Answer. To the best of my knowledge, neither I nor my staff has had 
such consultations. Throughout my time as a member of the U.S. House of 
Representatives, I have abided by and adhered to all ethics and 
conflict of interest rules applicable to me.
                  innate immunotherapeutics purchases
    Question. The nominee owns 461,238 shares of Innate 
Immunotherapeutics Ltd. (``Innate''), a small Australian 
biopharmaceutical firm developing a multiple sclerosis therapy. The 
nominee acquired the stock in four separate purchases on January 8, 9 
and 23 of 2015 (``2015 tranche''), and in a pair of private stock 
placements on August 31, 2016 (``2016 tranche''). Regarding Innate:

    Please describe how and when the nominee first learned about 
Innate.

    Answer. I previously answered this question for the SFC. I learned 
about Innate during the course of a conversation in the fall of 2014 
with Representative Chris Collins regarding their respective personal 
backgrounds. I cannot recall the specific date of that conversation. 
During that exchange, Representative Collins told me that he sat on a 
number of public company boards including Innate, which was developing 
a treatment for multiple sclerosis (MS).

    Question. Did the nominee or his staff ever meet or otherwise 
communicate with current or former employees, directors, consultants, 
or other officials affiliated with Innate? If so, please describe the 
communication, including who it involved, the date, subject, place and 
form (e.g., in person, by phone) of communication.

    Answer. I previously answered this question for the SFC.

    I communicated with Representative Collins, who is a director of 
Innate. As noted above, I learned about Innate through a general 
conversation with him in the fall of 2014. I also communicated with 
Simon Wilkinson of Innate regarding my interest in participating in the 
2016 private placement of company stock. According to Innate's website, 
Mr. Wilkinson is currently the Managing Director and CEO of Innate.

    My congressional staff has not met or otherwise communicated with 
current or former employees, directors, consultants or other officials 
affiliated with Innate.

    Question. Please describe any communication between the nominee and 
Congressman Collins regarding Innate Immunotherapy, including the date, 
subject, place and form.

    Answer. I previously answered this question for the SFC.

    I had a conversation with Representative Collins in the fall of 
2014 that brought Innate, as a company, to my attention. The nature of 
that conversation did not, however, influence my decision to invest in 
the company in either 2015 or 2016.

    I believe I had subsequent general communications with 
Representative Collins regarding Innate. I do not have a specific 
recollection of when those conversations occurred or their substance. 
Any such communications did not impact my investment decisions, 
however, because my purchases of Innate stock were based solely on my 
own research.

    Question. The nominee bought 400,316 shares in the 2016 tranche in 
a private stock sale that included two placements at two prices. Please 
provide the number of shares bought in each placement, and the price at 
which the shares were bought.

    Answer. I previously answered this question for the SFC. I 
purchased 250,000 shares of Innate in Private Placement 1 at US$0.18/
share--the same price offered all participants in this private 
placement. I purchased 150,613 shares of Innate in Private Placement 2 
at US$0.26/share--the same price offered all participants in this 
private placement.
                      zimmer biomet stock holding
    Question. Did you or your staff meet with Zimmer Biomet employees 
or representatives, including but not limited to lobbyists, executives, 
or board members, between July 14, 2015 and April 1, 2016? If so, 
please describe the communication, including who it involved, the date, 
subject, place and form (e.g., in person, by phone) of communication.

    Answer. To the best of my knowledge, neither I nor any members of 
my staff met with or attended an event with a lobbyist or 
representative from Zimmer Biomet during the specified dates.
                  house ethics committee consultation
    Question. House rule 3, clause 1, provides that members of the 
House ``shall vote on each question put, unless having a direct 
personal or pecuniary interest in the event of such question.'' 
However, the House Ethics Manual (House Ethics Manual, U.S. House of 
Representatives Committee on Standards of Official Conduct, 110th Cong, 
2d Sess. (2008), pp. 233-37) makes a sharp distinction between, on one 
hand, voting on the House floor, and, on the other, more active 
advocacy. The House Ethics Manual states:

        The provisions of House Rule 3, clause 1, as discussed in this 
        section apply only to members voting on the House floor. They 
        do not apply to other actions that members may normally take on 
        particular matters in connection with their official duties, 
        such as sponsoring legislation, advocating or participating in 
        an action by a House committee, or contacting an executive 
        branch agency. Such actions entail a degree of advocacy above 
        and beyond that involved in voting, and thus a member's 
        decision on whether to take any such action on a matter that 
        may affect his or her personal financial interests requires 
        added circumspection. Moreover, such actions may implicate the 
        rules and standards, discussed above, that prohibit the use of 
        one's official position for personal gain. Whenever a member is 
        considering taking any such action on a matter that may affect 
        his or her personal financial interests, the member should 
        first contact the [Ethics] Committee for guidance.

    Before, or any time after, you introduced H.R. 4848, the Healthy 
Inpatient Procedures Act of 2016 (HIP Act) in the 114th Congress, did 
you consult with the House Ethics Committee concerning the possibility 
of, or appearance of, a conflict of interest or other ethics concern 
arising from your ownership of shares in ZimmerBiomet? If so, when?

    Answer. My investment accounts, particularly the Morgan Stanley 
Portfolio Management Program account wherein the noted stock 
transaction occurred, were established so as to place trading 
discretion in the hands of my broker/financial advisor. No conflict of 
interest existed and no consultation was necessary. Throughout my time 
as a member of the U.S. House of Representatives, I have abided by and 
adhered to all ethics and conflict of interest rules applicable to me.

    Question. Before, or at any time after, you introduced H.R. 4185, 
the Protecting Access through Competitive-pricing Transition Act of 
2015 (the PACT Act) in the 114th Congress, did you consult with the 
House Ethics Committee concerning the possibility of, or appearance of, 
a conflict of interest or other ethics concern arising from your 
ownership of shares in health-care stocks? If so, when?

    Answer. My investment accounts, particularly the Morgan Stanley 
Portfolio Management Program account wherein the noted stock 
transactions occurred, were established so as to place trading 
discretion in the hands of my broker/financial advisor. No conflict of 
interest existed and no consultation was necessary. Throughout my time 
as a member of the U.S. House of Representatives, I have abided by and 
adhered to all ethics and conflict of interest rules applicable to me.

    Question. Before, or at any time after, you introduced H.R. 5400, 
an Act to amend the Internal Revenue Code of 1986 to make permanent the 
deduction for income attributable to domestic production activities in 
Puerto Rico in the 114th Congress, did you consult with the House 
Ethics Committee concerning the possibility of, or appearance of, a 
conflict of interest or other ethics concern arising from your 
ownership of shares in Eli Lilly, Bristol Myers Squibb, and Amgen? If 
so when?

    Answer. My investment accounts, particularly the Morgan Stanley 
Portfolio Management Program account wherein the noted stock 
transactions occurred, were established so as to place trading 
discretion in the hands of my broker/financial advisor. No conflict of 
interest existed and no consultation was necessary. Throughout my time 
as a member of the U.S. House of Representatives, I have abided by and 
adhered to all ethics and conflict of interest rules applicable to me.

    Question. Before, or at any time after, you introduced H.R. 5210, 
the Patient Access to Durable Medical Equipment (PADME) Act of 2016 in 
the 114th Congress, did you consult with the House Ethics Committee 
concerning the possibility of, or appearance of, a conflict of interest 
or other ethics concern arising from your ownership of shares in 
Blackstone, Inc. or any other company that markets or manufacturers 
durable medical equipment? If so, when?

    Answer. My investment accounts were established so as to place 
trading discretion in the hands of my broker/financial advisor. No 
conflict of interest existed and no consultation was necessary. 
Throughout my time as a member of the U.S. House of Representatives, I 
have abided by and adhered to all ethics and conflict of interest rules 
applicable to me.
                         resurgens orthopaedics
    Question. Do you have any financial or business relationship 
including an equity or ownership stake in Resurgens Orthopaedics, and/
or do you derive any financial interest or benefit from the company? If 
so, please detail the type of financial or business relationship you 
have, and any income you do or may derive related to Resurgens. In 
addition, if you answered ``yes,'' please describe your plan to divest 
your financial interest in the company.

    Answer. I have no current financial stake or interest in Resurgens 
Orthopaedics.
                           lgbtq health care
    Question. LGBTQ individuals often experience exceptional barriers 
to care; health disparities associated with gender identity are 
partially driven by lower rates of insurance. Under the ACA, the LGBTQ 
population cannot be excluded from health plans due to pre-existing 
conditions such as HIV. Discrimination based on sex and gender identity 
is also prohibited for programs receiving Federal funds. Additionally, 
all insurance plans must offer the same coverage to married same-sex 
couples as is offered to opposite-sex couples. In terms of national 
health surveys, the ACA changed data collection requirements to include 
sexual orientation and gender identity, which supports future advocacy 
and research.

    Will you maintain health-care protections for the LGBTQ community? 
Please explain.

    Answer. It is essential that health-care services be available to 
all people with the highest level of quality, affordability, and 
respect for their human dignity. If confirmed, I will ensure that HHS 
follows Congress's lead in defining and enforcing nondiscrimination 
laws, and that HHS will comply with all statutory and judicial 
requirements in doing so.
                    medicaid and disability services
    Question. Medicaid serves as the primary health insurance program 
for Americans with disabilities, especially those with limited income. 
A lack of adequate health and long-term care coverage is often cited as 
a primary barrier to the ability to live in the community and the 
ability to succeed in employment. Many of the most important Medicaid-
funded services for people with disabilities can be the most expensive. 
States must offer three of these services: inpatient hospital care, 
home health care, and Early and Periodic Screening, Diagnostic, and 
Treatment (EPSDT). State Medicaid programs currently have the option to 
cover the remaining services important to Americans with disabilities 
including: many home-and-community based services; prescription drugs; 
private duty nursing, physical therapy, occupational therapy; speech, 
hearing, and language therapy; prosthetic devices; intermediate care 
facilities; and personal care services.

    Since the enactment of the Americans with Disabilities Act (ADA) in 
1990, there has been a concerted effort at the State, Federal, and 
community levels to transform the Medicaid program from institutional-
care focused financing mechanism into a comprehensive and flexible 
community-based long-term services and supports program. Examples of 
such congressional efforts can be seen in the Affordable Care Act, 
which strengthened and expanded the Money Follows the Person program 
and created the State Balancing Incentive Program and Community First 
Choice Option.

    How will the administration ensure Medicaid supports the 
protections of the Americans with Disabilities Act?

    Answer. The coordination of two complex laws such as Medicaid and 
the Americans with Disabilities Act requires the close interaction of 
those who are expert in each. At some level the protections referred to 
are best supported by allowing States the flexibility to approach them 
in a way that makes sense for their program, so long as Federal 
requirements are met. As to those Federal requirements, there may be a 
need for close coordination with the Department of Justice or the Equal 
Employment Opportunity Commission as well as the Department's own 
Office for Civil Rights.

    Question. How will you ensure that Federal dollars are not used in 
a way that promotes unnecessary institutionalization of individuals 
with disabilities?

    Answer. Community integration, beneficiary autonomy in decision 
making, and person-centered planning are central tenets articulated in 
CMS' approach to Home and Community Based Services and the HCBS 
Settings Rule with a compliance date in March 2019, and I support each 
of those principles. It is also important to note that many 
residential, disability-specific settings have long provided a safe and 
integrated community alternative to institutional placement for 
individuals with disabilities, and appropriate weight should be given 
to the preferences of families and individuals with disabilities 
because they are in the best position to decide what type of setting 
best meets their individualized needs and circumstances.

    Question. How will you work to ensure States have sufficient 
resources to fund home- and community-based services?

    Answer. As with any program or initiative relying on States, the 
central question for the State is often one of funding. If confirmed, I 
would work to see that the Department is a helpful resource to the 
States with respect to these services at least by providing clarity 
regarding their flexibility, technical assistance and support as 
needed, and sharing best practices.

    Question. Will you direct CMS in its approval of waivers to 
encourage States to expand home- and community-based services and shift 
away from waiting lists and institutional care?

    Answer. Every State is unique in their specific approach to the 
provision of services for the population eligible to receive HCBS, and 
we stand ready to assist States as they develop strategies to meet 
their particular goals.
                       medicaid equal access rule
    Question. Congressman Price, as you have previously stated, some 
providers do not accept Medicaid. Studies show that provider payment 
rates are a leading reason that some providers choose not to 
participate in Medicaid.

    Recently, the Centers for Medicare and Medicaid Services (CMS) has 
finalized two major rules to help address this issue--the ``equal 
access'' rule and the Medicaid managed care rule.

    Congressman Price, given that this is an issue you seem 
particularly concerned about, will you commit to ensuring successful 
enforcement of the Medicaid Equal Access rule, the Medicaid managed 
care rule, and other Federal standards that help ensure States set 
appropriate payment rates as required under the Medicaid statute's 
equal access provision?

    Answer. If confirmed as Secretary, I will faithfully implement laws 
written by Congress and the regulations issued by the Department. This 
includes enforcement action as appropriate. As a doctor who has 
actually treated thousands of Medicaid patients, I do care deeply about 
the Medicaid program and the access of Medicaid patients to actual 
care, not just a card they can carry with them.
                        medicare balance billing
    Question. Congressman Price, you have championed legislation to 
allow providers participating in Medicare to enter into private 
contracts with Medicare beneficiaries, meaning that those providers 
would be permitted to balance bill seniors and other Medicare 
beneficiaries for the difference between what Medicare pays and what 
the provider decides to charge--potentially putting seniors and other 
Medicare beneficiaries on the hook for high medical bills. More than 30 
years ago, Congress passed legislation to protect against exactly that 
situation. One study found that out-of-pocket medical spending declined 
by 9% in Medicare households as a result of these protections.

    Those who want balance billing in Medicare often claim that doctors 
are fleeing the Medicare program, but evidence demonstrates this is 
simply not true. Provider participation in Medicare remains strong. In 
fact, 9 in 10 primary care physicians accept Medicare, and 96 percent 
of people with Medicare report having regular access to a physician's 
care. Allowing balance billing would essentially create two tiers of 
Medicare beneficiaries--those who can afford to access needed care and 
those who cannot.

    Will you commit to the more than 55 million Americans who rely on 
Medicare that, if confirmed as HHS Secretary, you will advise the 
President to veto any legislation that would undermine these decades-
old protections and allow providers participating in Medicare to 
balance bill seniors and other Medicare beneficiaries?

    Answer. In considering Medicare, it is important to appreciate that 
the bipartisan Medicare Trustees have told everyone that Medicare, in 
less than 10 years, is going to be out of the kind of resources that 
will allow us as a society to keep the promise to beneficiaries of the 
Medicare program. My goal, if confirmed, is to work with Congress to 
make certain that we save and strengthen Medicare. It is irresponsible 
for us to do anything else. If I am confirmed, my role will be one of 
carrying out the laws Congress passes and as to that I would convey to 
the Medicare population that we look forward to assisting them in 
getting the care they need.

    Question. Do you believe low- and middle-income seniors can afford 
to pay more for Medicare services than they currently do?

    Answer. In previous legislation, I have proposed giving our seniors 
more flexibility within the Medicare Program and providing the 
opportunity to make decisions with their physicians without 
interference from Washington. The measure would help ensure that 
Medicare beneficiaries maintain adequate access to health-care 
professionals by increasing the number of physicians who will accept 
Medicare patients and addressing physician shortages by attracting new 
professionals to the field of medicine. In addition, the bill provides 
safeguards to Medicare beneficiaries. More importantly, it would allow 
a provider to see a Medicare patient pro-bono or charge minimal cost 
(below the standard fee schedule) without prosecution.
                  raising the medicare eligibility age
    Question. Congressional Republicans support increasing the Medicare 
eligibility age from 65 to 67 to generate savings for the Federal 
Government. It is well documented that these savings ultimately shift 
costs to the American people, States, and employers. According to 2014 
estimates, increasing the Medicare eligibility age would result in a 
$11.4 billion shift to individuals, States, and employers. The Federal 
savings would amount to only half of this cost, or $5.7 billion.

    Most Americans retire well before age 67. By age 63, nearly half of 
the population is no longer working. Advocacy groups argue that 
increasing the Medicare eligibility age is an across the board benefit 
cut that undercuts a promise made to working families and seniors more 
than 50 years ago.

    Would you recommend President Trump veto legislation that would 
increase the Medicare eligibility age?

    Answer. In considering Medicare, it is important to appreciate that 
the bipartisan Medicare Trustees have told everyone that Medicare, in 
less than 10 years, is going to be out of the kind of resources that 
will allow us as a society to keep the promise to beneficiaries of the 
Medicare program. My goal, if confirmed, is to work with Congress to 
make certain that we save and strengthen Medicare. It is irresponsible 
for us to do anything else. If am confirmed, my role will be one of 
carrying out the laws Congress passes and as to that I would convey to 
the Medicare population that we look forward to assisting them in 
getting the care they need.

    Question. If implemented, would Federal savings from a higher 
eligibility age be shifted onto Medicare beneficiaries, States, or 
employers instead?

    Answer. If such a change is made and the savings do not accrue to 
beneficiaries and the Trust Fund, then we may be right back where we 
started without the change. However, the allocation of savings from 
such a change, whether to the Medicare Trust Fund or to other budgetary 
priorities, will be a decision for the Congress.
                             mental health
    Question. As you must know, mental illness is highly prevalent in 
the United States. Over 43 million adults, just over 18 percent of the 
population, had any mental illness in 2014. In the past year, over 68 
million Americans, representing 20 percent of the population, 
experienced a psychiatric or substance use disorder.

    Medicaid is the country's primary payer for all mental health 
services and is an important source of funding for mental health 
services that would otherwise be out of reach for low-income people. 
Under Medicaid, children and adults with mental illness receive vital 
services and supports that are not typically covered by private 
insurance. Medicaid accounted for 25% of all mental health spending in 
the United States in 2014.

    Thanks to Medicaid expansion under the Affordable Care Act (ACA), 
an additional 3.8 million Americans have access to mental health 
coverage. Furthermore, due to consumer protections under the ACA, it is 
now required that health insurers provide mental health and substance 
use disorder services as an essential health benefit.

    In your 2017 budget and 2015 reconciliation bill, you call for a 
full-out repeal of the Medicaid expansion; do you still support full 
repeal?

    Answer. This is a matter for the legislative branch to consider. If 
confirmed, I will work to ensure that HHS (appropriately) implements 
the statutes within its purview.

    Question. In 2015 you voted to eliminate important coverage 
protections for Medicaid beneficiaries in alternative benefit plans so 
they can access the treatment they need.

    Do you still support eliminating these protections?

    Answer. This is a matter for the legislative branch. I remain 
committed to making sure health care is affordable and accessible for 
all Americans. And if confirmed, I will work to ensure that HHS 
(appropriately) implements the statutes within its purview.

    Question. In your Empowering Patients First Act you call for full 
repeal of the ACA including important protections such as mental health 
parity that help to ensure that a person receives the same level of 
mental health coverage that they would for any physical illness.

    Do you still support repeal of these protections?

    Answer. I believe it is important that we as a nation make sure 
that every American has access to the kind of mental health and 
substance abuse care that they need. This is a matter for the 
legislative branch, however, and if confirmed, I will work to ensure 
that HHS (appropriately) implements the statutes within its purview.

    Question. The Office of the Assistant Secretary for Planning and 
Evaluation (ASPE), which will be your principal advisor as HHS 
Secretary should you be confirmed, reported that in States that didn't 
expand Medicaid nearly 2 million low-income adults with mental health 
and substance use disorders are uninsured.

    How do you plan to work with States to expand Medicaid coverage to 
these individuals?

    Answer. Every State has different demographic, budgetary, and 
policy concerns that shape their approach to Medicaid and Medicaid 
expansion. That is one of the reasons I devoted so much time working to 
help identify creative solutions, and why I believe a one-size-fits-all 
approach is not workable for a country as diverse as the United States. 
If I am confirmed, I will work with CMS and SAMHSA to help the 
population of uninsured low-income adults with mental health and 
substance use disorders.

    I note that the conversation and focus in these topics has been the 
question of coverage rather than true access to care. For many 
Americans, they might have an insurance card and yet not be able to 
afford care or it might not be available to them for other reasons.
                     opioids and medicaid expansion
    Question. In November, I released a report describing the 
consequences of not adequately funding treatment and prevention 
services for opioid addiction. However, as we both know, the effects of 
opioid crisis go far beyond mere statistics. People all across the 
country end up struggling with opioid addiction simply because they got 
into a car accident, or had a painful surgery. Medicaid expansion has 
provided millions of Americans an opportunity to get the treatment they 
need to get back on their feet.

    Congressman Price, in your 2017 budget you call for ending the 
Medicaid expansion, can you confirm whether you still support getting 
rid of the Medicaid expansion?

    Answer. This is a matter for the legislative branch. If confirmed, 
I will work to ensure that HHS (appropriately) implements the statutes 
within its purview.

    Question. In your role as a cabinet Secretary, would you advise the 
President to veto a bill that repeals the Medicaid expansion?

    Answer. I am committed to making sure all Americans have access to 
affordable health care that is of the highest quality. Every State has 
different demographic, budgetary, and policy concerns that shape their 
approach to Medicaid. That is one of the reasons I devoted so much time 
to working with States to help them to identify creative solutions, and 
why I believe a one-size-fits-all approach is not workable for a 
country as diverse as the United States. I would encourage anyone to 
keep this principle front and center in considering any changes to 
Medicaid, which themselves might well be part of a greater context that 
further informs the best approach. In the meantime, I look forward to 
faithfully executing whatever law that Congress passes and the 
President signs, if I am confirmed. I will promise you this: Regardless 
of the final legislative outcome, I would work as HHS Secretary to 
ensure that the Medicaid program is well administered, effective, and 
available for eligible beneficiaries and that the States/Governors are 
given the flexibility to pursue innovative approaches that fits the 
needs of their States.

    Question. Would you advise the President to support ending coverage 
for the 1.6 million Americans struggling with substance use disorders 
who gained access to coverage for treatment under the Medicaid 
expansion?

    Answer. It is important that we as a nation make sure that every 
American has access to the kind of mental health and substance abuse 
care that they need. If I am confirmed, I am committed to ensure that 
access is not diminished.

    Question. Will you promise that people dealing with opioid 
addiction will not lose their Medicaid expansion coverage that has 
provided them with the treatment they need and deserve?

    Answer. Opioid addiction has had a severe and devastating impact to 
communities and families across the country. If I am confirmed, I am 
committed to ensure that access to treatments is not diminished and 
will work with CMS and SAMHSA to help low-income adults with mental 
health and substance use disorders.
            network adequacy rules for specialty pharmacies
    Question. Pharmacy Benefit Managers (PBMs) may or may not own the 
pharmacies in their pharmacy networks. Recently, PBMs have been 
criticized for using aggressive tactics to restrict access to 
pharmacies that they do not own. If pharmacy networks are narrowed, 
then individuals will have limited access to pharmacies and necessary 
medications.

    I have heard from Oregon pharmacies that pharmacy benefit managers 
(PBMs) are using aggressive tactics to, in the pharmacies' opinion, 
restrict access to pharmacies not owned by the PBM.

    This issue was described in a January 9, 2017 New York Times 
article: (https://mobile.nytimes.com/2017/01/09/business/specialty-
pharmacies-say-benefit-manag
ers-are-squeezing-
themout.html?_r=0&referer=https%3A%2F%2Fwww.google.com%
2F).

    I am concerned that if pharmacy networks are narrowed, access to 
needed medications will be limited.

    Can you explain if practices described in the New York Times 
article are permitted under Medicare Part D and the Exchanges 
established under the Affordable Care Act (ACA)?

    Answer. Part D plans are required to accept any pharmacy willing to 
participate in the plan under the terms of its standard contract. 
Qualified health plans do not have such a requirement though State 
insurance commissioners may consider such practices in their regulatory 
oversight.

    Question. What minimum standards regarding network adequacy for 
specialty pharmacies exist for both Part D plans and plans offered on 
the ACA Exchanges?

    Question. For Part D plans, network adequacy requirements are set 
forth in 42 CFR 423.120 and in subregulatory guidance. The requirements 
vary by the type of drug. For home infusion drugs, they vary by State. 
See https://www.cms.gov/Medicare/Prescription-Drug-Coverage/
PrescriptionDrugCovContra/Downloads/Adequate-Access-to-HI-Pharmacies-
Rewrite-012610.pdf.

    For Qualified Health Plans, network adequacy requirements are set 
forth at 45 CFR 156.230, 45 CFR 156.122(e), and QHP application and 
attestation materials, as well as in State laws.
                            preventive care
    Question. Countless studies have proven that early detection of 
disease saves lives and improves quality of life. Early detection, 
through preventive screenings, can save the health-care system the 
expense of more costly treatments that may be necessary with a later 
stage diagnosis. However, early detection of disease is often not 
possible without preventive screenings, for both acute conditions like 
cancer and chronic conditions like diabetes. High copays and high 
deductibles can be a deterrent to patients utilizing these preventive 
screenings, regardless of socioeconomic status.

    The ACA included a provision requiring private health plans to 
cover recommended preventive services without any co-payments or cost-
sharing. It also added coverage of an annual wellness visit and 
eliminated cost-sharing for recommended preventive services under the 
Medicare program.

    As HHS Secretary, how will you guarantee that Americans will retain 
their current level of coverage for preventive screenings and ensure 
early detection screenings are preserved?

    Answer. I would convey to the Medicare population that we look 
forward to assisting them in getting the care they need and the 
caregivers that they need too.

    As we consider what to do with regards to the Affordable Care Act, 
my hope is to move in a direction where insurers can offer products 
people want and give them the coverage they want. Getting to that kind 
of system requires changes that will inevitably involve working with 
Congress and considering the tradeoffs of various proposals to achieve 
our shared objective of the best and highest quality care being 
available to Americans.
                   spousal impoverishment protections
    Question. In the 1980s, married couples commonly were driven into 
complete poverty when one spouse developed a need for nursing home 
care. The couple often had to spend down their joint resources to just 
a few thousand dollars before Medicaid could provide assistance. 
Congress addressed this problem in 1988 legislation signed by President 
Reagan. Beginning in October 1989, the spouse of a nursing home 
resident has been allowed allocations of income and resources in 
determining the resident's Medicaid eligibility. These allocations 
allow the at-home spouse to retain adequate but not lavish amounts of 
income and savings. To allow for State flexibility, the Federal 
Government sets a range for these allocations, and indexes those ranges 
to inflation. Each State sets its own income allocation and resource 
allocation, as long as the allocation falls within the Federal range.

    Spousal impoverishment protections are mandatory for nursing home 
residents and were optional for people receiving home and community-
based services (HCBS). Due to the Affordable Care Act, people receiving 
HCBS are also entitled to spousal impoverishment protections.

    Do you support the requirement for State spousal impoverishment 
protections?

    Answer. I support the flexibility of States to make decisions about 
eligibility so that they can ensure the broadest set of people get 
access to the highest quality care on the budget available to the 
State. Spousal impoverishment protections allow States to delay or 
prevent the impoverishment of spouses lest they too need to be added to 
the Medicaid rolls.

    Question. Should a person be required to receive long-term care in 
a nursing home in order to protect a spouse from poverty?

    Answer. My hope is that we can move to a system where States can 
make decisions like this with their population, values, dynamics, and 
funding in mind.

    Question. How will HHS ensure spouses are protected from living in 
poverty when a loved one reaches a stage of fragility that requires 
long-term care?

    Answer. I have seen that the best solutions to seemingly 
intractable problems like this rely on States to find the right 
approach for that State. If confirmed, I look forward to working with 
Governors (and Congress) to help States chart their course in this 
regard.
                             women's health
    Question. Congressman Price, in the past, when asked whether birth 
control should have to be covered, you've stated that not a single 
woman has been left behind.

    Will you reject any proposals that limit a women's access to 
contraceptive care or make it cost more for her?

    Answer. Women should have the health care that they need and want. 
The system we ought to have in place is one that equips women and men 
to obtain the health care that they need at an affordable price.

    Question. As a cabinet adviser to the President, will you advise 
the President to veto any bill that reduces guaranteed access to 
affordable contraceptive coverage?

    Answer. As we consider what to do with regards to the Affordable 
Care Act, my hope is to move in a direction where insurers offer 
products people want and give them the coverage they want. Getting to 
that kind of system requires changes that will inevitably involve 
working with Congress and considering the tradeoffs of various 
proposals to achieve our shared objective of the best and highest 
quality care being available to Americans.

    Question. In your hearing last week, you were asked about your vote 
against the DC Council's efforts to protect employees from being fired 
for taking birth control. Congressman Price, to clarify for the record, 
do you or do you not think an employer should be able to fire or 
discriminate against an employee for taking birth control?

    Answer. I do not believe so. My vote regarding the DC Council law 
you mentioned does not relate to this particular issue or question.

    Question. Will you advise the President to veto any bill that rips 
access to care away from hundreds of thousands of women by defunding 
Planned Parenthood?

    Answer. Deciding whether to sign any particular law, particularly 
one that involves as many different moving parts as one to replace the 
Affordable Care Act, inevitably involves considering many competing, 
complementary, or countervailing issues. If Congress passes a law that 
makes certain that every single American has access to the coverage 
they want for themselves and ensures the individuals who lost coverage 
under the Affordable Care Act get or maintain coverage, that is 
something I would hope would be strongly considered for signature.

    Question. You sponsored the 2015 reconciliation bill (H.R. 3762) 
that would repeal key components of the Affordable Care Act (ACA) and 
rescind Federal funding for Planned Parenthood for 1 year. Please 
provide the names of providers other than Planned Parenthood health 
centers that H.R. 3762 would prohibit from participating in Medicaid?

    Answer. H.R. 3762 restricts the availability of Federal funding to 
a State for payments to any entity that is a 501(c)(3) tax-exempt 
organization, is an essential community provider primarily engaged in 
family planning services and reproductive health; provides abortions 
other than in cases of rape, incest or life of the mother, and receive 
a total of more than $350 million under Medicaid in FY 2014.

    It should also be noted that H.R. 3762 would increase funding 
available to the Community Health Center Program (CHC) by $470 million 
over 2 years. As I said in my hearing before the Senate Health, 
Education, Labor, and Pensions (HELP) Committee last week, community 
health centers are a vital part of the health care delivery system, 
filling a void in so many areas across the county. We need to do all we 
can to strengthen them, ensuring they are staffed with the highest 
quality providers and providing the highest quality care, and look 
forward to working with you on this if confirmed.
                work requirements for medicaid services
    Question. Your Budget Plan for 2017 proposes work requirements for 
so called ``able-bodied'' adults in order to qualify for Medicaid 
coverage. Specifically, these individuals must be actively seeking 
employment or participating in an education or training program in 
order to qualify for health-care coverage under Medicaid.

    According to independent evaluations of programs that have imposed 
work requirements, imposition of work requirements found only modest, 
short-term increases in employment with families living in deep poverty 
rising under such programs. The evidence also shows that over the long-
term, those in programs with work requirements were as likely to find 
employment as enrollees in Medicaid programs that did not have strict 
work requirements.

    How do you define an ``able-bodied'' adult?

    Do you support work requirements in order for these ``able-bodied'' 
adults to qualify for Medicaid?

    Given you're interest in employment, how do you plan on working to 
support local economies to ensure that those looking for work 
regardless of income are actually able to obtain jobs?

    Answer. One major lesson learned from welfare reform signed into 
law by President Clinton is that the American people, when given the 
opportunity, work exceptionally hard. This view is also shared by 
President Trump and reflected in his commitment to job creation and the 
dignity of work. Encouraging work allows more families to realize the 
American dream, earn their success and rise out of poverty. I will 
faithfully execute any laws passed by Congress to institute work 
requirements and if given the opportunity to serve I will allow States 
greater flexibility for determining how to care for their most needy 
citizens.
                              ama recusal
    Question. Congressman Price, in your January 11th letter to the 
Associate General Counsel for Ethics at HHS, you said you would resign 
from your position as a Delegate of the American Medical Association 
(AMA) if confirmed as HHS Secretary. You also promised that--for 1 year 
after your AMA resignation--you would ``not participate personally and 
substantially in any particular matter involving specific parties in 
which (you know) the American Medical Association is a party or 
represents a party, unless (you are) first authorized to participate.''

    In 2016 alone, the AMA submitted 21 formal comment letters to HHS 
and CMS--almost two per month on average--covering a wide range of 
issues, including, for example, the implementation of the Medicare 
physician payment reforms in MACRA (the Medicare Access and CHIP 
Reauthorization Act) and key provisions of last year's Comprehensive 
Addiction and Recovery Act (CARA).

    In this context, what criteria would you use to determine what 
constitutes participating ``personally and substantially'' in a matter?

    Answer. I view the term ``personally and substantially'' in the 
context of its statutory and regulatory definitions. To the extent 
necessary, I will seek advice from his designated agency ethics 
official and other appropriate parties when assessing whether 
participation in a matter is indeed personal and substantial.

    Question. In this context, what criteria would you use to determine 
whether the level of AMA's involvement means that it is a party or 
represents a party in a particular matter?

    Answer. I will abide by the actions agreed to in my publicly 
available ethics agreement with the Office of Government Ethics, and 
seek advice (when necessary) from the designated agency ethics official 
and other appropriate persons.

    Question. Will you recuse yourself from any matter in which the AMA 
has submitted formal comments to HHS or CMS?

    Answer. This matter has already been addressed with the OGE and 
designated agency ethics official, and I will abide by the obligations 
agreed to in my publicly available ethics agreement.

    Question. For example, will you recuse yourself from any decision-
making regarding the implementation of the physician payment reforms in 
MACRA--given how actively engaged AMA has been with HHS and CMS on that 
issue?

    Answer. This matter has already been addressed with the OGE and 
designated agency ethics official, and I will abide by the obligations 
agreed to in my publicly available ethics agreement.

    Question. Will you also recuse yourself from any matter about which 
the AMA sent correspondence to HHS or CMS?

    Answer. This matter has already been addressed with the OGE and 
designated agency ethics official, and I will abide by the obligations 
agreed to in my publicly available ethics agreement.

    Question. Do you think an HHS Secretary can effectively do his job 
if he cannot participate in any of the above described matters?

    Answer. Adherence to all applicable ethics and conflict of interest 
obligations under Federal law is an essential component of being an 
effective HHS Secretary, and in no way limits the ability of an 
individual to successfully carry out his or her responsibilities within 
the Department.
                     automatic cuts to entitlements
    Question. The day after you were nominated for HHS Secretary, you 
rolled out a set of budget process changes that would force automatic 
cuts to almost all Federal programs--including Social Security, 
Medicare, and Medicaid--if the national debt exceeds targets specified 
by Congress. If the Trump tax plan is signed into law, but Congress 
cannot agree on how to pay for its cost of more than $6 trillion over 
10 years, your budget process would automatically cut Social Security 
by $1.7 trillion and Medicare by $1.1 trillion over 10 years. This 
would cut the average Social Security benefit by $168 per month. 
President Trump has pledged not to cut Social Security, Medicare, and 
Medicaid; but your budget process seems to provide a way to cut these 
programs without President Trump having to sign any specific cuts into 
law.

    If Congress passed your budget changes today, would you recommend 
he veto that legislation?

    Answer. Should the budget pass, I will carefully review the 
legislation and communicate the health-care implications of that budget 
to the President.

    Question. The sequester, under current law, shields vulnerable 
populations from across the board cuts. Why do you believe the 
sequester should be expanded to programs that serve the most vulnerable 
Americans?

    Answer. It is my belief that the Federal Government needs to 
strengthen mandatory programs if we are going to ensure future 
generations have access to the programs.
                       children's health coverage
    Question. Congressman Price, you once remarked that low-income 
children already have access to all the health care they need. You've 
publicly said that you, ``know of no study that shows these individuals 
have no access,'' and that uninsured children are already treated by 
doctors and hospitals even though they often do not pay for the care 
they receive.

    Do you still believe that all children had adequate access to 
health care before the ACA?

    Answer. Though programs like CHIP have made substantial progress in 
the availability of health-care coverage to children, there has always 
been more work to do in this regard. I should add that what is most 
important in this regard is not just that children have coverage but 
also actual access to care that is affordable and available to them.

    Question. Do you agree that maintaining these coverage gains and 
not taking a step back on children's health is vitally important?

    Answer. With regards to health care for children, our goal is to 
make certain that every single American has access to the coverage they 
want for themselves and their children and ensures the individuals and 
children who lost coverage under the Affordable Care Act get or 
maintain coverage.

    Question. Congressman Price, according to independent reports, 
repeal of the ACA would mean over 4 million children would become 
uninsured. As advisor to the President, will you advise the President 
to veto any bill if the result is fewer children have coverage?

    Answer. Deciding whether to sign any particular law, particularly 
one that involves as many different moving parts as one to replace the 
Affordable Care Act, inevitably involves considering many competing, 
complementary, or countervailing issues. I look forward to working with 
the Congress to ensure that fewer children having coverage is not one 
of those tradeoffs, but rather that every single American has access to 
the coverage they want for themselves and their children and ensures 
the individuals and children who lost coverage under the Affordable 
Care Act get or maintain coverage.
               children's health insurance program (chip)
    Question. Today, the bipartisan Children's Health Insurance Program 
provides 8 million children with access to comprehensive, affordable 
health care including thousands of children in Oregon's Healthy Kids 
program. Yet you've publicly referred to CHIP as ``government-run 
socialized medicine'' and put forth proposals that would have denied 
families with access to more affordable care for their children through 
this successful bipartisan health program.

    Congressman Price, in your role as a cabinet Secretary, would you 
advise the President to support an extension of the Children's Health 
Insurance Program?

    Answer. It is important that every child has access to high-quality 
health coverage, and CHIP plays an important role in accomplishing this 
objective.

    Question. Will you commit to ensuring that not a single child under 
Oregon's Healthy Kids program gets left behind under any CHIP 
extension?

    Answer. If confirmed as Secretary, my goal would be to ensure that 
no child in Oregon or anywhere else is left behind. CHIP plays a major 
role in this, but there is also a need for coordinated family coverage 
in the private market and employer plans, and giving States the needed 
flexibility to accomplish this.

    Question. As a cabinet-level advisor to the President, will you 
advise the President to veto any bill that results in coverage being 
stripped away from a single child in Oregon benefiting from our Healthy 
Kids program?

    Answer. Deciding whether to sign any particular law inevitably 
involves considering many competing, complementary, or countervailing 
issues. I look forward to working with the Congress to ensure that 
fewer children having coverage is not one of those tradeoffs, but 
rather that every single child in Oregon and America has access to 
high-quality care. That means not just having a card, but being able to 
access the care it covers.
                        cost sharing in medicaid
    Question. Your 2017 budget used the Healthy Indiana Plan as an 
example of an innovative State program that is reducing State Medicaid 
costs. However, the Healthy Indiana Plan has not worked as intended in 
some important ways and has created access barriers for some. In fact, 
studies show that the required premiums for many low-income people 
depress participation and make it harder for people to access the 
coverage they need. According to an independent evaluation of the 
program, thousands of individuals in the program were penalized or 
kicked off and locked out of coverage under the complicated structure.

    If these types of complicated structures used in a State's Medicaid 
program is shown to keep eligible people from getting the health care 
they need, will you disallow it as not meeting the objectives of the 
Medicaid statute?

    Answer. The Healthy Indiana Plan has long been and continues to be 
a national model for State-led Medicaid reforms pertaining to the low-
income, able-bodied adult population. It is important that Medicaid's 
design helps its members to transition successfully from the program 
into commercial health insurance plans, as HIP's 
consumer-driven approach and underlying incentive structures encourage. 
HIP members are more engaged with their providers, less reliant on the 
emergency room, and more satisfied with their coverage than traditional 
Medicaid members. HIP is achieving Indiana's objective to increase 
access to consumer-driven coverage as well as the broader objectives of 
the Medicaid program, and I support the use of HIP's reforms in future 
1115 demonstration requests by other States.
                         delivery system reform
    Question. Congressman Price, you have been an outspoken critic of 
the delivery system reforms included in the Affordable Care Act (ACA), 
particularly the Center for Medicare and Medicaid Innovation (CMMI) and 
the movement away from traditional fee-for-service payments for 
providers and toward value-based payment models such as bundled 
payments.

    Do you agree that the traditional fee-for-service payment system--
in which providers are paid based on volume instead of value--creates 
incentives for overutilization of health-care services?

    Answer. Our health-care system is complex, and we cannot attribute 
overutilization trends to a single cause. For instance, efforts to curb 
overutilization in emergency rooms have been unsuccessful. 
Overutilization is a complex issue that needs to be carefully 
addressed.

    Question. Do you also agree that the successful implementation of 
the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) 
will require the continued development of value-based payment models?

    Answer. The Medicare Access and CHIP Reauthorization Act of 2015 
(MACRA) is built on the principle of encouraging providers to develop 
Alternative Payment Models (APMs) that can ultimately be adopted by CMS 
and commercial payers.

    Question. Will you commit to supporting the continued development 
of value-based payment models in Medicare and increasing the percentage 
of provider payments made through those models?

    Answer. We share the goal of improving Medicare by empowering 
providers to be creative and develop payment models that best suit the 
unique needs of their patients to ultimately improve patient care.
                 medicare-medicaid coordination office
    Question. ``Dual eligibles'' receive benefits under the Medicare 
and Medicaid programs. Full benefit dual eligibles suffer from serious 
health care needs including debilitating physical and mental 
disabilities, often requiring complicated and expensive long-term 
services and supports. The ACA created the Medicare-Medicaid 
Coordination Office, also called the Medicare-Medicaid Coordination 
Office, to coordinate and address the needs of dual eligibles. The 
office has led Federal efforts to improve how programs are delivered to 
this high need, high cost population.

    Will the administration continue to support the Medicare-Medicaid 
Coordination Office?

    Answer. If confirmed as Secretary, and if legislation regarding 
this Office changes, I will work with the CMS Administrator to consider 
how best to deploy the tremendous resources of CMS against the enormous 
challenge of ensuring access to the highest quality care for dual 
beneficiaries. In the meantime, I will implement the law as passed by 
Congress.

    Question. Does the administration plan to continue the financial 
alignment demonstration currently underway in several States?

    Answer. Commenting on specific potential models is premature at 
this point. These models go through a lengthy development and modeling 
process, as well as internal review and approval at CMMI and OMB. If 
confirmed, as HHS Secretary, I plan to work closely with CMS to ensure 
that CMMI--after appropriate consultation with Congress, the States, 
health-care stakeholders, and Innovation Center staff--tests innovative 
models that reduce costs and improve quality for Medicare and Medicaid 
beneficiaries.
                        federal data collection
    Question. The Department of Health and Human Services (HHS) 
collected valuable data related to the Affordable Care Act (ACA). This 
includes rate filings, enrollment data, and analytical reports on the 
efficacy of the law in different sectors of the health system. 
Additionally, the ACA invested in the implementation of a new health 
data collection and analysis strategy. Section 4302 of the Affordable 
Care Act contains provisions requiring all national Federal data 
collection efforts collect information on race, ethnicity, sex, primary 
language and disability status. The law also provides HHS the 
opportunity to collect additional demographic data to further improve 
our understanding of health-care disparities.

    Will health-care data collected by the government continue to be 
publicly available to promote government transparency?

    Answer. If confirmed as Secretary, I would implement the law 
regarding these topics as written and passed by the Congress.

    Question. Will health-care data continue to require the collection 
of information on race, ethnicity, sex, primary language, and 
disability status?

    Answer. If confirmed as Secretary, I would implement the law 
regarding these topics as written and passed by the Congress, including 
with respect to the data points required to be collected.

    Question. How does CMS plan to leverage this data to address health 
disparities?

    Answer. Any data that can inform CMS's approach to understanding 
where people's needs are not being met will help us understand how best 
to move towards a system where every single American has access to the 
coverage they want for themselves.
                  ban on health agency communications
    Question. News reports on January 24th indicate that Trump 
administration officials have issued what amounts to a gag order 
essentially muzzling external communications by employees of the 
Department of Health and Human Services (HHS) and the National 
Institutes of Health between now and February 3. This ban on external 
communications reportedly includes correspondence with public officials 
including members of Congress as well as press releases and social 
media posts.

    What communications are covered by the Trump administration's 
restriction of external communications?

    Are there any exceptions allowed for releases of information about 
matters of public health or safety?

    If a public health or safety matter arises between now and February 
3rd, will the agencies be prevented from communicating with public 
officials or the general public about these matters?

    Under what circumstances would external communications be allowed?

    Who within the Department is authorized to allow communications in 
a public health or safety situation or otherwise? Please provide the 
criteria that has been developed to determine if and when external 
communications are permitted.

    What impact will this restriction have on whistleblowers who are 
exercising rights protected by law?

    What is the reason for this action?

    Is it possible the restriction will be extended beyond February 
3rd? Under what circumstances could it be extended?

    Does the restriction apply to Federal employees' personal use of 
social media or only use of official agency accounts?

    Will the restriction prevent HHS employees from responding to 
outstanding questions from members of Congress including letters or 
other communications awaiting answers? If so, when will such questions 
be answered?

    Will questions submitted by members of the Finance Committee be 
answered in a timely manner and in any case before February 3rd 
notwithstanding the restriction on external communications?

    Answer. The Acting Secretary Memo to Department of Health and Human 
Services operating and staff division heads is straightforward and 
consistent with Chief of Staff Memo issued on behalf of President Trump 
with regard to regulatory review of new or pending regulations and 
guidance. As noted in the HHS memo, the purpose of the directive is to 
ensure ``President Trump's appointees and designees have the 
opportunity to review and approve any new or pending regulations or 
guidance documents.'' Furthermore, the Chief of Staff memo provides 
explicit exceptions for ``emergency situations or other urgent 
circumstances relating to health, safety, financial, or national 
security matter. . . .'' This request is standard for a new 
administration. With regard to correspondence to public officials, such 
as members of Congress, the memo outlines a clear and expedited process 
for adequate review and is by no means intended to impede the agencies 
or staff divisions from continuing their important work on behalf of 
the American people, including routine constituent service 
communications.
                        cost-sharing reductions
    Question. Under the Affordable Care Act, individuals and families 
with incomes between the Federal poverty level and 250 percent of the 
poverty level are eligible for cost-sharing reductions (CSRs) if they 
are eligible for a premium tax credit and purchase a silver plan 
through the health insurance exchange. The cost-sharing reductions 
reduce the deductibles, copayments, and other out-of-pocket costs for 
these lower- and moderate-income Americans.

    In House v. Burwell, House Republicans challenged the legality of 
Federal funding of CSR subsidies. In a May 2016 ruling, U.S. District 
Judge Rosemary Collyer ruled in favor of the House Republicans, 
although she stayed implementation of the ruling. The previous 
administration appealed the decision, but the case was stayed until 
after the 2016 presidential election.

    If confirmed as HHS Secretary, will you recommend that the 
administration continue to reimburse insurers for the cost-sharing 
reductions that reduce deductibles, copayments and other out-of-pocket 
costs for lower- and moderate-income Americans?

    Answer. The agency is currently involved in litigation related to 
this matter, and it would be inappropriate for me to comment at this 
time.

    Question. If confirmed as HHS Secretary, will you recommend that 
the administration protect the Federal Government's authority to make 
payments for cost-sharing reductions, which was challenged in House v. 
Burwell, and move forward with its appeal of the lower court's ruling?

    Answer. The agency is currently involved in litigation related to 
this matter, and it would be inappropriate for me to comment at this 
time.

    Question. If confirmed as HHS Secretary, will you recommend that 
the administration seek an appropriation from Congress for the cost-
sharing reductions?

    Answer. It will be up to the President and Congress to determine 
the appropriate policy on this issue. My job, if confirmed, would be to 
faithfully execute that law.
                         risk corridor payments
    Question. The Affordable Care Act's temporary risk corridor program 
was intended to promote accurate premiums in the early years of the 
exchanges (2014 through 2016) by cushioning insurers from extreme gains 
and losses. It was modeled after the Medicare Part D prescription drug 
program's successful risk corridor program. The Federal Government 
currently owes insurers approximately $8.3 billion under the risk 
corridor program to offset losses from 2014 and 2015. This is largely 
due to a rider attached to the 2015 and 2016 appropriations bills 
requiring the risk corridor program to be revenue neutral, meaning that 
the Centers for Medicare and Medicaid Services (CMS) can only pay out 
funds under the program that it collected under the program.

    Under the previous administration, HHS and CMS acknowledged that 
risk corridor payments are an obligation of the government and that 
full payment must be made to insurers. The Department of Justice 
defended the lawsuits brought by insurers for the full risk corridor 
payments, but also expressed a willingness to engage in settlement 
discussions.

    If confirmed as HHS Secretary, will you also acknowledge that risk 
corridor payments are an obligation of the government and that full 
payment must be made to insurers?

    Answer. The agency is currently involved in litigation related to 
this matter, and it would be inappropriate for me to comment at this 
time.

    Question. If confirmed as HHS Secretary, will you recommend that 
the administration engage in settlement discussions with insurers on 
overdue risk corridor payments?

    Answer. The agency is currently involved in litigation related to 
this matter, and it would be inappropriate for me to comment at this 
time.
                             gender rating
    Question. Before the Affordable Care Act, insurance companies were 
able to charge women more for their health insurance compared to men. 
This practice was widespread, as 92 percent of the best-selling plans 
on the individual market used gender rating in setting their premiums. 
This cost women approximately $1 billion in additional costs each year 
that men did not have to pay.

    Do you believe that insurance companies should be required to 
charge men and women the same rate for premiums?

    Answer. The setting of premiums is something that has historically 
been a matter of State law and regulation, so that the dynamics of that 
State and its population and risk pool and consumer behavior can be 
taken into account. Nevertheless, of course, if confirmed as HHS 
Secretary, my role would be to implement the law as it is now written.
                              1332 waivers
    Question. The ACA included a provision known as the State 
Innovation Waiver (SIW), or 1332, that provides States the opportunity 
to tailor their own health care system in a way that best aligns with 
the individual State's needs. This waiver was written to give States a 
chance to implement the ACA better; it was not written as a tool to 
undermine the law. States may apply to use these waivers beginning 
January 1, 2017.

    As a reminder, a waiver must meet the following requirements:

        Ensure that individuals get insurance coverage that is at 
least as comprehensive as provided under the ACA.
        Ensure that insurance coverage offered to individuals is at 
least as affordable as it would be under the ACA.
        Ensure that as many people are covered as would be under the 
ACA.
        Not increase the Federal deficit.

    Please respond to the following questions.

    What opportunities do you see for States to use the SIW? Are there 
particular reforms that you think would enhance access to affordable, 
quality coverage?

    Answer. These waivers present an opportunity for CMS to encourage 
State innovation and allow for adaptation of national requirements to 
the needs of individual States. If confirmed, I would work with CMS to 
enable States to utilize this--and other--authority provided by 
Congress to ensure access to high-quality, affordable health insurance.

    Question. How do you envision the SIW working in conjunction with 
Medicaid and any corresponding Medicaid waivers? What checks would you 
put in place to ensure that those individuals entitled to Medicaid 
receive the full benefits and protections afforded them under title 
XIX?

    Answer. There is a tremendous opportunity to allow States to 
innovate with respect to the intersection of their Medicaid programs 
and qualified health plans and the risk pools within each. State fair 
hearing processes (as well as the Medicaid waiver process and CMS 
oversight) provide substantial procedural and other protections that 
would address concerns regarding Medicaid beneficiaries not getting 
benefits due to them.

    Question. What precautions would you put in place to ensure 
consumers are protected in States that choose to move forward with a 
1332 waiver application?

    Answer. The statute itself has protections in place relating to the 
findings that must be made that would protect consumers in States that 
move forward with a 1332 waiver application. Furthermore, the 
democratic process in each State, where government is even closer to 
the people, provides substantial protection with regards to any 1332 
waiver application and its implementation. Such protection may well be 
even more effective than that available to consumers vis-a-vis the 
Federal Government.

    Question. What steps would you take, as Secretary of HHS, to 
implement this provision, as intended by congressional drafters, to 
ensure it is not used to undermine the ACA?

    Answer. As part of the ACA, the use of section 1332 to allow States 
to innovate would not undermine the ACA. In fact, failing to 
successfully use this important tool to allow States flexibility with 
regards to the ACA as allowed by the law would undermine the ACA.
                              rural health
    Question. Americans living in rural areas often have difficulty 
accessing quality care due to physical and economic barriers. The 
Health Resources and Services Administration estimates that 65 percent 
of primary care health professional shortage areas are in rural areas. 
These challenges translate into significant health disparities for 
rural populations, including higher rates of chronic disease and 
disability as well as lower life expectancy. Rural Americans have also 
historically experienced lower rates of insurance. The Affordable Care 
Act provided new access to coverage for people living in rural areas 
through the Health Insurance Marketplaces and Medicaid expansions, as 
well as critical consumer protections.

    If confirmed how will you protect access to quality health care in 
rural areas?

    Answer. Too often rural health care is overlooked in the broader 
discussion of national health-care issues. Significant health 
disparities exist for rural populations for a variety of reasons, 
including challenges with access to affordable coverage and health-care 
services. Rural Americans are acutely aware of the dire need for 
expanded health insurance options. If confirmed, I will work tirelessly 
to address the health-care needs of all Americans, rural or urban.
      pre-existing conditions and continuous coverage requirement
    Question. The Affordable Care Act prohibits insurers from denying 
coverage to individuals with pre-existing conditions, charging them 
higher premiums, or refusing to cover benefits related to a pre-
existing conditions.

    Your Empowering Patients First Act (H.R. 2300 in the 114th 
Congress) repeals the Affordable Care Act in its entirety (including 
the protections for those with pre-existing conditions) and instead 
puts in place a ``continuous coverage requirement,'' meaning that 
individuals with pre-existing conditions must maintain continuous 
health insurance coverage for at least 18 months in order to qualify 
for protections against discrimination by insurers. Under your 
legislation, insurers would once again be allowed to exclude coverage 
of a pre-existing condition for lengthy periods of time or charge much 
higher premiums unless individuals had maintained continuous coverage 
for at least 18 months.

    According to a recent report from the HHS Office of the Assistant 
Secretary for Planning and Evaluation (ASPE), up to 133 million non-
elderly Americans may have a pre-existing condition, and nearly one-
third (44 million) went uninsured for at least 1 month during the 2-
year period beginning in 2013.

    If any of these individuals were to face difficult circumstances 
that resulted in a temporary loss of coverage--such as losing a job or 
being unable to work due to serious illness--your legislation would 
allow insurers to refuse to cover services related to the pre-existing 
condition or charge a much higher premium than many of these 
individuals would likely be able to afford.

    Do you agree that individuals with pre-existing conditions who 
experience a loss of coverage--for example, due to the loss of a job or 
being unable to work due to a serious illness--should not be denied 
coverage for their condition or charged high, unaffordable premiums as 
a result of that temporary loss of coverage?

    Under the continuous coverage requirement included in your 
Empowering Patients First Act, what would prevent insurers from doing 
exactly that to any individual with a pre-existing condition who 
experiences a temporary loss of coverage?

    Answer. I believe it is important that we as a nation make sure 
that every American has access to the kind of mental health care and 
health coverage that best meets their need. Additionally, it is 
imperative that all Americans have access to affordable coverage and 
that no one is priced out of the market due to a bad diagnosis. This is 
a matter for the legislative branch, however, and if confirmed, I will 
work to ensure that HHS appropriately implements the statutes within 
its purview.
                        human services programs
    Question. In recent years, there has been an increasing focus on 
using evidence to make policy decisions.

    What is your view on this?

    Answer. There is no question we must use available evidence when 
making governmental decisions.

    Question. What evidence would you use to decide whether policies or 
program changes that you have championed are successful?

    Answer. When championing policy or program changes, outcomes should 
always be a top indicator when determining whether or not those changes 
are successful.

    Question. What evidence leads you to believe that TANF was a 
success?

    Answer. Since the passage of TANF, we have seen employment rates of 
single mothers increase, lower poverty rates among female-headed 
households with children and African-American households, a reduction 
in child poverty overall, and a sharp decline in the number of families 
receiving cash assistance.

    Question. The annual data from HHS through the Adoption and Foster 
Care Analysis Reporting Systems (AFCARS) released in fall 2016 show a 
third consecutive annual increase in foster care to 427,910 children. 
This represents an 8-percent increase since 2012. Your home State is no 
exception. A recent AP story stated that, ``the most dramatic increase 
has been in Georgia, where the foster-care population skyrocketed from 
about 7,600 in September 2013 to 13,266 last month. The State is 
struggling to provide enough foster homes for these children and keep 
caseloads at a manageable level for child-protection workers.'' \1\ HHS 
recently indicated that:
---------------------------------------------------------------------------
    \1\ http://www.bigstory.ap.org/article/
12658e69b70148fc8d4743fa631fa9f9/5-states-struggle-surging-numbers-
foster-children.

        A rise in parental substance use is likely a major factor 
        driving up the number of children in foster homes. Citing 
        opioid and methamphetamine use as the most debilitating and 
        prevalent substances used, some State officials expressed 
        concern that the problem of substance use is straining their 
        child welfare agencies.\2\
---------------------------------------------------------------------------
    \2\ https://www.acf.hhs.gov/media/press/2016-number-of-children-in-
foster-care-increases-for-the-third-consecutive-year.

    Clearly, substance use is having a big impact on children, 
families, and child welfare systems. I am particularly concerned about 
the strain the epidemic is placing on grandparents and other relatives 
who often unexpectedly take on the role of caretaker for children in 
foster care and at risk of entering foster care. Thankfully, there are 
programs that work and can even save taxpayer dollars over the long 
run. For example, research shows that when parents are able to get into 
substance use treatment programs that permit them to live with their 
children, two-thirds of these parents successfully complete the 
program. That compares with only one-fifth of parents when their 
children aren't allowed to stay in the treatment facility with them.\3\ 
The results achieved by these model programs have saved millions of 
dollars every year in the costs of keeping kids in foster care.
---------------------------------------------------------------------------
    \3\ https://www.ncbi.nlm.nih.gov/pubmed/11291901 and https://
www.ncbi.nlm.nih.gov/pubmed/11291900.

    What will you do to ensure that drug treatment and services will be 
both maintained and coordinated to target these families that need 
treatment and whose children could end up in foster care without the 
---------------------------------------------------------------------------
appropriate services?

    Answer. There needs to be better coordination between Federal 
departments, State governments, and local governments to ensure we are 
meeting the challenges of one of the great crises of our times: the 
opioid epidemic. A top agenda of all levels of government is to ensure 
innocent children, including those in foster homes, are protected from 
the scourge of this epidemic. As a strong proponent of the 
Comprehensive Addiction and Recovery Act of 2016, I will do all I can 
to effectively administer and implement this law should I be confirmed 
as Secretary.

    Question. How will you help grandparents and other family members 
receive the supportive services they need in the event that parents 
cannot safely retain custody of their children?

    Answer. Should I be confirmed as HHS Secretary, I will do all 
within my power, under the laws passed by Congress, to help 
grandparents and other family members receive supportive services.

    Question. Will you pledge to me that, if confirmed, you will work 
with me to provide Federal support for effective programs, and to 
ensure that the children and grandparents caught up in the opioid 
epidemic get support from your Department?

    Answer. I absolutely pledge to work with you to ensure support for 
effective programs and to see that children and grandparents get 
appropriate support from HHS to deal with the tragic opioid epidemic.

    Question. As part of the Comprehensive Addiction and Recovery Act 
of 2016, Congress required States to have plans of ``safe care'' for 
infants born exposed to substances.\4\ This requirement, along with 
numerous existing requirements, is a condition of State receipt of 
grants under the Child Abuse Prevention and Treatment Act, or CAPTA. 
Grants to States under CAPTA total $26 million per year. Discretionary 
spending for child welfare services under CAPTA, the Adoption/Kinship 
Incentives Program, the Promoting Safe and Stable Families Program and 
Child Welfare Services have all faced significant reductions in 
appropriations over the past 5 years.
---------------------------------------------------------------------------
    \4\ http://www.cwla.org/discussion-on-plans-of-safe-care/.

    What is your position on proposals that would move mandatory 
funding to discretionary funding (thus limiting the committee's ability 
---------------------------------------------------------------------------
to fund both child welfare and other vital services)?

    Answer. This is a legislative matter. Should I be confirmed as HHS 
Secretary, I will implement the laws passed by Congress.

    Question. How will you ensure adequate funding for these services 
that have suffered significant reductions over the recent past despite 
a backdrop of increasing foster care numbers?

    Answer. Should I be confirmed as HHS Secretary, I will strive to 
make effective use of all dollars appropriated by Congress in order to 
provide the most effective services possible.

    Question. The United States is the only industrialized country 
without paid maternity leave.\5\ The President has endorsed such leave 
for new mothers.
---------------------------------------------------------------------------
    \5\ http://www.oecd.org/els/family/
PF2_5_Trends_in_leave_entitlements_around_childbirth.
pdf.

    If confirmed, how might you lead the Department to help support 
this goal? Please be specific about resources and expertise that may be 
available at HHS, including in such areas as benefit design, 
---------------------------------------------------------------------------
eligibility determination, IT systems, and program access.

    Answer. If I am so honored as to be confirmed as HHS Secretary, I 
will implement the laws passed by Congress and support the President's 
initiatives as they fall within HHS's authorities. I will do so in a 
way that is as effective and as efficient as possible, drawing on the 
expertise and experience of the fine men and women currently working at 
HHS.

    Question. Access to high-quality child care is fundamental to the 
economic security of families and too many parents cite lack of 
dependable child care as a key barrier to finding and maintaining 
employment. The President's child care tax proposals would primarily 
benefit high-income families through tax deductions, while providing 
little or no help to low- and middle-income families.\6\ The most 
significant Federal child care program for families of modest means is 
the Federal Child Care and Development Block Grant (CCDBG) which 
provides funds to States to help low-income families afford child care 
of their choice. Yet the CCDBG serves only one out of seven children 
eligible for assistance.
---------------------------------------------------------------------------
    \6\ https://papers.ssrn.com/sol3/
papers.cfm?abstract_id=2842802&download=yes.

    If confirmed, under your leadership how might the Department 
improve access to high quality child care? Please be specific about 
resources and expertise that may be available at HHS, including in such 
areas as benefit design, eligibility determination, IT systems, and 
---------------------------------------------------------------------------
program access.

    Answer. Should I be confirmed as HHS Secretary, I will implement 
the laws passed by Congress. I will do so in a way that is as effective 
and as efficient as possible, utilizing the ample and exemplary 
expertise available by the fine men and women currently working at HHS.

    Question. As Budget Chairman, you proposed eliminating funding for 
the Social Services Block Grant (SSBG), a flexible funding stream for 
social services programs such as substance use disorder treatment 
services, child protection, elder protection, services for the elderly 
like Meals on Wheels, and other critical safety net programs. It also 
helps fill in financial gaps for overburdened State foster care systems 
which are facing an increased strain in light of the opioid epidemic.

    In light of increased demands on State human services programs 
brought on by the opioid epidemic, has your position on the SSBG 
changed?

    Answer. During my time in Congress, I have been acutely aware of 
the need to eliminate duplicative programs and strengthen those 
programs that work. However, as SSBG continues to be a program 
authorized by Congress, I will do all I can to effectively administer 
this law should I be so honored as to be confirmed as HHS Secretary.

    Question. If not, where do you suggest States turn to make up for 
the loss of these flexible SSBG dollars if funding is eliminated? 
Please be specific in terms of which programs you believe would fill 
the void left by SSBG.

    Answer. Given the nature of our Federal system, there is not a one-
size fits all approach to how States might react should there be an 
elimination of any Federal program.

    Question. Can you explain what makes the flexibility in the Social 
Services Block Grant inherently different and worse than either 
existing or proposed block grants (such as TANF as it exists or 
Medicaid as you have proposed)? I'd be especially interested in why you 
consider SSBG to be a failure while you consider TANF to be a success.

    Answer. As a 2011 GAO report pointed out, SSBG is a program of 
fragmentation, overlap, and duplication. SSBG essentially offers a no-
strings-attached approach whereas TANF, while maintaining a great deal 
of flexibility for the States, has been successful in moving recipients 
off of welfare and on to work. That being said, SSBG continues to be a 
program authorized by Congress, I will do all I can to effectively 
administer this law should I be confirmed as HHS Secretary.

    Question. One of the most significant sources of assistance on the 
human services side of the Department of Health and Human Services is 
Temporary Assistance for Needy Families, or TANF. During the hearing, 
in your response to Senator McCaskill, you touted the success of TANF. 
However, according to HHS data, between 1996--when the welfare reform 
law was enacted--and 2015, the number of poor families in Georgia 
receiving support through TANF dropped from 82 per 100 to just 5 
families per 100 while the population of poor Georgia families 
increased by over 50 percent.\7\ While Georgia is one of the most 
drastic examples, this overall trend is not unique to your home State. 
Nationally, TANF reached 68 percent of poor families when the 1996 law 
passed. It now reaches just 23 percent of such families, despite the 
fact that extreme poverty has more than doubled.\8\ Moreover, TANF has 
faced effective cuts of over 30 percent since its creation in 1996 and 
benefit levels have also declined.\9\
---------------------------------------------------------------------------
    \7\ http://www.cbpp.org/sites/default/files/atoms/files/
tanf_trends_ga.pdf and http://www.
cbpp.org/research/family-income-support/how-states-use-funds-under-the-
tanf-block-grant.
    \8\ http://www.cbpp.org/research/family-income-support/tanf-
continues-to-weaken-as-a-safety-net and http://poverty.ucdavis.edu/faq/
what-deep-poverty.
    \9\ http://www.cbpp.org/research/family-income-support/tanf-cash-
benefits-have-fallen-by-more-than-20-percent-in-most-states and https:/
/fas.org/sgp/crs/misc/RL32760.pdf.

    Do you believe TANF has been a success both across the Nation and 
---------------------------------------------------------------------------
in your home State of Georgia?

    Answer. Yes. Since the passage of TANF, we have seen employment 
rates of single mothers increase, lower poverty rates among female-
headed households with children and African-American households, a 
reduction in child poverty overall, and a sharp decline in the number 
of families receiving cash assistance.

    Question. What metrics do you use in making this determination? 
Please specifically address time periods beyond 2005 in describing your 
views.

    Answer. I think the best way to measure the success of the law is 
to see where the Nation was prior to its passage and where we are now. 
As I've pointed out, since passage of TANF, we have seen employment 
rates of single mothers increase, lower poverty rates among female-
headed households with children and African-American households, a 
reduction in child poverty overall, and a sharp decline in the number 
of families receiving cash assistance.

    Question. Can you provide a commitment that Medicaid will not see 
cuts like what you've proposed in your budget and what has happened to 
TANF?

    Answer. I will provide a commitment that if I am honored to be 
confirmed as HHS Secretary, I will faithfully implement and administer 
all the laws passed by Congress.

    Question. President George H.W. Bush's welfare advisor and one of 
the conservative architects of the 1996 law, Ron Haskins, has said, 
``States did not uphold their end of the bargain,'' and argued that 
TANF is not a model for other programs, asking ``So why do something 
like this again?'' \10\ A recent piece published by the conservative 
think-tank, American Enterprise Institute came to a similar conclusion 
noting that unfortunately, ``some States have abandoned their 
responsibility to provide support to poor families and help them get 
jobs,''and that enough States have stopped spending money on core 
services that, ``it tarnishes the entire program.'' \11\
---------------------------------------------------------------------------
    \10\ http://www.cbpp.org/blog/tanfs-worsening-track-record-shows-
why-its-not-a-model.
    \11\ https://www.aei.org/publication/welfare-reform-progress-
states-step-up/.

    However, you resisted recent Republican-authored legislation that 
aimed to ensure States met even the most basic TANF spending 
obligations.\12\ You insisted on changes that essentially would 
grandfather in practices that let Georgia and other States continue to, 
to use the AEI publication's words, ``abandon their responsibility to 
provide support to poor families and help get them jobs.''
---------------------------------------------------------------------------
    \12\ https://waysandmeans.house.gov/event/39841647/ and http://
mlwiseman.com/wp-content/uploads/2016/05/Profiles-in-
Courage.052216.pdf.

    If confirmed, will you continue to oppose efforts to ensure States 
hold up their end of the bargain with respect to investing their own 
---------------------------------------------------------------------------
dollars into the TANF program?

    Answer. States should contribute their part in State-Federal human 
services programs, even if we don't always agree on the method for 
getting there. I have an open mind and welcome proposals to improve 
State-Federal human services programs to achieve the goal to reduce 
low-income families' dependence on government aid through high levels 
of paid work, especially those that are well supported by evidence. We 
have a duty to the American taxpayers, and the people these programs 
were created to help, to find workable solutions to problems within 
these programs. If I am privileged to serve as the HHS Secretary, I 
will follow the policies adopted by the Congress and signed into law by 
the President that reform State-Federal human services programs.

    Question. Specifically, will you advise the President to oppose 
legislation, like H.R. 2959 as introduced in the 114th Congress, that 
would phase out the practice of States being able to count third party 
spending towards their TANF maintenance of effort requirements? \13\
---------------------------------------------------------------------------
    \13\ https://www.gpo.gov/fdsys/pkg/BILLS-114hr2959ih/pdf/BILLS-
114hr2959ih.pdf.

    Answer. The ultimate objective of human services programs is to 
help people stand on their own again after they have fallen down. 
Certain interpretations cut against this objective by keeping people 
down even when they want to stand up. I have a broad and open mind and 
welcome proposals to improve programs like TANF that would help people 
stand on their own again, especially those that are well-supported by 
evidence. If I am privileged to serve as the HHS Secretary, I will 
follow the policies adopted by the Congress and signed into law by the 
---------------------------------------------------------------------------
President.

    Question. In your testimony and meetings with committee staff, you 
stressed the need to establish better measures by which to evaluate the 
effectiveness of Federal human services programs. As you know, timely, 
accurate and relevant evaluations rely on: modern, efficient and 
integrated State and Federal data systems; effective data use 
agreements; and transparent and strong privacy and data security 
measures. Moreover, system modernization cannot only improve client 
services but reduce waste, fraud, and abuse. However, much of the 
funding currently being used to modernize and integrate systems comes 
through ACA and the OMB A-87 waiver.

    Will you commit to working, if confirmed, with Congress and the 
administration to sustain the current efforts to improve State and 
Federal health and human services data systems?

    Answer. Good data is an essential element for ensuring that we have 
accurate information and are able to effectively manage the programs 
under our charge. While funding decisions ultimately rest with 
Congress, if I am privileged to serve as the HHS Secretary, I will 
follow the policies adopted by the Congress and signed into law by the 
President to modernize State and Federal human services data systems.

    Question. The Maternal, Infant, and Early Childhood Visitation 
program (MIECHV) is a program that members on both sides of the aisle 
have championed due to the demonstrated success of its models in 
improving the health and well-being mothers and children. MIECHV's 
innovative model has well-established goals, outcomes and metrics.

    MIECHV is due for reauthorization this year. At current funding 
levels ($400M/year), the Department of Health and Human Services (HHS) 
estimates that only 3% of the eligible population receives MIECHV 
services. To me, reauthorization represents an opportunity to increase 
access to the program and improve the life course of children born into 
low-income households, while also reducing preventable government 
spending in the short and long term.

    In your home State of Georgia, the Great Start Georgia program 
receives MIECHV funds. The program's aim is to provide evidence-based 
home visiting services to those families who are most in need of 
support and has met all 6 program benchmarks, including maternal and 
newborn health, family economic self-sufficiency, improving at-risk 
students' school readiness, and reducing crime and domestic violence.

    If confirmed, how do you plan on continuing the successful MIECHV 
program?

    Answer. I share your goal of increasing access to affordable, 
quality health coverage. While I cannot comment specifically on 
legislation that would reauthorize MIECHV, I look forward to working 
with you on examining this program's funding and working on ways to 
improve rural and child health using evidence-based approaches.

                                 ______
                                 
                Questions Submitted by Hon. Bill Nelson
    Question. Your health proposal would remove protections for 
individuals with pre-existing conditions, allowing insurers to charge 
them higher premiums or denying them coverage altogether, unless an 
individual has maintained coverage for 18 months. Your bill would 
expand high-risk pools as an option to individuals with pre-existing 
conditions. In Florida, more than 7.8 million people have pre-existing 
conditions.

    Please explain how you believe high-risk pools will provide quality 
coverage to the 7.8 million people in my State who have pre-existing 
conditions.

    Answer. Pooling mechanisms that allow individuals to come together 
for the purchase of coverage, like the traditional Blue Cross Blue 
Shield Plan, have been successful in bringing down the cost of 
insurance for Americans. I believe this same concept could be 
successful in pooling the risk among those Americans with pre-
existing conditions.

    Question. Have high-risk pools been successful in providing 
adequate and affordable coverage in populous, high-costs States like 
New York or Florida?

    Answer. If confirmed, I look forward to working with you to 
implement commonsense solutions that prioritize flexibility for States 
like New York and Florida to design and operate their own high-risk 
pools or other risk-mitigation programs that suit their citizens' 
unique needs.

    Question. You introduced the 2015 reconciliation bill, which would 
have repealed key parts of the Affordable Care Act, had it not been 
vetoed. The nonpartisan Congressional Budget Office released a report 
on the effects of your bill, including increased numbers of uninsured 
Americans and increased premiums.

    Last week, President Trump said the Republican replacement plan is 
``coming down to the final strokes.'' He said that as soon as the HHS 
Secretary is confirmed, a repeal and replace plan will be submitted, 
``essentially simultaneously.''

    Is there a nearly fully formed replacement plan?

    If yes, what's in the replacement plan?

    Does it provide insurance coverage for everyone as President Trump 
said?

    Does it protect individuals with pre-existing conditions from 
paying higher premiums or being denied coverage altogether?

    Does it allow children to stay on their parents' insurance until 
age 26?

    Does it ensure that individuals struggling with substance use 
disorders or diagnosed with behavioral health conditions have adequate 
access to quality treatment?

    Answer. Plans for real health-care reform are a work in progress, 
but the President and I share the same goal: to provide relief to all 
Americans from Obamacare. Obamacare has raised premiums and 
deductibles, narrowed doctor networks, reduced choices of plans, 
limited Americans' liberty, and undermined the doctor patient 
relationship. The goal is to make certain that every single American 
has access to the coverage they want for themselves.

    Question. What will you do to provide coverage to the more than 
800,000 Floridians that could have been covered by Medicaid expansion?

    Answer. I look forward to faithfully executing whatever law that 
Congress passes and the President signs, if I am confirmed. I will 
promise you this: Regardless of the final legislative outcome, I would 
work as HHS Secretary to ensure that the Medicaid program is well 
administered, effective, and available for eligible beneficiaries and 
that the States/Governors are given the flexibility to pursue 
innovative approaches that fit the needs of their States.

    Question. Can you explain how, under a Medicaid block grant 
program, States like Florida would cover the unforeseen costs 
associated with public health crises, like Zika virus, or high cost 
prescription drugs, or unexpected sudden changes in demographics 
without harming another population?

    Answer. My work in the Congress has been focused on how to improve 
Medicaid and provide additional flexibility. If I have the privilege of 
being confirmed as Secretary, I would look forward to the opportunity 
to work with States and Congress using the tools and authorities given 
by Congress in legislation. The mechanics of any new Medicaid program 
along the lines described would be a legislative decision that would 
need to account for how to encourage States to save for such 
eventualities or how the Federal and State governments do so together.

    Question. Florida is currently in the process of renegotiating its 
section 1115 Medicaid managed care waiver.

    What safeguards and beneficiary protections do you believe HHS 
should keep in place when reviewing Medicaid waivers?

    Answer. The 1115 waivers are an important tool for States to 
innovate within the Medicaid program, as they have for many years prior 
to the ACA becoming law. The statute itself has requirements for 
certain procedures. Furthermore, the democratic process in each State, 
where government is even closer to the people, provides substantial 
protection with regards to any 1115 waiver application and its 
implementation.

    Question. You introduced a bill to allow practitioners to enter 
into private contracts with their Medicare patients and charge higher 
fees than what is currently allowed under the Medicare program. 
Currently, when seniors in Medicare see their doctors, they are 
responsible for a set amount of costs and don't encounter any surprise 
bills. Under current law, physicians who choose to participate in 
Medicare are not allowed to bill their patients for any costs that 
remain once Medicare pays their share of the bill, a practice that is 
commonly known as balance billing.

    Did you know that half of all Medicare beneficiaries had incomes of 
less than about $24,000 and savings below $63,350 in 2014? Is this the 
population that your bill targets?

    Answer. The Medicare Patient Empowerment Act is one approach to 
giving our seniors more flexibility within the Medicare Program and 
providing the opportunity to make decisions with their physicians 
without interference from Washington. The measure would help ensure 
that Medicare beneficiaries maintain adequate access to health-care 
professionals by increasing the number of physicians who will accept 
Medicare patients and addressing physician shortages by attracting new 
professionals to the field of medicine. In addition, the bill provides 
safeguards to Medicare beneficiaries. More importantly, my legislation 
would allow a provider to see a Medicare patient pro-bono or charge 
minimal cost (below the standard fee schedule) without prosecution. 
Without this legislation, a physician can be charged with fraud for 
failure to attempt to collect the full coinsurance amount under 
Medicare.

    Question. The Medicare Advantage program provides quality care to 
over 1.6 million Floridians and over 18 million seniors across the 
United States.

    Do you have any ideas about how to strengthen and build upon this 
vital and proven part of the Medicare program? In your role as 
Secretary of HHS, will you commit to supporting Medicare Advantage and 
protecting the Nation's seniors as they age?

    Answer. Medicare Advantage provides an important option for 
Medicare beneficiaries to access coordinated care and greater benefits. 
If confirmed as Secretary, I would seek to ensure Medicare Advantage 
remains a stable option for beneficiaries and that Medicare Advantage 
plans are afforded the flexibility to design plans that beneficiaries 
want and give them the coverage they want.

    Question. Today, I joined a bipartisan group of Senators in 
reintroducing the Public Health Emergency Response and Accountability 
Act, which would fund the nearly empty Public Health Emergency Fund 
through mandatory appropriations designated as emergency spending, a 
proposal modeled after FEMA's disaster relief fund.

    As HHS Secretary, would you work with me to protect my constituents 
from the Zika virus and other public health emergencies? Do you support 
the creation of an emergency health fund to provide mandatory 
appropriations to fight Zika and other infectious diseases?

    Answer. If confirmed as HHS Secretary, I give you my word I will do 
all within my power to protect your constituents, and the constituents 
of every Senator, from the Zika virus and other public health 
emergencies. Should Congress create a new program or alter an existing 
program, I will work to ensure the program is as effective as it can be 
in fighting Zika and other infectious diseases.

    Question. The increased use of generic drugs results in real 
savings due to their lower costs as compared to brand name drugs. 
Senator Collins and I asked GAO to examine the factors behind recent 
spikes in some generic drugs. GAO found that Part D generic drug prices 
declined overall since 2010--they fell about 59 percent. Additionally, 
GAO found that 300 of the more than 1,400 established generic drugs 
analyzed had at least one price increase of 100 percent or more between 
2010 and 2015.

    What do you believe should be done to keep generic drugs 
affordable?

    Answer. I appreciate that generic drugs play an important role in 
meeting many American's health-care needs. If confirmed, I look forward 
to focusing on how we can make health care more affordable, including 
prescription drugs, and build on policies that have helped to empower 
patients in meeting their health-care needs.

    Question. Amyotrophic lateral sclerosis (ALS) usually strikes 
people between the ages of 40 and 70, and for unknown reasons, military 
veterans are approximately twice as likely to be diagnosed with ALS. 
There is currently one FDA approved drug that modestly slows the 
progression of ALS in some people. While there is no cure or treatment 
that that halts or reverses ALS, scientists have made significant 
progress in learning more about this disease.

    The Centers for Disease Control and Prevention operate a National 
ALS Registry, which is a critical resource for (1) providing data to 
researchers focused on developing treatments and prevention strategies; 
and (2) matching patients to potential clinical trials.

    Please advise how the administration will support this work in 
fiscal year 2018 and work with Congress to make the registry even more 
effective at confronting ALS.

    Answer. ALS is a devastating disease with far-reaching consequences 
for both those afflicted and their families, and as a physician I 
understand the hardships these individuals must endure. If confirmed, I 
plan to work to advance patient-
focused health care, which will support efforts to better serve those 
suffering from ALS.

    Question. The ACA reauthorized the Minority Centers of Excellence 
(COE) program, housed within the Department of Health and Human 
Services. The Florida Agricultural and Mechanical University (FAMU) 
Pharmacy, located in Florida, is a grantee. COE supports curriculum-
based initiatives for increasing minority and underrepresented 
individuals to become health professionals.

    Do you support preserving important programs like COE, Health 
Careers Opportunities Program, and Area Health Education Centers?

    Answer. As a physician, I understand the critical importance of 
diversity among health-care practitioners in order to meet the varied 
health-care needs of the American people. If confirmed, I look forward 
to working with you and others to ensure that we are supporting efforts 
to increase diversity within our Nation's health-care workforce as part 
of advancing patient-focused health care.

    Question. CT colonography (CTC), also known as virtual colonoscopy, 
are diagnostic medical tests, which produce detailed images of the 
colon by using a combination of 2-dimensional x-rays and a 3-
dimensional computer views. They have the ability to identify lesions 
and tumors on the kidneys and other organs and blockages in the 
coronary arteries.

    Currently, Tricare and private payers in 21 States and the District 
of Columbia cover virtual colonoscopies for colorectal cancer 
screening, but Medicare does not.

    Will you use your authority as Secretary to consider the addition 
of virtual colonoscopies as a colon cancer screening option for 
Medicare beneficiaries?

    Answer. As you know, CMS has a detailed process for making 
determinations regarding whether items and services are reasonable and 
necessary, if they can be considered eligible for Medicare coverage 
given other restrictions and prohibitions. I understand CMS's decision 
to cover CT colonography only for diagnostic testing but not screening 
was based on the state of the technology at the time and the possible 
need for a confirmation colonoscopy in so many cases. If confirmed as 
Secretary, I would look forward to working with you to understand if 
revisiting this issue is appropriate and warranted.

    Question. On July 16, 2015, Proposed/Draft Local Coverage 
Determination for Lower Limb Prostheses (DL33787) (Draft LCD) was 
published by the four Durable Medical Equipment Medicare Administrators 
(``DME MACS''). Last year, the Coverage and Analysis Group, headed by 
CMS, was created to review the DME MAC recommendations. That Group 
continues to deliberate.

    Can you speak to what actions as an administrator you would take on 
finalizing this Draft LCD?

    Answer. Medicare coverage for prostheses can be a particularly 
challenging topic given the role this durable medical equipment plays 
in the lives of many Medicare beneficiaries. I understand CMS has 
stated it is committed to providing high quality care to Medicare 
beneficiaries in need of a prosthesis, that it has committed to a 
Workgroup the task of making recommendations concerning the best and 
most relevant measures in this realm, and that CMS will ensure there is 
opportunity for public comment and engagement. If confirmed as 
Secretary, I would be pleased to work with you to look into the timing 
of this matter and see what can be done to either expedite it or 
further support the work so there is assurance of its comprehensiveness 
and objectivity.

    Question. Representative Price, I know you are very familiar with 
the Centers for Medicare and Medicaid Service's (CMS) Home Health pilot 
program known as the ``Pre-Claim Review Demonstration (PCRD)'' which 
affects five States, including Florida. I am concerned that the PCRD 
may restrict beneficiary access to timely services, divert clinical 
resources to paperwork management, and incur high administrative costs. 
These concerns were amplified after hearing what the State of Illinois 
had been dealing with when PCRD began there in August 2016.

    In response to my concerns, CMS delayed PCRD in Florida until April 
2017. While I understand the concern, CMS has with needing to tackle 
the improper payment rates, PCRD may not get to the root of the 
problem.

    As Secretary, how do you plan to tackle the problem of improper 
payments? Do I have your commitment that you will work with me to 
alleviate the concerns raised by the PCRD?

    Answer. The topic of improper payments is one of concern in the 
Medicare program--both overpayments and in some cases underpayments. 
Tackling them requires close support for the payment integrity team 
within CMS and close cooperation with the Office of the Inspector 
General and the Department of Justice. But it also involves a 
definition of scope and a prioritization--which improper payments are 
ones that reflect services not rendered and which involve a missing 
signature on a form. With that prioritization in mind, I am hopeful we 
can align resources to those areas of highest risk.

    As to the Pre-Claim Review Demonstration (PCRD), if confirmed, I 
would be pleased to work with you to address your concerns. For 
example, we may want to explore the experience of the Prior 
Authorization of Repetitive Scheduled Non-
Emergent Ambulance Transport demonstration to understand if there are 
applicable lessons for PCRD or vice-verse.

    Question. During the public comment period for the FDA's tobacco 
deeming rule, the Small Business Administration's Office of Advocacy 
filed concerns that the economic impact analysis conducted by FDA was 
``deficient'' and should be recalculated. Small business premium cigar 
retailers and manufacturers in my State have expressed the same concern 
to me. Unfortunately, FDA took no action to address these concerns.

    Do you believe additional review of the costs of this regulation 
should be conducted before any additional implementation?

    Answer. Whenever the Federal Government implements its regulatory 
responsibilities, it is important to consider the costs, especially 
those imposed on small businesses. Any time economic impact analyses 
are conducted, I believe they must be fact-based. If I am confirmed, I 
would seek to better understand the SBA's views of the regulation in 
question, which is consistent with the President's commitment to reduce 
the overall regulatory burden on American businesses.

                                 ______
                                 
              Questions Submitted by Hon. Thomas R. Carper
    Question. The number one concern I hear from my constituents about 
health care is affordability. I was pleased to hear the President say 
that under his plan, health insurance will be better and less expensive 
for all Americans. Americans cannot afford to pay more for their health 
care. Even supporters of the President value the health benefits they 
have gained through the Affordable Care Act and could not bear the 
higher deductibles and decreased benefits that your earlier plans have 
called for.

    Can you ensure that under the President's health-care plans, health 
insurance premiums, deductibles, and co-pays will decrease for all 
Americans? How exactly will you do this?

    Answer. President Trump and I have the same goals for health-care 
reform and the same general approach to meeting those goals. Neither 
one of us is wedded to a particular plan to the exclusion of all 
others. We see eye-to-eye on this, and are looking forward to giving 
the American people what they've been longing for, for 7 long years: 
real health-care reform. But they have never wanted Obamacare: It has 
raised premiums and deductibles, narrowed doctor networks, reduced 
choices of plans, limited Americans' liberty, and undermined the doctor 
patient relationship.

    Question. The Congressional Budget Office (CBO) has found that 
repealing the ACA will cause more than 30 million Americans to lose 
their insurance and increase premiums by more than 20 percent.

    Do you agree that the President's executive order to begin 
repealing the Affordable Care Act while there is no alternative plan 
creates instability and uncertainty that will only drive up costs in 
our health-care system?

    Answer. The insurers are deciding right now as they come forward in 
March and April what the premium levels will be for 2018. What they 
need to hear from us is a level of support and stability in the market, 
the kinds of things that are able to provide stability. There are 
counties in the State where there is only on provider. We must, as 
policymakers, ask what is going on. Where are the problems out there? 
The President's Executive order is directed towards exactly that--
reducing costs and the other burdens on the American people imposed by 
Obamacare. The initial reactions to the order from plans and others 
indicate this is something they anticipated based on the President's 
promises and that the recent and current discussions regarding how to 
address the issue of costs have been productive. In fact, it is the 
costs of inaction which are not acceptable.

    Question. Do you believe that all Americans, regardless of income, 
should have health insurance and does the President share your views on 
this? Have you told the President that repealing the ACA without a 
replacement means 32 million Americans will lose their health insurance 
and add $9 trillion to our national debt? Have you had direct 
discussions with members of the Transition Team or the President's 
current health-care advisers since your nomination? Would you insist 
that Congress hold multiple bipartisan hearings on the President's 
health care proposal? Will you commit to, should you be confirmed, to 
answer our questions when such a proposal is sent to Congress and 
evaluated by the non-partisan, independent Congressional Budget Office?

    Answer. I think the conversation and focus in these topics has been 
the question of coverage rather than true access for too long. By that 
I mean that Americans might have an insurance card and yet not be able 
to afford care or it might not be available to them for other reasons. 
And so when we talk about coverage we ought to make clear what we 
really mean and want to have happen. In any case, the President has 
made clear his hope and plan for a replacement to Obamacare. The goal 
is to make certain that every single American has access to the 
coverage they want for themselves.

    Question. Sixty percent of the children born outside of marriage 
are from unplanned pregnancies. This is a major public health 
challenge, as children born from unintended pregnancies and raised in 
single parent households have a higher rate of mental health problems, 
a lower rate of high school graduation, earn less income than their 
peers, and cost more to taxpayers. Because of the Affordable Care Act, 
millions of American women can now afford contraception, without co-pay 
or cost-sharing, and the rate of unplanned pregnancies has dropped.

    Will the President's plan to replace the ACA ensure these women 
will not have to pay more for contraception and put birth control out 
of reach for millions of young women and families?

    Answer. Women should have the health care that they need and want. 
The system we ought to have in place is one that equips women and men 
to obtain the health care that they need at an affordable price.

    Question. Health-care experts have found that obesity, smoking, and 
mental health challenges are the ``root causes'' of our country's most 
persistent public health challenges. Together, tobacco, obesity, and 
mental health lead to more than a million deaths and cost us more than 
half a trillion dollars each year. It's critical that all health 
insurance plans fully cover the treatment for these conditions. If the 
ACA is repealed, Americans would lose access to treatment for mental 
health care, smoking cessation, and obesity treatment.

    Under the bills and proposals you have championed, would the 
treatment and cost of insurance coverage for obesity, smoking 
cessation, and mental health care remain the same or decrease?

    Answer. It has been the goal, for any legislation I have 
championed, for the treatment and cost of insurance coverage for all 
Americans to decrease.

    Question. The obesity epidemic has had a devastating impact on our 
health-care system, increasing the prevalence of nearly every major 
chronic condition, including heart disease, hypertension, diabetes, and 
cancer, and costing our country hundreds of billions of dollars every 
year to treat the variety of conditions attributable to this 
increasingly prevalent disease. A critical step in combating obesity 
was the decision by the AMA in 2013 to designate obesity as a disease. 
This designation is an important step towards ensuring the best medical 
care is provided to those suffering from this disease.

    Will you, as Secretary of Health and Human Services, follow the 
leading medical association and declare obesity as a disease and will 
you assist us in maximizing the use of all the medical interventions 
currently available to combat this crisis?

    Answer. Obesity is a chronic condition that takes its toll over 
many years and in many quiet ways. I agree it is an important priority 
for all involved in the health-care system to address this toll. This 
is particularly the case because obesity is generally a preventable 
condition and can be controlled through changes in behavior. 
Fundamental to that is the relationship between patient and doctor 
which our current system has undermined in many ways. I can tell you 
that I will consider the legal framework within which any decision 
regarding the formal designation of any disease ought to take place and 
come to any decision with these considerations in mind.

    Question. Have you ever been a member of the Association of 
American Physicians and Surgeons? This group has said that the 
government poses a greater threat to patients than tobacco use, drug 
addiction, and excessive alcohol intake, and that patients should seek 
doctors who do not participate with Medicare, Medicaid, and private 
health insurers. When you were a member of this group, did you agree 
with this position? Do you agree with this position now? This group has 
also compared the use of advance directives--the process by which 
patients and their health-care providers plan for end of life care 
decisions in advance and when they are of sound mind and body--as 
``population control.'' Do you agree with this comparison?

    Answer. My work has been focused on making sure that physicians and 
patients are ones making medical decisions, rather than the government. 
Once that relationship is undermined and patients do not trust their 
doctors or doctors do not think first about their patients then no 
other medical or public health goal can be achieved. This is important 
when it comes to chronic disease, preventive care and healthy choices, 
and life and death decision-making. For all these reasons, I have 
fought alongside many to ensure patients have these choices to make for 
themselves and with their doctors.

    Question. As you know, the Affordable Care Act prohibits health 
insurance companies from limiting coverage to individuals on the basis 
of sexual orientation and gender identity. But a number of your 
previous statements regarding lesbian, gay, bisexual, and transgender 
people indicate that you don't support these consumer protections.

    As HHS Secretary would you support reversing these protections and 
jeopardizing the LGBT population's access to health care? As Secretary 
of Health and Human Services, would you uphold the department's efforts 
to ensure that health insurance companies do not deny or limit health-
care coverage to LGBT people?

    Answer. If confirmed, my efforts and work as Secretary will be to 
seek the availability of the highest quality care for all Americans. 
The goal is to make certain that every single American has access to 
the coverage they want for themselves. Of course, consumer protections 
at Federal and State levels ought to be available to all consumers, not 
just certain ones who meet certain criteria.

    Question. Data has shown repeatedly that Federal resources devoted 
to fighting health-care fraud is well worth the investment. The Health 
and Human Services Department has found that for every dollar that is 
invested to fight fraud, the government recovers $5. On January 23, 
2017, the President announced a hiring freeze on government workers, 
which would include a freeze on hiring investigators and attorneys 
devoted to protecting Medicare and Medicaid from criminals. The GAO has 
repeatedly listed Medicare and Medicaid as two of the Federal 
Government programs most vulnerable to fraud, waste, and improper 
payments. Unfortunately, this freeze only leaves Medicare and Medicaid 
more vulnerable to fraud.

    Do you agree with these concerns and if confirmed, will you 
recommend to the President that the hiring freeze should be lifted for 
Federal workers fighting criminal activity, waste, and fraud in 
Medicare and Medicaid?

    Answer. The President's memorandum is not for time immemorial. It 
provides that within 90 days of its issuance, the Director of OMB, in 
consultation with the Director of OPM, shall recommend a long-term plan 
to reduce the size of the Federal Government's workforce through 
attrition and that the ``freeze'' will expire upon implementation of 
the OMB plan. If confirmed as Secretary, I will take into account in 
weighing in with OMB and OPM the clearly important role our fraud 
fighters play which you outline.

    Question. During your time in Congress, you have supported 
proposals that would block grant Medicaid or put a per capita cap on 
Medicaid spending. The Congressional Budget Office has found that 
reversing the Medicaid expansion under the Affordable Care Act would 
lead to the loss of health care for millions of Americans and would 
lead to State funding shortfalls of $1 to $2 trillion.

    Do you support proposals to block grant or cap Medicaid? Do you 
agree that block granting or capping Medicaid would save the Federal 
Government as much as $1 to $2 trillion?

    Answer. Every State has different demographic, budgetary, and 
policy concerns that shape their approach to Medicaid. That is one of 
the reasons I devoted so much time to working with States to help them 
to identify creative solutions, and why I believe a one-size-fits-all 
approach is not workable for a country as diverse as the United States. 
Of course, the specifics of any particular proposal to provide more 
flexibility to States will determine its budgetary consequence.

    Question. The American Association of Actuaries has pointed to risk 
corridors and other risk mitigation programs as important mechanisms 
for stabilizing our insurance markets. These programs were also 
included in the Medicare Part D program and remain in place today. 
Please just give us a yes or no answer to the following questions.

    Do you support the use of these programs in Medicare Part D? Did 
you support these programs as a part of the State insurance 
marketplaces created by the Affordable Care Act? Do you think these 
types of programs should be included in any plan to improve on the ACA 
or to replace the ACA?

    Answer. Risk adjustment is used to adjust payments to health plans 
based on the relative risk of plan participants. Reinsurance has been 
used to reimburse insurers for the cost of individuals who have 
unusually high claims. And risk corridors are used to mitigate the 
pricing risk that insurers face when they lack data on health spending 
for potential enrollees. Part D has successfully deployed these 
mechanisms consistent with the underlying direction of Congress. The 
issue with any of these programs is often in the way they are 
implemented and the direction Congress gives with respect to them. In 
any current or future legislation, it would be important to consider 
these issues closely.

    Question. You have expressed concerns with delivery system reforms 
and in particular, bundled payments.

    Please talk about your recommendations for how we can move away 
from fee for service reimbursement to a health care payment system that 
rewards better health outcomes and reduced costs.

    Answer. For certain populations, bundled payments make a lot of 
sense. And they can often lead to both better health outcomes and 
reduced costs. But it is important we not get fixated on one of those 
two outcomes. That is, I support making certain that we deliver care in 
a cost-effective manner but we absolutely must not do things that harm 
the quality of care being provided to patients. What we ought to do is 
allow for all sorts of innovation. Not just in this area. There are 
things that haven't been thought up yet that would actually improve 
health-care delivery in our country and we ought to be incentivizing 
that kind of innovation. And in finding our way to those innovations, 
we ought to remember we are not talking about science experiments in a 
lab or a computer simulation, but about experiments involving real 
patients' lives.

    Question. During your time in Congress, how have you worked to 
strengthen and improve community health centers in your district and in 
the country? Do you think we should increase the presence of community 
health centers to increase Americans' access to health care?

    Answer. Community health centers are a vital part of our medical 
infrastructure. They fill a void in so many States and are often times 
the entry point if not the main source of health care. I have sought to 
support them to make sure they can provide the highest quality care and 
will continue to do so if confirmed.

    Question. I have always felt that we can't manage what we can't 
measure. You point to having good metrics as an important tool for 
ensuring we've made good progress. I agree with you wholeheartedly.

    With your wealth of experience as a physician, a State legislator, 
a Congressman, and the chairman of a major House committee writing 
major legislation, please share with me the metrics we should use to 
measure our progress towards a more just and equal health-care system 
that ensures affordable and high quality health care for all Americans. 
If you cannot name any specific metrics, can you outline the process by 
which we should determine what metrics we should use to measure 
progress towards increasing access to health care?

    Answer. The fundamental metric for knowing that our system is on 
the right track is the centrality of the patient in the system and 
their ability to make choices about their care in consultation with 
their doctor. Without that, the most impressive facilities and 
technology are not serving our people's needs, nor is the most 
efficient system doing what is most important. With the patient at the 
center of the system as a foundation, all else is possible and 
achievable.

    Question. During the debate over the Affordable Care Act, Congress 
held more than 100 bipartisan hearings, roundtable discussions, and 
negotiations, which were predominantly open and transparent to the 
public. The legislation was open to amendment by both parties in 
lengthy committee markups and by the full Senate, completely evaluated 
by the Congressional Budget Office, and reported on extensively by the 
news media before Congress voted on final passage. I understand that 
you place a high premium on transparency and honesty.

    Will you commit to having the same level of bipartisan discussion, 
transparency, and honesty in putting together the President's proposal 
for reforming our country's health-care system and ensuring that all 
Americans will have affordable and high quality health care?

    Answer. The President has made clear his hope and plan for a 
replacement to Obamacare. At the same time, many in Congress have their 
own ideas. And the conversation about how those will play out is 
ongoing. That is the nature of our democracy. I certainly hope we will 
have bipartisan support for any approach to fixing the current system, 
which we must all agree is broken. If confirmed, I look forward to 
working with anyone in Congress willing to work with me and the 
administration generally to come up with the best replacement plan 
under the procedures and involving the processes the Congress considers 
appropriate so as to make available the highest quality care to all 
Americans.

    Question. Do you agree with the President that the sale of health 
insurance over State lines will increase competition and lower the cost 
of health insurance? Section 1333 of the Affordable Care Act already 
allows States to form interstate compacts to allow for the sale of 
health insurance over States lines? The States of Georgia, Maine, 
Kentucky, and Wyoming allow for out-of-state insurance sales, but 
virtually no out-of-state insurers have tried to sell insurance in 
these States. How would you increase the sale of insurance over State 
lines while maintaining consumer protections such as insurance coverage 
for contraception, preventive screenings, maternity care, and mental 
health treatment?

    Answer. The idea of allowing interstate sale of insurance may take 
many different forms. I agree with the President that it is an 
important option to increase competition and lower the cost of 
insurance. While the details of any such proposal would have to 
consider the extent to which benefit design varies among States, it is 
important that individuals be able to purchase the coverage that they 
want and there has to be a floor of creditable coverage.

                                 ______
                                 
               Questions Submitted by Hon. Chuck Grassley
    Question. As someone who is being considered to lead the Department 
of Health and Human Services, and as a physician, do you have any 
doubts about safety and effectiveness of vaccines?

    Answer. I understand the significant impact vaccines have had on 
our Nation's public health, as well as the importance of patients 
having confidence in the therapies they receive as part of their care.

    Question. As a physician would you recommend that families follow 
the recommended vaccine schedule that has been established by experts 
and is constantly reviewed?

    Answer. As a physician, I encourage individuals and families to 
consult with their physician on the most appropriate care for them and 
their loved ones.

                                 ______
                                 
              Questions Submitted by Hon. Robert Menendez
        clampdown on communications with the public and congress
    Question. Shortly after your hearing concluded, press reports came 
out that a memo was issued to employees of the Department of Health and 
Human Services and the National Institutes of Health prohibiting any 
external communication throughout the entire Department. Specifically, 
the press accounts quote the memo as stating ``[f]or your additional 
awareness, please note that (HHS employees) have been directed not to 
send any correspondence to public officials (to include Members of 
Congress and State and local officials) between now and February 3, 
unless specifically authorized by the Department[.]''

    I find this to be an unconscionable clampdown of information and a 
rejection of basic transparency and accountability standards that 
should seriously concern all Americans. This is made all the more 
concerning given the health-care, public safety, research, and 
biodefense programs that operate within HHS.

    Do you support this directive or any other department-wide order to 
suppress the flow of information between the Department of Health and 
Human Services, the public and Congress?

    If confirmed, do you commit to never imposing such restrictions on 
any agency, office, or employee at HHS that limits their ability to 
communicate with the public and Congress?

    During your hearing today you agreed ``to provide a prompt response 
in writing to any questions that may be submitted to you or addressed 
to you by any Senator of this committee[.]'' Do you believe this 
directive prohibits you from fulfilling that commitment to the 
committee?

    Were you aware this directive was going to be issued prior to the 
time of your hearing on January 24, 2017?

    Answer. The Acting Secretary Memo to Department of Health and Human 
Services operating and staff division heads is straightforward and 
consistent with the Chief of Staff Memo issued on behalf of President 
Trump with regard to regulatory review of new or pending regulations 
and guidance. As noted in the HHS memo, the purpose of the directive is 
to ensure ``President Trump's appointees and designees have the 
opportunity to review and approve any new or pending regulations or 
guidance documents.'' Furthermore, the Chief of Staff memo provides 
explicit exceptions for ``emergency situations or other urgent 
circumstances relating to health, safety, financial, or national 
security matters. . . .'' This request is standard for a new 
administration. With regard to correspondence to public officials, such 
as members of Congress, the memo outlines a clear and expedited process 
for adequate review and is by no means intended to impede the agencies 
or staff divisions from continuing their important work on behalf of 
the American people, including routine constituent service 
communications.
       fidelity to science and to debunking dangerous falsehoods
    Question. During the hearing I raised a series of debunked and fake 
health and science claims, all of which have been perpetrated and 
advanced by the Association of American Physicians and Surgeons, a 
group to which you currently, or previously, have been a member. These 
debunked and factually inaccurate claims include linking undocumented 
immigrants to a spike in leprosy, connecting abortions to breast 
cancer, and claiming that the HIV virus doesn't lead to AIDS. This 
group has also promoted widely debunked and untrue claims that 
vaccinations lead to the development of autism spectrum disorder. These 
are dangerous claims made all the more toxic for being promoted by a 
group comprised of medical professionals. What's even more dangerous is 
that the President himself has a long history of promoting falsehoods 
linking vaccinations to autism.

    Will you state unequivocally that vaccines do not have any link to 
the development of an autism spectrum disorder and confirm that such 
all claims are fraudulent and have been widely debunked?

    Answer. General scientific consensus at this time is that vaccines 
do not lead to autism spectrum disorder. As always, this is an area 
where patients and the parents of patients should consult with their 
doctor.

    Question. Will you, if confirmed to be the Nation's highest ranking 
health care official, actively work to debunk these types of false 
health-care and scientific claims?

    Answer. If confirmed, I will work to hold HHS to the highest 
scientific standards.

    Question. Do you ensure that no political appointee within any 
agency, department or office in the Department of Health and Human 
Services believes in, or has promoted, demonstrably false statements 
about health-care practices or debunked scientific claims?

    Answer. As a physician, I understand the importance of patients 
having confidence in the therapies they receive as part of their care. 
When confirmed, I commit to conducting the due diligence HHS must to 
ensure that factual, science-based information is clearly communicated 
to the American people.

    Question. Will you advise that the President not appoint anyone to 
the staff of the Executive Office of the President who believes in, or 
has promoted, demonstrably false statements about health-care practices 
or debunked scientific claims?

    Answer. As a physician, I understand the importance of patients 
having confidence in the therapies they receive as part of their care. 
When confirmed, I commit to conducting the due diligence HHS must to 
ensure that factual, science-based information is clearly communicated 
to the American people.
                             autism policy
    Question. Since I first learned that New Jersey has the highest 
incidence of autism in the country, I have been Congress's leading 
advocate for advancing Federal policy to help individuals and families 
with autism and other developmental disabilities. Recently, the CDC 
released updated numbers showing that 1 in just 41 children in New 
Jersey are diagnosed with an autism spectrum disorder by the age of 8. 
This is the highest rate in the Nation.

    In 2014, I authored the Autism Collaboration, Accountability, 
Research, Education, and Support Act of 2014, known as Autism CARES. 
Among the several key policies included in this law was the 
continuation of the Interagency Autism Coordinating Committee and the 
elevation of a senior Health and Human Service official to serve as the 
HHS Autism Coordinator.

    Do you commit to ensuring individuals appointed to these key 
positions maintain a fidelity to science, and will you ensure that they 
will have the ability and freedom to debunk false claims linking autism 
to vaccines (or any other similar demonstrable falsehoods) without fear 
of retribution from you or the White House?

    Do you commit to promoting, through your capacity as Secretary and 
through the President's annual budget, increased funding for autism 
research and supports and services programs?

    What specific steps will you take as Secretary to promote and 
support a robust environment throughout the Department that focuses on 
research into diagnosis, treatments, supports and services, 
specifically those targeting adolescents and adults with autism and 
other developmental disabilities?

    The Centers for Disease Control and Prevention report that a child 
with an autism spectrum disorder can be diagnosed as early as age 2, 
yet children are frequently much older at the time of diagnosis. List 
the specific steps will you take to promote early diagnosis and early 
intervention?

    Answer. As a physician, I understand the importance of patients 
having confidence in the therapies they receive as part of their care. 
If confirmed, I commit to conducting the due diligence HHS must to 
ensure that factual, science-based information is clearly communicated 
to the American people. HHS is involved in a number of autism-related 
initiatives with the important goal of helping the individuals and 
families living with autism. When confirmed, I look forward to 
continuing this important work on behalf of these individuals and 
families.

    Question. The Affordable Care Act, as part of the Essential Health 
Benefit Package for plans sold on the Marketplace, requires that all 
carriers provide coverage for behavioral health-care services, 
including those for autism. This was an amendment that I had included 
into the ACA, and it has provided families across the Nation with 
assurances that their children's coverage will provide them with the 
care they need.

    Do you commit to maintaining nationwide access to behavioral health 
care by preserving the Essential Health Benefits package?

    Answer. My hope is to move in a direction where insurers offer 
products people want and give them the coverage they want. And in so 
doing, we want to not lose sight of our shared objective of the best 
and highest quality care being available to every American. I refer to 
care because ultimately, having maternity or other coverage is not 
meaningful if one cannot access the care they need or the quality of 
care leaves them worse off. So we must work towards both coverage and 
care.

    Question. Do you strongly disavow any attempt to weaken this 
coverage standard or any attempt at the Federal level to preempt 
States, like New Jersey, that have a long-standing State requirement 
that insurance provides benefits that cover services for autism?

    Answer. I am respectful of the role of States and, if confirmed as 
Secretary, will work to provide States with flexibility along the lines 
described and consistent with President Trump's Executive order 
Minimizing the Economic Burden of the Patient Protection and Affordable 
Care Act Pending Repeal.

    Question. Medicaid is a literal lifeline to those with autism and 
other developmental disabilities. Every year, 50,000 of these 
individuals age out of school-based services and need access to home 
and community-based care to ensure they live as active and integrated a 
life as possible. This is largely accomplished through Medicaid.

    List the specific policies will you promote as Secretary to expand 
access to home and community-based services for individuals with autism 
and other developmental disabilities?

    Answer. Every State is unique in their specific approach to the 
provision of services for the population eligible to receive HCBS, and 
we stand ready to assist States as they develop strategies to meet 
their particular goals.

    Question. List the specific steps will you take to improve outcomes 
for transition-aged youth and ensure that they maintain access to 
services and supports?

    Answer. If confirmed, I would work as HHS Secretary to ensure that 
the Medicaid program is well administered, effective, and available for 
eligible beneficiaries and that the States/Governors are given the 
flexibility to pursue approaches that fit the needs of their States.

    Question. The Autism CARES Act of 2014 requires the Secretary of 
Health and Human Services to submit to this committee a report 
concerning young adults with autism and the challenges related to the 
transition from existing school-based services to those services 
available during adulthood. This report is long overdue.

    When will this report be finalized? Will you prioritize the 
finalization and submission of this report to Congress before March 31, 
2017?

    Answer. If confirmed, I would be pleased to work with you on the 
status and finalization of this report.
                        community health centers
    Question. Federally Qualified Health Centers (FQHCs) are the 
health-care home for more than 25 million patients nationwide with 
494,912 Community Health Center patients in New Jersey. In New Jersey, 
FQHCs save the State and hospitals millions of dollars when patients 
are seen at health centers rather than in emergency rooms. FQHCs cost 
of care is substantially lower than other types of providers, even 
though they provide a wide range of ancillary services not offered in 
other health-care settings. As an example, FQHCs in New Jersey have a 
lower average per-
episode cost than health centers nationally, and almost half that of 
hospitals.

    Further, community health centers are essentially one-stop shops 
for health care, providing medical, oral health, mental health, 
substance abuse, and other critical services at the same location. The 
23 New Jersey Community Health Centers make up the largest primary care 
network in the State, providing care to almost half a million patients 
in over 131 sites of care including in schools, homeless centers, and 
public housing. Beyond just providing health care, our State's FQHCs 
employ more than 180,000 individuals, and generate over $26 billion 
annually in economic impact to some of the Nation's most distressed 
communities.

    What is the specific dollar amount that Community Health Centers 
stand to lose as a result of ACA repeal and the repeal of Medicaid 
expansion funding?

    Answer. I am not aware of the specific dollar amount.

    Question. How many fewer patients will not get health-care services 
at Community Health Centers as a result of ACA repeal and the repeal of 
Medicaid expansion funding?

    Answer. I do not have this figure.

    Question. What will be the impact on any ongoing Community Health 
Center expansion project that will be halted as a result of ACA repeal 
and the repeal of Medicaid expansion funding?

    Answer. We are committed to supporting Community Health Centers, 
providing increased access to care for patients across the Nation.

    Question. Please provide an economic impact, including lost jobs 
and diminished economic impact, that will occur as a result of ACA 
repeal and the repeal of Medicaid expansion funding?

    Answer. To my knowledge, repeal of the ACA is projected to have a 
positive impact on the labor market and the economy.

    Question. If the ACA is repealed, list the specific steps you will 
take to further promote the importance of seeking preventative care 
rather policies which encourage patients to wait until they have to go 
to the emergency room?

    Answer. Our goal is to ensure that all Americans have access to 
affordable coverage that best meets the needs of them and their 
families so that they can receive preventative care from the doctor of 
their choice in a primary care setting.

    Question. Do you commit to maintaining current funding levels for 
Community Health Centers, not only in the Department's annual budget 
submission to Congress, but in ongoing operations that will be 
financially damaged by the repeal of the Affordable Care Act?

    Answer. I support Community Health Centers, however, funding levels 
are determined by Congress. If confirmed, I will uphold the law as 
passed by Congress and signed by the President.
                  interstate sale of health insurance
    Question. One of the policies that you and President Trump often 
refer to in your talks about an ACA ``replace'' plan is to allow 
insurance to be sold across State lines. As you must be aware, the ACA 
already allows for this, and several States--including your home State 
of Georgia--have passed State laws to allow for it too.

    In the 5 years since Georgia started allowing out-of-state 
insurance to be sold, how many insurance companies have started selling 
out-of-state plans?

    How has allowing out-of-state plans impacted consumer choice in 
available health insurance plans, what has been the impact on insurance 
costs, and what has been the impact on access to care in Georgia?

    How many States have indicated they want to form a compact to allow 
out-of-state plans, under the current law?

    How would this lack of interest on the part of States and insurance 
companies change under the plan you've previously proposed (e.g., title 
III of H.R. 3200, the Empowering Patients Act)?

    As a former physician who had to negotiate with insurance companies 
to be in their networks, wouldn't you prefer to work with an insurance 
company that knew you and your patients, or would you prefer one from 
across the country that knows nothing about you, your practice, or your 
patient population?

    Answer. It's no surprise that an overwhelming majority (85%) of 
Americans support the ability to purchase insurance across State lines. 
More important than insurance companies' views about more competition 
or State regulators' views about greater regulatory competition is the 
fact that American families are desperate for more affordable health-
care choices. It's our job to make certain that every American has 
access to the highest quality care and coverage that is possible. 
Opening up more health options for American families by allowing them 
to purchase a plan from another State will do just that. 
Understandably, insurance companies and States have been reluctant to 
take bold action to sell products across State lines with the heavy 
burden of Obamacare already on the books. Removing Obamacare's 
insurance mandates and regulations combined with the ability to reach 
more customers will ultimately reward American families with more 
choices at lower costs.

    Question. One of the consistent arguments you've made against the 
ACA is that it was a Federal takeover of health care and that oversight 
of the health industry is better left to States.

    If you do in fact believe that, how does undermining States and 
their insurance commissioners by imposing interstate sale of health 
insurance follow that same logic?

    Answer. If confirmed, I look forward to working with States to 
increase access to affordable coverage.
                  recusal from ama-related activities
    Question. The American Medical Association's (AMAs) House of 
Delegates is, to quote their website, the ``principal policy-making 
body of the AMA.'' You've been a Delegate for more than a decade and 
have presumably been involved in the development of the organization's 
policies relating to key issues before both Congress and HHS during 
that time. You've stated that if confirmed you intend to recuse 
yourself from any issues the AMA has worked on for 1 year.

    How did you determine that a year is a sufficient period of time 
for your recusal from all AMA-related activity?

    Answer. This matter has already been addressed with the OGE and 
designated agency ethics official, and I will abide by the obligations 
agreed to in my publicly available ethics agreement.

    Question. Does the clock on this year start on the day you assume 
the role of Secretary or do you currently consider that year to have 
already started?

    Answer. The terms of my publicly available ethics agreement, which 
I entered into in consultation with the Office of Government Ethics and 
my designated agency ethics official, make clear that the 1-year 
recusal window begins on the day of the confirmation.

    Question. If the Department's General Counsel, Office of Inspector 
General or any other authority within the HHS determines that a year 
recusal is insufficient to properly distance yourself from your 
previous work with the AMA, will you commit to extending the recusal 
period for the remainder of your tenure as Secretary?

    Answer. I will abide by the obligations agreed to in my publicly 
available ethics agreement, which I entered into in consultation with 
the OGE and my designated agency ethics official.

    Question. A quick search on the AMA's website shows that the 
organization has formally commented on issues as varied as Medicare 
Advantage, the physician fee schedule, FDA oversight of laboratory 
developed tests, Medicaid and CHIP, CMS quality measures, Medicare 
prescription drug benefits, electronic health record meaningful use 
requirements, guidelines for opioid prescribing, and the comprehensive 
joint replacement model you've spoken out against so frequently. 
Obviously the group representing doctors has myriad interests in the 
workings of virtually every agency and office within HHS.

    Please provide me with documentation outlining exactly how you will 
recuse yourself from all AMA-related activities, which includes 
specific details on the HHS policies this recusal impacts. Further, 
please provide a list of all personnel within the Department that will 
be designated to act on your behalf for all the listed polices for 
which you will be recused.

    Answer. This matter has already been addressed with the OGE and 
designated agency ethics official, and I will abide by the obligations 
agreed to in his publicly available ethics agreement.

    I have not yet been confirmed or hired any personnel to assist 
efforts in the Department of Health and Human Services.

    Question. As a member of the AMA's House of Delegates for more than 
a decade, it's safe to presume that you are familiar with, and 
supportive of, their policies. One of these policies states that the 
``AMA recognizes that uncontrolled ownership and use of firearms, 
especially handguns, is a serious threat to the public's health'' 
because they are the leading cause of premature death in the country.

    Do you agree that guns are a top cause of intentional and 
unintentional death, as the AMA states?

    As a member of the AMA's House of Delegates, at any point did you 
fight against the AMA taking a stance declaring guns to be a public 
health issue?

    Do you oppose government prohibitions on studying how gun violence 
affects the public health? If confirmed, will you commit to not 
imposing government prohibitions on any agency, department or office 
from conducting gun-related health research to improve public health?

    Answer. Violence is a challenge in our society that deserves 
greater attention. All Americans want our communities to be safe places 
to live, learn, work and play. To my best recollection, I have not 
taken an individual stance on this matter. To the question of how best 
to prevent the tragic loss of innocent lives, I believe we must take a 
hard look at the underlying issues contributing to these tragic events, 
including too often unmet mental health needs among our citizens. A 
proper diagnosis and treatment as part of patient-focused care are 
critical to ensuring we are identifying indicators of violent behavior 
that may contribute to tragic events.
                 evidence-based home visiting programs
    Question. I have been a strong supporter of the Maternal, Infant, 
and Early Childhood Visitation program (MIECHV), which has always 
enjoyed bi-partisan support. MIECHV was enacted as part of the 
Affordable Care Act to help States build capacity to provide in-home 
visits to at-risk mothers and families with the stated goals of 
improving maternal and child health, preventing child abuse and 
neglect, encouraging positive parenting, and promoting child 
development and school readiness.

    The Medicare Access and CHIP Reauthorization Act (MACRA), passed in 
2015, reauthorized the program for 2 years. This reauthorization 
maintains current funding, which unfortunately is only enough resources 
to provide services to only 3 percent of the eligible population who 
are currently receiving MIECHV services. This points to a missed 
opportunity to improve the life course development of children born 
into low-income households, while also reducing preventable government 
spending in the short and long term.

    Do you commit to supporting continuation of funding for the MIECHV 
program in the Department's annual budget submission? Do you recognize 
the value of the MIECHV program and its evidence-based design by 
proposing increases in funding to capture more than just 3 percent of 
those children and families who could greatly benefit through the 
program's services?

    Answer. I share your goal of increasing access to affordable, 
quality health coverage for rural America. While I cannot comment 
specifically on legislation that would reauthorize MIECHV, I look 
forward to working with you on examining this program's funding and 
working on ways to improve rural and child health using evidence-based 
approaches.
                          diversity in hiring
    Question. The Affordable Care Act expanded health-care coverage to 
millions of Americans who were previously uninsured. Because of the 
greater demands on the health-care industry, the ACA has also become an 
engine for job growth in the health related fields. This is especially 
true for women and people of color.

    For example, women represent 75% of the health-care workforce. 
Nearly half of workers in the long-term/residential and home health-
care services are people of color. The future of our American workforce 
in the health industry promises increasing diversity. Between 2003-2004 
and 2013-2014 the number of doctoral degrees conferred in health 
profession fields increased by 61 percent (from 41,900 to 67,400 
degrees).\14\ In 2013-2014, one-third of those doctoral degrees were 
awarded to people of color.\15\ The importance of a diverse workforce 
in the health industry has been well-documented in scientific 
literature. One of the more significant outcomes of a diverse workforce 
is greater access to and quality patient care.\16\ Diversity in the 
workforce also increases career opportunities for people of color.
---------------------------------------------------------------------------
    \14\ https://nces.ed.gov/programs/coe/indicator_svc.asp.
    \15\ https://nces.ed.gov/programs/digest/d15/tables/
dt15_324.25.asp.
    \16\ Mitchel, D.A. and Lassiter M.A. (2006) Addressing health care 
disparities and increasing workforce diversity: The next step for the 
dental, medical, and public health professions, American Journal of 
Public Health, 96 (12), pp. 2093-2097.

    Given the fact that the current administration intends on gutting 
the Affordable Care Act, which, along with leaving millions of 
Americans uninsured, will also leave thousands of women and minorities 
---------------------------------------------------------------------------
without an opportunity to build a career in their field of study:

    Will you commit to minimizing the impact of leaving thousands of 
incoming women and minority health-care professionals without a career 
path to look forward to?

    Answer. Workforce issues are a major challenge in health care. We 
should work together to expand career options and paths for all health-
care professionals.

    Question. The Department of Health and Human Services is among the 
most diverse agencies to work for within the government, except when it 
comes to its Hispanic labor force. In FY 2015, Hispanics comprised 
3.08% of HHS's workforce compared to 9.96% of the National Civilian 
Labor Force.\17\
---------------------------------------------------------------------------
    \17\ https://www.hhs.gov/sites/default/files/asa/ohr/spd/di/
newsletter/dinewsletterfallwinter
15.pdf.

    What concrete steps does the Department of Health and Human 
Services plan to take to increase diversity and inclusion in its 
---------------------------------------------------------------------------
agency, especially at its Senior and Executive levels?

    Answer. If confirmed, I would be pleased to work with you to 
identify steps that could be taken to ensure the Department is drawing 
upon the widest and most diverse pool of applicants possible in the 
hopes of it resulting in an even more diverse workforce.
                      diversity in health outcomes
    Question. Eliminating health-care disparities among Americans from 
minority racial and ethnic backgrounds has long been a bipartisan 
issue. In 1985 under President Reagan, then Secretary of Health a Human 
Services Margaret Heckler commissioned a report on Black and Minority 
Health where she noted that there was a ``continuing disparity in the 
burden of death and illness experienced by [. . .] minority Americans 
as compared with our Nation's population as a whole.'' The report, as 
she envisioned, should have marked ``the beginning of the end of the 
health disparity that has, for so long, cast a shadow on the otherwise 
splendid American track record of ever improving health.'' \18\
---------------------------------------------------------------------------
    \18\ https://minorityhealth.hhs.gov/assets/pdf/checked/1/
ANDERSON.pdf.

    Unfortunately that shadow is still cast over our country. There is 
a significant body of literature that indicates that disadvantaged 
populations, such as racial and ethnic minorities, still face systemic 
barriers to achieving ideal health. For example, African Americans are 
50% more likely to die from heart disease or stroke; Asian/Pacific 
Islanders are 60% more likely to have acute Hepatitis B, which causes 
liver disease; and African-American, Native Hawaiian/Other Pacific 
Islander, and Hispanic adults all have rates of HIV infection diagnosis 
that range from three to nine times the rate of non-Hispanic Whites. 
\19\ To that end, the Affordable Care Act established Offices of 
Minority Health within six agencies, thus expanding the work begun by 
President Reagan 30 years ago. The purpose of creating these offices 
was to have greater interagency coordination when it comes to 
eliminating minority health disparities.
---------------------------------------------------------------------------
    \19\ https://minorityhealth.hhs.gov/assets/pdf/
FINAL_HHS_Action_Plan_Progress_Report_11_2
_2015.pdf.

    To the extent that this administration has taken and will continue 
to take concrete steps to repeal the ACA, which created the Offices of 
Minority Health within the Agency for Healthcare Research and Quality 
(AHRQ), the Centers for Disease Control and Prevention (CDC), the Food 
and Drug Administration (FDA), the Health Resources and Services 
Administration (HRSA), the Centers for Medicare and Medicaid Services 
(CMS), and the Substance Abuse and Mental Health Services 
---------------------------------------------------------------------------
Administration (SAMHSA):

    Will you commit to prioritizing the elimination of minority health 
disparities in America a priority? Please provide specifics of how you 
plan to make this a priority.

    Answer. Health outcome disparities are a challenge and prioritizing 
work in this area is important. Using the proper metrics may provide 
important insight into new solutions.

                                 ______
                                 
     Question Submitted by Hon. Rob Portman and Hon. Sherrod Brown
    Question. HHS, through CMS, has a long tradition of supporting 
nursing education. Our State of Ohio is home to 12 facilities that 
receive Medicare pass-through funding for nursing education. Over the 
past few years, CMS support for nursing education funding has been 
under threat due to accreditation changes. We have authored a bill, the 
MEND Act that would ensure CMS support of nursing education through 
pass-through funding continues and that we can continue educating high 
quality nurses.

    If you are confirmed, will you commit to work with us in Congress 
to provide technical assistance and ensure that the MEND Act is quickly 
implemented if passed?

    Answer. I look forward to working with you on this issue and 
sharing both feedback and assistance regarding the important policy and 
technical issues in nursing education funding, an issue related to and 
similar to the challenges with physician shortages but broader in 
geographic scope and impact. If the law is implemented, and if 
confirmed, I will ensure it is implemented on the timeline Congress 
imposes.

                                 ______
                                 
  Question Submitted by Hon. Rob Portman and Hon. Robert P. Casey, Jr.
    Question. Section 154 of MIPPA 2008 specifically excludes from the 
Medicare DME competitive bidding program (CBP) CRT power wheelchairs, 
as well as the accessories that consumers use with those wheelchairs. 
Consistent with the law, Congress did not include those CRT items in 
Rounds 1 or Rounds 2 of the DME bidding program and has repeatedly 
expressed to CMS that it was not the intent of the law to apply bid 
rates to accessories used with CRT wheelchairs. Unfortunately, CMS has 
interpreted MIPPA contrary to congressional intent and in December 2014 
CMS posted on-line a ``Frequently Asked Questions'' (FAQ) document 
stating that starting in January 2016 CMS intended to use bid pricing 
information obtained from the CBP for standard wheelchair accessories 
to reduce the payment amounts for CRT wheelchair accessories.

    At the end of 2015, Congress included in the Patient Access and 
Medicare Protection Act (PAMPA) a 12-month delay (through December 31, 
2016) of CMS's planned application of CBP prices based on standard 
accessories to CRT accessories that share the same HCPCS code. In 
December 2016, as part of the 21st Century Cures Act, Congress included 
an additional 6-month delay that will expire on June 30, 2017.

    Based on your support for this non-application of CBP prices to CRT 
accessories as a member of Congress, if confirmed as Secretary of HHS, 
can you commit to work with Congress to correct this CMS policy and 
adhere to the intent of Congress in MIPPA?

    Answer. As a member of Congress, I have been engaged in 
understanding and improving the competitive bidding program. If 
confirmed, I will continue this work but with the different role of 
carrying out the law for the benefit of the American people. If 
confirmed, I fully expect to work with Congress on this issue and many 
others that arise when Congress's intent encounters the details of 
implementation. I also hope to bring to that role, if confirmed, the 
informative and valuable perspective of serving as a member of Congress 
writing and voting on these laws.

                                 ______
                                 
             Questions Submitted by Hon. Benjamin L. Cardin
                cmmi and health care delivery innovation
    Question. What are your views of State demonstrations, State 
innovation, and Centers for Medicare and Medicaid Innovation (CMMI) 
authority?

    Answer. I believe these authorities can be important ways to ensure 
there is flexibility in CMS programs and activities for the individual 
and varying needs of States.
                              drug prices
    Question. Last year the country was shocked by a series of price-
hikes on older, off-patent drugs by manufacturers who had played no 
part in the research and development that produced them. The Senate 
debated numerous solutions last Congress to prevent price gouging 
behavior, and many put the ball squarely in HHS's court.

    What is your view on HHS's role in preventing price-gouging, and if 
confirmed, how do you propose to use the Office of Secretary to ensure 
Americans have access to affordable prescription drugs?

    Answer. The issue of drug pricing and drug costs is one of great 
concern to all Americans. You have my commitment to work with you and 
others to make certain that Americans have access to the medications 
that they need. If confirmed, I look forward to focusing on how we can 
make health care more affordable, including prescription drugs. I share 
your concern regarding the importance of individuals and families being 
able to afford the prescription drugs they need.
                       emergency health services
    Question. The Balanced Budget Act of 1997 requires Medicaid managed 
care organizations (MCOs), and others, to cover emergency services 
without prior authorization and established a Federal ``prudent 
layperson standard.'' This standard defines an ``emergency medical 
condition'' as one that manifests itself by acute symptoms of 
sufficient severity (including severe pain) such that a prudent 
layperson, who possess an average knowledge of health and medicine 
could reasonably expect the absence of immediate medical attention to 
result in placing the health of the individual in serious jeopardy, 
serious bodily functions, or serious dysfunction of any bodily organ or 
part.

    Do you support this Federal policy?

    Answer. I appreciate the aim of this Federal policy is to ensure a 
minimum level of emergency room coverage for Medicaid managed care 
organizations. Every State has different demographic, budgetary, and 
policy concerns that shape their approach to Medicaid and potential 
Medicaid managed care coverage requirements. While I believe that in 
the long run a one-size-fits-all approach is not workable for a country 
as diverse as the United States, my hope is to make sure that Medicaid 
beneficiaries need not rely on the emergency room to reliably access 
care because they have a doctor they trust in their community and a 
strong relationship and reliable access to that doctor.

    Question. Will you ensure the Centers for Medicare and Medicaid 
Services continues to enforce the prudent layperson standard for all 
Medicaid MCOs?

    Answer. If confirmed as Secretary, I will faithfully implement laws 
written by Congress and the regulations issued by the Department. This 
includes enforcement action as appropriate. As a doctor who has 
actually treated thousands of Medicaid patients, I do care deeply about 
the Medicaid program and the access of Medicaid patients to actual 
care, not just a card they can carry with them.
                            federal workers
    Question. Do you believe that the Office of the Actuary's actuarial 
and economic projections should be based on ``best professional 
estimates'' and remain as free as possible from political 
considerations? Why or why not?

    Answer. In getting advice from any professional it is important 
that advice be objective and consistent with relevant professional 
standards. Just as I would expect that from any doctor I visit I would 
expect the same from an actuary.
                     global health security agenda
    Question. What are your views on President Obama's Global Health 
Security Agenda?

    Answer. In an interconnected world, no nation is safe from the 
risks posed by infectious diseases. I agree that the international 
community must continue to work together towards the common goal of a 
world safe from infectious diseases. I also agree that the 
international community must build-up our capacities in order to 
achieve this goal. If confirmed I will meet with the Office of Global 
Affairs and CDC to review the progress we have made on this agenda.

    Question. For decades the U.S. Government has been a leader in 
strengthening health systems around the world to prevent, detect, and 
minimize the impact of emerging infectious diseases. The United States 
is one of over 50 countries that have committed to the Global Health 
Security Agenda, which aims to help countries improve their capacity to 
prevent, detect, and respond to infectious disease outbreaks.

    As Secretary, how would you support and enhance global efforts to 
detect, prevent, and respond to diseases internationally to prevent 
them from becoming a threat to the United States?

    How will you ensure that we effectively address emerging crises and 
maintain our leadership role in global health?

    Answer. No global effort to detect, prevent, and respond to 
diseases internationally can be successful without an active and 
engaged United States. Rapid response in fighting infectious diseases 
is essential. Oftentimes, we can ensure these diseases do not spread to 
our shores if we do what we can to stop them spreading abroad. Few 
responsibilities are more important than keeping the public safe from 
potential public health pandemics and if confirmed I will make this a 
top priority.

    Question. America's approach to global health has been extremely 
successful, including the effort to move toward ending the epidemics of 
AIDS, tuberculosis and malaria. The hallmark of America's work against 
the three diseases has been to support results-oriented, accountable 
and transparent programming through the Global Fund and bilateral 
programs including PEPFAR, PMI and the USAID tuberculosis program. The 
Global Fund and our bilateral programs closely coordinate their work 
and depend on each other to implement comprehensive programming.

    As Secretary, will you be committed to continuing America's 
leadership against AIDS, TB and malaria through Global Fund 
investments?

    Answer. United States leadership has been crucial in fighting AIDS, 
TB and malaria. Should I be confirmed, I fully expect these efforts to 
continue as we build upon and learn from our past and current 
initiatives. HHS and CDC are critical to fighting a range of global 
health security threats from Ebola and Zika to polio and HIV/AIDS. Yet, 
as was made clear during the Ebola epidemic, severe shortages of health 
workers greatly hamper efforts for infectious disease prevention, 
detection and response.

    Question. HHS and CDC are critical to fighting a range of global 
health security threats from Ebola and Zika to polio and HIV/AIDS. Yet, 
as was made clear during the Ebola epidemic, severe shortages of health 
workers greatly hamper efforts for infectious disease prevention, 
detection and response.

    In your view, what is the role of the Department of Health and 
Human Services in growing and developing a better-trained health 
workforce worldwide?

    Answer. If confirmed as HHS Secretary, I look forward to working 
with the health secretaries of other nations in helping the world 
community train an international health workforce capable of tackling 
the myriad public health challenges of the 21st century.
                    graduate medical education (gme)
    Question. The current Medicare GME system is not producing enough 
doctors who will practice in rural America. Data show less than 5% of 
all graduates practice in rural areas. When Congress set limits on the 
number of Medicare funded GME slots (BBA 1997) there was clear intent 
in both the statute and the report language to treat rural training 
differently and provide special consideration to meet the needs of 
underserved rural areas. Unfortunately, the technicalities of the 
statute, and the regulations deriving from it, have not succeeded in 
achieving this intent.

    What will you do as Secretary of HHS, specifically, to support 
changes to Medicare GME to increase the production of physicians 
practicing in rural areas?

    Answer. I have always been a strong supporter of efforts to support 
medical education. Congress has used the Medicare program from its 
inception to invest in future generations of doctors. Regardless of 
what we do in Washington, health care should always be about that one 
to one relationship of a patient to a doctor. That relationship of 
course requires a doctor. And so I am hopeful we can continue to find 
ways to remove disincentives to the practice of medicine and its 
rewards as well as support the profession in other ways. This issue is 
all the more important in the case of a rural area, where there is 
already an ongoing physician shortage and difficulty in recruiting 
talent and capital for medical infrastructure. If confirmed as 
Secretary, I would look for opportunities to address these situations 
through GME but also through programs administered by the Health 
Resources Services Administration and by taking a closer look at 
telemedicine.
                                medicare
    Question. Your ACA replacement proposal, the Empowering Patient's 
First Act, eliminates benefit expansions for beneficiaries such as free 
preventive benefits (blood pressure screenings, colorectal screenings 
and immunizations) and closing the Part D donut hole which helped with 
out-of-pocket prescription drug costs.

    If confirmed as HHS Secretary, how will you prevent any care 
reductions for or our-of-pocket health-care cost increases to Medicare 
beneficiaries?

    Answer. In considering Medicare, it is important to appreciate that 
the bipartisan Medicare Trustees have told everyone that Medicare, in 
less than 10 years, is going to be out of the kind of resources that 
will allow us as a society to keep the promise to beneficiaries of the 
Medicare program. My goal, if confirmed, is to work with Congress to 
make certain that we save and strengthen Medicare. It is irresponsible 
for us to do anything else. If I am confirmed, my role will be one of 
carrying out the laws Congress passes and as to that I would convey to 
the Medicare population that we look forward to assisting them in 
getting the care they need.
                        mental health workforce
    Question. Mental health professions face chronic workforce 
shortages, and the future for many of these professions remain grim. 
For example, a recent survey from the American Association of Medical 
Colleges found that almost 60% of psychiatrists are aged 55 or older, 
making psychiatry the fourth oldest medical specialty in terms of 
practitioner age.

    Along with the overall shortage, the distribution of mental health 
practitioners heavily favors key urban and suburban areas of the 
country over rural regions. The 21st Century Cures Act requires the 
Substance Abuse and Mental Health Services Administration to develop a 
strategic plan every 4 years to identify strategies to improve the 
recruitment, training, and retention of a mental health and substance 
use disorder workforce.

    While this provision and similar provisions are steps in the right 
direction, the numbers clearly suggest that growing a robust workforce 
to meet the mental health and substance use needs of nearly 70 million 
Americans will be of paramount importance in the coming years. Please 
describe in detail how you, if confirmed, will support the growth of 
the next generation of mental health practitioners.

    What strategies will you use to encourage medical students and 
others to pursue careers in these fields?

    Answer. It is important that we as a nation make sure that every 
single individual has access to the kind of mental health and substance 
abuse care that they need. If I am confirmed, I look forward to working 
closely with you and the other members of Congress to faithfully 
execute the 21st Century Cures Act, which aims to ensure that the 
mental health profession is adequately staffed for current and the 
future generations.
                            minority health
    Question. In Maryland, the ethnic minorities make up roughly 41% of 
the State's population. This is important because the health outcomes 
of minority populations are significantly lower and morbidity rates are 
higher than that of majority populations. Your Department, HHS, 
recognized this when it produced with what is commonly called the 
Heckler Report back in the 1980s, under President Ronald Reagan, 
looking at what are now commonly called ``health disparities'' and the 
need for more health professionals coming from minority and 
underrepresented backgrounds.

    Racial and ethnic communities suffer disproportionate higher rates 
of illnesses, disabilities and preventable deaths. In fact, according 
to Johns Hopkins and University of Maryland researchers, racial health 
disparities cost the United States $229 billion between 2003 and 2006.

    The Affordable Care Act is allowing communities coverage and access 
to much needed care, treatment, and prevention services from diabetes, 
to cancer, to asthma, and more. Specifically, how do you plan to 
further the elimination of racial and ethnic health disparities?

    Answer. I am committed to ensuring that minorities in this country 
have access to the highest quality care. To address these challenges, 
we need to examine what is happening on the ground in these 
communities. From there, we can establish better metrics and better 
accountability, and I look forward to working with you on this when I 
am confirmed.
                  national institutes of health (nih)
    Question. Young scientists in the United States are finding it more 
difficult--and more time-consuming--to secure stable funding to launch 
their research careers, which stifles America's competitiveness. More 
and more talented young people are dropping out of the scientific 
workforce or choose not to enter in the first place.

    What do you plan to do to ensure barriers facing young scientists 
are addressed and can we count on your leadership to implement the 
recommendations that come out of the National Academies report?

    Answer. If confirmed, I will look at flexibilities given to us 
through the 21st Century Cures Act and the focus on ``young emerging 
scientists'' to better recruit and retain top talent in order to help 
us achieve our mission of promoting innovation in order to benefit 
patients and their families across the country.

    Question. What do you see as the future roadmap for NIH over the 
next four years?

    Answer. If confirmed, I will work with NIH leadership to map out a 
forward-
leaning NIH agenda. As I mentioned in my testimony, NIH is a true 
treasure for our country. With the increased resources provided in the 
Cures Act and the President's commitment to innovation and patient-
centric health care, great opportunities lie ahead for the NIH.
                            pediatric dental
    Question. According to the CDC, tooth decay (cavities) is one of 
the most common chronic conditions of childhood in the United States 
and if left untreated, tooth decay can cause pain and infections that 
may lead to delays in important cognitive skills, such as eating, 
speaking, playing, and learning.

    How will you plan to ensure that children will continue to have 
access to early prevention services for oral health?

    Answer. If confirmed as Secretary, I would hope to work with you to 
revisit the current CMS' ``Oral Health Strategy'' for children (https:/
/www.medicaid.gov/medicaid/quality-of-care/downloads/cms-oral-health-
strategy.pdf). I would also aim to provide States with flexibility in 
their Medicaid programs to provide both coverage and access to these 
services. Lastly, there may be opportunities to encourage innovation in 
both the coverage and payment for these services as well as the actual 
technology and even the relevant public health education strategies.
                   social services block grant (ssbg)
    Question. This important program funds a variety of social services 
programs, from child protection to elder abuse to Meals on Wheels. I 
see every day in Maryland how this grant program helps our neediest and 
most vulnerable citizens. You proposed eliminating this $1.7 billion a 
year program as the chairman of the House Budget Committee.

    What was your rationale for trying to eliminate this program, and 
what would you put in its place?

    Answer. During my time in Congress, I have been acutely aware of 
the need to eliminate duplicative programs and strengthen those 
programs that work. As a 2011 GAO report pointed out, SSBG is a program 
of fragmentation, overlap, and duplication. SSBG essentially offers no-
strings attached approach and a blank check to States. However, as SSBG 
continues to be a program authorized by Congress, I will do all I can 
to effectively administer this law should I be so honored as to be 
confirmed as HHS Secretary.
                        substance use disorders
    Question. The United States currently faces a growing epidemic in 
the form of prescription drug misuse, abuse, addiction and overdose. 
The numbers are disquieting. One person dies every 19 minutes from a 
drug overdose, now the leading cause of death among those ages 25-44, 
according to Johns Hopkins experts.

    In Maryland in 2015, fatal overdoses in the State were up 21 
percent from the year before, and nearly twice the number in 2010. 
There is an urgent need for evidence-informed solutions ready for rapid 
implementation.

    How will HHS balance the twin-priorities of preventing new cases of 
opioid addiction and expanding access to effective addiction treatment 
while safely meeting the needs of patients experiencing pain?

    Answer. The opioid epidemic is real. This epidemic is a rampant 
crisis that is harming families and communities across the Nation. I 
firmly believe it is vital that those suffering from substance abuse 
have continued access to addiction treatment. If confirmed, I am 
committed to working closely with you and the other members of Congress 
to ensure that the Substance Abuse and Mental Health Services 
Administration (SAMHSA) fulfills its duty of treating those who are in 
addiction recovery, and prioritizes prevention efforts to keep 
America's families and communities healthy.

    Question. Last month, the Centers for Medicare and Medicaid 
Services (CMS) granted Maryland a Medicaid section 1115 waiver to 
implement initiatives to address substance use disorders throughout the 
State. This is great news for my home State and a first step to 
addressing opioid abuse and heroin use. Now, Medicaid enrollees will 
have access to residential treatment for substance use disorders, 
putting them on the road to recovery.

    If confirmed as HHS, will you commit to ensuring States' ability to 
use Medicaid section 1115 models to provide life-saving care, including 
addiction treatment and recovery services covered by Medicaid, to 
Americans in need?

    Answer. If I am confirmed, I will work with CMS and SAMHSA to help 
low-
income adults with mental health and substance use disorders. With 
respect to Medicaid specifically, every State has different 
demographic, budgetary, and policy concerns that shape their approach 
to Medicaid. That is one of the reasons I devoted so much time to 
working with States to help them to identify creative solutions, and 
why I believe a one-size-fits-all approach is not workable for a 
country as diverse as the United States. Waivers are an important tool 
for States to innovate within the Medicaid program. If confirmed, I 
would work with CMS to ensure that it evaluates waivers like Maryland's 
on their merits, taking into account the desirability of States 
charting their own course, and ensure that they are compliant with the 
law.
             temporary assistance for needy families (tanf)
    Question. I am concerned that, while the TANF caseload had declined 
by over 60 percent over the last 2 decades, the number of children in 
poverty and deep poverty (meaning income below half the poverty line) 
has increased.

    What steps would you take to reverse this trend?

    Answer. If confirmed as HHS Secretary, I am going to do all I can 
to effectively and efficiently administer the laws passed by Congress 
to address and alleviate the very real problem of children living in 
varying levels of poverty.

    Question. Do you agree that TANF is not succeeding as a program 
even if caseloads are declining while the number of persons in poverty 
and deep poverty are increasing?

    Answer. Respectfully, I must disagree with this assessment of 
TANF's success. Since passage of TANF, we have seen employment rates of 
single mothers increase, lower poverty rates among female-headed 
households with children and African-American households, a reduction 
in child poverty overall, and a sharp decline in the number of families 
receiving cash assistance.
                              therapy caps
    Question. As you know, the therapy cap exceptions process expires 
in less than a year--on December 31, 2017. We have all heard from 
constituents whose therapy needs exceeded the cap and their conditions 
have deteriorated, necessitating more expensive medical intervention.

    As Secretary of HHS, how will you support the repeal of these 
arbitrary and discriminatory limits and maintain access to 
rehabilitation therapy that Medicare beneficiaries clearly need?

    Answer. If confirmed as Secretary, I will look into this issue and 
seek to understand the competing objectives and issues motivating the 
current CMS policy. Part of the frustration with the current health-
care system is rules like this that do not make sense to many people. 
However, that is not surprising when one considers that Medicare Parts 
A, B, C, and D have each developed in silos and that even payment for 
particular types of services sometimes reflect silos within the silos. 
It may be that other approaches to therapy provide greater quality care 
at reduced cost with more respect for the individual needs of each 
patient in consultation with their doctor. If confirmed as Secretary, I 
would hope to break down these silos and encourage approaches based on 
a broader perspective.

    Question. Given the problems associated with monitoring the therapy 
cap, are the Centers for Medicare and Medicaid capable of achieving a 
timely uniform and defensible streamlined, responsive, and transparent 
process for manual medical review of Medicare records by Medicare 
administrative contractors?

    Answer. Any time there is manual review of anything in an 
organization with the scale of Medicare, there is a recipe for 
something to go wrong. If confirmed as Secretary, I would be pleased to 
work with you to confirm whether the staffing and other resources 
needed would be up to the challenge you describe.

                                 ______
                                 
                Questions Submitted by Hon. Dean Heller
                           medicaid expansion
    Question. Do I have your commitment to working with Congress, and 
members of this committee, to protect access to care for all patients 
in Nevada, particularly the over 600,000 Nevadans currently covered 
under Medicaid?

    Answer. I am committed to ensuring that Medicaid is available for 
eligible beneficiaries, and working with States to ensure they are able 
to make the most use of available resources to serve their citizens, if 
confirmed as Secretary of Health and Human Services. Each State has 
different needs, and I believe CMS needs to work with States to ensure 
that, consistent with those needs, the Medicaid and CHIP programs 
provide the best possible coverage to their residents.

    Question. Under your leadership, how will the U.S. Department of 
Health and Human Services work with States likes Nevada, who expanded 
Medicaid, to ensure that they are successful in protecting access to 
health care, particularly the 200,000 newly eligible Nevadans, as we 
transition out of Obamacare?

    Answer. I look forward to faithfully executing whatever law that 
Congress passes and the President signs, if I am confirmed. I will 
promise you this: Regardless of the final legislative outcome, I would 
work as HHS Secretary to ensure that the Medicaid program is well 
administered, effective, and available for eligible beneficiaries and 
that the States/Governors are given the flexibility to pursue 
innovative approaches that fits the needs of their States.
                            doctor shortage
    Question. Nevada is 47th in the Nation for doctor-to-patient ratio. 
What can Congress and HHS do to attract more health-care providers to 
practice medicine in rural and underserved areas in States like Nevada 
that are facing a significant doctor shortage?

    Answer. If confirmed, I would work closely with the Center for 
Medicare within CMS to see that critical access hospitals are able to 
serve rural populations well. I would also work with the HRSA (Health 
Resources and Services Administration) Administrator to consider how 
CMS and HRSA can best cooperate with regards to community health 
centers and other issues. I would also consider how we can allow for 
reimbursement of telehealth in general and to further help address 
provider shortages.

    Question. Do you believe that tele-medicine would be helpful for 
predominantly rural States like Nevada expand access to care for 
patients in underserved areas?

    Answer. Telemedicine is an exciting innovation that will allow for 
individuals to access resources that are otherwise not available. In 
the State of Georgia, we have a program that is a spoke and wheel 
program. There is a neurologist who works with a network of clinics and 
hospitals around the State. If somebody comes in with symptoms of a 
stroke, that neurologist is able to see the patient in real time and 
determine if they are having a stroke, whether they can be treated in 
the community or ought to be transferred. Innovations like this have 
been particularly helpful for rural areas.
                          financial disclosure
    Question. To the best of your knowledge, as a member of the House 
of Representatives, did you fully comply with the Stop Trading on 
Congressional Knowledge Act (STOCK Act, Pub. L. 112-105) and the Office 
of Government Ethics (OGE) to publicly disclose your personal financial 
transactions?

    Answer. To the best of my knowledge, I have met all compliance 
obligations for the disclosure of personal financial transactions by 
members of the House of Representatives.

    Question. If confirmed, do you commit to fully complying with the 
law that would require you to sell stock in companies regulated by HHS?

    Answer. If confirmed, I commit to fully comply with all applicable 
ethics and conflict of interest obligations required by law, including 
the divestment of all applicable securities identified for sale in my 
publicly disclosed ethics agreement with the Office of Government 
Ethics (``OGE'').
                        nevada state legislature
    Question. Please see the attached questions from the Nevada State 
Legislature. I respectfully ask that you respond to these important 
issues in the State, and cc Governor Sandoval.

    Answer. I look forward to writing to you and the Governor regarding 
these important issues. I expect my response will include the 
following.

    Q. What steps do you plan to take to ensure that the more than 
88,000 Nevadans who have purchased health insurance through the Silver 
State Health Exchange continue to have the ability to purchase health 
insurance with adequate coverage in a transparent marketplace?

    A. I think the conversation and focus in these topics has been the 
question of coverage rather than true access for too long. By that I 
mean that Americans might have an insurance card and yet not be able to 
afford care or it might not be available to them for other reasons. And 
so when we talk about coverage we ought to make clear what we really 
mean and want to have happen. In any case, the President has made clear 
his hope and plan for a replacement to Obamacare. The goal is to make 
certain that every single American has access to the coverage they want 
for themselves.

    Q. What steps do you plan to take to ensure that the more than 
77,000 Nevadans who are eligible for Federal tax credits under the 
Affordable Care Act to help purchase private insurance will continue to 
have access to affordable health insurance options with adequate 
coverage?

    A. I think the conversation and focus in these topics has been the 
question of coverage rather than true access for too long. By that I 
mean that Americans might have an insurance card and yet not be able to 
afford care or it might not be available to them for other reasons. And 
so when we talk about coverage we ought to make clear what we really 
mean and want to have happen. In any case, the President has made clear 
his hope and plan for a replacement to Obamacare. The goal is to make 
certain that every single American has access to the coverage they want 
for themselves.

    Q. What steps do you plan to take to ensure that the 217,000 
Nevadans who are receiving health care under the Medicaid expansion 
remain covered?

    A. Regardless of the final legislative outcome, I would work as HHS 
Secretary to ensure that the Medicaid program is well administered, 
effective, and available for eligible beneficiaries and that the 
States/Governors are given the flexibility to pursue innovative 
approaches that fits the needs of their States.

    Q. The Affordable Care Act guarantees coverage vital to 
preventative services for women, including cancer screenings and birth 
control. What steps do you plan to take to ensure that the Affordable 
Care Act's coverage guarantees remain intact for women's health?

    A. My hope is to move in a direction where insurers can offer 
products people want and give them the coverage they want. Getting to 
that kind of system requires changes that will inevitably involve 
working with Congress and considering the tradeoffs of various 
proposals to achieve our shared objective of the best and highest 
quality care being available to Americans. And note that I refer to 
care because ultimately, having maternity or other coverage is not 
meaningful if one cannot access the care they need or the quality of 
care leaves them worse off. So we must work towards both coverage and 
care.

    Q. The Affordable Care Act guarantees that Nevadans with pre-
existing conditions will not be denied health care and ends lifetime 
minimums on coverage. It also allows younger people, many of whom are 
saddled with college debt and cannot afford insurance, to stay on their 
parents' insurance until they are 26. What steps do you plan to take to 
preserve those coverage guarantees?

    A. Nobody ought to lose insurance because they get a bad diagnosis. 
As to coverage until age 26, the insurance industry has applied that 
across the board. In any case, if confirmed as HHS Secretary, my role 
would be to implement the replacement passed by Congress and signed by 
President Trump. Regardless of my own ideas, it is Congress that will 
ultimately decide what a replacement bill will look like, and my job 
would be to faithfully execute the law as passed by Congress.

                                 ______
                                 
             Questions Submitted by Hon. Michael F. Bennet
    Question. The Medicare Advantage program has been used to provide 
quality, affordable health care to about 18 million seniors and 
individuals with disabilities. Many of these seniors indicate that they 
are satisfied with their choice of Medicare Advantage program. In fact, 
36% of Coloradans are in Medicare Advantage plans.

    In your role as Secretary of HHS, how do you plan to support 
Medicare Advantage plans? What other steps do you plan to take to 
ensure that seniors have access to coordinated care plans?

    Answer. Medicare Advantage provides an important option for 
Medicare beneficiaries to access coordinated care and greater benefits. 
If confirmed as Secretary, I would seek to ensure Medicare Advantage 
remains a stable option for beneficiaries and that Medicare Advantage 
plans are afforded the flexibility to design plans that beneficiaries 
want and give them the coverage they want.

    Question. According to the Medicare Boards of Trustees, the 
Affordable Care Act (ACA) has extended the solvency of the Medicare 
hospital insurance trust fund by 11 years in total. The Committee for a 
Responsible Federal Budget estimates that a full repeal of the ACA 
would push up the insolvency date to 2021 and more than triple the 
program's 10-year deficit.

    How would you structure an ACA replacement bill that does not 
reduce the solvency of the Medicare Hospital Insurance Trust Fund?

    Answer. Neither President Trump nor I are wedded to a particular 
plan to the exclusion of all others. We are looking forward to giving 
the American people what they've been longing for, for 7 long years: 
real health-care reform. But they have never wanted Obamacare: It has 
raised premiums and deductibles, narrowed doctor networks, reduced 
choices of plans, limited Americans' liberty, and undermined the doctor 
patient relationship. A replacement need not affect the Medicare trust 
fund if the provisions related to Medicare are ones that are carefully 
considered.

    Question. Do you plan to advise the administration to advocate for 
premium support as a means of extending the Medicare trust fund?

    Answer. One of my goals in discussing these matters is to lower the 
temperature regarding what we are talking about. These issues have 
real-life impact for folks in their lives and so, if confirmed, I would 
advise the administration that we convey to the Medicare population 
that they do not have reason to be concerned and that we look to 
assisting them in getting the care they need and the caregivers that 
they need too.

    Question. Colorado has 2.3 million people living with a pre-
existing condition that rely on the protections of the ACA to receive 
coverage.

    How would your plan keep coverage for pre-existing conditions and 
control costs while dissolving other parts of the ACA such as the 
individual mandate, the exchanges, and Medicaid expansion?

    Answer. Our goal is to ensure every single American has access to 
the coverage they want for themselves and ensures the individuals who 
lost coverage under the Affordable Care Act get or maintain coverage. 
If we preserve the patient-doctor relationship and put the patient at 
the center, then we will see quality go up and costs go down. In any 
case, I look forward to faithfully executing whatever law that Congress 
passes and the President signs, if I am confirmed.

    Question. I have heard from rural hospitals in Colorado that may 
lose significant funding if the ACA is repealed. The Medicaid Expansion 
provided some financial stability to hospitals that were on the brink 
of closure before the bill was passed. In fact, hospitals in Colorado 
saw a 30% drop in uncompensated care.

    What metrics would you use to ensure that an ACA replacement does 
not hurt rural or critical access hospitals?

    Answer. Our goal is to ensure every single American has access to 
the coverage they want for themselves and ensures the individuals who 
lost coverage under the Affordable Care Act get or maintain coverage. 
This of course includes individuals who access care at rural or 
critical access hospitals. And so the best metric in the end is one 
that measures the extent of access to actual care, not just coverage 
and the quality of that care as determined by patients working 
individually with their doctors.

    Question. You have included health savings accounts in previous 
proposals to replace the ACA. As you know, health savings accounts are 
essentially a way for people to save their own money that they can then 
spend on health care. They are not a substitute for quality coverage 
and are paired with a high deductible, making it difficult to obtain 
health care.

    How can a middle-class family making $60,000 a year successfully 
use a health savings account if they live paycheck to paycheck and 
can't afford to set aside thousands of dollars to pay for their health-
care bills?

    Answer. Our goal is to ensure every single American has access to 
affordable coverage they want for themselves and their families. Health 
savings accounts are powerful tools that can be used to help lower 
costs and empower individuals, providing greater flexibility to spend 
health-care dollars as they see fit.

    Question. The ACA took steps to enhance price transparency of 
health-care services by requiring health plans to be more explicit 
about what they cover. A knee replacement in the United States could 
cost $11,000 in one area of the country and nearly $70,000 in another 
area. Consumers are still largely unaware of what they will be billed 
after a certain test or procedure.

    What steps do you plan to take as HHS Secretary to improve price 
transparency for consumers?

    Answer. If confirmed as HHS Secretary, I would work to improve 
price transparency to foster and facilitate patient choice. In so 
doing, I would be focused on actual costs and not costs billed to 
insurance companies or from a master price list no one uses. At the end 
of the day though, until patients rather than government are making the 
purchasing decisions, the price transparency information we might aim 
to provide is of limited utility because it does not reflect the 
patients' collective choice and willingness to pay but the 
government's.

    Question. I worked with Senator Portman to introduce the Medicare 
PLUS Act which would set up a pilot program to help the top 15% of the 
highest-cost Medicare beneficiaries by coordinating their health care 
needs. As you may know, 15% of Medicare beneficiaries have six or more 
chronic conditions and account for 50% of total Medicare spending.

    What steps will you take as HHS Secretary to pilot this program and 
ensure that these patients get the coordinated care they need?

    Answer. If confirmed as Secretary, I would explore what voluntary 
options we can make available to the Medicare beneficiaries with the 
greatest needs and their physicians. I think many will appreciate the 
opportunity to work with a care manager and possibly others who will 
spend the time and effort needed to help the patient make different 
choices to manage their own care. I would seek to work with you on your 
proposal to explore how it and others like it can be a path to 
empowering those who are subjected to the most uncoordinated and 
challenging aspects of our health-care system.

    Question. Congress and the last administration have made it a 
priority to pursue delivery system reforms that improve quality and 
lower costs. The Advancing Care for Exceptional (ACE) Kids Act, on 
which I worked with Senator Grassley, aims to coordinate care for 
vulnerable children with complex medical conditions.

    What steps will you take as HHS Secretary to promote increased 
emphasis on reforms that target the needs of children with complex 
medical conditions?

    Answer. If confirmed as Secretary, I would look across the 
Department to identify all the ways in which HHS aims to help these 
children in need. And I would hope to encourage our use of existing 
authorities and funding to better align resources to meet this 
challenge. I would also work with members of Congress on their ideas on 
this important topic.

    Question. Over 500,000 children in Colorado are enrolled in 
Medicaid. Nationally, the program covers over 30 million kids.

    If Medicaid is transformed from an entitlement program to a block 
grant, can you guarantee that those children will maintain coverage? 
What metrics will you use to ensure that those children are covered and 
have access to the same services that they do today?

    Answer. It is important that every child has access to high-quality 
health coverage, and Medicaid plays an important role in accomplishing 
this objective. If confirmed as Secretary, my goal would be to ensure 
that no child in Colorado or anywhere else is left behind.

    Question. The Children's Health Insurance Program (CHIP) currently 
covers 60,000 children in Colorado, increasing access to routine check-
ups, prescriptions, and emergency services for vulnerable kids. 
Extension of the program needs to occur early this year in order for 
States to plan and have budget certainty.

    What is your position on CHIP? What reforms would you recommend as 
HHS Secretary before supporting extending the program?

    Answer. It is important that every child has access to high-quality 
health coverage, and CHIP plays an important role in accomplishing this 
objective. CHIP plays a major role in this, but there is also a need 
for coordinated family coverage in the private market and employer 
plans, and giving States the needed flexibility.

    Question. The National Health Service Corps Loan Repayment Program 
has been vital in supporting primary care providers who then practice 
in Health Professional Shortage Areas (HPSAs). The ACA expanded this 
program and it has added necessary primary care providers in Colorado.

    If confirmed as HHS Secretary, will you recommend that Congress 
support this program to increase the number of primary care providers 
in rural and underserved areas?

    Answer. As a physician, I understand the value and importance of 
the National Health Service Corps (NHSC) and the NHSC Repayment 
Program. I have included loan forgiveness for primary care providers in 
past legislative proposals, and I look forward to working with Congress 
on this issue when I am confirmed.

    Question. The Pharmacy and Medically Underserved Areas Enhancement 
Act recognizes pharmacists as health-care providers in underserved 
areas in order to expand access to care. In areas with a shortage of 
primary care providers, pharmacists may play a key role in helping 
patients manage their diseases to avoid Emergency Department visits and 
hospitalizations. These services are especially important for patients 
with multiple chronic conditions who may be taking several medications 
at a time. As HHS Secretary, would you support this approach as a way 
to increase care in rural and underserved areas?

    Answer. We ought to step back and say, ``What are we doing wrong?'' 
as one out of every eight physicians no longer sees Medicare patients. 
Therefore, if confirmed as Secretary, I would be open to all options to 
address the impact of the ongoing physician shortage in rural areas. 
Paying pharmacists in underserved areas to engage in certain medical 
services could work well in those States where pharmacists have such 
licensure and a setting appropriate to the services, where primary care 
doctors continue to be involved in care, and where there is a patient 
and consumer demand for such services.

                                 ______
                                 
               Questions Submitted by Hon. Sherrod Brown
                           medicaid expansion
    Question. During your testimony in front of the Senate HELP 
Committee last week, you told Senator Murkowski that Medicaid is an 
absolutely imperative program. You also said, in a response to one of 
Senator Young's question, that Medicaid is a program where ``the States 
know best how to care for their Medicaid population.''

    I agree that every State's role in the Medicaid program is 
significant, which is why I want to protect State flexibility when it 
comes to this program. Thirty-one States--including my home State of 
Ohio--have made the decision to expand Medicaid coverage under the 
Affordable Care Act (ACA).

    Ohio's Governor John Kasich, in a letter to Senator Hatch just last 
week, wrote ``we strongly recommend that States be granted the 
flexibility to retain the adult Medicaid coverage expansion and Federal 
matching percentage.''

    Governor Kasich's letter also said that those States that have 
opted to expand Medicaid are experiencing significant positive results. 
In Ohio, high-cost ER utilization has gone down, health status has 
improved, and most enrollees have found it easier to keep or find work. 
Further, thanks to ACA's Medicaid expansion, Ohio was able to extend 
coverage to 700,000 previously uninsured Ohioans.

    Do you support the flexibility provided to States under the ACA to 
expand Medicaid?

    Answer. State flexibility is an important component in making 
Medicaid more workable for patients. Every State has different 
demographic, budgetary, and policy concerns that shape their approach 
to Medicaid and Medicaid expansion. That is one of the reasons I 
devoted so much time to working to help identify creative solutions, 
and why I believe a one-size-fits-all approach is not workable for a 
country as diverse as the United States.

    Question. As a cabinet-level advisor to the President, how will you 
advise the President on any bill that would limit a State's flexibility 
to expand Medicaid--like Ohio did--as provided for under the ACA?

    Answer. I look forward to faithfully executing whatever law that 
Congress passes and the President signs, if I am confirmed. 
Furthermore, I am committed to ensure that the Medicaid program is well 
administered, effective, and available for eligible beneficiaries and 
that the States/Governors are given the flexibility to pursue 
innovative approaches that fit the needs of their States.

    Question. As part of the Medicaid program in Ohio, Governor Kasich 
has led efforts to engage providers, payers, community organizations, 
and employers and encourage them to work with the Medicaid population 
and provide a ladder out of poverty. As a result, more than 70% of the 
expansion population in Ohio reports that, since getting covered, it 
has been easier for them to keep or find a job.

    One program in particular, CareSource's Life Services pilot program 
provides supports and mentoring to help individuals achieve physical 
and behavioral health and economic stability. The CareSource Life 
Services program could serve as a national model for lifting 
individuals out of poverty.

    As Secretary of Health and Human Services, how will you work to 
support and expand funding for programs like Life Services?

    Answer. I understand that some enrollees in CareSource's Medicaid 
managed care product have access to a program called Life Services 
which provides services and supports to help the enrollees obtain and 
keep jobs. Although I understand this Life Services program is a 
benefit of the managed care plan and not part of an Ohio Medicaid 1115 
waiver demonstration, I would be interested to explore with you and 
others how such programs might be integrated or associated with a 
Medicaid waiver. This kind of development shows why waivers are an 
important tool for States to innovate within the Medicaid program, as 
they have for many years prior to the ACA becoming law.
                   medicare negotiations/drug prices
    Question. Last week when you testified in front of the HELP 
Committee, you were also asked how we should address the high cost of 
prescription drugs.

    You avoided answering questions from many of my colleagues by 
saying that, as Secretary of HHS, your job will be to ``administer'' 
programs and not ``legislate.''

    President Trump supports the elimination of the noninterference 
clause in Medicare Part D. He would like to have the Centers for 
Medicare and Medicaid Services (CMS) negotiate directly with drug 
manufacturers to get the best deals on prescription drugs for our 
Nation's seniors.

    If Congress passes legislation supported by the President that 
gives the Secretary of HHS the authority to negotiate and this 
legislation is signed into law--would you use this administrative 
authority to negotiate better prices on behalf of the more than 40 
million Part D beneficiaries?

    What are your ideas on effective ways to reduce out-of-pocket 
prescription drug costs for Medicare beneficiaries?

    Answer. We all share concern when prescription drug prices are too 
high for anyone to access the drugs they need. This especially concerns 
me as a doctor. If confirmed, I look forward to using tools Congress 
provides to lower health-care costs. In addition, we need to continue 
to build on the gains towards affordability allowed by the Generic Drug 
User Fee Act and find additional ways to facilitate more efficient 
generic entry. This starts with making sure that we are giving generic 
sponsors clear guidance so that they can prepare approvable 
applications on the first try. If I'm confirmed, I'm committed to 
working with the FDA (and Congress, if appropriate) to find additional 
efficiencies and administrative steps that can help facilitate 
appropriate generic entry.
                       fair pay/home-care workers
    Question. The majority of the home-care workforce--or those 
individuals who provide services to older Americans and individuals 
with disabilities who receive home- and community-based services 
through Medicaid--is made up of female workers.

    This workforce is primarily paid through Medicaid and, on average, 
States pay these workers an average of just $13,000 a year. This means 
that those women caring for the disabled and elderly are often forced 
to rely on Medicaid themselves.

    In order to provide the highest level of quality care to our most 
vulnerable Americans--the elderly and those with disabilities--do you 
agree that those home-care workers providing this care full time should 
be paid more than $13,000 a year by their State Medicaid program--
``yes'' or ``no''?

    Answer. I agree it is important to provide those who care for our 
most vulnerable total compensation that reflects the important work 
they do. In many cases, this compensation may include more than wages 
and could, depending, e.g., on housing prices, be significantly more 
than the number given.

    Question. Past leadership at CMS committed in writing to exploring 
Federal actions under its current authority that could work with States 
to strengthen and support home-care workers. In a meeting with Finance 
Committee Staff last week, you expressed an interest in building off of 
the work of the prior administration.

    Will you commit to continuing this work to ensure fair pay and 
advancement opportunities for the home-care workforce. Describe how you 
would go about achieving this goal.

    Answer. If confirmed, I would be pleased to work with you to 
explore such options. One potential issue is to ensure that such 
workers are not somehow considered State employees and therefore 
subject to unique requirements and diversions from income that relate 
to that labor workforce. Another longer term situation is to empower 
patients, as the ultimate recipient of these services to make choices 
regarding providers of these services that leads to a competitive 
market for higher performing workers who satisfy customers.
                        infant mortality/tobacco
    Question. Ohio has one of the highest infant mortality rates in the 
country. In 2015, our State ranked 42nd in the Nation for infant 
mortality, and even worse for African American babies.

    We don't know exactly why Ohio does so poorly when it comes to 
infant mortality, but one thing that we do know is that health 
complications caused by preterm births are the leading causes of infant 
mortality. We also know that a major factor in premature births is 
tobacco use, and Ohio's smoking rate among pregnant women is nearly 
twice the national rate.

    In addition to providing coverage to an additional 20 million 
Americans, the Affordable Care Act also strengthened Medicaid coverage 
of services that help tobacco users to quit. Local groups have taken 
advantage of these provisions in their fight against infant mortality.

    Medicaid covers nearly 50 percent of births in this country. Do you 
support the current requirement that State Medicaid programs provide 
pregnant women with effective tobacco cessation services without cost 
sharing?

    Answer. The science is pretty clear that tobacco use during 
pregnancy is risky for both moms and babies. States should have maximum 
flexibility to prioritize critical health risks such as smoking during 
pregnancy. When it comes to Medicaid requirements, I hope to return a 
lot of control to States, and if confirmed, I will be reviewing such 
requirements and their efforts in order to develop policy 
recommendations for reform.

    Question. How will you work with Congress to maintain this 
requirement so that all pregnant women--regardless of their income--has 
access to tobacco cessation services?

    Answer. The science is pretty clear that tobacco use during 
pregnancy is risky for both moms and babies. Availability of cessation 
programs is important. I look forward to faithfully executing whatever 
law that Congress passes and the President signs, if I am confirmed. 
Regardless, I commit to work as HHS Secretary to ensure that the 
Medicaid program is well administered, effective, and available for 
eligible beneficiaries and that the States/Governors are given the 
flexibility to pursue innovative approaches that fits the needs of 
their States.
                            infant mortality
    Question. As I mentioned in the hearing and in my question above, 
the infant mortality rate among African American infants in the State 
of Ohio is among the worst in the United States. The overall rate of 
infant mortality in Ohio is 42nd in the Nation. I have introduced 
legislation to improve prevention efforts nationwide by improving 
Federal reporting of infant and childhood deaths, putting the power in 
the hands of the Secretary of HHS to generate the metrics by which 
these incidences are reported.

    As Secretary of HHS, how would you work to ensure adequate funding 
for the issue of infant mortality, and which metrics and protocols 
would you use to improve reporting of infant mortality cases across the 
country?

    Answer. Infant mortality is a serious concern for our Nation. While 
many of the underlying factors that contribute to infant mortality are 
poorly understood, we know that certain health behaviors, including 
alcohol consumption and tobacco use during pregnancy, have contributed 
to higher rates of infant mortality in the United States. Access to 
prenatal care is also vitally important.

    If confirmed as Secretary of HHS, I would work to examine the range 
of HHS programs, including research to prevent infant mortality, 
programs to prevent child abuse and neglect, efforts to increase access 
to health services for low-income pregnant women and infants, childhood 
vaccination initiatives, home visitation programs, and other 
initiatives across the Department to ensure these resources are used 
more effectively to address this issue and, if necessary, seek 
additional funds.

    Regarding metrics used to report infant mortality, I agree that 
measurement is extremely important as we tackle this problem. I intend 
to work with the Congress and within the Department to bring more 
consistency and accuracy to how we measure infant mortality.
                      medicare part d/dir payments
    Question. As you know, community pharmacies serve on the front 
lines as health-care providers and play an integral role as part of the 
Medicare Part D benefit. In recent years, however, pharmacies have 
faced increasing uncertainty in their ability to serve Medicare 
beneficiaries due to the increasing use of post-claim adjudication 
price concessions and fees imposed by pharmacy benefit managers, called 
Direct and Indirect Remuneration (DIR) fees.

    CMS has recognized issues with how DIR fees are reported by part D 
plan sponsors, how these fees impact pharmacy business, and the 
resulting challenges they create for Part D beneficiaries. To respond 
to these issues, CMS proposed guidance (Proposed Guidance on Direct and 
Indirect Remuneration and Pharmacy Price Concessions) to standardize 
the timing of how these fees are reported on September 29, 2014. This 
proposed guidance would help pharmacists better serve Part D 
beneficiaries by providing greater clarity about their reimbursement 
when medications are dispensed and would benefit beneficiaries in that 
they would be able to make more accurate comparisons in plan 
selections.

    Will you commit to supporting the finalization of such guidance? 
Are there other things you would do to ensure pharmacies have the 
information they need--in real time--to best serve their beneficiaries? 
If so, what are they?

    Answer. If confirmed, I will look forward to working with you to 
consider how to resolve this pending guidance issue. Incidentally, I 
understand that on January 19, 2017, CMS released a fact sheet with 
information about recent trends in drug costs and Direct and Indirect 
Remuneration (DIR) under Medicare Part D.
                                 epsdt
    Question. Identifying and treating conditions early in life--during 
childhood--before they become expensive long-term liabilities, is not 
only the right thing to do, but also cost effective. In 1967, Congress 
added a guaranteed benefit for children in the Medicaid program called 
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 
benefit.

    To this day, EPSDT continues to guarantee that children in the 
Medicaid program are appropriately screened and given the necessary 
treatments they need to thrive. If Medicaid were turned into a block 
grant--and existing Federal standards were cut back--EPSDT would be at 
serious risk, and child health would be put in jeopardy.

    Are you committed to maintaining EPSDT as a guaranteed benefit for 
children in the Medicaid program?

    Answer. Children are, and will continue to be, a high-priority 
population within the Medicaid program. States are well-positioned to 
determine the most appropriate ways to ensure access to the highest 
quality care for children, which includes diagnosis and screening 
procedures and the illnesses and conditions they uncover.

    Question. What are the most important metrics in evaluating the 
success of the EPSDT program?

    Answer. From a clinical perspective, successful diagnosis and 
screening procedures are determined by how well they identify illnesses 
and conditions. Successful treatment of those illnesses and conditions 
is best evaluated by the extent to which the patient's care goals are 
achieved.

    Question. If confirmed, how will you use your authority to make 
sure EPSDT remains an effective program in ensuring children's health 
through Medicaid?

    Answer. I look forward to working with States interested to advance 
initiatives designed to improve the quality of care provided to all 
Medicaid members, especially children.

    Question. Through the creation of the EPSDT benefit, Medicaid 
solidified dental services as a necessary component of coverage for 
low-income children and adolescents. Similarly, Congress recognized the 
need to include dental coverage as a requirement in the second 
iteration of the Children's Health Insurance Program (CHIP). The ACA 
then built on these two programs, and now pediatric dental coverage and 
preventive oral health services are included in many private insurance 
packages. Despite these advances, tooth decay remains the most common 
chronic condition among children.

    How would you ensure that any major health reform efforts 
appropriately prioritize children's oral health, both in terms of 
benefits and affordability?

    Answer. If confirmed as Secretary, I would hope to work with you to 
revisit the current CMS's ``Oral Health Strategy'' for children 
(https://www.medicaid.gov/medicaid/quality-of-care/downloads/cms-oral-
health-strategy.pdf). I would also aim to provide States with 
flexibility in their Medicaid programs to provide both coverage and 
access to these services. Lastly, there may be opportunities to 
encourage innovation in both the coverage and payment for these 
services as well as the actual technology and even the relevant public 
health education strategies.
                        medicaid payment parity
    Question. On average, Medicaid pays providers about 70 percent of 
what a Medicare provider receives for the same service. The only 
difference is the age of the patient being served. There are 45 million 
children enrolled in Medicaid and as you noted in your hearing, and 
inappropriately low Medicaid payments impede the ability of providers 
to accept more patients--both pediatric and adult--covered through this 
program.

    Along with Senator Murray, I have worked to introduce the Ensuring 
Access to Primary Care for Women and Children Act in past Congresses, 
legislation that would solidify parity between Medicare and Medicaid 
reimbursements for primary care.

    In today's hearing, you mentioned that only one in three providers 
accepts Medicaid patients. You cannot deny that lower Medicaid 
reimbursements is a contributing factor to this issue.

    This is a platform in which the HHS Secretary can take a stance and 
move legislation forward. Do you believe that a child's care should be 
valued at only 70 percent of that of an adult?

    Answer. A child's care should not be valued at only 70 percent of 
that of an adult. The current Medicaid payment system is an inelegant 
combination of base rates set by States, supplemental payments to 
providers, and other Federal and State funding sources for care to the 
Medicaid or uninsured populations.

    Question. If confirmed, how will you work to improve access to care 
under Medicaid by adequately and equitably reimbursing physicians that 
treat Medicaid patients?

    Answer. I agree that adequate Medicaid reimbursement is essential 
to ensuring care for some of our most vulnerable citizens, and I look 
forward to working with Congress to accomplish this important 
objective.
                                  lead
    Question. Dr. Price, do you believe that there is no safe level of 
lead in children's blood?

    Answer. Science should guide our conclusions in this area. If 
confirmed, I look forward to working with you to ensure safe 
environments for America's children.

    Question. The CDC very recently lowered its reference level for 
public health intervention for elevated childhood blood lead levels 
from 5 to 3.5 micrograms per deciliter.

    Lead is a neurotoxin, and exposure to it can have devastating 
lifelong consequences for children. Ohio is one of 29 States receiving 
funding from CDC for a State-wide lead poisoning prevention program. In 
2014, almost 6,000 children under age six in Ohio, or 3.85% of those 
tested, had elevated blood lead levels.

    If confirmed, will you keep the CDC's lowered lead reference level?

    Answer. If confirmed, I pledge to work with our public health 
specialists at CDC and throughout the Department to learn more about 
the impact of lead poisoning and communicate the dangers to families 
and communities.

    Question. At the end of 2016, CMS committed to developing and 
improving a targeted blood lead screening policy to ensure more 
children eligible for EPSDT benefits are tested. Can you commit to 
continuing this work and improving coordination across Federal agencies 
to enhance our lead screening and treatment policies and achieve better 
outcomes?

    Answer. If confirmed, I commit work to improve coordination across 
Federal agencies to enhance our lead screening and treatment policies 
to achieve better outcomes.

    Question. What additional actions would you have HHS take to reduce 
the number of American children with elevated blood lead levels?

    Answer. If confirmed, I pledge to work with our public health 
specialists at CDC and throughout the Department to learn more about 
the impact of lead poisoning and communicate the dangers to families 
and communities in order to reduce the number of American children with 
elevated blood lead levels.
             temporary assistance for needy families (tanf)
    Question. As part of welfare reform, Congress restructured the 
Temporary Assistance for Needy Families--or TANF--program as a fixed 
block grant. Evidence shows that one effect of turning TANF into a 
block grant program has been that States are spending less and less on 
TANF programs and instead using these Federal dollars to support gaps 
in State budgets. This change has resulted in more Ohioans who struggle 
to support their families with earnings below the poverty level.

    What does that say about other proposals to block grant programs 
like Medicaid? Do you think that the block grant approach should be a 
model for other safety net programs?

    Answer. While this would ultimately be a matter for Congress to 
decide, I have long supported States finding their own solutions in 
addressing unique or complex situations in their States.

    Question. In November 2015, the State of Ohio asked HHS for a TANF 
waiver that would have (1) removed the distinction between ``core'' and 
``non-core'' hours, (2) increased the vocational education training 
limit from 12 to 36 months, (3) increased the job search and job 
readiness time limit from 6 to 12 weeks and removed the 4 consecutive 
week time limit, and (4) removed the 16 hour monthly cap on good cause 
hours credited towards work participation (while maintaining the 80 
hour annual cap). HHS never acted on this request.

    Given that this application has the support of Governor Kasich, if 
confirmed as HHS Secretary, would you grant this waiver to the State of 
Ohio?

    Answer. In 2012, GAO responded to a congressional inquiry about an 
ACF Information Memorandum inviting States to apply for waivers to the 
TANF work requirement. GAO concluded that the Information Memorandum 
was a rule that must be submitted to Congress and the Comptroller 
General before taking effect. If confirmed as HHS Secretary, I will 
enquire about the status of this matter and the waiver request from the 
State of Ohio, and provide a response if one has not previously been 
sent.
                 medicare observation status/3-day rule
    Question. Instead of privatizing Medicare or raising the 
eligibility age, we should be discussing ways to make Medicare stronger 
for our Nation's seniors. One way to strengthen the program--which you 
brought up in today's hearing--is to enable beneficiaries better access 
to skilled nursing facilities after hospitals stays by revisiting the 3 
day rule.

    In order for Medicare Part A to cover skilled nursing facility 
care, a beneficiary must be admitted to a hospital for 3 days under 
inpatient status. I have heard from too many Ohioans whose skilled 
nursing facility care was not fully covered by Medicare because their 
hospital stays were classified as ``observation'' rather than 
inpatient.

    My Improving Access to Medicare Coverage Act, which I plan to 
reintroduce this Congress, which would enable time beneficiaries spend 
in the hospital under observation to count toward the 3-day requirement 
for Medicare coverage.

    If confirmed, will you work to administratively correct this 
billing technicality that adversely impacts Medicare beneficiaries? If 
you are unable to do so administratively, will you work with me to pass 
this legislation to correct the deficiency in current law?

    Answer. If confirmed, I will be pleased to work with you to further 
consider the necessity of the 3 day rule and its pros and cons. I will 
endeavor to work with CMS to identify what more can be done with regard 
to the observation status issue as well. And if the best path forward 
involves legislation, I would be pleased to work with you on that as 
well.
                              biosimilars
    Question. Last year, a number of my colleagues and I sent a letter 
to then President-elect Trump, encouraging him to work with us on 
reducing prescription drug prices for all Americans. Specifically, we 
highlighted the need to promote innovation and foster competition in 
drug development.

    I have introduced legislation in the past that would help achieve 
this by shortening the patent exclusivity period for expensive, brand-
name biologic drugs and allow biosimilars to enter the market sooner. 
Biosimilars, which are equivalent in safety and efficacy to their 
reference biologics, have the capacity to reduce prescription drug 
costs, yet physicians must be willing to prescribe them and patients 
need the information necessary for them to be confident in taking them.

    As a physician, do you believe physicians and patients understand 
what biosimilars are and how they work? Do you believe the patients and 
physicians see biosimilars as a safe, effective, and less-costly 
alternative to biologics?

    What do you believe to be the FDA's role in educating patients, 
providers, and other stakeholders about biosimilars? How will you, as 
Secretary of HHS, support and encourage the robust uptake of 
biosimilars in the United States?

    Answer. As a doctor, I appreciate your concern that health-care 
providers and patients be informed when making health-care decisions. 
It is important that the FDA provide clear and timely guidance as it 
carries out its responsibilities with respect to biosimilars. I 
understand that this is particularly important given that the number of 
biosimilars available to consumers is expected to increase and the 
potential that these products have to increase consumers' health-care 
options.
                              cost-sharing
    Question. More than 25 years ago, Congress implemented protections 
to ensure that Medicare beneficiaries are treated and billed fairly by 
their providers in response to growing concerns that patients charged 
more than the standard 20% Part B coinsurance were opting out of 
critical care due to high out-of-pocket costs. However, while you were 
in Congress, you backed legislation that would have weakened these 
protections, allowing Medicare providers to enter into private 
contracts with seniors and people with disabilities to determine cost 
sharing amounts.

    Do you maintain your position that these patient protections should 
be undone and will you continue to advocate for permitting doctors who 
serve seniors to charge them more than 20% over what Medicare pays, 
your concern being that those limits compromise access to care for 
seniors?

    Answer. If there are any program changes in this area, they should 
be voluntary for both patient and physician.

    Question. Do you believe that Medicare doctors should be allowed to 
charge patients whatever they choose?

    Answer. If there are any program changes in this area, they should 
be voluntary for both patient and physician.

    Question. What would you say to fixed-income seniors who receive 
unexpected additional costs simply so that physicians can be paid more 
than the agreed-upon insurance coverage limit? Is this not putting 
patients above profits?

    Answer. Our goal is to ensure all Medicare recipients are able to 
obtain the highest quality health care. If there are any program 
changes in this area, they should be voluntary for both patient and 
physician.
           state health insurance assistance programs (ships)
    Question. The State Health Insurance Assistance Programs (SHIPS) 
are the only source of one-on-one Medicare counseling for seniors and 
people with disabilities. In 2015, over 7 million people with Medicare 
received help from SHIPs, including 375,000 Ohioans using the Nation's 
best-ranked SHIP program in the country. Since 1992, counseling 
services have been provided via telephone, one-on-one in-person 
sessions, interactive presentation events, health fairs, exhibits, and 
enrollment events. Individualized assistance provided by SHIPs almost 
tripled over the past 10 years.

    This modest program is operated in every State and U.S. territory, 
and has been significantly under-funded for years despite the growing 
demand for services by our Nation's seniors and individuals with 
disabilities.

    Will you pledge to support increased funding for SHIPs as the 
country's Medicare-eligible population continues to grow in the 
President's proposed budgets?

    Answer. If confirmed, I will fairly consider the needs and work of 
the SHIPs in light of a growing Medicare population, as well as 
consider other ways to support them to make them even more efficient. 
SHIPs and others like them play an important role in making sure 
patients are actual health-care consumers. This is a virtuous cycle 
because it facilitates putting the patient at the center of both health 
care and health-care coverage decision-making.
                              drug pricing
    Question. In December, President Trump told Time magazine, ``I'm 
going to bring down drug prices. I don't like what has happened with 
drug prices.''

    Do you agree with President Trump? If confirmed as Secretary of 
HHS, will you work to bring down drug prices?

    Answer. Yes. We all share concern when prescription drug prices are 
too high for anyone to access the drugs they need. This especially 
concerns me as a doctor. If confirmed, I will ensure that CMS looks for 
ways to ensure that it uses the authorities and tools it has at its 
disposal to ensure drug prices in the Medicare program, in both part B 
and part D, are manageable for beneficiaries.

    Question. Given the significant burden prescription price tags have 
on individuals and taxpayers, what do you see as the best market-based 
solution to combat prescription drug price gouging?

    Answer. In addition, we need to continue to build on the gains 
towards affordability allowed by the Generic Drug User Fee Act and find 
additional ways to facilitate more efficient generic entry. This starts 
with making sure that we are giving generic sponsors clear guidance so 
that they can prepare approvable applications on the first try. If I'm 
confirmed, I'm committed to working with the FDA (and Congress, if 
appropriate) to find additional efficiencies and administrative steps 
that can help facilitate appropriate generic entry.

    Question. Do you believe that Americans deserve more information 
about when and how prescription drug prices rise so that they can make 
the most informed decisions for their families?

    Answer. Yes. I support empowering patients by putting more 
information in their hands so they can make health care consumer 
choices that make sense for them and their families.
                     office of refugee resettlement
    Question. The Secretary of HHS responsible for overseeing the 
Office of Refugee Resettlement at HHS. This office is in charge of 
providing for the basic needs of refugees when they first arrive in the 
United States, including victims of human trafficking, torture 
survivors, individuals who are granted asylum, and those who are 
resettled here after helping our troops abroad because it is no longer 
safe for them in their home country.

    If confirmed, what will you do to ensure these necessary services 
are provided despite a significant lack of funding for this program? 
What are your plans for this office?

    Answer. The law is clear when it comes to administering services 
for refugees, survivors of torture, and other populations who receive 
assistance through ORR. If I am confirmed, I will work to effectively 
and efficiently administer this Office.

    Question. Will you advocate for additional resources for this 
office, given the current refugee crisis across the globe?

    Answer. Should circumstances on the ground change, and current 
resources are found to be insufficient, I will inform Congress and work 
with them on finding solutions.

    Question. How will you work with our partners around the globe to 
ensure a safe and smooth transition for refugees coming into the United 
States?

    Answer. Should I be confirmed, it would be my expectation to work 
with the U.S. Department of State, as well as our partners around the 
globe, to ensure a safe and smooth transition for refugees coming into 
the United States.
           center for medicare and medicaid innovation (cmmi)
    Question. You've stated that you support innovation and see 
potential in CMMI. Would you support continued testing through CMMI in 
its current form?

    Answer. CMMI is a program providing significant opportunity for 
testing new models for health-care financing and delivery. I defer to 
the Congress regarding the funding of the Innovation Center and any ACA 
repeal and replacement legislation. If confirmed, as HHS Secretary--and 
if the Innovation Center remains funded--I will ask CMS to pursue 
models that will lower health-care costs and improve quality for 
Medicare and Medicaid beneficiaries.
                 accountable care organizations (acos)
    Question. Many hospitals, physicians, nursing facilities, and 
others have invested significant resources to participate in ACOs and 
bundled payment systems. Ohio is home to some of the largest ACOs, by 
membership, in the Nation.

    How would you respond to the concerns of ACO administrators and 
providers that there may be delays or disruptions in their innovative 
models due to a repeal of the ACA?

    Answer. If confirmed, I am committed to working with all providing 
health care to incentivize innovative models for care financing and 
delivery.

    Question. Do you support the continued implementation of the 
current voluntary models--ACOs and bundled payment models?

    Answer. In general, yes. I look forward to reviewing all models, if 
confirmed. As a physician, I appreciate the goal behind the creation of 
the ACO model: better patient care. As a legislator, I would agree 
their successes have been modest to date, and there are some challenges 
they face as well. ACOs are a tool in the toolbox to help ensure high 
quality, low cost health care for beneficiaries. They are not a silver 
bullet to all of our country's delivery system challenges. If 
confirmed, I plan to work with the CMS Administrator to ensure that we 
learn from ACOs' successes and challenges to date as we chart the path 
forward.

    For certain populations, bundled payments make a lot of sense. And 
they can often lead to both better health outcomes and reduced costs. 
But it is important we not get fixated on one of those two outcomes. 
That is, I support making certain that we deliver care in a cost-
effective manner but we absolutely must not do things that harm the 
quality of care being provided to patients.

    What we ought to do is allow for all sorts of innovation. Not just 
in this area. There are things that haven't been thought up yet that 
would actually improve health-care delivery in our country and we ought 
to be incentivizing that kind of innovation. And in finding our way to 
those innovations, we ought to remember we are not talking about 
science experiments in a lab or a computer simulation, but about 
experiments involving real patients' lives.
                          pama implementation
    Question. In 2014, Congress passed the Protecting Access to 
Medicare Act (PAMA), which included a provision to change the way labs 
are reimbursed under the Medicare program by moving away from the 
Clinical Laboratory Fee Schedule (CLFS) and toward a more market-based 
payment methodology.

    We are concerned that CMS's regulations implementing this 
provision, finalized in June 2016, contain a reporting deadline that is 
difficult for the laboratory community to meet. In addition, many of 
our community-based and regional laboratory constituents serving the 
Medicare program have expressed significant concerns over requirements 
from the regulation that make reporting accurate data a concern, and 
requirements from the regulation that result in the exclusion of market 
data from the hospital outreach laboratory community. Lastly, we have 
concerns over CMS's definition of an ``applicable lab'' in the final 
regulation. We believe the current definition would result in very few 
labs having to report their data.

    The Office of the Inspector General has also raised each of these 
issues--the timeline, accuracy, exclusion of hospital labs, and lack of 
required reporting--as potential flaws in the regulation in their 
September 2016 report, which addressed PAMA implementation. In fact, 
the OIG reported that only 5% of labs will be required to report payer 
data, excluding 95% of the market and thereby potentially skewing the 
market rates.

    In order to fulfill the goals of PAMA, it is critical that the 
market data collected and assessed by CMS represents the entire 
laboratory market, consistent with the statute, to ensure both 
equitable and successful implementation of the law. Understanding that 
this regulation is on a short time-line, given that CMS is set to 
finalize a new fee schedule in 2017 for implementation in 2018, what 
would you do to address the concerns listed above and ensure the new 
market-based payment methodology and payment processes for clinical 
laboratory tests are not unduly burdensome on community-based labs or 
potentially detrimental to patient access?

    Answer. I appreciate your concerns regarding the implementation of 
PAMA. Certainly, we should strive for accuracy in this market data 
collection process. I look forward to following up with CMS staff and 
agree that community-based labs should not be unduly burdened and thus 
limiting patient access.

    Question. Will you commit to revisiting the definition of 
``applicable lab'' to ensure equitable and successful implementation of 
the law, accurately reflecting the entire market?

    Answer. As you know, section 216(a) of the Protecting Access to 
Medicare Act of 2014 (PAMA) added section 1834A to the Social Security 
Act (the Act), which requires revisions to the payment methodology for 
clinical diagnostic laboratory tests paid under Medicare, including 
reporting requirements for laboratories.

    CMS finalized a low expenditure threshold to reduce the reporting 
burden on small laboratories. Under the final rule, CMS will generally 
exclude a laboratory from being an applicable laboratory, and thus from 
having its private payor data reported, if it is paid less than $12,500 
under the CLFS during a data collection period. CMS expects that 95 
percent of physician office laboratories and 55 percent of independent 
laboratories will not be required to report. Additionally, I understand 
CMS-imposed reporting requirements at the TIN level will be less 
administratively burdensome for the laboratory industry as compared to 
requiring data to be reported at the NPI level.
                 medicaid and family planning services
    Question. Two-thirds of births from unintended pregnancies in the 
United States are paid for by Medicaid or the Children's Health 
Insurance Program (CHIP). In 2010, these unintended pregnancies cost a 
total of $21 billion dollars, including $824 million in Ohio.

    We know that publicly funded family planning allows families to 
prevent unwanted pregnancies, and it is estimated that investing in 
family planning services would have saved public funding of unintended 
pregnancies by a total of $15 billion, including $607 million for Ohio. 
That's striking--almost 75 percent of the money that would otherwise be 
spent could be saved through more robust, fully funded family planning 
programs.

    Do you acknowledge the effectiveness of investing in contraception 
and the need to continue the Medicaid State option to expand family 
planning services?

    Answer. If confirmed, I would work as HHS Secretary to ensure that 
the Medicaid program is well administered, effective, and available for 
eligible beneficiaries and that the States/Governors are given the 
flexibility to pursue approaches that fit the needs of their States. 
That being said, I would be hesitant to develop policy on the basis of 
financial cost of life.

    Question. How will ensure that family planning services, included 
access to preferred contraception methods, will remain available to all 
women, as you committed to do in today's hearing?

    Answer. Women should have the health care that they need and want. 
The system we ought to have in place is one that equips women and men 
to obtain the health care that they need at an affordable price. As we 
work towards a replacement for the ACA, I expect this will be one of 
the topics of discussion.
                            federal research
    Question. As chairman of the House Budget Committee, you stated in 
your FY17 Budget Resolution that ``the Federal Government has a role to 
play in supporting breakthrough research.'' As a medical doctor, you 
must understand the importance not only of funding research to find 
better cures for your patients, but also of funding the training of the 
next generation of doctors and researchers.

    If confirmed, how do you pledge to protect and advocate for the 
government's critical Federal research initiatives?

    Answer. As a physician, I am keenly aware of the progress that has 
been made and still to be made through important research initiatives 
that are fully or partially funded by the Federal Government. 
Implementing the recently passed 21st Century Cures Act will be a 
priority in coming months and years, including leveraging the 
significantly increased funding for the NIH. NIH plays a leading role 
in so many public-private initiatives, and if confirmed, I look forward 
to working with leaders at the NIH to advance their important mission 
and our administration's efforts to promote innovation on behalf of the 
American people.
                       syringe exchange programs
    Question. Like many communities in Ohio, your district in Georgia 
has been hit by a significant increase, a 4,000 percent increase, in 
opioid-related deaths in the last 5 years. Simultaneously, we are also 
seeing an increase in hepatitis C infections and HIV infections among 
those who inject opioids and share syringes. One of the clearest 
examples of this connection is the HIV outbreak in Scott County, 
Indiana, the home State of Vice President Pence. In response to this 
crisis, then-Governor Pence declared a public health emergency and 
changed Indiana's policy to allow State dollars to support Syringe 
Exchange Programs or SEPs.

    The Centers for Disease Control and Prevention (CDC), Institute of 
Medicine, and many other scientific bodies have stated unequivocally 
that SEPs are highly effective in stopping the spread of HIV/AIDS and 
Hepatitis C. Cleveland has one of the longest standing SEPs, and as a 
result has seen a decrease in the rate of new HIV infections as a 
result of intravenous drug use. In response to progress like this, 
Congress partially lifted the restrictions related to the use of 
Federal funds for SEPs in 2015. In fact, I note that your wife, who 
serves in the Georgia House of Representatives, has also worked to 
expand access to needle exchange programs.

    In the past, you have voted against funding for needle exchange 
programs. Has your position changed?

    Answer. As I mentioned in the hearing, I recognize that the opioid 
epidemic is real and that substance abuse disorders are plaguing many 
Americans. It is important that we as a nation make sure that every 
single individual has access to the kind of mental health and substance 
abuse care that they need. I have a broad and open mind and welcome 
proposals to our Nation's mental health and substance-abuse related 
crises, particularly those solutions that are evidence-based. If I am 
privileged to serve as the HHS Secretary, I will follow the policies 
adopted by the Congress and signed into law by the President.

    Question. Do you support continued availability of Federal funds 
for SEPs, based on local public health department determination of 
need? Why did you oppose it in the past?

    Answer. The opioid epidemic is real and substance abuse disorders 
are a serious concern for communities across the country. It is 
important that we as a nation make sure that every single individual 
has access to the kind of mental health and substance abuse care that 
they need. I recognize that we may not always agree on the solutions, 
but we have a duty to those who are suffering to work together to find 
the best answers to these severe problems. I welcome proposals to our 
Nation's mental health and substance-abuse related crises, especially 
those that are well supported by evidence. Funding decisions ultimately 
rest with the Congress, which holds the power over the purse. If I am 
privileged to serve as the HHS Secretary, I will follow the policies 
adopted by the Congress and signed into law by the President.

    Question. If confirmed as Secretary of HHS, how will you work with 
States to ensure they have the resources and support necessary to 
continue and open new SEPs?

    Answer. It is important that we as a nation make sure that every 
single individual has access to the kind of mental health and substance 
abuse care that they need. All levels of government need to engage and 
collaborate to identify effective solutions to these problems.
                         antibiotic resistance
    Question. The emergence of this superbug is extremely serious and 
illustrates both how quickly infectious pathogens can spread across the 
world and the need for international cooperation in detecting newly 
emerging health threats.

    Do you agree that a dedicated effort to improving surveillance, 
data collection and research efforts is needed to prevent such rapid 
spread and evolution of antibiotic resistant bacteria?

    Will you advise President Trump to continue President Obama's 
National Strategy for Combating Antibiotic-Resistant Bacteria (CARB 
initiative)?

    How will you ensure that the threat of antimicrobial resistance 
remains a high priority for HHS and its affiliates the National 
Institutes of Health (NIH), Food and Drug Administration (FDA), and 
CDC? In your opinion, how should the United States work with other 
nations to combat these threats?

    Answer. I share your concern regarding the need to take seriously 
the public health threat posed by antibiotic resistance. I appreciate 
the important role HHS can play in combatting this public health 
threat, from identifying resistance and educating the American people 
about it, to helping to advance innovative, new therapies to treat 
emerging infections. If confirmed, I look forward to continuing to work 
in this area as part of HHS' public health mission.
                           powdered caffeine
    Question. In 2014, Logan Stiner--who was a senior at Keystone High 
School in LaGrange, OH--died just 3 days before his high school 
graduation from ingesting too much powdered caffeine. For the last 
several years, I have worked with Logan's family to raise awareness 
about the dangers of powdered caffeine and encourage the FDA to take 
meaningful action to limit access to powdered caffeine.

    Right now, children and teenagers can buy this potentially deadly 
chemical in bulk from domestic and international retailers by simply 
going online and clicking a button--without their parents even knowing 
about it. Further, companies are trying to find creative new ways to 
reach consumers and to dodge States like Ohio that have already passed 
laws cracking down on this dangerous substance.

    The FDA advises consumers against using powdered caffeine and has 
called upon manufacturers to more accurately label these products. But 
these actions by the FDA do not go far enough. As Secretary of HHS, 
which has jurisdiction over FDA, how will you ensure that the 
Department's affiliates, particularly the FDA, are effectively 
educating and protecting consumers about the products available to 
them?

    Answer. FDA plays a valuable role in providing the American public 
with timely information about FDA regulated products. I appreciate the 
importance of FDA informing individuals and families about whether or 
how to use these products. If confirmed, I will ensure that FDA is 
fulfilling its statutory responsibilities consistent with its public 
health mission.
                medicare advantage star ratings program
    Question. As you know, CMS uses a star rating system to display the 
quality of Medicare Advantage plans. High performing plans receive 
quality bonus payments. CMS also has an audit and appeals process by 
which to periodically evaluate plans on specific measurements.

    Over the past several years, there have been several circumstances 
we are aware of where plans are penalized in their star-ratings based 
on deficiencies found in an audit. We have heard from a plan based in 
our home State of Ohio that was penalized by the interaction between 
the audit and appeals policies and the star-ratings program.

    If you are confirmed, can you commit to taking a deeper look at the 
interaction of these two policies and the potentially negative effect 
on plans, on beneficiaries, and on innovative care delivery?

    Answer. Yes. If confirmed, I would be pleased to work with your 
office and CMS to ensure that the Medicare Advantage stars system 
reflects quality and the Medicare Advantage sanctions system reflects 
program audit performance, as well as explore whether and how these 
policies can be made to work in concert rather than against each other.
                            cancer moonshot
    Question. During last year's State of the Union address, President 
Obama announced the Cancer Moonshot initiative, an ambitious project 
aimed at improving cancer prevention, diagnosis, and treatment at twice 
the rate of current progress of clinical cancer research. The 21st 
Century Cures Act re-committed to this critical initiative through the 
inclusion of funding for the next 5 years of the program.

    Academic and clinical centers in Ohio are playing important roles 
in the execution of this initiative, through partnerships like that 
that exists between The Ohio State University's Comprehensive Cancer 
Center and Columbus's Richard J. Solove Research Institute with Tampa's 
Moffitt Cancer Center to form the ORIEN partnership. This initiative is 
particularly focused on inclusion and retention of minorities in 
cancer-specific clinical trials, an important diversity metric to 
improve clinical care for all Americans.

    As Secretary of HHS, how will you work to facilitate collaborations 
between researchers and clinicians to improve cancer care under the 
goals outlined by the Cancer Moonshot?

    Answer. If confirmed, we will make treating and helping to cure 
cancer a priority and there likely will be overlap with the Cancer 
Moonshot goals. Implementing the recently passed 21st Century Cures Act 
will be a priority in coming months and the administration will 
accelerate efforts to promote innovation in many areas--including the 
prevention, diagnosis and treatment of cancer.
                              tuberculosis
    Question. Globally, tuberculosis is now killing more people than 
HIV/AIDS, with a death toll of nearly 5,000 per day. In 2015, the 
United States experienced the first national increase in TB cases since 
1992, with 9,557 total cases. And in 2013, CDC identified drug 
resistant TB as a serious public health threat.

    CDC provides critically important support to local health 
departments to address the TB epidemic, and it supports crucial TB 
research. CDC also provides crucial support to the global fight against 
drug resistant TB.

    Despite these sobering statistics and impressive work done by the 
CDC, funding for CDC's domestic TB program has remained stagnant since 
FY 2005 at $135 million. As a result, the CDC has stated that are our 
national response to TB ``has stalled.''

    If confirmed, will you implement the U.S. National Action Plan for 
Combating Multi-Drug Resistant Tuberculosis, and will you support 
increased Federal funding for the U.S. response to this deadly, 
airborne infectious disease?

    Better TB drugs and diagnostics are being developed, thanks to U.S. 
ingenuity, and these new tools can help us stop this epidemic. What 
will you do, if confirmed as Secretary of HHS, to advance these drugs 
and diagnostics and provide support to the communities working to 
develop new treatments?

    Answer. As a physician, I recognize and share your concern 
regarding the public health threat posed by tuberculosis, particularly 
drug resistant tuberculosis. If confirmed, I look forward to working 
with CDC officials in their efforts to combat the spread of 
tuberculosis.
             low-income heating assistance program (liheap)
    Question. As you may know, the LIHEAP program plays a key role in 
helping low-income families stay warm in the winter and avoid dangerous 
heat in the summer. It is a program that is critical to nearly 450,000 
households in Ohio that otherwise would be forced to choose between 
keeping warm or going hungry.

    If confirmed, will you commit to maintaining the program as 
currently structured?

    Answer. If I am confirmed, I will implement the program dutifully 
in as effective and efficient manner as possible.

    Question. Nationwide, nearly 7 million of our Nation's poorest and 
most vulnerable households rely on the program. Will you commit to 
maintaining and possibly even supporting an increase in the program's 
annual appropriation?

    Answer. If I am confirmed, I will implement the program dutifully 
in as effective and efficient manner as possible. Should circumstances 
on the ground change, and current resources are found to be 
insufficient, I will inform Congress and work with them on finding 
solutions.
                            nuclear medicine
    Question. Diagnostic nuclear medicine procedures help millions of 
Medicare beneficiaries detect life altering illnesses, such as heart 
disease and cancer, each year. The quick turnaround on nuclear testing, 
when used appropriately, helps improve the quality and efficiency of 
care by helping to reduce inappropriate or unnecessary procedures. 
Despite these positives, CMS continues to treat the diagnostic 
radiopharmaceutical drugs used in nuclear medicine procedures as 
supplies--not drugs--and, as a result, they are not appropriately 
reimbursed under this system.

    Physician and industry groups have been working for years to try to 
address this issue. If confirmed, will you work with stakeholders to 
develop superior payment models to these drugs and nuclear medicine 
procedures are appropriately reimbursed?

    Answer. I share your concerns and look forward to working with you, 
if confirmed.
                              therapy caps
    Question. As you know, the therapy cap exceptions process expires 
in less than a year--on December 31, 2017. We have all heard from 
constituents whose therapy needs exceeded the cap and their conditions 
have deteriorated, necessitating more expensive medical intervention.

    As Secretary of HHS, how will you support the repeal of these 
arbitrary and discriminatory limits and maintain access to 
rehabilitation therapy that Medicare beneficiaries clearly need?

    Answer. Rehabilitative therapy is a vital component of recovery for 
many patients. Arbitrary limits on its use are not a wise decision for 
patient-centered care. If confirmed as Secretary, I will look into this 
issue and seek to understand the competing objectives and issues 
motivating the current CMS policy. Part of the frustration with the 
current health care system is rules like this that do not make sense to 
many people. However, that is not surprising when one considers that 
Medicare Parts A, B, C, and D have each developed in silos and that 
even payment for particular types of services sometimes reflect silos 
within the silos. It may be that other approaches to therapy provide 
greater quality care at reduced cost with more respect for the 
individual needs of each patient in consultation with their doctor. If 
confirmed as Secretary, I would hope to break down these silos and 
encourage approaches based on a broader perspective.

    Question. Given the problems associated with monitoring the therapy 
cap, is CMS capable of achieving a timely uniform and defensible 
streamlined, responsive, and transparent process for manual medical 
review of Medicare records by Medicare administrative contractors?

    Answer. We will strive to do so. Any time there is manual review of 
anything in an organization with the scale of Medicare, it is a recipe 
for something to go wrong. If confirmed as Secretary, I would be 
pleased to work with you to confirm whether the staffing and other 
resources needed would be up to the challenge you describe.
                          addiction treatment
    Question. If confirmed as Secretary of HHS, how will you prioritize 
the prevention, treatment, and recovery from mental and substance use 
disorders in States like Ohio?

    As our country continues to explore potential reforms to our health 
care delivery systems, what will you do to prioritize access to 
behavioral health services?

    Answer. Mental and substance abuse disorders continue to be a 
serious challenge felt in communities across the Nation. I firmly 
believe, that it is absolutely vital that substance abuse disorders and 
other mental health problems are treated. If confirmed, I will work 
closely with you and the other members of Congress to ensure that the 
Substance Abuse and Mental Health Services Administration fulfills its 
duty of treating those who are in addiction recovery while working to 
prevent people from becoming addicted in the first instance.
                              pharmacists
    Question. The Pharmacy and Medically Underserved Areas Enhancement 
Act recognizes pharmacists as healt-care providers in underserved areas 
in order to expand access to care. In areas with a shortage of primary 
care providers, pharmacists may play a key role in helping patients 
manage their diseases to avoid Emergency Department visits and 
hospitalizations. These services are especially important for patients 
with multiple chronic conditions who may be taking several medications 
at a time.

    If confirmed as HHS Secretary, would you support this approach as a 
way to increase care in rural and underserved areas?

    Answer. We ought to step back and say, ``What are we doing wrong?'' 
as one out of every eight physicians no longer sees Medicare patients. 
Therefore, if confirmed as Secretary, I would be open to all options to 
address the impact of the ongoing physician shortage in rural areas. 
Paying pharmacists in underserved areas to engage in certain medical 
services could work well in those States where pharmacists have such 
licensure and a setting appropriate to the services, where primary care 
doctors continue to be involved in care, and where there is a patient 
and consumer demand for such services.

                                 ______
                                 
            Questions Submitted by Hon. Robert P. Casey, Jr.
                           medicaid and chip
    Question. You have proposed eliminating the Patient Protection and 
Affordable Care Act, an action that would end the expansion of Medicaid 
to millions of people and would result in an addition $1.1 trillion 
being cut from State budgets. This action would throw millions of 
people into the realm of the uninsured, including hundreds of thousands 
with disabilities. They would no longer have access to such services 
and treatments as behavior health care, mental health treatment, and 
preventative services. The services provided by Medicaid expansion have 
greatly improved the quality of life for millions of citizens, 
particularly those with disabilities.

    Do you propose those individuals return to being uninsured? Do you 
propose that their health care, including mental health treatments, be 
discontinued? Does your plan mean you support returning hundreds of 
thousands of people with disabilities into the category of the 
uninsured?

    Answer. Our goal is to ensure access to affordable, quality health 
care for all citizens.

    Question. If your plan is implemented, many people who will lose 
Medicaid coverage will be people with disabilities who depend on 
Medicaid for services that are unavailable through private insurance; 
services such as personal care services, respite care, or intensive 
mental health services. These health, personal care, and preventative 
services allow individuals to live in the neighborhoods of their 
choice, be independent, work, and participate in their communities. 
Many of these people, capable, able people, will be forced into 
institutions if they lose access to these crucial services. They will 
lose their independence and we will pay more tax dollars for their 
care.

    How is this a good outcome for these people and for America?

    Answer. Changes to the ACA should not be done in isolation. Our 
goal is to ensure access to affordable, quality healthcare for all 
citizens. This, of course, includes people with disabilities who depend 
on Medicaid. I note that community integration, beneficiary autonomy in 
decision making, and person-centered planning are central tenets 
articulated in CMS' approach to Home and Community Based Services and 
the HCBS Settings Rule with a compliance date in March 2019, and I 
support each of those principles. It is also important to note that 
many residential, disability-
specific settings have long provided a safe and integrated community 
alternative to institutional placement for individuals with 
disabilities, and appropriate weight should be given to the preferences 
of families and individuals with disabilities because they are in the 
best position to decide what type of setting best meets their 
individualized needs and circumstances.

    Question. Federal flexibility in Medicaid has allowed Pennsylvania 
to take extra steps to ensure that children with extensive health care 
needs have access to Medicaid, in what's referred to as Family of One 
program. This program, in addition to the Medicaid expansion for 
parents, has improved the economic security of families in 
Pennsylvania. The State's budget relies on the Federal share in order 
to support these Medicaid programs. However, the budget you authored in 
the House last year would have cut Medicaid funding by $1 trillion 
dollars, about one-third over a 10-year period.

    Given that half of Medicaid enrollees in this country are children, 
how will you ensure that children and families aren't harmed by cuts in 
Medicaid funding through block grants?

    Answer. Changes to the ACA should not be done in isolation. Our 
goal is to ensure access to affordable, quality health care for all 
citizens.

    Question. As a physician you know that Medicaid covers a broad 
range of services to address the diverse needs of the populations it 
serves. In addition to covering the services required by Federal 
Medicaid law, many States elect to cover optional services such as 
prescription drugs, physical therapy, eyeglasses, and dental care. 
Coverage for Medicaid expansion adults contains the ACA's ten 
``essential health benefits,'' which include preventive services and 
expanded mental health and substance use treatment services. Medicaid 
provides comprehensive benefits for children, known as ``EPSDT,'' that 
are considered a model of developmental pediatric coverage. EPSDT is 
especially important for children with disabilities because private 
insurance, which is designed for a generally healthy population, is 
often inadequate to their needs.

    Unlike commercial health insurance and Medicare, Medicaid also 
covers long-term care, including both nursing home care and many home 
and community-based long-term services and supports. More than half of 
all Medicaid spending for long-term care is now for services provided 
in the home or community that enable seniors and people with 
disabilities to live independently rather than in institutions. Given 
that both EPSDT for kids and long term services and supports are not 
generally covered in commercial health plans, I fail to see how people 
will not be worse off if the structure or financing of the Medicaid 
program is restructured in the ways that you and other administration 
officials have suggested.

    Can you guarantee that under a block grant, per capita cap and/or 
an HSA structure that all of these vital services will be covered for 
the millions of Americans who count on them?

    Answer. My work in the Congress has been to improve Medicaid and 
provide additional flexibility. If I have the privilege of being 
confirmed as Secretary I would look forward to the opportunity to work 
with States and Congress using the tools and authorities given by 
Congress in legislation to ensure the highest number of people get 
access to the highest quality care.

    Question. Forty percent of Pennsylvanian children rely on Medicaid 
and CHIP, which serves our State's most vulnerable children: children 
living in or near poverty; infants, toddlers and preschoolers during 
key developmental years; children with special health-care needs; and 
children who have been place in foster care due to neglect or abuse. 
Medicaid's comprehensive, pediatrician-recommended services under 
EPSDT--Early and Periodic Screening, Diagnostic and Treatment 
services--are critical for their health and to ensure that they hit key 
development milestones. In recent years, there is clear evidence of the 
long-term return on investments in Medicaid. Children enrolled in 
Medicaid are healthier as adults and more likely to graduate from high 
school, attend college, resulting in greater economic success.

    Do you support the EPSDT benefit package for children which ensures 
that America's most vulnerable children receive the services they need 
to thrive? Are you willing to protect these benefits by not allowing 
States to waive this important benefit?

    Answer. Every State has different demographic, budgetary, and 
policy concerns that shape their approach to Medicaid and Medicaid 
expansion. That is one of the reasons I devoted so much time to working 
with States to help them to identify creative solutions, and why I 
believe a one-size-fits-all approach is not workable for a country as 
diverse as the United States. If I am confirmed, I will work with CMS 
as they take a look at waivers that are pending and appropriate for my 
input and will have to make a decision at that point.

    Question. Your 2016 budget proposal would have block granted 
Medicaid and would have eliminated many critical patient protections. 
With our current Medicaid structure, children have a right to the full 
array of services they need, from critical health screenings for cancer 
treatment to services for children with autism or mental health needs. 
For many children, this coverage can be the difference between life and 
death. Medicaid as currently structured also enables children with 
disabilities to live up to their potential, be successful in school, 
and have the opportunities to be full citizens.

    Do you support the continuation of Medicaid's requirement to cover 
a comprehensive array of services for children through the Early 
Periodic Screening Diagnosis and Treatment (EPSDT) program? Will you 
commit to ensuring that HHS will actively enforce the requirement to 
provide screenings, diagnosis, and treatment for children with 
disabilities or with potential disabilities?

    Answer. Our goal is to ensure every single American has access to 
the coverage they want for themselves or their children and dependents. 
I think the conversation and focus in these topics has been the 
question of coverage rather than true access for too long. By that I 
mean that Americans might have an insurance card and yet not be able to 
afford care or it might not be available to them for other reasons.

    Question. Many people with disabilities want to work and can do so 
with the services only available through Medicaid, to help them work. 
These services include supported employment for people with mental 
health disabilities or personal care attendants for those with 
intellectual or physical disabilities. Without these services, many 
people with disabilities will be unable to work.

    How will you ensure that a person with a disability, mental health, 
intellectual, physical, sensory, or any other type of disability as 
defined by the Americans with Disabilities Act, has access to the 
services currently available through Medicaid?

    Answer. I look forward to faithfully executing whatever law that 
Congress passes and the President signs, if I am confirmed. I commit to 
work as HHS Secretary to ensure that the Medicaid program is well 
administered, effective, and available for eligible beneficiaries and 
that the States/Governors are given the flexibility to pursue 
innovative approaches that fit the needs of their States.

    Question. As economies evolve, professions change and while new 
types of jobs emerge, certain types of jobs are reduced or eliminated 
and workers must make transitions. This happens to people across the 
workforce, but it happens almost twice as often to workers with 
disabilities.

    Do you support taking away people's Medicaid coverage because they 
lose their jobs? How will you ensure that people with disabilities who 
become unemployed are able to retain Medicaid benefits?

    Answer. Medicaid is a vital safety-net program, and it is our goal 
to strengthen it. If confirmed, I look forward to faithfully executing 
laws to strengthen the Medicaid program that Congress passes and the 
President signs.

    Question. In 1999, in the Olmstead decision, the U.S. Supreme Court 
agreed that individuals with significant disabilities have the right, 
under the Americans with Disabilities Act, to access services in the 
community rather than only in an institutional setting. Since the 
Olmstead decision, the U.S. Department of Health and Human Services has 
employed its authority over Medicaid waivers to encourage States to 
expand home and community-based services and to shift away from 
overreliance on institutional care.

    Will you continue this longstanding Federal policy? If no, why not? 
If yes, what steps will you take?

    Answer. I support encouraging the use of home and community-based 
services if the services are appropriate, the individual does not 
oppose the treatment, and the services can be reasonably accommodated.

    Question. Since the Olmstead decision, Congress has authorized 
several programs to incentivize States to meet their obligations under 
the Olmstead decision by increasing Federal dollars for providing 
community-based services. These programs include the Money Follows the 
Person program, the State Balancing Incentive Program, the Community 
First Choice State Plan option, and the Home and Community Based 
Services option. These programs are implemented and managed through the 
Department of Health and Human Services.

    Is it your view these programs should continue? Why or why not?

    Answer. I support ensuring that individuals are able to receive 
services in community-based settings.

    Question. You are a vocal proponent of passing Federal laws to 
change Medicaid from a program that includes an open-ended Federal 
financial commitment to fixed block-grant payments to the States.

    Would this change end the Federal oversight and incentive programs 
that have helped State systems transform into systems that allow 
individuals with significant disabilities to live in the community? How 
would you ensure that any changes in Medicaid would not move people 
with disabilities back into nursing homes and other institutional 
settings that are linked to significantly poorer quality of life, 
physical and mental health outcomes, and longevity?

    Answer. We are committed to supporting high-quality health care for 
all Americans, including individuals with disabilities. If confirmed, I 
look forward to working with you to achieve these goals.

    Question. In 2011, the Department of Health and Human Services 
promulgated a rule to ensure that Medicaid funds designated for 
services in home and community-based settings were not used to fund 
services in segregated, institutional settings. For example, the second 
floor of a building used to provide inpatient hospital care could not 
be considered a community-based setting. That rule has been championed 
by the disability community as critical to afford people with 
disabilities the chance to live independent and fulfilling lives in 
their own homes and communities.

    Do you support the continuation of this rule? Do you commit to 
ensure that HHS assertively enforces it?

    Answer. Community integration, beneficiary autonomy in decision 
making, and person-centered planning are central tenets articulated in 
the Home and Community Based Services (HCBS) Settings rule you refer 
to, and I support each of those principles. It is also important to 
note that many residential, disability-specific settings have long 
provided a safe and integrated community alternative to institutional 
placement for individuals with disabilities, and appropriate weight 
should be given to the preferences of families and individuals with 
disabilities because they are in the best position to decide what type 
of setting best meets their individualized needs and circumstances. 
States must come into compliance with the final rule by March 17, 2019, 
and I plan to work with States during this transition period to ensure 
continuity of services for Medicaid participants and minimize any 
disruptions to them and the service systems they currently rely on.

    Question. With an additional 16 million people gaining access to 
Medicaid since its expansion and a total of 75 million people covered 
by the program, Medicaid continues to be a critical, State-based health 
care program. In order to provide effective, high-quality care, States 
need dedicated funding for the full Medicare-eligible population as 
well as sufficient Federal funding that reflects actual State costs and 
increases in health-care costs.

    As Secretary of HHS will you ensure that State-funding for health 
care is adequate and reflects the actual costs of caring for each 
State's Medicaid population?

    Answer. States are not just regulatory partners in the Medicaid 
program but also co-funders. As we look to provide them with more 
flexibility but also continue to provide Federal funds, I agree it is 
important States meet their funding commitments and the Federal 
Government oversee and check that is the case.

    Question. Medicaid provides care to some of the Nation's most 
vulnerable and complex populations. In order for States to continue to 
provide high-quality and effective care, adequate and sustainable 
funding is required.

    As Secretary of HHS, will you work to prevent disruption and ensure 
adequate and sustainable funding for Medicaid?

    Answer. If confirmed, as Secretary I will work to prevent 
disruption and ensure adequate and sustainable funding for Medicaid. In 
fact, it is just this goal that is at the root of many improvements I 
have offered in my career.

    Question. During the hearing in the Finance Committee, you gave 
your commitment that you would ``absolutely'' support an extension of 
the Children's Health Insurance program, and even expressed support for 
a longer extension of the program, beyond the typical 5-year 
authorization. Yet Gene Sperling wrote in the New York Times on 
Christmas Day that--``Mr. Price's own proposal, which he presented as 
the chairman of the House Budget Committee, would cut Medicaid by about 
$1 trillion over the next decade. This is on top of the reduction that 
would result from the repeal of the Affordable Care Act, which both Mr. 
Trump and Republican leaders have championed. Together, full repeal and 
block granting would cut Medicaid and the Children's Health Insurance 
Program funding by about $2.1 trillion over the next 10 years--a 40 
percent cut.''

    Do you deny that you have advocated for these changes to Medicaid 
and CHIP? You also said during the hearing that there were elements of 
the budget that you did not support. Which parts do you not support?

    Answer. In the past, as a member of Congress, I have advocated 
policies that would strengthen our health-care programs so that they 
remain solvent for the sake of future generations.

    Question. During the hearing, you claimed we were looking at CHIP 
and Medicaid in a silo, instead of looking at the entire range of what 
the policy will be with respect to health insurance programs. We do not 
have anything to compare CHIP and Medicaid to, because this 
administration cannot provide a clear plan that is a viable alternative 
to the Affordable Care Act, the CHIP program and Medicaid.

    What will those policies be, and how will they provide better 
options for the children and individuals with disabilities who rely on 
CHIP and Medicaid?

    Answer. If confirmed, I look forward to working with you to ensure 
there are better options available.

    Question. In your answer to Senator Alexander's question at the 
HELP Committee hearing, you stated, ``folks at the State level know 
their populations better than we (in Washington) ever could know 
them.'' The bipartisan, consensus-driven National Association of 
Medicaid Directors advocated for continuing the State Innovation Model 
(SIM) out of the Center for Medicare and Medicaid Innovation. The SIM 
has fueled 35 States (led by both Democrats and Republicans) to improve 
their local health-care systems.

    Given your desire to move decisions and innovation to the local 
level, as HHS secretary would you continue to support CMMI's State-
level initiatives?
http://medicaiddirectors.org/wp-content/uploads/2016/12/Key-
Considerations-in-Affordable-Care-Act-Repeal-and-Replace-
Initiatives.pdf

    Answer. CMMI is a program providing significant opportunity for 
testing new models for health-care financing and delivery.

    Question. In reference to your reply to Senator Alexander, 16 
States who have expanded Medicaid have Republican leadership. As of 
January 19th, at least 5 Republican governors have publicly advocated 
to retain the Federal-State Medicaid expansion partnership.

    Given that several local leaders--including Republicans--favor 
retaining this program, what is your plan as HHS secretary to honor the 
wishes of State leadership, preserve this program, and avoid adverse 
consequences to States?
http://www.politico.com/story/2017/01/gop-governors-republicans-
obamacare-233576

    Answer. If confirmed, I look forward to working with Congress and 
Governors to ensure access to affordable, quality health care for all 
citizens.

    Question. In the past, you have stated support of expanding State 
waiver authority for the Medicaid program. Do you support efforts to 
evaluate the impact of these waivers in terms of access to care, 
quality of care, and costs of care?

    Answer. It is my strong belief that we need to look at all possible 
outcomes of policy changes.

    Question. In 2015, your budget proposal would have repealed the 
Affordable Care Act, reduced Medicaid spending, and cut the 
Supplemental Nutrition Assistance Program--all told, up to $519 billion 
in cuts to needy families--yet your proposal would have increased 
defense spending higher than the administration requested, gathering 
criticism from other Republicans.

    Are you only concerned with increased Federal spending when it 
benefits families and children?

    Answer. In my time in Congress, I have been concerned with 
increased Federal spending at all levels.

    Question. In your conversation with Senator Warren and Senator 
Kaine during your appearance at the HELP committee, you cited access to 
care as your critique for the Medicaid program. You stated that 
Medicaid recipients have access to insurance, but they do not have 
access to the care they need. Yet the Government Accountability Office 
has stated that ``Medicaid enrollees report access to care that is 
generally comparable to that of privately insured individuals and 
better than that of uninsured individuals.'' The report does cite more 
challenges with accessing specialty and dental care.

    Do you agree with the GAO's assessment? If so, what strategies 
would you suggest to increase access to specialty and dental care for 
Medicaid recipients? If you don't agree with the GAO's assessment, 
please outline your plan to increase access to Medicaid-eligible 
Americans.

    Answer. As a doctor who has actually treated thousands of Medicaid 
patients, I do care deeply about the Medicaid program and the access of 
Medicaid patients to actual care, not just a card they can carry with 
them. I know from personal experience the difficulties Medicaid 
patients face, and I receive letters about it all the time. My plan is 
to work with States to ensure they have the flexibility to make high 
quality care truly available.

    Question. It is true that Medicaid faces challenges, including low 
payment rates and barriers to interstate care which limit access and 
must be improved. Greater consistency of national data could 
significantly improve Medicaid's ability to serve children and other 
beneficiaries and drive quality improvement. Access to certain 
services, such as pediatric mental health services is a pressing 
concern.

    What would you do as Secretary to drive improved outcomes in child 
health across States?

    Answer. Ensuring children have access to the health care they need 
is undoubtedly a top priority. If confirmed, I look forward to working 
with you to increase access to affordable health plans for families and 
children as well as taking the necessary steps to strengthen American 
families.

    Question. A major focus of Congress and the administration has been 
on pursuing delivery system reforms that improve quality and reduce 
costs. The Federal Government over time has focused more on the needs 
of children in these reforms, but Medicaid for children still lags 
behind Medicare in supporting improvements in care.

    What steps will you take to promote increased emphasis on reforms 
targeting the unique needs of children?

    Answer. Our goal is to make certain that every single American has 
access to the coverage they want for themselves and their children; and 
we must ensure that the individuals and children who lost coverage 
under the Affordable Care Act are able to access quality health care. 
If confirmed, I look forward to working with you on this effort.

    Question. To ensure kids continue to receive the critical care they 
need under Medicaid, any potential restructuring needs to consider 
children's unique health care needs and the impact of limiting our 
investments into their future and the Nation's as a whole. Any reforms 
must ensure children's funding is stable, clearly defined, protects 
current services, and begins to remediate shortages in critical areas, 
such as mental and behavioral health services.

    How will you ensure that Medicaid continues to deliver essential 
services tailored to the unique needs of children?

    Answer. If confirmed, I look forward to working with you to 
prioritize a nation of healthy children through increased access to 
affordable health plans for families and children, as well as taking 
the necessary steps to strengthen American families.
                                medicare
    Question. Do you support converting Medicare's successful 
Independence at Home (IAH) demonstration into a nationwide program? Do 
you support the inclusion of licensed mental health professionals on 
the primary teams for home-based team care?

    Answer. If confirmed, I look forward to working with you on this 
issue. As a general matter, I believe we ought to allow for all sorts 
of innovation. Not just in this area. There are things that haven't 
been thought up yet that would actually improve health-care delivery in 
our country and we ought to be incentivizing that kind of innovation. 
And in finding our way to those innovations, it is important to 
remember many of these experiments involve real patients' lives.

    Question. The Medicare program requires that to receive telehealth 
services, a patient must be in a rural area and at an eligible 
originating site that currently does not include the patient's home. Do 
you support making a rural Medicare beneficiary's home as an eligible 
originating site for the use of telehealth services?

    Answer. This is certainly something that we will take under 
consideration. Telehealth holds great promise, particularly for rural 
areas experiencing physician shortages and for patients with limited 
mobility. At the same time, allowing a beneficiary's home to qualify as 
an eligible originating site could create significant Program Integrity 
challenges. If confirmed, I will certainly direct CMS to take another 
look at this issue to ensure we are doing everything we can to maximize 
beneficiary access to care with appropriate safeguards against fraud.

    Question. Do you support the continuation of the new Merit-based 
Incentive Payment System as presented in the final rule on the Medicare 
Access and CHIP Reauthorization Act (MACRA)?

    Answer. The recent CMS MACRA final rule approached the first year 
of the Quality Payment Program as a transition year, and took steps to 
address physician concerns regarding the burdens associated with 
program participation. I think significant challenges remain with 
respect to provider burden, and, if confirmed, I plan to direct the CMS 
Administrator to ensure that the program is structured to achieve its 
quality and budgetary goals, while ensuring that patients and the 
providers who care for them are at the center of our reform efforts.

    Question. In both the Medicare and Medicaid programs, we are 
witnessing increased participation in managed care plans. Yet in 1995, 
you objected to managed care as ``the antithesis of our society,'' 
citing that managed care threatens the doctor-patient relationship.

    As HHS Secretary, what plans do you have to monitor the quality and 
effectiveness of Managed Care plans offered in Medicare (through 
Medicare Advantage) and Medicaid programs?

    Answer. If confirmed, I will not pick winners and losers among 
different plans or methods of health-care delivery. It is my intention 
to fairly and accurately monitor the quality and effectiveness of our 
entire care system, including managed care Medicare and Medicaid plans. 
The facts on the ground will determine our plan ahead.

    Question. In September 2011, DHHS released a new policy that 
implements the recommendations of the Memorandum on Hospital 
Visitation. The rules updated the Conditions of Participation (CoPs). 
The policy states that hospitals receiving Medicare or Medicaid 
payments should allow patients to designate visitors, regardless of 
sexual orientation, gender identity, or any other non-clinical factor. 
The HHS policy has enhanced hospital visitation rights of same-sex 
couples.

    Assuming no legislative changes are made, as HHS Secretary, will 
you continue to support and enforce these existing rules?

    Answer. It is essential that health-care services be available to 
all people with the highest level of quality, affordability, and 
respect for their human dignity. As a physician, I believe that 
patients should be at the center of health care. This policy allows 
patients to designate their visitors, regardless of their identity, and 
I believe patients should have that authority.

    Question. In 2012, the Center for Medicare and Medicaid Innovation 
under Provision 5590 of the ACA funded the Medicare Graduate Nurse 
Education Demonstration project to address the primary care provider 
shortage, including the Hospital of the University of Pennsylvania. In 
Philadelphia alone, the project has produced 703 advanced practice 
nurses, the majority of whom have assumed primary care roles, a 78% 
increase since before the project launched.

    As HHS Secretary, do you plan to continue to support novel 
reimbursement models to address the Nation's shortage of primary care 
providers? Would you consider expanding the successful Graduate Nurse 
Education demonstration project to other sites?

    Answer. I remain committed to ensuring that every American receives 
access to the care that he or she needs. Funding decisions, however, 
ultimately rest with the Congress, which holds the power over the 
purse. If I am privileged to serve as the Secretary of Health and Human 
Services, I will implement the policies agreed upon by the Congress and 
signed into law by the President.

    Question. There is universal agreement on the need to improve 
patient care and reduce costs. One way to do so is for the Federal 
Government to continue to promote the growth of health information 
technology and electronic health records. One success in this space 
over the past several years has been the development and growth of the 
Direct Exchange network, which has allowed for millions of health care 
record exchanges over the past several years.

    Will you as HHS Secretary continue to support the expansion of 
Health IT and the use of networks such as Direct Exchange working with 
HHS-ONC to encourage and ensure the safe and interoperable exchange of 
medical records?

    Answer. Electronic information sharing, as supported by 
interoperable health information technology (IT) systems, impacts 
overall care and the patient experience. Patients and providers often 
rely on the fast exchange of relevant, trustworthy information across 
health IT systems. Methods to improve flexibility and patient 
engagement, and clear the way for increased health IT interoperability 
should be examined as we work to improve health-care delivery. I look 
forward to continued discussions with you regarding various means to 
improve the current health IT infrastructure.
                     foster care and child welfare
    Question. You have hardly any record on child welfare issues. The 
largest Federal investment in child welfare is made through title IV-E 
of the Social Security Act, which reimburses States for activities 
associated with foster care, and it is managed by the Department of 
Health and Human Services. While foster care is a critical, often life-
saving intervention, we should be moving toward a system that not only 
supports children who can no longer remain safely with their families, 
but one that also helps stabilize struggling families so that they can 
keep their children when it is possible to do so safely. This focus on 
prevention is not only often in the best interest of children, but also 
in the best interest of State budgets, and States that have started 
shifting to a prevention-focused model have seen lower downstream costs 
associated with foster care, homelessness, health care and criminal 
justice. This is an especially critical issue right now, at a time when 
we are seeing foster care caseloads increasing as a result of the 
opioid epidemic.

    Do you agree that we must make investments in services aimed at 
helping vulnerable families?

    Answer. Yes. The family is the foundation of society. It is 
critical that we build and sustain strong families by providing 
assistance when necessary for those struggling with addiction and 
mental health issues so that we prevent child neglect and violence 
against children.

    Question. The Department of Health and Human Services is the lead 
Federal agency responsible for addressing child abuse and neglect, 
including prevention, foster care, reunification, and adoption when 
children cannot return home. As was discussed during your hearing, the 
new administration is proposing to block grant Medicaid, which is the 
primary source of services to help families involved in the child 
welfare system. This system is experiencing additional strain as a 
result of the opioid epidemic, which has shattered many families across 
the Nation.

    Have you considered the potential implications of block-granting 
Medicaid for families in the child welfare system?

    Answer. I look forward to working with the Congress to ensure that 
all children have access to the coverage, regardless of family 
situation or personal circumstance.

    Question. Will you commit that, if confirmed as Secretary of Health 
and Human Services, you will take action to guarantee parents coverage 
of and access to mental health and substance use disorder services, to 
prevent child abuse and neglect and help reunify families?

    Answer. Substance abuse disorder is a problem and the opioid 
epidemic is real. As I mentioned in the hearing, this is a rampant 
crisis that is harming families and communities across the Nation. This 
harm includes the potential for abuse and neglect that you mention. I 
also said, and I firmly believe, that it is vital that substance abuse 
disorder and other mental health problems are treated. If confirmed I 
will work closely with you and other members of Congress to ensure that 
the Substance Abuse and Mental Health Services Administration (SAMHSA) 
fulfills its duty of leading public health efforts to advance 
behavioral health and reduce the impact of substance abuse and mental 
illness on America's communities.

    Question. According to the Substance Abuse and Mental Health 
Administration, there are 21.6 million people that have a substance use 
disorder, with just 9.3 percent receiving treatment. According to 
research by Richard G. Frank, the Department of Health Care Policy at 
Harvard Medical School, and Sherry Glied, Dean of the Wagner School of 
Public Service at NYU, repeal of the Affordable Care Act will take $5.5 
billion from the treatment of low-income individuals with mental and 
substance use disorders--11 times the funding that Congress just 
provided through the 21st Century Cures Act.

    Do you think such a reduction in both mental health and substance 
use treatment funds through a repeal will have an impact on the child 
welfare system and foster care numbers?

    Answer. Changes to the ACA should not be done in isolation. I 
remain committed to ensuring that every American receives access to the 
mental health and substance abuse care that he or she needs. If I am 
privileged to serve as the Secretary of Health and Human Services, I 
will implement the policies agreed upon by the Congress and signed into 
law by the President.

    Question. The Affordable Care Act included a provision to allow 
children aging out of foster care to continue their health coverage 
through Medicaid up to age 26. Block-granting or capping Medicaid would 
essentially end this guarantee.

    Do you believe we should end this right to health coverage for 
former foster youth?

    Answer. This would be a part of the new legislation that Congress 
will be voting on, so that decision is in Congress's hands. If 
confirmed, I will work to ensure that HHS appropriately implements the 
statutes within its purview.

    Question. Currently, when families adopt children with special 
needs from foster care, those children are guaranteed Medicaid coverage 
through the age of 18. This is an important support for these children 
and their adoptive families.

    If confirmed as Secretary of Health and Human Services, what 
assurances can you give to these children and their adoptive parents 
that their health-care needs will continue to be met?

    Answer. The life and health of children with special needs is of 
great importance to me, as it has been when I practiced medicine and 
while I have been in Congress. I offer every assurance to children and 
their adoptive parents that I will do all I can, if confirmed as HHS 
Secretary, to ensure their needs continue to be met to the best of the 
Department's ability.
       ethics of providing health care to people on public plans
    Question. You have been a member of a fringe physician group, the 
American Association of Physicians and Surgeons (AAPS), which espouses 
a number of very dangerous ideas, including perpetuating debunked myths 
about vaccines and claiming that it is ``immoral'' for doctors to 
provide care to people who rely on publicly funded health plans such as 
Medicare, Medicaid, and CHIP.

    Were you aware of these positions published by AAPS before joining 
the organization, and do you support those positions?

    Answer. My initial membership in AAPS was based on their successful 
opposition to destructive health policy changes promoted in the early 
1990s.
                          the opioid epidemic
    Question. According to the recent Facing Addiction: Surgeon 
General's Report on Alcohol, Drug, and Health, ``Substance misuse and 
substance use disorders are estimated to cost society $442 billion each 
year in health-care costs, lost productivity, and criminal justice 
costs.'' The National Survey on Drug Use and Health (NSDUH) reported in 
2015 that 21.5 million people in the United States, over 8 percent of 
the population, had a substance use disorder. The Center for Disease 
Control and Prevention reported over 52,000 drug overdose deaths in 
2015. Of the millions of people struggling with a substance use 
disorder, only about 10 percent receive substance use disorder 
treatment in a given year.

    If confirmed as Secretary of Health and Human Services, what 
actions will you take to address the needs of Americans struggling with 
substance use disorders, especially those who are seeking treatment?

    Answer. Substance abuse disorder is a problem and the opioid 
epidemic is real. As I mentioned in the hearing, this is a rampant 
crisis that is harming families and communities across the Nation. This 
harm includes the potential for abuse and neglect that you mention. I 
also said, and I firmly believe, that it is absolutely vital that 
substance abuse disorder and other mental health problems are treated. 
If confirmed, I will work closely with you and other members of 
Congress to ensure that the Substance Abuse and Mental Health Services 
Administration (SAMHSA) fulfills its duty of leading public health 
efforts to advance behavioral health and reduce the impact of substance 
abuse and mental illness on America's communities treating those who 
are in addiction recovery while working to prevent people from becoming 
addicted in the first instance, and explore other means available to 
HHS to assist those struggling with substance use disorders obtain 
treatment and to prevent addiction.

    Question. If confirmed as Secretary of Health and Human Services, 
will you commit to supporting, and as a Cabinet member advising the 
President to support, continued funding for opioid crisis grants, as 
administered by SAMHSA?

    Answer. I remain committed to ensuring that every American receives 
access to the mental health and substance abuse care that he or she 
needs. Funding decisions, however, ultimately rest with the Congress, 
which holds the power over the purse. If I am privileged to serve as 
the Secretary of Health and Human Services, I will implement the 
policies agreed upon by the Congress and signed into law by the 
President.

    Question. If confirmed as Secretary of Health and Human Services, 
will you commit to supporting, and as a Cabinet member advising the 
President to support, funding for the Substance Abuse Prevention and 
Treatment Block grant to preserve the critical safety net for Americans 
who require substance abuse treatment but who are uninsured?

    Answer. Access to mental health and substance abuse care is 
absolutely vital. If I am privileged to serve as the Secretary of 
Health and Human Services, I will implement the policies agreed upon by 
the Congress which holds the power of the purse, and signed into law by 
the President.

    Question. If confirmed as Secretary of Health and Human Services, 
would you commit to supporting, and as a Cabinet member advising the 
President to support, funding requests for the National Institute of 
Mental Health and the National Institute on Drug Abuse to develop 
better treatments for substance use disorders?

    Answer. I remain committed to ensuring that all Americans maintain 
access to the mental health and substance abuse disorder treatments; 
however, funding decisions ultimately rest with the Congress, which 
holds the power over the purse. If I am privileged to serve as the HHS 
Secretary, I will implement the policies adopted by the Congress and 
signed into law by the President.

    Question. Integrated primary care and mental health care is one 
promising strategy to improving outcomes for Americans with substance 
use disorders. If confirmed as Secretary of Health and Human Services, 
will you support demonstration programs--which as Secretary you would 
have the ability to direct--to integrate primary and behavioral health 
care, through the Center for Medicare and Medicaid Innovation?

    Answer. CMMI is a program providing significant opportunity for 
testing new models for health-care financing and delivery. If 
confirmed, as HHS Secretary, I plan to work closely with CMS to ensure 
that CMMI--after appropriate consultation with Congress, the States, 
health-care stakeholders, and Innovation Center staff--tests innovative 
models that reduce costs and improve quality for Medicare and Medicaid 
beneficiaries.

    Question. A key challenge to effectively addressing the opioid 
epidemic in the United States is a shortage of qualified providers. The 
Affordable Care Act included a provision to establish a National 
Healthcare Workforce Commission, yet this Commission has never met.

    If confirmed as Secretary of Health and Human Services, would you 
commit to supporting, and as a Cabinet member advising the President to 
support, a congressional appropriation to convene this commission so we 
can understand the root cause of mental health provider shortages and 
develop evidence-based strategies to address them?

    Answer. As I mentioned in the hearing, it is important that we as a 
nation make sure that every single individual has access to the kind of 
mental health and substance abuse care that they need. I look forward 
to working closely with you and the other members of Congress to ensure 
that the mental health profession is adequately, if not robustly, 
staffed for this and the future generations.
                                coverage
    Question. On January 7, 2009, you penned a commentary in the Wall 
Street Journal that advocated for ``access to coverage for all 
Americans and coverage that is truly owned by patients.'' Yet under the 
policy proposals you have authored, according to the Congressional 
Budget Office, ``the number of people who are uninsured would increase 
by 18 million in the first new plan year.'' After repeal of Medicaid 
expansion and exchanges, 32 million Americans would be uninsured by 
2026.

    How do you reconcile your position in 2009 with the analysis by the 
CBO in 2017?

    Answer. I disagree with the conclusion drawn by CBO. If there are 
any changes to Medicaid, they should not be done in isolation.

    Question. You introduced the Medical Freedom Act of 2015, which 
would repeal the requirement that insurers offer dependent coverage 
until the age of 26. HHS estimates this provision has affected 2.3 
million young adults.

    If confirmed, what is your plan to protect the health and well-
being of young adults under the age of 26?

    Answer. This would be a matter for Congress to determine through 
legislation. If confirmed, I will work to ensure that HHS appropriately 
implements the statutes within its purview.
                                children
    Question. Oftentimes, changes in the larger health-care landscape 
take place, for example in the Medicare program, without a full 
examination of how these changes could potentially impact children, 
even inadvertently.

    As you look at health-care changes at the national level as 
Secretary, how will you ensure that children's unique health-care needs 
are taken into account?

    Answer. I look forward to working with Congress to ensure that 
children will not be inadvertently impacted by potential changes to the 
health-care system.
                                 liheap
    Question. The Low-Income Home Energy Assistance Program (LIHEAP) 
provides short-term aid to vulnerable populations for heating or 
cooling assistance, crisis assistance or weatherization assistance. 
Without this support, many low-income participants would quickly fall 
behind on their bills and face shut-off of essential energy services. 
The program effectively utilizes a partnership between the Federal 
Government, State government and the private sector.

    LIHEAP protects the most vulnerable in our society. According to 
the Campaign for Home Energy Assistance, in Pennsylvania in 2014, 35% 
of households receiving LIHEAP were elderly, 30% were disabled, and 18% 
had children under 5. You were a member of the Task Force on Poverty, 
Opportunity, and Upward Mobility that drafted the ``A Better Way'' plan 
that proposed to combine LIHEAP with 10 other social program grants to 
create a large block grant to States. Should such a plan come to pass, 
it would eliminate a dedicated fund for utility crisis assistance. In 
addition, your recent budget took across the board cuts from safety net 
programs and highlighted LIHEAP as one of several ``duplicative anti-
poverty programs.'' While the Department of Energy also oversees an 
energy program (the Weatherization Assistance program), this program 
provides grants to States to improve the weatherization and energy 
efficiency of low-income homes. Thus, serving a different, though just 
as important, service from LIHEAP.

    Can you explain why you think LIHEAP is a duplicative anti-poverty 
program and which other programs in particular you think are providing 
the same services?

    Answer. One of the main goals of the ``A Better Way'' plan was to 
match poverty-fighting programs with the needs of those on Federal Aid 
more effectively so that it is easier for them to get back on their 
feet. Using block grants, rather than dedicated grants, gives States 
and communities more freedom to use the funds where they are most 
necessary.

    Question. According to the National Energy Assistance Directors 
Association, States have been forced to reduce the number of households 
served by LIHEAP from 8 million to the current level of 6.7 million due 
to Federal cuts to the program. This equates to 1.3 million eligible 
households nationwide that did not receive assistance.

    LIHEAP is a critical safety net program to support the elderly and 
families as the country recovers from the economic recession. Families 
should not have to choose between heating their homes and putting food 
on the table. You have previously voted in the House of Representatives 
against increasing funding for LIHEAP.

    Do you support increasing funding for LIHEAP? If not, why do you 
not support it?

    Answer. If confirmed, I will administer LIHEAP as effectively and 
efficiently as possible. If once in office, and should circumstances on 
the ground change and current resources are found to be insufficient, I 
will inform Congress and work with them on finding solutions.

    Question. Will you support maintaining the funding at the current 
level of $3.3 billion in the President's final recommendations for FY 
2017 and proposed FY 2018 budget?

    Answer. If confirmed, I will administer LIHEAP at the levels passed 
by Congress.
                               tax issues
    Question. Do you think the President should disclose how much he 
stands to benefit from the repeal of the net investment income tax 
prior to signing the repeal of the Affordable Care Act into law?

    Answer. This is a matter for the President.

    Question. With respect to subsidizing the cost of health care, 
please explain why an annually disbursed refundable tax credit is 
superior to a monthly insurance premium support credit.

    Answer. There are many health-care scholars who have promoted the 
superiority of a credit versus a subsidy, as it may provide greater 
flexibility and options for patients.

                                 ______
                                 
              Questions Submitted by Hon. Debbie Stabenow
                          continuous coverage
    Question. Last week we held a forum and asked folks from around the 
county to share their stories and help inform the debate around repeal 
of the ACA. One of the women on the panel, Holly Jensen, was a small 
business owner insured with a plan she selected on the marketplace. 
Holly was living with undiagnosed depression, anxiety, and obsessive 
compulsive disorder that was getting worse by the day. It got to the 
point that she withdrew from her community, her work, and was really 
struggling. She was unable--understandably--to make her monthly premium 
payments. Luckily, because of Medicaid expansion, she was able to get 
the treatment she needed a few months later and is doing well today. 
Her small business is back up and running. However, she did not 
maintain coverage continuously, as your plan and many others require.

    If the continuous coverage requirement were in place, Holly would 
re-enter the health insurance market and could be labeled with a pre-
existing mental health condition, correct? How do you believe this 
problem is best addressed?

    Answer. I believe it is important that we as a nation make sure 
that every American has access to the kind of mental health care and 
health coverage that best meets their need. Additionally, it is 
imperative that all Americans have access to affordable coverage and 
that no one is priced out of the market due to a bad diagnosis. This is 
a matter for the legislative branch, however, and if confirmed, I will 
work to ensure that HHS (appropriately) implements the statutes within 
its purview.
                           maternity coverage
    Question. As I mentioned today, prior to the ACA, the vast majority 
of plans on the individual market did not offer maternity coverage. You 
said today that women would likely opt not to purchase one of those 
plans if they were pregnant or planning to be. However, over the course 
of a health plan year, couples and families make many decisions about 
their health-care future, sometimes including whether or not to have a 
child.

    Given this fact, do you believe that all health plans should be 
required to cover maternity and newborn care?

    Answer. My hope is to move in a direction where insurers can offer 
products people want and give them the coverage they want. That, of 
course, can and would in many cases include maternity and newborn care. 
Getting to that kind of system requires changes that will inevitably 
involve working with Congress and considering the tradeoffs of various 
proposals to achieve our shared objective of the best and highest 
quality care being available to Americans. And note that I refer to 
care because ultimately, having maternity or other coverage is not 
meaningful if one cannot access the care they need or the quality of 
care leaves them worse off. So we must work towards both coverage and 
care.

                                 ______
                                 
               Questions Submitted by Hon. Maria Cantwell
                             long-term care
    Question. Do you share my view that patients should be able to age 
in their homes and communities instead of in nursing homes and other 
institutional/inpatient settings, so long as the patient chooses this 
option and it is clinically appropriate?

    Answer. Our health-care system should be able to accommodate the 
choices of patients, in consultation with their physicians, regarding 
the ideal setting for their care.

    Question. Do you agree with me that home- and community-based care 
is, in general, far less costly and more convenient for patients 
compared to institutional care in nursing homes?

    Answer. Home- and community-based care is often less costly and 
more convenient as compared to institutional care in nursing homes. Our 
goal ought to be the right care in the right setting and the best care 
possible for Medicaid patients and all Americans. Too many Medicaid 
beneficiaries lack access to care.

    Question. Do you support incentives for States to transition or 
``rebalance'' their Medicaid long-term care population from nursing 
homes to home- and community-based care?

    Answer. If confirmed, I will work to provide States the flexibility 
to pursue innovative approaches that fit the unique needs of their 
citizens.

    Question. Are you aware that, under the Affordable Care Act's 
Balancing Incentive Program (section 10202), the State of Georgia was 
approved for $57 million to transition Medicaid beneficiaries from 
institutional long term services and supports (LTSS) settings to home-
and community-based settings (HCBS), and, as a result of that 
investment, Georgia has been able to shift more than 10 percent of its 
long-term care costs from high-cost nursing homes to low-cost home and 
community care, according to reports submitted to CMS and Georgia's 
program application?

    Answer. Each State has different needs, and I believe CMS needs to 
work with States to ensure that, consistent with those needs, the 
Medicaid program provides the best possible coverage to their 
residents. It is not surprising that providing States with flexibility 
to tailor their Medicaid program leads to good results in general.

    Question. Do you support the Balancing Incentives Program in the 
Affordable Care Act?

    Answer. I am committed to ensuring that Medicaid is available for 
eligible beneficiaries, and working with CMS to make sure that States 
are able to make the most use of available resources to serve their 
citizens with the highest quality care, if I am confirmed.

    Question. If you do support this program, or if you at least agree 
with its intent and goals, will you commit to working with me and my 
staff to expand Federal incentives for States to ``rebalance''?

    Answer. Yes, I will look forward to working with you and your staff 
to explore proposals you have in mind and otherwise consider how best 
to provide States with flexibility to provide the highest-quality care 
for Medicaid beneficiaries.

    Question. Do you believe that, if executed well, ``rebalancing'' 
programs such as Balancing Incentives can improve the care experience 
for patients and reduce State Medicaid costs?

    Answer. The experience of our system is that while many different 
States may face the same problem, the approach that is most likely to 
succeed may depend on the particular State and other details specific 
to the circumstances.
                          basic health program
    Question. The Basic Health Program (section 1331 of the Affordable 
Care Act) is a State option that is providing health insurance and 
access to care to more than 750,000 working low-income individuals in 
New York and Minnesota. States that have taken advantage of this 
voluntary program are seeing lower costs for beneficiaries, higher 
enrollment, and net State budget savings, compared to not implementing 
the program. Through the Basic Health Program, States are price-makers, 
not price-takers.

    Do you support the Basic Health Program as a way to empower States 
to negotiate a better deal on health insurance for their citizens?

    Answer. I support the efforts of States to innovate and find 
solutions for their citizens with respect to health care, in the area 
of insurance and otherwise.

    Question. Will your Department and CMS commit to funding and 
administering the Basic Health Program as required under current 
Federal law?

    Answer. If confirmed as Secretary of HHS, my role will be to 
administer the laws of the land as they originate from the Congress, 
including those relating to the Basic Health Program.

    Question. If Congress repeals the Affordable Care Act, will you 
commit to ``not pulling the rug out'' from the 750,000 low-income 
individuals who are benefitting from the Basic Health Program?

    Answer. In working through the current situation and options for 
the future, I am committed to working towards solutions that provide 
meaningful access to care, not just insurance but actual care, for all, 
including--of course--these individuals.

    Question. In other words, will you use your administrative 
discretion as HHS secretary to not rescind funding for State Basic 
Health Programs, unless a rescission of that funding is explicitly 
required by a change to the statute?

    Answer. If confirmed, I will follow the directions of Congress as 
contained in appropriations and other law regarding funding for health-
care programs.
                         delivery system reform
    Question. Washington State and the Pacific Northwest have led the 
way in pioneering nationally recognized innovations in the delivery of 
health care--whether it is the Qliance Direct Primary Care medical home 
model, Group Health Cooperative's highly popular integrated coverage 
and care model, the Everett Clinic's price transparency initiatives, 
Boeing's Accountable Care Organizations, or dozens of others. Despite 
their innovations, health-care providers in my State are paid nearly 
$2,000 less (per Medicare enrollee, per year) than the national 
average, based on CMS spending data compiled by the Kaiser Family 
Foundation. I would argue that, due to our current volume-based system, 
my constituents are paid less specifically because they are efficient 
and because they do a good job of keeping patients healthy.

    Should the Federal Government reward such high-value health care 
providers, as long as we clearly define and agree upon metrics for what 
constitutes ``high-value'' care?

    Answer. I look forward to faithfully executing the laws Congress 
passes pertaining to health-care provider reimbursement.

    Question. Does the current fee-for-service system encourage 
unnecessary health-care spending? If so, can you please explain 
specifically how this system encourages unnecessary health-care 
spending, including in which specialties of medicine?

    Answer. The current system encourages unnecessary spending since 
too many of the decisions providers and patients make are determined by 
a distant Federal bureaucracy and not based on the value of care that 
is provided to patients by their health-care providers. If confirmed, I 
look forward to executing laws that reduce unnecessary health-care 
spending.

    Question. As a physician, do you share my view that clinicians 
should focus more on keeping their patients healthy and less on 
paperwork?

    Answer. Clinicians should focus more on keeping their patients 
healthy and less on paperwork. Unfortunately, it does not seem that is 
the current trend.

    Question. As a physician, do you share my view that the current 
fee-for-service system requires significant paperwork, including 
substantial time spent on coding and billing for each individual 
procedure or service rendered?

    Answer. Clinicians should focus more on keeping their patients 
healthy and less on paperwork. Unfortunately, it does not seem that is 
the current trend.

    Question. You voted for the bipartisan Medicare Access and CHIP 
Reauthorization Act (MACRA) when it was considered on the House floor. 
Will you commit to working with Washington State health-care providers 
to help them succeed in Medicare's new Quality Payment Program, as 
outlined in regulations by CMS, including Advanced Alternative Payment 
Models?

    Answer. If confirmed, I commit to work closely with the CMS 
Administrator to make sure we implement MACRA in a way that is easy to 
understand, minimizes burden, and is fair to all affected providers.

    Question. Will you commit to fund and administer Medicare's 
Accountable Care Organizations, including the Medicare Shared Savings 
Program under section 3022 of the Affordable Care Act, and will you 
commit to helping health-care providers participate in these models, 
should they choose to do so? Will you commit to not taking any 
administrative action that would make it more difficult for Medicare 
beneficiaries or health-care providers to participate in this voluntary 
program?

    Answer. As a doctor, I appreciate the goal behind the creation of 
the ACO model: better patient care. As a legislator, I would agree 
their successes have been modest to date, and there are some challenges 
they face as well. ACOs are a tool in the toolbox to help ensure high 
quality, low cost health care for beneficiaries. They are not a silver 
bullet to all of our country's delivery system challenges. If 
confirmed, I plan to work with the CMS Administrator to ensure that we 
learn from ACOs' successes and challenges to date as we chart the path 
forward.

    Question. Will you commit to fully fund approved grants under the 
Center for Medicare and Medicaid Innovation (CMMI), and will you 
continue to fund and administer future payment initiatives under CMMI, 
consistent with the legislative intent of Congress in the Affordable 
Care Act?

    Answer. If confirmed, I will work to ensure that HHS 
(appropriately) implements the statutes within its purview.

    Question. Do you share my view that, given Congress's significant 
ongoing investment in the delivery of health-care services, the Federal 
Government should fund research into health-care quality? Will you 
commit to not taking administrative actions that would weaken the work 
of the Agency for Healthcare Research and Quality (AHRQ) within HHS?

    Answer. I appreciate your concerns about health-care quality. I 
also appreciate the fact that health-care research may address patient 
safety, care management and methods to broaden access to health-care 
services, among other issues. Health-care studies also help to inform 
the discussion on ways to improve the quality of care and reduce costs. 
As you know, Congress will ultimately make the decision on whether to 
fund the Agency for Healthcare Research and Quality (AHRQ). 
Nonetheless, if confirmed, I look forward to working with you to more 
carefully examine AHRQ and determine how it may best drive positive 
patient-centered solutions in healthcare. And if confirmed, I will work 
to ensure that HHS (appropriately) implements the statutes within its 
purview.
                        health care legislation
    Question. I have authored bipartisan legislation (S. 2259 in the 
114th Congress) to make it easier for rural health-care providers to 
participate in the Medicare Shared Savings Program by allowing CMS to 
adopt a broader beneficiary assignment method than is provided under 
current law. Will you commit to providing me and my office responsive 
and accurate technical assistance on this legislation?

    Answer. I look forward to working with you on this issue and 
sharing both feedback and assistance regarding the important policy 
issues in beneficiary assignment for the Medicare Shared Savings 
Program.

    Question. I have authored bipartisan legislation (S. 2373 in the 
114th Congress) to require Medicare to cover an essential preventive 
product, compression therapy items, for beneficiaries who experience 
swelling from lymphedema. Will you commit to providing me and my office 
responsive and accurate technical assistance on this legislation?

    Answer. As you know, CMS has a detailed process for making 
determinations regarding whether items and services are reasonable and 
necessary, if they can be considered eligible for Medicare coverage 
given other restrictions and prohibitions. From time to time, Congress 
sees it fit to make its own determination regarding specific items or 
services. If confirmed, I would be pleased to work with your team to 
provide information on the Medicare coverage process and potentially 
relevant considerations.

    Question. I have cosponsored bipartisan legislation (S. 3129) to 
preserve patient access to outpatient therapeutic services in Critical 
Access Hospitals and other rural hospitals. Similar legislation has 
been signed into law the last 3 years. Will you commit to working with 
me, my staff, and bill sponsors and cosponsors, on this issue?

    Answer. If confirmed, I look forward to working with you and others 
in the Congress to see that critical access hospitals are best enabled 
to serve rural populations well.

    Question. Will you commit to providing me and my office responsive 
and accurate technical assistance on any future legislation I author or 
on which I seek assistance?

    Answer. Federal agencies play a significant role in the legislative 
process, often including providing technical assistance. Such technical 
assistance can involve situations where the agency provides feedback 
but clarifies that the assistance does not reflect the views or 
policies of the agency or administration. If confirmed, I will endeavor 
to work with you in this way as appropriate to ensure proposed 
legislation is consonant with the existing statutory and regulatory 
scheme.
            washington state's section 1115 medicaid waiver
    Question. On January 9, 2017, CMS approved Washington State's 
proposed Medicaid waiver (``Medicaid Transformation Project, No. 11-W-
00304/0'') under section 1115(a) of the Social Security Act. In 
securing agreement on this waiver, Washington State health officials 
and CMS spent countless hours over more than a year in good-faith 
negotiations. This approved waiver will help Washington State pursue a 
smarter and more innovative Medicaid program that reflects changes in 
health-care delivery, technology, and the preferences of patients.

    Will you commit to honor this approved waiver and not take any 
administrative action to rescind, weaken, or de-fund its components?

    Answer. It would be inappropriate at this point to comment on any 
specific waivers under consideration at CMS, but, if confirmed, I would 
work with the CMS Administrator to ensure that CMS uses its waiver 
authority to provide much needed flexibility to States to innovate 
within the Medicaid program.
                       graduate medical education
    Question. The vast majority of Washington State counties are Health 
Professional Shortage Areas (HPSA's) according to HHS's HRSA. Do you 
agree with an established body of research illustrating that there are 
physician shortages in the United States, especially in primary care 
specialties and in rural communities?

    Answer. Access to care is a critical issue in many parts of the 
country, particularly for primary care in rural areas. The underlying 
physician shortage is sometimes worsened by government policies. If 
confirmed, I look forward to the opportunity to address these physician 
shortages, particularly as they relate to the Medicare and Medicaid 
programs.

    Question. Do you agree with previous congressional intent that the 
Federal Government, through Medicare and other programs, has a strong 
role to play in graduate medical education (GME) policy and funding?

    Answer. I have always been a strong supporter of efforts to support 
medical education. Congress has used the Medicare program from its 
inception to invest in future generations of doctors. Regardless of 
what we do in Washington, health care should always be about that one 
to one relationship of a patient to a doctor. That relationship of 
course requires a doctor. And so I am hopeful we can continue to find 
ways to remove disincentives to the practice of medicine and its 
rewards as well as support the profession in other ways.

    Question. Was your own surgery residency funded by Medicare?

    Answer. Both my wife and I were residents at Emory University. I 
completed my residency in 1984. The Medicare program has paid for some 
portion of GME at participating hospitals since its inception in 1965.

                                 ______
                                 
               Questions Submitted by Hon. Mark R. Warner
                          affordable care act
    Question. In December 2016, the Congressional Budget Office issued 
a report noting that it would define as insurance coverage only ``a 
comprehensive major medical policy that, at a minimum, covers high-cost 
medical events and various services, including those provided by 
physicians and hospitals.'' The ACA established a set of services, 
known as Essential Health Benefits, that all insurance policies must 
include to make sure patients have appropriate health coverage.

    What would you advise the President define as ``coverage'' under a 
Republican ACA replacement plan?

    In a repeal-and-replace scenario, will coverage obtained by 
individuals provide adequate financial protections against high medical 
costs?

    Will you advocate for insurance policies under the Republican 
replacement plan that provide meaningful coverage so that insurers 
could not once again: (1) charge higher premiums to women, people with 
pre-existing conditions, or others for reasons such as their profession 
or the industry in which they work; (2) drop or severely limit benefits 
such as maternity care and prescription drugs, which insurers must 
currently cover as ``essential health benefits;'' (3) reinstate annual 
and lifetime limits on coverage; or (4) charge deductibles, co-payments 
and co-insurance without limits?

    Will you commit to safeguarding the consumer protections that the 
Affordable Care Act put in place?

    Answer. This is a work in progress. If confirmed, I would 
appreciate your thoughts on how best to address these matters. It is 
important that any system have safeguards so that no one loses access 
to care due to a bad diagnosis. Additionally, credible coverage is 
important. Patients should be provided an array of options so they may 
select the one best for themselves and their family; and consumer 
protections are integral to any patient-centered system.
                              drug prices
    Question. The rise in prescription drug costs is squeezing American 
families as well as Federal spending. We need to address this now. In 
your testimony to the HELP Committee last week, you agreed that we need 
to work in ``a bipartisan way (to address the) root causes of drug 
prices, (and) to make sure that drug pricing is reasonable.'' But you 
refused to commit to specific policies. President Trump has said that 
we should allow Medicare to leverage its power as a payer, and 
negotiate drug prices with pharmaceutical companies.

    Do you agree with President Trump that Medicare should negotiate 
drug prices?

    Answer. The issue of drug pricing and drug costs is one of great 
concern to all Americans. You have my commitment to work with you and 
others to make certain that Americans have access to the medications 
that they need. If confirmed, I look forward to focusing on how we can 
make health care more affordable, including prescription drugs. I share 
your concern regarding the importance of individuals and families being 
able to afford the prescription drugs they need.
                          drug price and value
    Question. While we are moving towards paying for value in many 
areas of healthcare, in the drug space we have largely lagged behind. 
In the past year, we have seen some insurers and drug manufacturers 
pilot value-based arrangements that hold the manufacturer accountable 
for how their product performs in the real world on an agreed upon set 
of metrics. In 2015, I led a letter with my colleagues, Senator Kaine, 
Senator Nelson, Senator Shaheen, and Senator Heitkamp, to the Centers 
for Medicare and Medicaid asking them to examine the potential of using 
value-based arrangements in Medicare and other public programs.

    Will you commit to working with me to identify potential regulatory 
policy barriers that should be reviewed in order to continue to move 
towards reimbursement for value rather than volume in the drug space?

    Answer. If confirmed, I look forward to working with you and others 
to ensure that we are moving toward a health-care system defined by 
high-quality, patient-focused care. I appreciate how reimbursement--and 
other regulatory policies impact physician behavior. If confirmed, I 
will ensure that HHS is a good steward of taxpayer dollars, with the 
goal of delivering the highest-quality care through its health-care 
programs, including the Medicare program serving our Nation's seniors.
                          gabriella miller/nih
    Question. Gabriella Miller, a 10-year old girl from Leesburg, VA 
who suffered from pediatric brain cancer, became an extremely 
impressive activist on behalf of childhood cancer awareness before her 
untimely death. Her work led to the passage of the Gabriella Miller 
Kids First Act, and NIH has been moving forward to implement this law 
and expand pediatric research.

    Will you prioritize pediatric cancer research and implement the 
Gabriella Miller Kids First Research Act?

    Answer. I am always inspired by the courage cancer patients bring 
to their fight against this devastating disease. This is particularly 
true when the patients are some of the youngest amongst us. It 
underscores why we must cure cancer. The NIH plays a pivotal role in 
supporting cutting-edge biomedical research across our country, 
including key efforts related to pediatric research, and I recognize 
that we must make progress on this front for the adults and children 
fighting cancer. If confirmed, I look forward to continuing HHS's 
important work to advance cancer research and bring forward innovative 
treatments as part of our shared goal of defeating cancer.
                    cybersecurity/internet of things
    Question. The declining cost of digital storage and Internet 
connectivity have made it possible to connect an unimaginable range of 
products and services to the Internet, with medical devices at the 
forefront of this trend. However, in many cases, manufacturers have 
brought insecure devices to market, with few incentives to design the 
products with security in mind, or to provide ongoing support to 
address vulnerabilities. For example, we have seen cases where an 
implantable device lacked meaningful authentication methods, leaving it 
susceptible to unauthorized or malicious commands sent remotely.

    The FDA has taken important steps to addressing cybersecurity in 
the ``Internet of things.'' This includes promulgating post-market 
guidance, working closely with cybersecurity researchers, and engaging 
manufacturers to promote development of more secure devices. Will you 
commit to continue and build on these efforts?

    Answer. The safety of American citizens will always be a top 
priority of the HHS and ensuring the security of medical devices 
against the threat of hacking is critical to that end. If I am 
confirmed, the FDA will continue and improve upon its efforts to 
strengthen cybersecurity within the medical device industry as well as 
other related industries.
                        ban on cdc gun research
    Question. Since 2013, Americans have died from incidents involving 
firearms and automobiles at almost identical rates. Over the last two 
decades, the Federal Government has spent $240 million a year on motor 
vehicle safety research, and motor vehicle deaths plummeted nearly 25 
percent from 2004 to 2013 thanks to data supporting new policies. CDC 
has done virtually no research into gun-related injuries and deaths 
after an appropriations rider was added that prohibits the CDC from 
``participating in advocacy or promotion of gun control.'' Roughly 
100,000 Americans injured or killed each year by guns, including over 
2,000 in 2016 from accidental shootings alone. The original author of 
the appropriations rider, Representative Jay Dickey (R-AR), has 
declared he regrets it and would like to see the CDC able to research 
violence and injury related to firearms. To make smart policy, it's 
necessary to have accurate information and data.

    If confirmed, would you direct CDC staff to interpret the 
appropriations rider in a reasonable way, so that CDC could in fact 
conduct unbiased research on the relation of firearms to public health?

    Answer. The CDC performs an important role in helping to understand 
and communicate public-health issues. If confirmed, I will work to 
faithfully ensure that the Department and its operating divisions 
fulfill their statutory responsibilities.
                            rural hospitals
    Question. Rural hospitals, serve older, sometimes more economically 
disadvantaged populations challenged by less access to primary, dental, 
and mental health care than their urban counterparts. Rural hospital 
leaders from across Virginia continue to share with me their concerns 
with efforts to repeal the Affordable Care Act. The ACA lowered the 
percentage of uninsured by 8 percentage points in rural counties, 
decreasing bad debt for providers in these areas, and providing them 
with some financial breathing room. Yet despite this progress, the 
Virginia Hospital Association estimates that 43% of rural hospitals in 
Virginia operate at a financial loss.

    Should there be supports included in an ACA replacement proposal to 
ensure these safety net providers can afford to keep their doors open 
to serve these vulnerable patients?

    Answer. Our goal is to ensure access to affordable, quality health 
care for all citizens. This of course includes individuals who access 
care at rural or critical access hospitals. And so the best metric in 
the end is one that measures the extent of access to actual care, not 
just coverage, and the quality of that care as determined by patients 
working individually with their doctors. I look forward to working on 
this important issue with you, if confirmed.

    Question. Last week, CBO reported that in the first year after a 
repeal of the ACA marketplace subsidies would take effect, about half 
of the Nation's population would live in an area that would have no 
insurer participating in the individual market, increasing to three-
quarters of the population by 2026. You have emphasized ``access'' to 
coverage but the report suggests repeal in its effects will eliminate 
choice, competition, and access in rural communities, reversing much of 
the progress we've made to reduce the number of the uninsured, as well 
as reducing uncompensated care.

    What advice would you give President Trump on addressing the bad 
debt issues these rural hospitals would face post-repeal?

    Answer. Changes to the ACA should not be done in isolation. Our 
goal is to ensure access to affordable, quality health care for all 
citizens.
                             home infusion
    Question. While I supported the 21st Century Cures Act when it 
passed in December, I remain concerned about a provision which caused 
the misalignment of effective dates of two important policies. The act 
included a provision Senator Isakson and I fought hard to include that 
would pay for services associated with allowing Part B to reimburse for 
Medicare patients to receive infusion drugs at their home starting in 
January 2021. However, a provision which was used to help pay for such 
payment, a cut to the reimbursement rates for Part B Durable Medical 
Equipment (DME) home infusion drugs, had an effective date of January 
2017. This leaves a 4-year gap where home infusion services will not be 
adequately reimbursed. While I work with my colleagues in Congress to 
fix this issue, I hope that the Centers for Medicare and Medicaid 
Services (CMS) will make every effort to ensure Medicare beneficiaries 
continue to have access to these lifesaving medications.

    Can you commit to report back on actions CMS and HHS can take to 
protect beneficiaries from losing access to life-saving care?

    Answer. Yes. I look forward to working with you to find approaches 
to this issue that ensure access to the highest quality care.
                               telehealth
    Question. I've worked with bipartisan members of the Finance 
Committee to expand the use of telehealth, especially in Medicare, and 
I was glad that at your hearing last week you called telehealth an 
``exciting innovation for rural and underserved areas.''

    As Secretary, will your Department work with my staff and others to 
find ways to fully leverage HHS's existing authority to lower barriers 
for telehealth and remote patient monitoring in Medicare?

    Answer. I share your interest in promoting telehealth. Telehealth 
can provide innovative means of making health care more flexible and 
patient-centric. Innovation within the telehealth space could help to 
expand access within rural and underserved areas. If confirmed, I look 
forward to continued discussions on telehealth, including on the best 
means to offer patients increased access, greater control and more 
choices that fit their medical needs.

                                 ______
                                 
    Submitted by Hon. Debbie Stabenow, a U.S. Senator From Michigan

                DPCC FORUM ON HEALTH AND HUMAN SERVICES 
                           NOMINEE TOM PRICE

_______________________________________________________________________

                       THURSDAY, JANUARY 19, 2017

              OPENING STATEMENT OF HON. DEBBIE STABENOW, 
                      A U.S. SENATOR FROM MICHIGAN

    Senator Stabenow. Well, good afternoon. We so appreciate all of you 
being with us, and I want to thank all of my colleagues for being here 
and for their hard work.

    Senator Murray will be joining us; she has been involved in helping 
to create the success of today, as well as Senator Warren. Senator 
Kaine of course is here, and Senator Hassan. It's very important for us 
to have an opportunity to hear from all of you as we are reviewing and 
making decisions on who will head the Health and Human Services 
Department for our country.

    And Senator Murray has joined us; welcome. Let me just start by 
saying that on all of these issues this is not personal to any nominee, 
this is about differences, fundamental differences, and ideas and 
policies and what helps people, what hurts people. I mean these are 
very important debates, and your voice, your opinions are very 
important to all of us.

    So you're here at a critical time, and we know that just last week 
Republicans in both the House and the Senate pulled the first thread 
that will unravel potentially the entire health-care system, voting to 
adopt a budget resolution that would allow for repeal of the Affordable 
Care Act, and we don't know what comes after that. If this happens, 
according to the Congressional Budget Office, 32 million people, 
including many of you on this panel today, would lose health insurance 
coverage and individual market premiums would double in the next 10 
years, according to the budget office.

    Unfortunately, the damage would not end there. Another 52 million 
adults, including 1.7 million in my own home State of Michigan, could 
become uninsured due to pre-existing conditions. Forty-eight million 
people could lose mental health parity protections, which makes sure 
that diseases are treated above the neck, as well as below the neck. We 
could be sent back to a time when being a woman was a pre-existing 
condition, when insurance companies would cut you off when you hit an 
annual or lifetime limit on coverage, even if you needed more care.

    One hundred and five million Americans no longer face bankruptcy 
when they get sick because those caps have been eliminated, and that is 
a good thing. The Medicare trust fund has been extended by 11 years, 
preserving future benefits, and 11 million seniors have saved an 
average of $2,000 because what has been called the ``donut hole,'' this 
gap in coverage, has been phased out; it's now closed so there is 
continuous coverage.

    I could go on with the numbers, but the most important thing is not 
the numbers. The most important thing is how all of this effects your 
families, our families, our children, our parents, our grandparents.

    If confirmed by the Senate, the Secretary has tremendous power. His 
or her decisions in office will affect all of us. His or her voice will 
strongly influence the President's decision to promote, sign, or veto 
legislation.

    We have heard mixed messages. Our President-elect campaigned on not 
cutting Medicare or Medicaid. Just over the weekend he said we would 
have insurance for everyone. We would certainly welcome the opportunity 
to see that plan, we do welcome it. But at the same time, just this 
fall, Congressman Price said he expects Medicare to be overhauled 
``within the first 6 to 8 months'' of President Trump's administration. 
He also believes, ``the age of eligibility needs to be increased,'' and 
that, ``the better solution is premium support,'' which is another word 
for vouchers.

    When it comes to covering pre-existing conditions, he has indicated 
that he thought that was, ``a terrible idea.'' So this is important, 
this is about ideas and policies and values and perspectives, and we 
are very grateful that all of you are here.

    We had asked the Chairmen of the two committees responsible for the 
nomination if we could in fact have a panel of all of you, of others, 
to share voices at the formal confirmation hearing. That was rejected, 
and so we're doing a public forum to give you an opportunity to share 
your thoughts.

    So thank you again, and before introducing our panelists, our 
terrific ranking member from the Health, Education, Labor, and Pensions 
Committee, Senator Murray, is here, if you would like to say a few 
words.

                OPENING STATEMENT OF HON. PATTY MURRAY, 
                     A U.S. SENATOR FROM WASHINGTON

    Senator Murray. Well, I won't talk long because I really do want to 
hear from all of you, it's so important, and I want to thank Senator 
Warren and Senator Stabenow for putting this together, because, as all 
of you know, we did have a hearing yesterday.

    I was disappointed we couldn't ask more questions of the nominee 
himself. We were only given one round. There is a lot to be concerned 
about.

    Congressman Price has a long record of making decisions I would not 
make, taking away affordable health care, going after people who depend 
on Medicaid. He is a politician who has worked hard to undermine 
reproductive rights, seniors who rely on Medicare--the list goes on--
and this is a cabinet secretary who will oversee the lives of literally 
every family in this country.

    So we have a responsibility to hear from those families in this 
country and the impact this department will have on them. So I really 
appreciate your doing this, and I look forward to all of your 
testimony.

    And I just want to give a shout out to our Democrats, both here and 
on my committee, who really did an excellent job, both with this 
hearing and the DeVos hearing, in really, in the very limited amount of 
time we had, showing some of their record.

    So, thank you all very much for being here.

    Senator Stabenow. Thank you so much. Senator Warren, who has played 
such an integral role as we have been bringing forth public voices on 
the nominees, is here. Thank you.

    Senator Warren?

              OPENING STATEMENT OF HON. ELIZABETH WARREN, 
                   A U.S. SENATOR FROM MASSACHUSETTS

    Senator Warren. So, thank you very much, Senator Stabenow, for your 
leadership in pulling this together so we get to have these people's 
hearings, and I also want to say ``thank you'' to Senator Murray. She 
really is our leader, and the one who is keeping us in this fight on 
the nominees, and the fight to protect what it is that we stand for 
here.

    And I welcome our newest member, Senator Hassan, who is also on the 
committee, and Senator Kaine. So we have a bunch of people who are in 
there fighting.

    You know, President-elect Trump has spent the past few weeks 
filling his cabinet and putting together his team for how he wants to 
run his administration. The decisions that he makes will have 
tremendous consequences on the lives of everyone in this country, and 
when it comes to the Secretary for the Department of Health and Human 
Services, President Trump's choice will have an enormous effect on the 
lives of everyone in this room and everyone in this country.

    They will help determine whether millions of Americans continue to 
have access to medical care, whether contraception or cancer screenings 
or flu shots must be covered by your health insurance, whether Medicare 
and Medicaid are protected for the 100 million Americans that rely on 
this program. In short, the hiring decisions that President-elect Trump 
is making tell us about the values of the incoming Trump 
Administration.

    Now, unlike many of President-elect Trump's nominees, who have 
little or no experience as they take over their various departments, 
Congressman Price has a lot of experience in health-care policy, and 
that is why we are so worried. His record makes clear that he has some 
very radical, scary ideas about how to change health care in America. 
Congressman Price once described the ACA's ban on discriminating 
against individuals with pre-existing conditions as ``a terrible 
idea.'' He has voted 10 times to defund Planned Parenthood, which 
provides lifesaving cancer screenings and treatment for sexually 
transmitted diseases to millions of people a year. He has proposed 
privatizing Medicare and increasing the eligibility age for coverage, 
and he has championed massive cuts to the Medicaid program that will 
leave millions of people either uninsured or with fewer benefits.

    Twenty-four Senators, led by Senator Casey of Pennsylvania, sent 
letters to Senator Hatch and Senator Alexander, asking them to include 
witnesses in Congressman Price's nomination hearings, witnesses who 
could talk about what the impact of his radical policy proposals would 
be on the lives of real people.

    Now, I am sorry that the Republicans refused to hear your voices, 
but I am deeply grateful that you came here today to make sure that 
your voices are heard anyway. I am grateful to my colleagues who are 
doing everything they can to amplify your voices, and to make sure that 
as the United States Senate considers its sacred obligation on advice 
and consent of the nominees in front of us, that we remember, most of 
all, that we are here to serve you. So thank you for being here.

    Senator Stabenow. Thank you so much.

    We have been joined by Senator Hirono from Hawaii, and with the 
indulgence of the rest of our distinguished Senators who are here, I 
think I'll move to hearing from our guests and then move to questions, 
if that is all right with everyone.

    So let me first take home State advantage here, our prerogative, by 
introducing Anne Serafin from Ferndale, Michigan. She lives with 
Multiple Sclerosis and is covered by Medicare.

    Anne and her husband also supported Anne's mom for the last decade, 
and after years of financial stress were able to get her mom into a 
nursing home, with the cost of her care covered by Medicaid, and we 
greatly appreciate hearing your story.

    We'll introduce everyone and then we will come back to you. And I 
am going to turn now to Senator Warren for our next guest.

    Senator Warren. That's right. I have the privilege of introducing 
Kanisha Hans, who is here today with us to talk about the impact of the 
Affordable Care Act on her personally.

    I just want to add that Kanisha discovered her passion for advocacy 
by volunteering in political campaigns, good for you, candidates for 
local office.

    Today Kanisha lives in Boston, and she works in a Cambridge tech 
start-up. She graduated from Boston University in 2015 with a B.A. in 
Political Science and a minor in Public Health.

    She is taking off time from work to be here today, and we are very 
grateful that she is willing to share her story, which underlines the 
critical protections that the Affordable Care Act gives us for women's 
health care.

    So thank you very much for joining us today, Kanisha.

    Senator Stabenow. Kanisha, welcome.

    Now we have also been joined by Senator Blumenthal from 
Connecticut; welcome.

    Alyce Ornella from Harpswell, Maine. So you've come a little bit, 
how is the snow up there right now? Much colder; okay.

    Alyce and her husband were self-employed when they were able to get 
health insurance coverage through the ACA exchange. Alyce's plan 
provided free pre-natal care, including prenatal tests while she was 
pregnant with her son, Sam. When Sam was unexpectedly born with serious 
birth defects, her plan covered all of his intensive care and surgery 
costs, and Sam now receives care through Medicaid, which has covered 
every test and exam that he has needed, and we wish him well, we hope 
where is Sam?

    Oh, well we want to see Sam.

    Okay, is that who I met earlier, with the terrific sweater on?

    Okay, we need to have him come back.

    So welcome, we're so glad to have him, and close to home, riding 
the Metro in I think today to avoid all the traffic, Diane Fleming. 
Diane is 75 years old, lives in Washington, DC, went on Medicare at age 
65, 5 years ago was diagnosed with thyroid cancer. Medicaid has covered 
the bills from the four surgeries, radioactive iodine treatment, CT 
scans, sonograms, MRIs, and needle biopsies she has needed to treat her 
cancer.

    We are very grateful to have you here to hear from your story and 
have you elaborate as well.

    And I know that Senator Brown is hoping to join us. I know I just 
left him a while ago in the Finance Committee.

    So, Holly, he wanted to introduce you, but I know he is going to 
join us if he can. Holly is from Cleveland, Ohio. Self-employed as a 
non-profit consultant in Cleveland, runs her own LLC., was able to 
access mental and behavioral health services through Medicaid, and has 
been able to go on--I'll let you tell your story about what you have 
been able to actually receive in terms of help as a result of that, but 
we are so pleased you are here as well.

    And Senator Bob Casey from Pennsylvania has just joined us. So I am 
going to ask Anne if you could share your story. We ask everyone to 
take no more than 5 minutes to start so that we can have an opportunity 
to ask questions as well, but, Anne, thanks so much for you and your 
husband being here.

         STATEMENT OF ANNE SERAFIN, PANELIST FROM FERNDALE, MI

    Ms. Serafin. Good afternoon. My name is Anne Serafin. I live in 
Ferndale, Michigan, and I am 66 years old. I just want to say, I'm 
reading this statement, so it may not convey the real passion I feel 
about this issue. But please know how important this is to me.

    I've had personal experience with Medicare since I was 40 years 
old, when I was diagnosed with multiple sclerosis.

    As you may know, MS is a neurological condition, which varies in 
severity and it's very unpredictable. My particular version resulted in 
functional quadriplegia. As a result, I am unable to walk, but I can 
stand up with personal assistance and a grab bar. I can use my right