[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
THE FISCAL YEAR 2020 HHS BUDGET
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
MARCH 12, 2019
__________
Serial No. 116-16
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
govinfo.gov/committee/house-energy
energycommerce.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
37-490 PDF WASHINGTON : 2020
--------------------------------------------------------------------------------------
COMMITTEE ON ENERGY AND COMMERCE
FRANK PALLONE, Jr., New Jersey
Chairman
BOBBY L. RUSH, Illinois GREG WALDEN, Oregon
ANNA G. ESHOO, California Ranking Member
ELIOT L. ENGEL, New York FRED UPTON, Michigan
DIANA DeGETTE, Colorado JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland PETE OLSON, Texas
JERRY McNERNEY, California DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice BILL JOHNSON, Ohio
Chair BILLY LONG, Missouri
DAVID LOEBSACK, Iowa LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon BILL FLORES, Texas
JOSEPH P. KENNEDY III, SUSAN W. BROOKS, Indiana
Massachusetts MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California RICHARD HUDSON, North Carolina
RAUL RUIZ, California TIM WALBERG, Michigan
SCOTT H. PETERS, California EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
------
Professional Staff
JEFFREY C. CARROLL, Staff Director
TIFFANY GUARASCIO, Deputy Staff Director
MIKE BLOOMQUIST, Minority Staff Director
Subcommittee on Health
ANNA G. ESHOO, California
Chairwoman
ELIOT L. ENGEL, New York MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina, Ranking Member
Vice Chair FRED UPTON, Michigan
DORIS O. MATSUI, California JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon BILLY LONG, Missouri
JOSEPH P. KENNEDY III, LARRY BUCSHON, Indiana
Massachusetts SUSAN W. BROOKS, Indiana
TONY CARDENAS, California MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont RICHARD HUDSON, North Carolina
RAUL RUIZ, California EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex
officio)
C O N T E N T S
----------
Page
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, opening statement............................... 2
Prepared statement........................................... 2
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 3
Prepared statement........................................... 4
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 5
Prepared statement........................................... 6
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 8
Prepared statement........................................... 9
Witnesses
Alex Azar, Secretary, Department of Health and Human Services.... 10
Prepared statement........................................... 11
Answers to submitted questions............................... 100
Submitted Material
Article of February 20, 2019, ``Texan Republican rejects Dems'
criticism of Homestead facility for migrant kids,'' Fort Worth
Star-Telegram, submitted by Mr. Burgess........................ 92
Article of March 9, 2019, ``U.S. Continues to Separate Migrant
Families Despite Rollback of Policy,'' The New York Times, by
Miriam Jordan and Caitlin Dickerson, submitted by Ms. Eshoo.... 94
THE FISCAL YEAR 2020 HHS BUDGET
----------
TUESDAY, MARCH 12, 2019
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 12:01 p.m., in
the John D. Dingell Room 2123, Rayburn House Office Building,
Hon. Anna G. Eshoo (chairwoman of the subcommittee) presiding.
Members present: Representatives Eshoo, Engel, Butterfield,
Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas,
Welch, Ruiz, Dingell, Kuster, Kelly, Barragan, Blunt Rochester,
Rush, Pallone (ex officio), Burgess (subcommittee ranking
member), Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long,
Bucshon, Brooks, Mullin, Hudson, Carter, Gianforte, and Walden
(ex officio).
Also present: Representatives DeGette, Schakowsky, and
Tonko.
Staff present: Kevin Barstow, Chief Oversight Counsel;
Jacquelyn Bolen, Health Counsel; Jeffrey C. Carroll, Staff
Director; Luis Dominguez, Health Fellow; Waverly Gordon, Deputy
Chief Counsel; Tiffany Guarascio, Deputy Staff Director; Megan
Howard, FDA Detailee; Zach Kahan, Outreach and Member Service
Coordinator; Saha Khaterzai, Professional Staff Member; Chris
Knauer, Oversight Staff Director; Una Lee, Senior Health
Counsel; Kevin McAloon, Professional Staff Member; Joe Orlando,
Staff Assistant; Kaitlyn Peel, Digital Director; Alivia
Roberts, Press Assistant; Tim Robinson, Chief Counsel; Samantha
Satchell, Professional Staff Member; Andrew Souvall, Director
of Communications, Outreach and Member Services; Kimberlee
Trzeciak, Senior Health Policy Advisor; Rick Van Buren, Health
Counsel; C.J. Young, Press Secretary; Jennifer Barblan,
Minority Chief Counsel, Oversight and Investigations; Mike
Bloomquist, Minority Staff Director; Adam Buckalew, Minority
Director of Coalitions and Deputy Chief Counsel, Health; Jordan
Davis, Minority Senior Advisor; Margaret Tucker Fogarty,
Minority Staff Assistant; Brittany Havens, Minority
Professional Staff, Oversight and Investigations; Peter Kielty,
Minority General Counsel; Ryan Long, Minority Deputy Staff
Director; James Paluskiewicz, Minority Chief Counsel, Health;
Brannon Rains, Minority Staff Assistant; Kristen Shatynski,
Minority Professional Staff Member, Health; and Danielle
Steele, Minority Counsel, Health.
Ms. Eshoo. The Subcommittee on Health will now come to
order.
The Chair now recognizes herself for 5 minutes. Actually, I
will only use 2, so that we can move things along today.
OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
We welcome the Secretary of Health and Human Services, Alex
Azar, to testify on the President's fiscal year 2020 budget.
Good morning, Mr. Secretary.
This is the first time that Secretary Azar is testifying
before the Energy and Commerce Committee in the new Congress,
and his first stop on the Hill to testify on the President's
budget is here. So thank you for starting with us.
The President's budget certainly reflects the priorities of
the administration, but I believe that our national budget
should be a statement of our nation's national values, and I
don't believe that the budget does that. The Trump
administration has taken a hatchet to every part of the
healthcare system, undermining the Affordable Care Act,
proposing a fundamentally-restructured Medicaid, and slashing
Medicare. This budget proposes to continue that sabotage.
In November, the American people rejected the sabotage of
healthcare that took place, and it is the reason that I am
sitting in this chair and that the ratios of this committee and
the Congress have changed.
Our subcommittee has worked hard over the past two months
to examine ways to undo the sabotage of the Affordable Care Act
and advance legislation that will bring down healthcare costs
for the American people, and we will continue that work.
I hope, Secretary Azar, that you will be willing to be a
partner in our work to lower healthcare costs for the American
people, and we welcome your testimony and your presence here
today.
[The prepared statement of Ms. Eshoo follows:]
Prepared Statement of Hon. Anna G. Eshoo
Today we welcome the Secretary of Health and Human Services
Secretary Alex Azar to testify on the President's Fiscal Year
2020 Budget.
This is the first time Secretary Azar has testified before
the Energy and Commerce Committee in the new Congress.
The Health Subcommittee is also Secretary Azar's first stop
during his visit to Capitol Hill to testify on the President's
Budget which was released yesterday. We're pleased you started
with us.
The President's Budget reflects the priorities of an
Administration, and I believe the priorities of this
Administration are misdirected.
It's clear this Administration has very different
aspirations for our country and what our healthcare system
should look like.
The Trump Administration has taken a hatchet to every part
of our healthcare system, undermining the Affordable Care Act,
proposing to fundamentally restructure Medicaid and slashing
Medicare. This budget proposes to continue that sabotage,
In November, the American people rejected the vision for
our country that this budget represents.
This Subcommittee has worked very hard over the past two
months to examine ways to undo the sabotage of the Affordable
Care Act and advance legislation that will bring down
healthcare costs for the American people. And we will continue
that work.
Secretary Azar, I hope that you'll be a partner in our work
to lower healthcare costs for the American people and we
welcome your testimony.
Ms. Eshoo. The Chair now recognizes Dr. Burgess, the
ranking member of the subcommittee, for 5 minutes for his
opening statement.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. Thank you, Chairwoman.
And, Mr. Secretary, good afternoon. Welcome to our humble,
little subcommittee. It is a pleasure to have you testifying
before us today to hear your views about the fiscal year 2020
budget proposal.
The President's budget provides Congress with an important
blueprint for our appropriations process and with the policies
that this President and his administration would like to see in
the coming fiscal year. As we know, under the Constitution, no
money may be spent from the Treasury unless it is appropriated
by Congress, and in a perfect world no money would be
appropriated unless the expenditure has previously been
authorized.
The Energy and Commerce Committee is a principal
authorizing committee of the United States House of
Representatives. I believe this is a critical task and it is
important to get input from the Department of Health and Human
Services when we are authorizing or re-authorizing or reforming
programs that are under your control.
While we do hear from the boots on the ground in our
districts, it is the agency that both oversees the
implementation of these programs and provides funding to ensure
that the organizations can carry out the initiatives' goals.
Secretary Azar, thus far, in your tenure as the Secretary
of the Department of Health and Human Services, you have proven
to be immensely helpful to this committee and its work. You and
your team have been responsive to our requests for information
and for input, and you have made yourself available to Members,
so that we can hear about your priorities and your intention to
work with Congress on a number of initiatives.
I will say this: of all the Secretaries of Health and Human
Services over the years that I have been in Congress, I have
found you to be the most transparent and accessible. And I look
can forward to continuing to partner with you on your efforts
to improve access and quality of healthcare for Americans.
One issue that I have raised in each hearing in this
Congress, and one that I hear consistently from constituents
back home, is the cost and complexity of the healthcare system.
North Texans frequently tell me that they can barely afford
their insurance premiums, let alone the cost they must pay to
seek the care they need, especially those with high-deductible
plans.
Secretary Azar, I know that addressing the cost of
healthcare, and specifically drug prices, has been a priority
for the Department under your leadership. I hope this
committee, being the one with the primary jurisdiction over
these issues, will work with you as we consider ways to solve
these issues.
Additionally, as the Energy and Commerce Committee
primarily drafted landmark laws, including the 21st Century
Cures and last year's opiate effort, the SUPPORT for
Communities Act, we should conduct responsible oversight to
ensure that the Department of Health and Human Services is
implementing these laws in alignment with congressional intent.
It is encouraging to see that the President's budget
request seeks to expand treatment and recovery support for
individuals suffering from substance use disorders, in addition
to enhancing prevention of addiction in the first place. While
it is important to stem the tide of addiction, we cannot ignore
those who have a legitimate need for pain treatment, including
cancer patients, patients with sickle cell anemia, and others.
To that effect, the budget requests $500 million to use for the
National Institute of Health to partner with private industry
to work towards the development of non-addictive pain
therapies, in addition to addiction treatments and overdose
reversal technologies.
Additionally, I am encouraged to see that the budget
proposes a significant sum of money for childhood cancer
therapies and significant money to defeat the HIV/AIDS
epidemic. Both efforts are worthy of congressional support.
Another important agency within Health and Human Services,
the Office of Refugee Resettlement, is required to provide care
for unaccompanied alien children, a task for which your agency
was unprepared when this crisis began in 2012, when president
Obama signed an Executive Order enacting the Deferred Action
for Childhood Arrivals. While conditions and quality of care
have improved, the number of illegal border crossings continues
to increase. And let me be clear, the Office of Refugee
Resettlement does not enforce immigration law. They receive
children as a result of other agencies' enforcement activities.
President Trump's budget includes $3.7 billion in fiscal
year 2020 for the Unaccompanied Alien Children Program.
Congress charged the Office of Refugee Resettlement with the
care of unaccompanied alien children. And I hope this committee
will support those dedicated HHS and ORR employees as they
continue to work with integrity in the face of baseless
allegations. If Congress does not want you to undertake that
task, Congress should change the law. It is up to you; it is up
to us.
Ms. Eshoo. The gentleman's time has expired.
Mr. Burgess. I yield back. Thank you.
[The prepared statement of Mr. Burgess follows:]
Prepared statement of Hon. Michael C. Burgess
Thank you, Chairwoman Eshoo, and welcome to Secretary Azar.
It is a pleasure to have you testifying before the Health
Subcommittee this afternoon about the fiscal year 2020 budget
proposal. The President's budget provides Congress with an
important blueprint for our appropriations process and with
policies that the President and his administration would like
to see in the coming fiscal year.
Under our Constitution, no money may be spent from the
Treasury unless appropriated by Congress and, in a perfect
world, no money would be appropriated unless the expenditure is
previously authorized. The Energy and Commerce Committee is a
principal authorizing committee of the U.S. House of
Representatives. I believe this is a critical task and that it
is important to get input from the Department of Health and
Human Services when we are reauthorizing and reforming programs
under its control. While we do hear from the boots on the
ground in our districts, it the agency that both oversees the
implementation of these programs and provides funding to ensure
that organizations can carry out the initiatives' goals.
Secretary Azar, thus far in your tenure as the Secretary of
the Department of Health and Human Services, you have proven to
be immensely helpful to this Committee and its work. You and
your team have been responsive to our requests for information
and input, and you have made yourself available to Members so
that we can hear about your priorities and your intention to
work with Congress on various initiatives. Of all the
Secretaries of Health and Human Services over my years in
Congress, I have found you to be the most transparent and
accessible, and I look forward to continuing to partner with
you on your efforts to improve access and quality of healthcare
for Americans.
One issue that I have raised in each hearing this Congress
and one that I hear consistently from constituents is the cost
and complexity of the healthcare system. North Texans
frequently tell me that they can barely afford their insurance
premiums, let alone the cost they must pay to seek the care
they need, especially of those with high deductible plans.
Secretary Azar, I know that addressing the cost of healthcare,
and specifically drug prices, has been a priority for the
Department under your leadership. I hope that this Committee,
being the one with primary jurisdiction over these issues, will
work with you as we consider ways to solve these issues.
Additionally, as the Energy and Commerce Committee
primarily drafted landmark laws, including 21st Century Cures
and last year's opioid effort--the SUPPORT for and Communities
Act, we should conduct responsible oversight to ensure that the
Department of Health and Human Services is implementing these
laws in alignment with Congressional intent. It is encouraging
to see that the President's budget request seeks to expand
treatment and recovery support services for individuals
suffering from substance use disorders, in addition to
enhancing prevention of addiction in the first place.
While it is important to stem the tide of addiction, we
cannot ignore those who have a legitimate need for pain
treatment, including cancer patients, sickle cell anemia
patients, and others. To that effect, the budget requests $500
million to use for the National Institutes of Health to partner
with private industry to work towards the development of non-
addictive pain therapies, in addition to addiction treatments
and overdose-reversal technologies. Additionally, I am
encouraged to see that the budget proposes $500 million for
childhood cancer therapies, and $291 million to defeat the HIV/
AIDS epidemic. Both efforts are worthy of Congressional
support.
Another important agency within HHS, the Office of Refugee
Resettlement, is required to provide care for unaccompanied
alien children, a task for which it was woefully unprepared
when this crisis began in 2012 when President Obama signed an
executive order enacting the Deferred Action for Childhood
Arrivals program. While conditions and quality of care have
improved, the number of illegal border crossings continues to
increase. Let me be clear, the Office of Refugee Resettlement
does not enforce immigration law; they receive children as a
result of ICE and CBP enforcement.
President Trump's budget includes up to $3.7 billion in FY
2020 for the Unaccompanied Alien Children program. Congress
charged the Office of Refugee Resettlement with the care of
unaccompanied alien children, and I hope this committee will
support these dedicated HHS and ORR employees as they continue
to work with integrity in the face of baseless allegations.
Again, thank you to Secretary Azar for your willingness to
testify and for taking the time out of your busy schedule to
answer our questions.
Ms. Eshoo. Thank you.
I now would like to recognize the chairman of the full
committee, Mr. Pallone, for his opening statement.
OPENING STATEMENT OF HON. FRANK PALLONE Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Madam Chair.
Last year, President Trump and Congressional Republicans
passed a deficit-busting $2 trillion tax cut for the wealthy
and corporations. At that time, we all knew who would take the
hit when it came time for the administration to produce a
budget. And now, President Trump proposes a sham of a budget
that sticks it to average working Americans across the board.
A budget is a reflection of priorities, and this budget
makes clear that ensuring all Americans have access to quality
healthcare is not a priority for this administration. The
proposed budget for HHS cuts $1.4 trillion in essential
healthcare programs that are critical to working families and
to seniors across the nation. Under President Trump's
leadership, HHS has played a major role in policies to sabotage
the Affordable Care Act, slash funding for Medicaid, restrict
access to women's contraception, and separate families at the
border. This is a devastating record for an agency whose
mission is to advance the health and well-being of all
Americans.
The fiscal year 2020 budget continues to sabotage by
reviving the failed Graham-Cassidy ACA repeal proposal, which
would lead to tens of millions of Americans losing their health
insurance and would undermine protections for people with
preexisting conditions.
The President's budget also continues the administration's
assault on the millions of hard-working families that rely on
Medicaid for health insurance, proposing $1.5 trillion in cuts
to Medicaid. It also continues the administration's illegal
efforts to kick vulnerable Americans off Medicaid through work
requirements, lockouts, and red tape. This misguided budget
also includes over $500 billion in cuts to Medicare, putting
healthcare for our seniors at risk. These are severe and
extreme healthcare cuts for hard-working middle-class families,
seniors, and our most vulnerable. This is a sham of a budget
that has absolutely no chance of ever becoming a reality, but
it shows the Trump administration's values, and not the values
of everyday Americans.
In addition to explaining the cruel cuts made by this
budget, Secretary Azar will need to account for HHS's role in
implementing the Trump administration's cruel policy of family
separation. This policy has caused so much pain and trauma for
thousands of children, and it is clear that children are still
wrongly being separated from their parents.
And finally, Secretary Azar will also have to answer for
HHS's lack of cooperation with this committee's oversight
requests. And I stress this, Mr. Secretary over the last two
months, this committee has attempted to work with HHS in good
faith in asking for information on a variety of topics from the
Affordable Care Act to the administration's family separation
policy. We are requesting important information that is
critical to our ability to conduct oversight of the Trump
administration.
But HHS has been largely unresponsive to our requests, and
our patience is wearing thin. If Secretary Azar can't commit to
providing us all of the information we have requested, we are
prepared to take additional steps to make sure that we get the
information that we need to conduct this necessary and long-
overdue oversight. And I will get back to that when we get to
our questions, Mr. Secretary.
But I do want to thank the Chair for having this important
budget hearing and thank the Secretary for appearing here
today.
Unless someone else would like some of my time, I am going
to yield back. All right, I yield back, Madam Chair.
[The prepared statement of Mr. Pallone follows:]
Prepared statement of Hon. Frank Pallone Jr.
Last year President Trump and Congressional Republicans
passed a deficit busting $2 trillion tax cut for the wealthy
and corporations. At that time, we all knew who would take the
hit when it came time for the administration to produce a
budget. And now, President Trump proposes a sham of a budget
that sticks it to average working Americans across the board.
A budget is a reflection of priorities, and this budget
makes clear that ensuring all Americans have access to quality
healthcare is not a priority for this administration. The
proposed budget for HHS cuts $1.4 trillion dollars in essential
healthcare programs that are critical to working families and
to seniors across the nation. Under President Trump's
leadership, HHS has played a major role in policies to sabotage
the Affordable Care Act, slash funding for Medicaid, restrict
access to women's contraception, and separate families at the
border. This is a devastating record for an agency whose
mission is to advance the health and well-being of all
Americans.
The FY 2020 budget continues this sabotage by reviving the
failed Graham-Cassidy ACA repeal proposal, which would lead to
tens of millions of Americans losing their health insurance and
would undermine protections for people with pre-existing
conditions.
The President's budget also continues the administration's
assault on the millions of hardworking families that rely on
Medicaid for health insurance--proposing $1.5 trillion in cuts
to Medicaid. It also continues the administration's illegal
efforts to kick vulnerable Americans off Medicaid through work
requirements, lock outs, and red tape.
This misguided budget also includes over $500 billion in
cuts to Medicare, putting healthcare for our seniors at risk.
These are severe and extreme healthcare cuts for hard-
working middle-class families, seniors and our most vulnerable.
This is a sham of a budget that has absolutely no chance at
ever becoming a reality, but it shows this administration's
values are not the values of everyday Americans.
In addition to explaining the cruel cuts made by this
budget, Secretary Azar will need to account for HHS' role in
implementing the Trump administration's disgraceful and cruel
policy of family separation. This policy has caused so much
pain and trauma for thousands of children and it's clear that
children are still wrongly being separated from their parents.
Finally, Secretary Azar will also have to answer for HHS's
lack of cooperation with this Committee's oversight requests.
Over the last two months, this Committee has attempted to work
with HHS in good faith in asking for information on a variety
of topics from the ACA to the administration's family
separation policy. We are requesting important information that
is critical to our ability to conduct oversight of this
administration. HHS has been largely unresponsive to our
requests. Our patience is wearing thin. If Secretary Azar can't
commit to providing us all the information we have requested,
we are prepared to take additional steps to make sure that we
get the information that we need to conduct this necessary and
long overdue oversight.
Thank you, I yield back.
Ms. Eshoo. We thank the chairman of the full committee.
I now would like to recognize Mr. Walden, the ranking
member of the full committee, for his opening statement. Is he
here? He is on his way? He is running?
I think that we will recognize----
Mr. Bucshon. I will claim the time on behalf of the
chairman at this point.
Ms. Eshoo. Are you going to----
Mr. Bucshon. Yes, the ranking member is on the way. So I
will start out, if that is OK with the chairwoman.
Ms. Eshoo. Are you making his opening statement? Otherwise,
we can just go----
Mr. Bucshon. I am going to make my statement, and then,
probably yield some of my time to the ranking member, yes.
Ms. Eshoo. You can proceed.
Mr. Bucshon. Thank you, Secretary Azar, for being here to
discuss the President's budget. I think every member of this
committee appreciates what you are doing, and I echo the
ranking member of the subcommittee's comments that you have
been open and accessible to Members of Congress, which is
greatly appreciated.
We will look forward to some of the questioning as we go
along. I do think that we will have some concerns related to
certain areas of the budget, including the National Institutes
of Health budget as it relates to healthcare. As you know, I
was a healthcare provider before.
And I think we will have a good and solid discussion about
our issues at our southern border. By the way, I have been
there, and I believe that the Department of Health and Human
Services is doing tremendous work with the situation they have
been relegated to address. Hopefully, you will continue to do
great work on behalf of all these people in the area of the
humanitarian crisis that is the southern border.
And with that, I yield to Mr. Walden, the ranking member of
the full committee.
OPENING STATEMENT OF HON. GREG WALDEN A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. Well, thank you, Doctor. Appreciate it.
To our witness, Mr. Secretary, thanks for being here.
Madam Chair, thanks for having this hearing.
We want to welcome Secretary Azar back to the committee.
Thank you.
On a bipartisan basis, this committee has led the way in
delivering meaningful healthcare reforms and policies for the
American people. Last year, we worked together to pass into law
the SUPPORT for Patients and Communities Act. That was the most
comprehensive legislation to address a single drug crisis in
our nation's history. That bill gave your agency unprecedented
resources and tools to stem the tide of the addiction crisis
that is still devastating our communities.
CDC data tell us there are more than 70,000 overdose deaths
in 2017, and overdoses take the lives of more Oregonians than
traffic accidents. Whenever we pass a major piece of
legislation, I really think it is important to dive back in and
do oversight to find out what is working, what projects are
still ongoing, and what we need to do to do better. So I would
love to hear from you today, Mr. Secretary, on the Department's
work to combat addiction and how we can continue to be partners
in getting help to those in need.
We also extended and funded a number of important public
health programs, including the longest extension of the
Children's Health Insurance Program in the history of the
program, 10 full years, with record funding for Community
Health Centers, which are both important for my Oregon district
and elsewhere across the country. I just met with the Community
Health Center over the weekend in Klamath Falls. There are 12
Community Health Centers, 63 sites, serving 240,000 Oregonians.
It is really, really important work.
We also need to continue our work on the cost of
healthcare. I know the administration is looking at the cost of
pharmaceutical drugs. From one end of the supply chain to the
other, we need to continue that work, so I appreciate your
personal interest in moving aggressively to bring down the cost
of prescription drugs for patients.
Last year, the FDA approved a record number of generic
drugs, I would say, in part, because of the bipartisan
legislation we passed here. It brings more competition to the
market. It drives down prices at the pharmacy counter for
consumers. But we have more work to do, and I look forward to
continuing this committee's partnership with HHS to rein-in
excessive costs for healthcare.
I was also encouraged to see a focus in the President's
budget on moving toward value-based care. As a country, we must
move into a healthcare system that pays for value and quality
of care, but those changes will require major shifts in policy
and reimbursement. We must work together on those changes to
get them right.
The budget also provides new funding dedicated to the
President's goal of ending the HIV epidemic. That is certainly
a goal I think everyone on this committee can share.
So in closing, Mr. Secretary, I appreciate your commitment
to appear before our committee today, and I look forward to
engaging in a thoughtful and meaningful discussion.
If there is anybody else on our side that would like the
final minute, I would be happy to yield. Otherwise, Madam
Chair, I will yield back to you.
[The prepared statement of Mr. Walden follows:]
Prepared statement of Hon. Greg Walden
Secretary Azar, welcome back to the Energy and Commerce
Committee. Thank you for being so generous with your time here
today, and for your leadership at the Department of Health and
Human Services.
On a bipartisan basis, this committee has led the way in
delivering meaningful healthcare reforms and policies for the
American people. Last year we passed into law the SUPPORT for
Patients and Communities Act, the most comprehensive bill to
address a single drug crisis in our nation's history. That bill
gave HHS unprecedented resources and tools to stem the tide of
the addiction crisis that is still devastating our communities.
CDC data tells us there were over 70,000 overdose deaths in
2017, and overdoses take the lives of more Oregonians than
traffic accidents. Whenever we pass a major piece of
legislation, I think it's important to dive back in and do
oversight to find out what's working, what projects are still
ongoing, and what we need to do better. I would love to hear
from you today on the department's work to combat addiction and
how we can continue to be partners in getting help to those in
need.
We also extended and funded a number of important public
health programs, including the longest extension of the
Children's Health Insurance Program (CHIP)-10 years--in history
and record funding for community health centers, which are both
important for my Oregon district. I just met with the community
health center over the weekend in Klamath Falls, Oregon, and
there are 12 community health centers with 63 sites that serve
more than 240,000 Oregonians in my district. We also extended
funding for teaching health centers and the special diabetes
programs in the last Congress. Some of those are whose funding
expires at the end of this fiscal year, and I look forward to
working with my colleagues across the aisle to ensure these
programs are extended and responsibly paid for.
We also need to continue our work on the cost of
healthcare, from one end of the supply chain to the other. I
appreciate your personal interest in moving aggressively to
bring down the costs of prescription drugs down for patients.
Last year the FDA approved a record number of generic drugs,
bringing more competition into the market and driving down
prices at the pharmacy counter. We have more work to do, and I
look forward to continuing this committee's partnership with
HHS to reign in excessive costs for healthcare.
I was also encouraged to see a focus in the President's
budget on moving towards value-based care. As a country, we
must move into a healthcare system that pays for value and
quality of care, but those changes will require major shifts in
policy and reimbursement. We must work together on those
changes to get them right.
The budget also provides new funding dedicated to the
President's goal of ending the HIV epidemic--a goal I think all
of us on this committee share.
In closing, Mr. Secretary, I appreciate your commitment to
appear before our committee today. I look forward to engaging
in a thoughtful and meaningful discussion.
Ms. Eshoo. We thank the gentleman.
I would like to remind all the Members that, pursuant to
committee rules, all Members' written opening statements shall
be made part of the record.
So now, welcome again, Mr. Secretary, and you have 5
minutes to address our not-so-small subcommittee, but very
powerful one. Welcome, and you have your 5 minutes to impart
your testimony to us.
STATEMENT OF ALEX AZAR, SECETARY, DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Mr.Azar. Thank you very much. Chairman Pallone, Chairwoman
Eshoo, Ranking Members Walden and Burgess, thank you for
inviting me here to discuss the President's budget for fiscal
year 2020.
It is an honor to have spent the year since I last appeared
before this committee leading the Department of Health and
Human Services. The men and women of HHS have delivered
remarkable results since then, including record new and generic
drug approvals, new affordable health insurance options, and
signs that the trend in drug overdose deaths is beginning to
flatten and decline.
The budget proposes $87.1 billion in FY 2020 discretionary
spending for HHS, while moving towards our vision for a
healthcare system that puts American patients first. It is
important to note that HHS had the largest discretionary budget
of any non-Defense Department in 2018, which means that staying
within the caps set by Congress has required difficult choices
that I am sure many will find quite hard to countenance.
Today, I want to highlight how the President's budget
supports a number of important goals for HHS. First, the budget
proposes reforms to help deliver Americans truly patient-
centered, affordable healthcare. The budget would empower
States to create personalized healthcare options that put you,
as the American patient, in control and ensure you are treated
like a human being, not a number. Flexibilities in the budget
would make this possible while promoting fiscal responsibility
and maintaining protections for people with preexisting
conditions.
Second, the budget strengthens Medicare to help secure our
promise to America's seniors. The budget extends the solvency
of the Medicare Trust Fund for eight years, while the program's
budget will still grow at a 6.9 percent annual rate.
In three major ways, the budget lowers costs for seniors
and tackles special interests that are currently taking
advantage of the Medicare program. First, we propose changes to
discourage hospitals from acquiring smaller practices just to
charge Medicare more. Second, we address overpayments to post-
acute providers. Third, we will take on drug companies that are
profiting off of seniors and Medicare. Through a historic
modernization of Medicare Part D, we will lower seniors' out-
of-pocket costs and create incentives for lower list prices. We
also protect seniors by transferring funding for graduate
medical education and uncompensated care from Medicare to the
General Treasury Fund, so all taxpayers, not just our seniors,
share these costs.
I also want to acknowledge the work of this committee on
lowering out-of-pocket drug costs. Thanks to legislation on
pharmacy gag clauses that this committee sent to President
Trump's desk, America's pharmacists can now always work with
patients to get them the best deal on their medicines. I
believe there are many more areas of common ground on drug
pricing where we can work together to pass bipartisan
legislation to help the American people.
Finally, the budget fully supports HHS's five-point
strategy for the opioid epidemic: better access to prevention,
treatment, and recovery services; better targeting the
availability of overdose-reversing drugs; better data on the
epidemic; better research on pain and addiction, and better
pain management practices. The budget provides $4.8 billion
towards these efforts, including the $1 billion State Opioid
Response Program in which we focused on access to medication-
assisted treatment, behavioral support, and recovery services.
The budget also invests in other public health priorities,
including fighting infectious disease at home and abroad. It
proposes $291 million in funding for the first year of
President Trump's plan to use the effective treatment and
prevention tools we have today to end the HIV epidemic in
America by 2030.
Finally, I want to highlight an announcement from HHS
today. As we commence a process to identify a new Commissioner
of Food and Drugs as quickly as possible, I am pleased to
announce that the current Director of the National Cancer
Institute, Dr. Ned Sharpless, will serve as Acting Commissioner
for Food and Drugs following the conclusion of Commissioner
Gottlieb's incredibly successful tenure at some point in early
April. NCI's Deputy Director, Dr. Douglas Lowy, will serve as
Acting Director of the Institute while Dr. Sharpless is the
Acting Commissioner.
This year's budget will advance American healthcare. It
will help deliver on promises we have made to the American
people. I look forward to working with this committee on our
shared priorities in the year ahead, and I look forward to your
questions today.
Thank you, Madam Chairwoman.
[The prepared statement of Mr. Azar follows:]
Prepared Statement of Mr. Alex Azar
The mission of the U.S. Department of Health and Human
Services (HHS) is to enhance and protect the health and well-
being of all Americans by providing for effective health and
human services and by fostering sound, sustained advances in
the sciences underlying medicine, public health, and social
services. This work is organized into five strategic goals, and
is unified by a vision of our healthcare, human services, and
public health systems working better for the Americans we
serve. By undertaking these efforts in partnerships with
States, territories, tribal governments, local communities, and
the private sector, we will succeed at putting Americans'
health first.
Since I testified before this committee in 2018, the HHS
team has delivered impressive results. This past year saw HHS,
the Department of Labor, and the Department of Treasury open up
new affordable health coverage options, at the same time the
Affordable Care Act (ACA) exchanges were stabilized, with the
national average benchmark premium on Healthcare.gov dropping
for the first time ever. According to a report by the Council
of Economic Advisers, actions taken by the administration,
along with the elimination of the individual mandate penalty,
are estimated to provide a net benefit to Americans of $453
billion over the next decade.
Congress worked with the administration to deliver new
resources for fighting the opioid crisis, allowing HHS to make
more than $2 billion in opioid-related grants to States,
territories, tribes, and local communities in 2018.
Prescriptions for medication-assisted treatment options and
naloxone are up, while legal opioid prescribing is down. HHS
also worked to bring down prescription drug prices, including
by setting another record for most generic drug approvals by
FDA in a fiscal year and working with Congress to ensure
pharmacists can inform Americans about the lowest-cost
prescription drug options.
The President's Fiscal Year (FY) 2020 Budget supports HHS's
continued work on these important goals by prioritizing key
investments that help advance the administration's commitments
to improve American healthcare, address the opioid crisis,
lower the cost of drugs, and streamline Federal programs, while
reforming the Department's programs to better serve the
American people.
The Budget proposes $87.1 billion in discretionary budget
authority and $1.2 trillion in mandatory funding for HHS. It
reflects HHS's commitment to making the Federal Government more
efficient and effective by focusing spending in areas with the
highest impact.
HHS's Fiscal Year 2020 Budget reflects decisions not just
to be prudent with taxpayer dollars, but also to stay within
the budget caps Congress created in the Budget Control Act.
With the largest non-defense discretionary appropriation of any
cabinet agency in 2019, HHS must make large reductions in
spending in order to stay within Congress's caps, set a prudent
fiscal course, and provide for other national priorities. This
budget demonstrates that HHS can prioritize its important work
within these constraints, and proposes measures to reform HHS
programs while putting Americans' health first.
REFORM, STRENGTHEN, AND MODERNIZE THE NATION'S HEALTHCARE SYSTEM
Reforming the Individual Market for Insurance
The Budget proposes bold reforms to empower States and
consumers to improve American healthcare. These reforms return
the management of healthcare to the States, which are more
capable of tailoring programs to their unique markets,
increasing options for patients and providers, and promoting
financial stability and responsibility, while protecting people
with preexisting conditions and high healthcare costs.
The Budget includes proposals to make it easier to open and
use Health Savings Accounts and reform the medical liability
system to allow providers to focus on patients instead of
lawsuits.
Lowering the Cost of Prescription Drugs
Putting America's health first includes improving access to
safe, effective, and affordable prescription drugs. The Budget
proposes to expand the administration's work to lower
prescription drug prices and reduce beneficiary out-of-pocket
costs. The administration has proposed and, in many cases, made
significant strides to implement bold regulatory reforms to
increase competition, improve negotiation, create incentives to
lower list prices, reduce out-of-pocket costs, improve
transparency, and address foreign free-riding. Congress has
already taken bipartisan action to end pharmacy gag clauses, so
patients can work with pharmacists to lower their out-of-pocket
costs. The Budget proposes to:
Stop regulatory tactics used by brand manufacturers to impede
generic competition;
Ensure Federal and State programs get their
fair share of rebates, and enact penalties to prevent
the growth of prescription drug prices beyond
inflation;
Improve the Medicare Part D program to lower
seniors' out-of-pocket costs, create an out-of-pocket
cap for the first time, and end the incentives that
reward list price increases;
Improve transparency and accuracy of payments
under Medicare Part B, including imposing payment
penalties to discourage pay-for-delay agreements; and
Build on America's successful generic market
with a robust biosimilars agenda, by improving the
efficient approval of safe and effective biosimilars,
ending anticompetitive practices that delay or restrict
biosimilars market entry, and harnessing payment and
cost-sharing incentives to increase biosimilar
adoption.
Reforming Medicare and Medicaid
Medicare and Medicaid represent important promises made to
older and vulnerable Americans, promises that President Trump
and his administration take seriously. The Budget supports
reforms to make these programs work better for the people they
serve and deliver better value for the investments we make.
This includes a plan to modernize Medicare Part D to lower drug
costs for the Medicare program and for Medicare beneficiaries,
as well as proposals to drive Medicare toward a value-based
payment system that puts patients in control. The Budget also
provides additional flexibility to States for their Medicaid
program, putting Medicaid on a path to fiscal stability by
restructuring its financing, reducing waste, and focusing the
program on the low-income populations Medicaid was originally
intended to serve: the elderly, people with disabilities,
children, and pregnant women.
Paying for Value
The administration is focused on ensuring Federal health
programs produce better care at the lowest possible cost for
the American people. We believe that consumers, working with
providers, are in the best position to determine value. The
Budget supports an expansion of value-based payments in
Medicare with this strategy in mind. That expansion, along with
implementation of a package of other reforms, will improve
quality, promote competition, reduce the Federal burden on
providers and patients, and focus payments on value instead of
volume or site of service. Two of these reforms are: (1) A
value-based purchasing program for hospital outpatient
departments and ambulatory surgical centers; and (2) a
consolidated hospital quality program in Medicare to reduce
duplicative requirements and create a focus on driving
improvements in patients' health outcomes. Advancing value in
Medicare along with the other reforms in the Budget will extend
the life of the Medicare Trust Fund by eight years, while also
helping to drive value and innovation throughout America's
entire health system. Furthermore, in December the
administration released a report entitled Reforming America's
Healthcare System Through Choice and Competition, which
contains a series of recommendations to improve the healthcare
system by better engaging consumers and unleashing competition
acrossproviders.
PROTECT THE HEALTH OF AMERICANS WHERE THEY LIVE, LEARN, WORK, AND PLAY
Combating the Opioid Crisis
The administration has made historic investments to address
opioid misuse, abuse, and overdose, but significant work must
still be done to fully turn the tide of this public health
crisis.
The Budget supports HHS's five-part strategy to:
Improve access to prevention, treatment, and
recovery services, including the full range of
medication-assisted treatments;
Better target the availability of overdose-
reversing drugs;
Strengthen our understanding of the crisis
through better public health data and reporting;
Provide support for cutting edge research on
pain and addiction; and
Improve pain management practices.
The Budget provides $4.8 billion to combat the opioid
overdose epidemic. The Substance Abuse and Mental Health
Services Administration (SAMHSA) will continue all opioid
activities at the same funding level as FY 2019, including the
successful State Opioid Response Program and grants, which had
a special focus on increasing access to medication-assisted
treatment-the gold standard for treating opioid addiction. At
this level, the Budget also provides new funding for grants to
accredited medical schools and teaching hospitals to develop
substance use disorder treatment curricula.
In FY 2020, the Health Resources and Services
Administration (HRSA) will continue to make investments to
address substance use disorder, including opioid use disorder,
through the Rural Communities Opioid Response Program, the
National Health Service Corps, behavioral health workforce
programs, and the Health Centers Program.
Medicare and Medicaid policies and funding will also play a
critical role in combating the opioid crisis. The Budget
proposes allowing States to provide full Medicaid benefits for
one-year postpartum for pregnant women diagnosed with a
substance use disorder. The Budget also proposes to set minimum
standards for Drug Utilization Review programs, allowing for
better oversight of opioid dispensing in Medicaid.
Additionally, it proposes a collaboration between the Centers
for Medicare & Medicaid Services and the Drug Enforcement
Administration to stop providers from inappropriate opioid
prescribing.
The Ending HIV Epidemic Initiative
Recent advances in HIV prevention and treatment create the
opportunity to not only control the spread of HIV, but to end
this epidemic in America. By accelerating proven public health
strategies, HHS will aim to reduce new infections by 90 percent
within 10 years, ending the epidemic in America. The Budget
invests $291 million in FY 2020 for the first phase of this
initiative, which will target areas with the highest infection
rates with the goal of reducing the number of new diagnoses by
75 percent in five years.
This effort focuses on investing in existing, proven
activities and strategies and putting new public health
resources on the ground. The initiative includes a new $140
million investment in the Centers for Disease Control and
Prevention (CDC) to test and diagnose new cases, rapidly link
newly infected individuals to treatment, connect at-risk
individuals to Pre-exposure prophylaxis (PrEP), expand HIV
surveillance, and directly support States and localities in the
fight against HIV.
Clients receiving medical care through the Ryan White HIV/
AIDS Program (RWHAP) were virally suppressed at a record level
of 85.9 percent in 2017. The Budget includes $70 million in new
funds for RWHAP within HRSA to increase direct healthcare and
support services, further increasing viral suppression among
patients in the target areas. The Budget includes $50 million
in HRSA for expanded PrEP services, outreach, and care
coordination in community health centers. Additionally, the
Budget also prioritizes the reauthorization of RWHAP to ensure
Federal funds are allocated to address the changing landscape
of HIV across the United States.
For the Indian Health Service (IHS), the Budget includes
$25 million in new funds to screen for HIV and prevent and
treat Hepatitis C, a significant burden among persons living
with HIV/AIDS. The Budget also includes $6 million for the
National Institutes of Health's regional Centers for AIDS
Research to refine implementation strategies to assure
effectiveness of prevention and treatment interventions.
In addition to this effort, the Budget funds other
activities that address HIV/AIDS including $54 million for the
Minority HIV/AIDS Fund within the Office of the Secretary and
$116 million for the Minority AIDS program in SAMHSA. These
funds allow HHS to target funding to minority communities and
individuals disproportionately impacted by HIV infection.
Prioritizing Biodefense and Preparedness
The Administration prioritizes the nation's safety,
including its ability to respond to acts of bioterrorism,
natural disasters, and emerging infectious diseases. HHS is at
the forefront of the nation's defense against public health
threats. The Budget provides approximately $2.7 billion to the
Public Health and Social Services Emergency Fund within the
Office of the Secretary to strengthen HHS's biodefense and
emergency preparedness capacity. The Budget also proposes a new
transfer authority that will allow HHS to enhance its ability
to respond more quickly to public health threats. Additionally,
the Budget supports the government-wide implementation of the
President's National Biodefense Strategy.
The Budget supports advanced research and development of
medical countermeasures against chemical, biological,
radiological, nuclear, and infectious disease threats,
including pandemic influenza. The Budget also funds late-stage
development and procurement of medical countermeasures for the
Strategic National Stockpile and emergency public health and
medical assistance to State and local Governments, protecting
America against threats such as: anthrax, botulism, Ebola,
chemical, radiological, and nuclear agents.
STRENGTHEN THE ECONOMIC AND SOCIAL WELL-BEING OF AMERICANS ACROSS THE
LIFESPAN
Promoting Upward Mobility
The Budget promotes independence and personal
responsibility, supporting the proven notion that work empowers
parents and lifts families out of poverty. To ensure Temporary
Assistance for Needy Families (TANF) enables participants to
work, the Budget includes a proposal to ensure States will
invest in creating opportunities for low-income families, and
to simplify and improve the work participation rate States must
meet under TANF. The Budget also proposes to create Opportunity
and Economic Mobility Demonstrations, allowing States to
streamline certain welfare programs and tailor them to meet the
specific needs of their populations.
The Budget supports Medicaid reforms to empower individuals
to reach self-sufficiency and financial independence, including
a proposal to permit States to include asset tests in
identifying an individual's economic need, allowing more
targeted determinations than are possible with the use of a
Modified Adjusted Gross Income standard alone.
Improving Outcomes in Child Welfare
The Budget supports implementation of the Family First
Prevention Services Act of 2018 and includes policies to
further improve child welfare outcomes and prevent child
maltreatment. The Budget also expands the Regional Partnership
Grants program, which addresses the considerable impact of
substance use, including opioids use, on child welfare.
Strengthening the Indian Health Service
Reflecting HHS's commitment to the health and well-being of
American Indians and Alaska Natives, the Budget provides $5.9
billion for IHS, which is an additional $392 million above the
FY 2019 Continuing Resolution. The increase supports direct
healthcare services across Indian Country, including hospitals
and health clinics, Purchased/Referred Care, dental health,
mental health and alcohol and substance abuse services. The
Budget invests in new programs to improve patient care,
quality, and oversight. The Budget fully funds staffing for new
and replacement facilities, new tribes, and Contract Support
Costs, ensuring tribes have the necessary resources to
successfully manage self-governance programs.
FOSTER SOUND, SUSTAINED ADVANCES IN THE SCIENCES
Promoting Research and Prevention
NIH is the leading biomedical research agency in the world,
and its funding supports scientific breakthroughs that save
lives. The Budget supports strategic investments in biomedical
research and activities with significant national impact.
NIH launched the Helping to End Addiction Long-term (HEAL)
initiative in April 2018 to advance research on pain and
addiction. Toward this goal, NIH announced funding
opportunities for the historic HEALing Communities Study, which
will select several communities to measure the impact of
investing in the integration of evidence-based prevention,
treatment, and recovery across multiple health and justice
settings. The Budget provides $500 million to continue the HEAL
initiative in FY 2020.
The Budget supports a targeted investment in the National
Cancer Institute to accelerate pediatric cancer research.
Cancer is the leading cause of death from disease among
children in the United States. Approximately 16,000 children
are diagnosed with cancer in the United States each year. While
progress in treating some childhood cancers has been made, the
science and treatment of childhood cancers remains challenging.
Through this initiative, NIH will enhance drug discovery,
better understand the biology of all pediatric cancers, and
create a national data resource for pediatric cancer research.
This initiative will develop safer and more effective
treatments, and provide a path for changing the course of
cancer in children.
The new National Institute for Research on Safety and
Quality (NIRSQ) proposed in the Budget will continue key
research activities currently led by the Agency for Healthcare
Research and Quality. These activities will support researchers
by developing the knowledge, tools, and data needed to improve
the healthcare system.
Addressing Emerging Public Health Challenges
CDC is the nation's leading public health agency, and the
Budget supports its work putting science into action.
Approximately 700 women die each year in the United States
as a result of pregnancy or delivery complications or the
aggravation of an unrelated condition by the physiologic
effects of pregnancy. Findings from Maternal Mortality Review
Committees indicate that more than half of these deaths are
preventable. The Budget supports data analysis on maternal
deaths and efforts to identify prevention opportunities.
The United States must address emerging public health
threats, both at home and abroad, to protect the health of its
citizens. The Budget invests $10 million to support CDC's
response to Acute Flaccid Myelitis (AFM), a rare but serious
condition that affects the nervous system and weakens muscles
and reflexes. With this funding, CDC will work closely with
national experts, healthcare providers, and State and local
health departments to thoroughly investigate AFM.
The Budget also provides $100 million for CDC's global
health security activities. Moving forward, CDC will implement
a regional hub office model and primarily focus their global
health security capacity building activities on areas where
they have seen the most success: lab and diagnostic capacity,
surveillance systems, training of disease detectives, and
establishing strong emergency operation centers. In addition,
CDC will continue on-going efforts to identify health
emergencies, track dangerous diseases, and rapidly respond to
outbreaks and other public health threats around the world,
including continuing work on Ebola response.
The Budget also strengthens the health security of our
nation by continuing CDC's support to State and local
Government partners in implementing programs, establishing
guidelines, and conducting research to tackle public health
challenges and build preparedness.
Innovations in the Food and Drug Administration
FDA plays a major role in protecting public health by
assuring the safety of the nation's food supply and regulating
medical products and tobacco. The Budget provides $6.1 billion
for FDA, which is an additional $643 million above the FY 2019
Continuing Resolution. The Budget includes resources to promote
competition and foster innovation, such as modernizing generic
drug review and creating a new medical data enterprise. The
Budget advances digital health technology to reduce the time
and cost of market entry, supports FDA opioid activities at
international mail facilities to increase inspections of
suspicious packages, strengthens the outsourcing facility
sector to ensure quality compounded drugs, and pilots a
pathogen inactivation technology to ensure the blood supply
continues to be safe. FDA will continue to modernize the food
safety system in FY 2020.
PROMOTE EFFECTIVE AND EFFICIENT MANAGEMENT AND STEWARDSHIP
Almost one quarter of total Federal outlays are made by
HHS. The Department employs more than 78,000 permanent and
temporary employees and administers more grant dollars than all
other Federal agencies combined. Efficiencies in HHS management
have a tremendous impact on Federal spending as a whole.
Advancing Fiscal Stewardship
HHS recognizes its immense responsibility to manage
taxpayer dollars wisely. HHS ensures the integrity of all its
financial transactions by leveraging financial management
expertise, implementing strong business processes, and
effectively managing risk.
In an effort to operate Medicare and Medicaid efficiently
and effectively, both to rein in wasteful spending and to
better serve beneficiaries, HHS is implementing actions such as
enhanced provider screening, prior authorization, and
sophisticated predictive analytics technology, to reduce
improper payments in Medicare and Medicaid without increasing
burden on providers or delaying Americans' access to care or to
critical medications. HHS continues to work with law
enforcement partners to target fraud and abuse in healthcare,
and the Budget increases investment in healthcare fraud and
abuse activities. The Budget includes a series of proposals to
strengthen Medicare and Medicaid oversight, including
increasing prior authorization, enhancing Part D plans' ability
to address fraud, and strengthening the Department's ability to
recoup overpayments made to States on behalf of ineligible
Medicaid beneficiaries.
Implementing ReImagine HHS
HHS eagerly took up the call in the Administration's
government-wide Reform Plan to more efficiently and effectively
serve the American people. HHS developed a plan --``ReImagine
HHS''--organized around a number of initiatives.
ReImagine HHS is identifying a variety of ways to reduce
Federal spending and improve the functioning of HHS's programs
through more efficient operations. For example, the Buy Smarter
initiative streamlines HHS's procurement process by using new
and emerging technologies.
Conclusion
Americans deserve healthcare, human services, and public
health programs that work for them and make good use of
taxpayer dollars. The men and women of HHS are committed,
innovative, hardworking public servants who work each day to
improve the lives of all Americans. President Trump's FY 2020
Budget will help advance us toward that goal, accomplish the
Department's vital mission, and put Americans' health first.
Ms. Eshoo. Thank you, Mr. Secretary.
We will now move to Member questions. Each Member, of
course, will have 5 minutes to question the Secretary. And I
will start by recognizing myself for 5 minutes.
Mr. Secretary, the budget proposes to cut funding for
premium tax credits which help Americans pay for comprehensive
health insurance, but your agency's 1332 waiver guidance
supports using Federal subsidies to pay for junk insurance
plans that don't cover patients when they get sick. The budget
also once again revives the failed Graham-Cassidy ACA repeal
bill, and the Trump administration has refused to defend,
obviously, the ACA in the Texas v. U.S. litigation, urging the
court to invalidate the entirety of the ACA's major protections
for people with preexisting conditions.
Now, really, I call these items out because they scare the
hell out of the American people. These policies have
consequences. These words walk into people's lives.
So where in your budget are those with preexisting
conditions protected as well or better than they are protected
under the ACA?
Mr. Azar. Well, thank you, Chairwoman, for that question.
Ms. Eshoo. Not really ``thank you,'' but----
[Laughter.]
Mr. Azar. No, that is a good question to have. It is a good
question to have.
Ms. Eshoo. You are a gentleman.
Mr. Azar. And we need to have a debate about this because
the position of many is that the Affordable Care Act solved all
issues for people with preexisting conditions, and that is
simply not the case, as 29 million Americans were priced out of
the market with unaffordable care, and those who have access to
that care, it may be under-insurance or a card that doesn't
really provide for them.
Ms. Eshoo. So will you work with us to strengthen that?
Mr. Azar. Well, we want to work--actually, that is our
proposal. It is a starting point.
Ms. Eshoo. On preexisting conditions?
Mr. Azar. It is the $1.2 trillion grant program.
Ms. Eshoo. We will hold you to that.
Now, on the actual numbers, $1.4 trillion over 10 years for
Medicaid, close to $460 billion from Medicare. How do you
reassure the American people that what they count on, what is
really necessary in their lives, Medicare beneficiaries,
Medicaid beneficiaries, that these numbers, what these numbers
are going to do to them? These are massive cuts.
Mr. Azar. So on Medicare, we are actually putting it on a
sounder footing for the future, and these are provider cuts.
Providers aren't going to be happy. Hospitals are not happy.
The post-acute providers are not happy, and the drug companies
are not happy.
Ms. Eshoo. Well, how does that affect the beneficiaries?
Mr. Azar. It actually reduces their cost-sharing because
they actually pay a percent often of what we reimburse these
providers. So as we end that abuse or minimize that abuse,
their sharing goes down and we save taxpayers money.
Ms. Eshoo. But why wouldn't providers lessen their coverage
to the people that are enrolled with them, if you are going to
take almost $460 billion out of it?
Mr. Azar. Well, some of these are----
Ms. Eshoo. Are we going to depend on the goodness of their
hearts?
Mr. Azar. Well, a lot of them need to be in Medicare. Your
hospital is not going to be in existence long if it is not a
Medicare provider. What is happening is, for instance,
hospitals are gobbling up doctors' practices----
Ms. Eshoo. Well, what about the patients----
Mr. Azar [continuing]. And jacking up the rates.
Ms.Eshoo [continuing]. The coverage for Medicare enrollees?
Mr. Azar. I do not believe any of those three which are the
major areas of reduction will impact in any way patient access
to services there. I think these areas, like MedPAC----
Ms. Eshoo. So you are stating that almost $460 billion,
reducing that out of Medicare is not going to affect any
beneficiary?
Mr. Azar. I don't believe it should affect. I think it
should reduce their out-of-pocket through their cost-sharing.
These are abuses that MedPAC and others----
Ms. Eshoo. I want to go back to the junk plans. They are
receiving Federal subsidies, and they are required to disclose
to an individual that the plan will not cover their medical
bills when they get sick. How does this strengthen coverage for
people across the country?
Mr. Azar. So short-term, limited-duration plans are meant
for people in a transition period. They are not right for
everybody. And we actually enhanced the consumer disclosures
from what the Obama administration had on them.
Mr. Azar. So we are going to enhance disclosure? I am all
for that. In fact, I offered legislation that would state to
people on the cover of the policy, ``Be advised you are not
covered for the following.'' So I think it needs a ``beware''
stamp on it.
But my time has expired, and I will now recognize--who am I
recognizing now?--the ranking member of the subcommittee, Dr.
Burgess, for 5 minutes.
Mr. Burgess. Thank you for the recognition.
Mr. Secretary, again, thank you for being here today.
Sometimes I feel like I am trapped in a Charles Dickens
novel. It is the best of times; it is the worst of times.
So just briefly, can you kind of give us a sense of what it
has meant for 2.5 to 5 million people to have been brought back
into the workforce, and now, perhaps have the availability of
employer-sponsored insurance?
Mr. Azar. With the booming economy and with the historic
low unemployment rates, we have got individuals who now are not
only having the pride and the long-term sustainability of job
but have access to healthcare through their employers. But, of
course, we have our safety nets. We have our programs like
Medicaid. We have, as long as it is on the books, we have the
Affordable Care Act and the subsidy program there. But what we
are trying to do is expand the reach of available options and
affordable insurance and coverage and access to care for the
people who were shut out from that marketplace.
Mr. Burgess. And I appreciate what you are trying to do. I
actually have a question I will do for the record on just that
issue.
This past Sunday night, ``60 Minutes,'' a television
program that I don't normally watch, aired a special on the
research that the National Institute of Health has conducted on
sickle cell disease. I worked with patients with sickle cell
disease back in my residency at Parkland Hospital. I know what
a devastating and painful illness that it is.
We heard in this committee two Congresses ago how there had
not been a new FDA-approved treatment for sickle cell in almost
40 years. In the last Congress, we approved, and got signed
into law, the first major sickle cell legislation, Danny Davis'
bill from Illinois, and the President signed it into law.
Can you talk just a little bit about what the American
people saw on Sunday night as far as the potential treatment
for sickle cell?
Mr. Azar. What an incredible story that was. And I have
talked to Francis Collins, our incredible Director of the NIH.
I think we all believe we could be within five years of an
actual cure for sickle cell anemia, an actual cure. And it is
using the modern techniques we have of both identifying the
defective genes that cause the disease, but then different
vectors, whether it is CRISPR or, in the case of the sickle
cell treatment you saw on ``60 Minutes,'' using a viral vector
to actually just change the body's wiring. I mean, to see that
young girl and the impact it has had on her life, it is a
miracle and we are all so excited about that. We want to keep
doing that across the work of NIH.
Mr. Burgess. Well, again, for somebody who has taken care
of sickle patients in crisis, we haven't had much to offer, and
this is, indeed, groundbreaking research. You and your team are
to be commended, and the administration, for putting their
efforts behind this.
So as you know, I have, since the passage of a bill that
got rid of the sustainable growth rate formula--we used to
fight about that every December; now we don't. And I believe
this committee is still committed to the development of
alternative payment models.
The physician-led technical advisory panel of PTAC--I think
they had a meeting this week--they have recommended over a
dozen models, and physicians are just clamoring to join. I
understand there is concern over the scalability of some of
these models, but can we agree that this is a sign, a good
sign, that APM providers want to participate and want to take
place?
Mr. Azar. Absolutely. And, in fact, I know there have been
some rough spots in the interactions with the PTAC and HHS. We
have met with leadership and the whole committee. We have
shared, actually, the alignment of our philosophies around
where we want to go on value-based transformation. I think we
are going to see that the projects that they review will help
align there. We have emphasized how important it is that these
projects be scalable across the program. So I am actually quite
optimistic about our work with PTAC. It is an incredible group
of people on that committee, and we want to make sure we are
getting the full advantage of their work and insight.
Mr. Burgess. And would you agree that that was particularly
visionary legislation that was passed by this Congress?
Mr. Azar. Absolutely.
Mr. Burgess. Thank you. I knew I could count on you.
Well, thanks for your comments about Dr. Gottlieb. Again,
what a leader he has been. And I appreciate your sharing with
us that the agency is going to remain under capable hands. It
is just so critically important. The generic throughput that
has occurred under Dr. Gottlieb's leadership is going to make a
big difference for patients and their pocketbooks. And your
commitment is to continue that?
Mr. Azar. Oh, absolutely, we are going to be carrying
forward Commissioner Gottlieb's vision without him. His agenda
is my agenda; my agenda is his agenda.
Mr. Burgess. Very good. Again, we appreciate you being here
today. Thank you.
Ms. Eshoo. I thank the gentleman. I now would like to
recognize the chairman of the full committee, Mr. Pallone, for
5 minutes of questioning.
Mr. Pallone. Thank you, Madam Chair.
Mr. Secretary, on June 7th of last year, the administration
declined to defend the ACA's protections for preexisting
conditions. In this extraordinary decision, the Department of
Justice sided with a group of Republican attorneys generals
seeking to strike down the ACA and declined to defend the
constitutionality of the guaranteed issue and community rating
provisions of the ACA. And let me be crystal clear. In
declining to defend these protections in the Texas v. U.S.
lawsuit, the Trump administration is seeking to, once again,
subject tens of millions of Americans with preexisting
conditions to the discrimination they faced before the ACA, and
I think it is appalling and indefensible.
Now my questions are about documents. So I just want you to
answer these questions yes or no about documents. That is what
I am asking, not about policy here.
On June 13, 2018, I sent you a letter regarding the
Department of Health and Human Services' involvement in the
DOJ's decision and requesting documents, communications, and
responses to a series of questions. I was trying to find out
whether the Department had conducted any analysis on the
effects of eliminating these protections on costs and access to
coverage, particularly for individuals with preexisting
conditions. And I asked about the Department's contingency
planning if the Trump administration prevails in this Texas
lawsuit. And yes or no, did you receive this letter I am
referring to?
Mr. Azar. I am sure we did. I don't recall the letter, but
I am sure we did.
Mr. Pallone. Thank you.
On December 7, 2018, a few months later, I sent you and
Administrator Verma a follow-up letter reiterating my request.
I requested a complete response to my letter, to my previous
letter. Again, yes or no, did you receive this letter, to your
knowledge?
Mr. Azar. Again, I am certain that we did.
Mr. Pallone. OK. So Secretary, my staff subsequently
reached out to your staff on December 21st, January 2nd,
January 11th, January 3rd, February 24th, February 26th,
February 28th, March 3rd, March 7th, March 8th, up to now, and
yesterday, to check on the status of the Department's document
production. On each of those occasions, my staff has made clear
that this inquiry regarding the Department's involvement in the
Texas lawsuit is the No. 1 investigative priority for our
committee, for our oversight. And it has been over nine months,
and I still haven't received a response to my letter or a
single document. So my question is, has the Department even
begun a search of your records, and the records of others on
your staff, in response to these letters, which, again, is how
you responded to whether the DOJ is moving forward?
Mr. Azar. So I apologize for the delay. I do want you to
know that I met with our team, I think it was, in fact, just
yesterday, and discussed our compliance with your requests
there. And I hope they have communicated to Chairwoman
DeGette's team. I believe they did yesterday or this morning.
We are going to try to get as much of that material over as
quickly as possible as we can around contingency planning and
analysis.
Mr. Pallone. Well, would you commit to providing those
documents to this committee by the end of the week?
Mr. Azar. I don't know about the date on it, but we have
already met with, we have talked to the staff, I was told, and
I was told the staff were happy with the discussion and will be
producing that on a rolling basis of reviewing the material.
Mr. Pallone. Well, look, let me----
Mr. Azar. I have told them I want to give you as much as we
can on that.
Mr. Pallone. Let me explain. I am not asking about the CMS
records, although those can be sent as well. I am asking about
your own records. Will you commit to making your records
available to search and ensure that the Department turns such
records responsive over to the committee? I am not talking
about CMS, but correspondence between--your own records, if you
will, relative to this Texas----
Mr. Azar. Well, obviously, materials that would involve
potential executive privilege would have to be reviewed by
interagency and the White House for review of that. But I have
told my team I want to get whatever we can that doesn't
implicate those types of concerns that we would have to work
together on respective and reasonable accommodations; I want to
get you materials that we can as quickly as possible.
Mr. Pallone. I just want a commitment to make your records
available to ensure that the Department turns these documents
over to the committee as soon as possible.
Mr. Azar. We will commit to be as responsive as we can, but
I, obviously, can't waive various privileges of the President,
if they are implicated.
Mr. Pallone. OK. Now I just have one more question, Madam
Chair.
I am just concerned--again, I have explained. Nine months,
no documents, no response. I just hope that this level of non-
cooperation doesn't continue moving forward with this Congress
on these committees' informational requests. Because if not, we
have to see what additional steps to ensure that the committee
actually has legitimate oversight. So I mean, do you want to
just respond? This level of cooperation is really not
acceptable. Is this going to continue where we don't get
anything or any response for nine months?
Mr. Azar. I want you to know, I respect your role and this
committee's role, and we have beefed up our oversight staffing.
We have tried to build the teams, and we will hope to have a
better relationship in the future going forward on any
oversight issues.
Mr. Pallone. All right.
Mr. Azar. We want to have a good, constructive, productive
relationship with you and this committee.
Mr. Pallone. Well, I appreciate that, and I hope so. And we
will continue to monitor it.
Thank you, Madam Chair.
Ms. Eshoo. Thank you, Mr. Chairman.
And we will just count on you getting the information to
us.
And now, I would like to recognize the ranking member of
the full committee, my friend, Mr. Walden, for 5 minutes.
Mr. Walden. Thank you, Madam Chair. And again, thanks for
holding this important hearing.
Secretary Azar, I understand that 2018 marked the highest
number of combined generic drug approvals and tentative
approvals in the history of the Food and Drug Administration's
Generic Drug Program. Can you just briefly speak to the savings
that created for the American people?
Mr. Azar. Well, this is thanks to the historic work of
Commissioner Gottlieb and the team at FDA. It has just been
incredible. They have shattered monthly and yearly generic drug
approval records since 2017, approving generics that CEA has
estimated have saved Americans since January of 2017 $26
billion.
Mr. Walden. Twenty-six billion dollars?
Mr. Azar. And I believe that is only through June of 2018
on that analysis. So that is on a rolling--that is going to
keep on adding savings to the American people.
Mr. Walden. That is really impressive. And I think part of
that is the new tools that this committee and this Congress, in
a bipartisan way, gave to your agency and certainly the FDA.
By the way, I would just say I am really saddened that Dr.
Gottlieb is leaving. I wish him godspeed and good health and
every success in the world. He has been a fantastic FDA
Director, and, frankly, Madam Chair, very cooperative, I think
on both sides of aisle. I think he was up here four days in a
row once testifying and participating. Sorry, but it was really
helpful to our cause.
Mr. Secretary, CMS has proposed a rule to change the
formularies for patients in Part D protected classes. What
assurances can you provide my constituents and those patients
that they will still be able to get access to the medications
they need?
Mr. Azar. Yes, thank you for that question, because there
is a lot of misunderstanding there.
Of course, with the protected classes, what is happening
is, we have, as a government, disabled these middlemen, the
pharmacy benefit managers, from being able to negotiate against
the drug companies to get discounts. So for the very drugs that
in the commercial space may be yielding 30 percent average
discounts, we are getting zero to six percent.
So what we are proposing--and it is a proposal, and we are
getting very important feedback from disease groups in, and we
will look at that.
Mr. Walden. Right.
Secretary Azar. It is to allow some of the basic formulary
management tools used in the commercial space for regular
commercial employees. For instance, step therapy, try this drug
before that drug.
Mr. Walden. Right.
Mr. Azar. Or prior authorization, make sure that this drug
is actually being used for the right indication, with our
speedy appeals and exceptions processes, and with the choice
that is embedded into Part D, where you can pick a plan; if it
is not meeting your needs, you can choose a different one.
But we are hearing the feedback, and we have heard very
vigorously back.
Mr. Walden. Yes.
Mr. Azar. We want to protect our beneficiaries, of course.
Mr. Walden. Because I have heard from some patients today,
before this becomes a rule, on step therapy, that they have a
drug that works. They change plans or something. Something
happens, and they are told they have to go back through all
these drugs they know don't work to get to the one that does.
And no patient wants to go through that. And so it is something
we have got to pay attention to.
Mr. Azar. I have heard that feedback, and obviously, we
will take that very seriously.
Mr. Walden. Yes, I think that is really, really important.
Mr. Secretary, currently, over one-third of beneficiaries
are choosing a Medicare Advantage Plan. And I know how
important that is to Medicare beneficiaries, especially my
colleague here to the left who has become one now. Can you
detail why seniors are increasingly choosing private insurance
options for their Medicare coverage?
Mr. Azar. Well, you know, the Medicare Advantage Plans have
become so popular. I think it is because so many of us as we
age into Medicare--forgive me----
Mr. Walden. Right.
Mr. Azar [continuing]. We are used to having an integrated
benefit package. We are used to having medical and drug
benefits all together rather than those being managed
separately. And so, it is a very convenient form, and it allows
us, also, with Medicare Advantage, we can add supplemental
benefits. The plans, we have actually authorized new
supplemental benefits that these MA plans can offer people.
Mr. Walden. And what would those look like, just quickly?
Mr. Azar. Oh, that could be lower cost-sharing. I mean, you
have Medicare Advantage Plans, for instance, that have zero-
dollar generic drug coverage in them. I mean, some of them are
just incredible, the opportunities they offer people.
Mr. Walden. So under H.R. 1384, known as Medicare for All,
my understanding is private health insurance would be
eliminated. So the 158 million Americans who get their health
insurance through employer or union would lose those policies,
but also--and something that has not been written much about--
my understanding is the Medicare for All Democrats' plan would
also eliminate Medicare Advantage Plans. What would happen to
those 20 million seniors?
Mr. Azar. I believe that is the case under at least that
plan. They would lose their Medicare Advantage Plan, and they
would have to go to what is called Medicare Fee-for-Service,
which has very high deductibles, very high cost-sharing. Now,
for the wealthier people, you can buy a very expensive Medigap
policy to cover some of that. I do not recall if that
particular Medicare for All plan outlaws those Medigap plans or
not. Being private insurance, it might. I am not sure.
Mr. Walden. So seniors would lose their Medicare Advantage
Plans under that legislation?
Mr. Azar. I believe that to be the case. They are private
plans.
Mr. Walden. All right. Thank you, Madam Chair. My time has
expired. I yield back.
Ms. Eshoo. I thank the gentleman. I now would like to
recognize a real gentleman, Mr. Butterfield, for 5 minutes.
Mr. Butterfield. Thank you. I was about to say, Madam
Chairman, Mr. Engel has stepped out for a few minutes. But
thank you for----
Ms. Eshoo. To your advantage.
Mr. Butterfield. Thank you for the compliment.
And thank you, Mr. Secretary, for your testimony here
today.
I started reading the President's budget very early this
morning. It is not a very thick budget as compared to other
Presidential budgets. But I started reading it this morning,
and this is the first section that I went to. It appears to me
that the President's budget would rip some $1.4-1.5 trillion
out of Medicaid by turning it into a block grant or a per-
capita program.
And, Madam Chair, if that weren't bad enough, the news
organizations this morning are reporting that the
administration has plans to bypass Congress entirely and issue
guidance that will allow States to block grant or cap Medicaid.
Now if you think the emergency declaration Executive Order that
the President announced a few weeks ago to bypass Congress has
created a firestorm, you just wait for the firestorm that this
will create.
One in five Americans, low-income Americans, depend on
Medicaid. The President's budget doesn't represent the values
of the American people. And so, this Medicaid play was one of
the main features of the Republicans' failed attempt to repeal
the ACA. Block-granting and capping Medicaid would endanger
access to care for some of the most vulnerable people in the
program, including children, children with complex medical
needs, and our seniors, and individuals with disabilities.
In September 2017, Avalere Health, a well-known consulting
firm, found that the Republican block grant proposal would cut
Federal spending on Medicaid by $4 trillion over the new two
decades.
Mr. Secretary, Congress has already rejected attempts to
block grant Medicaid. So it is deeply troubling to see this
administration double down. I will remind you, sir, that under
Federal law, you only have the authority to allow demonstration
projects. You know it and I know it. You only have the
authority to allow demonstration projects that are likely to
assist in promoting the objectives of the Medicaid program.
And so, I am asking you, sir, on the record today, do you
believe, does the administration believe that you have the
authority to block grant Medicaid on your own without the
participation of Congress?
Mr. Azar. So States are able to propose waivers or
demonstration projects, as you have described them, to reorient
their benefits. And any State could come in requesting, for
instance, an approach that might be what you describe as a
block grant or capitated amount or different payment
structures. If we get that kind of proposal, we have to assess
that with our legal counsel and with OMB to----
Mr. Butterfield. It appears you are going to be aggressive
with this, aggressive with block-granting Medicaid and rolling
it out.
Mr. Azar. Absent statute, we can't force a State to do
anything like that in Medicaid. That would have to be a
governor and legislature coming to us, asking us if that is
something that----
Mr. Butterfield. Let me put it to you this way: can you
guarantee this committee that capping Medicaid spending through
a block grant will not cause any individuals to lose their
health coverage or lose their benefits, or lose access to their
doctors or jeopardize their care? Can you make that commitment
to us?
Mr. Azar. Well, you couldn't make that commitment about any
type of waiver or demonstration in Medicaid because that is
precisely the types of changes that are made----
Mr. Butterfield. So it is conceivable? If a State came and
asked for a waiver, it is conceivable that some of the
beneficiaries could experience less care?
Mr. Azar. That would be, that could be the case with any
waiver that is already out there. We operate, my goodness, it
must be hundreds of waivers already. And each of those has an
impact that is redistributive among this beneficiary or that,
or this class. It is ways of States prioritizing and focusing
the benefits and the money that they have----
Mr. Butterfield. I see the direction that you are going
with this, and I don't like it. But you answer to the
President, and the President has a notion of taking Medicaid in
the wrong direction.
The cap of Medicaid that the administration is proposing
will only grow at the rate of inflation. That is what I am
being told. Do you believe that the rate of inflation will keep
pace with the rising cost of healthcare? Are they going to go
up equally, do you believe?
Mr. Azar. I think that is in the legislative proposal,
which, of course, Congress would have to agree to. You would
have to agree to that. And if that were the case, no, that
would be regular CPI I believe is in the budget. I don't
believe it is a CPI medical expense. And that is part of the
savings that come from the ongoing--I think it is $300-and-some
billion that would be part of the ongoing savings from those
types of changes to per-capital or block grant options in this
case.
Mr. Butterfield. Thank you, Mr. Secretary. I only have 14
seconds remaining. And I will say, as I close, that if this
administration is serious about block-granting or otherwise
readjusting and redefining Medicaid as we know it, we are going
to be in for a real serious firestorm, not just from the
Congress, but from the American people. So many people, low-
income folk, depend on Medicaid.
Thank you, Madam Chair. I yield back.
Ms. Eshoo. I thank the gentleman. I now would like to
recognize the former chairman of the full committee, Mr. Upton
of Michigan.
Mr. Upton. Well, thank you, Madam Chair.
And welcome, Mr. Secretary, back. We are pleased that you
are here.
And I wonder, as you know and you watch very carefully,
every member of this committee supported 21st Century Cures a
couple of years ago. Could you briefly give us an update as to
how you think things are going three years now since President
Obama signed it into law? Because I have a number of questions.
Mr. Azar. Let me just be short about it. I believe it is
directly attributable, and credit to you and this committee for
the Cures Act, that we have had the record number of new drug
approvals and the record number of generic drug approvals in
our system that are leading to such significant savings for the
system, for the American people, and frankly, leading to the
type of cures like what I hope we are going to see on sickle
cell, that the ranking member mentioned before.
Mr. Upton. That is good. And I missed that show on ``60
Minutes,'' but I am well aware of the progress that we are
making on that and other fronts as well.
Somewhat good news and bad news, it is my understanding
that the childhood cancer funds in NCI, you have a nice
increase for that in the proposal. But I must say that I was
alarmed to read a Politico story just in the last couple of
days that said, under the plan, the budget plan, the White
House proposes an $897 million cut to the NCI, plus more than a
billion dollars to institutes that do medical research. Is that
story accurate?
Mr. Azar. Well, it is. That is in the budget as the across-
the-board reduction to NIH. We are one of the biggest, if not
the biggest, non-Defense discretionary budgets. We take a 12
percent cut in the President's budget. At HHS, that is $12
billion. It is a proportionate cut at NIH that is proposed. I
understand the pain. I understand the concern there. And the
NCI cut would be proportionate to the NIH one. I believe it is
a 12 percent there also.
Mr. Upton. One of the things that we did in Cures was that,
when we saw increases, particularly in the NIH budget and FDA
budget, we actually came up with offsets to make sure that
those increases would come about. Are those offsets still in
place? I mean, are these reductions----
Mr. Azar. So we tried to prioritize certain funding within
NIH around the opioid funding; of course, the Pediatric Cancer
Initiative of the $500-million-over-10 package. And so, yes,
there are certain priority areas that we have tried to wall off
within that, but, overall, the budget does take that kind of
proportional charge because, otherwise, there is just not
enough money at HHS to go around to make that kind of a target.
Mr. Upton. Now a number of us from the House and the Senate
this last week participated in a pretty big opioid conference.
What is the level of funding, as we try to help the States deal
with this crisis that is impacting virtually every community
and so many families that we personally know?
Mr. Azar. The President keeps the opioid funding that this
Congress has prioritized last year and that we worked together
on. We are going to continue to strengthen our access to
treatment and recovery. So that is $2.9 billion. That is an
increase of 68 above what our FY19 allotment was across the
Department. That is your State Opioid Response Grants, for
instance, of $1.5 billion.
Mr. Upton. We started that in Cures.
Mr. Azar. And the STR, and that expanded with the State
opioid responses in last year's appropriation. Fifty-eight
million dollars for infectious disease and opioids, a critical
part, also, in our HIV and Hep C work, the spread of those
diseases caused through the opioid crisis; prioritizing
surveillance activities. So really, a continuation of the great
bipartisan work of Congress and the administration on the
opioid crisis from last year is what is presented in the budget
this year. I could give you details offline, if that is
helpful.
Mr. Upton. So the last question I have is, last week, a
letter was sent up to reprogram monies for the Office of
Refugee Resettlement. They found offsets for that increase. And
I am interested to know, what is the fiscal year '20 budget
request compared to the fiscal year '19 request? And is there a
chance, then, that you will ask for additional monies to be
reprogrammed again, following what happened last week for
fiscal year '19?
Mr. Azar. Thank you for that.
So in FY19, I believe the budget request was $1 billion
plus a $200 million contingency fund. And then, the
appropriators also put some money into the regular non-UAC
refugee program, knowing that usually doesn't spend that much
money.
For this budget request, what we have requested is actually
$1.3 billion as an appropriation, and then, to create a $2
billion mandatory fund that is a contingency fund with an
assumption of $700- or-so million used in this year, plus
transfer authority of up to 20 percent, which would be $361
million. So we have requested quite a lot, but at the rate that
we are going with the kids coming across the border, it is just
an incredible burden financially.
Mr. Upton. Thank you. My time has expired. Thank you, Mr.
Secretary.
Ms. Eshoo. We thank the gentleman. Now I have the pleasure
of recognizing the gentlewoman from California, Ms. Matsui, for
5 minutes.
Ms. Matsui. Thank you, Madam Chair.
And thank you, Mr. Secretary, for appearing before us
today.
I have to say I am extremely concerned by the priorities
reflected in the President's budget, because this proposal
directly and negatively impacts hardworking families who depend
on crucial services. It guts Medicaid by over a trillion
dollars. These cuts mean working single mothers in between
jobs, families with a family member who suffers from addiction,
and grandparents in long-term care facilities will have less
access to care.
I am disappointed that HHS, which has a mission to enhance
and protect the health and well-being of all Americans, has
presented a budget that targets the most vulnerable in our
communities--women, children, people with disabilities and
mental illness, and the LGBT community. I certainly hope that
in our conversation today we can address the failings in HHS's
budget vision and how the agency should, in fact, be working to
protect all Americans.
Now, Mr. Azar, you previously stated that one of your top
goals as Secretary is to address the opioids crisis, and this
committee shares that goal. Passing H.R. 6, the SUPPORT for
Patients and Communities Act, was a highlight of last Congress.
And I was pleased to see members of this committee and your
administration begin to take meaningful steps toward tackling
the opioid epidemic.
Yet, I am concerned that your proposed budget, while it
does include funding and investments for the Community Mental
Health Services Block Grant and for Certified Community
Behavioral Health Centers, it is accompanied by massive cuts to
Medicaid, which is a vital source of coverage for mental health
and substance use disorder treatment.
The President's 2020 budget proposes to cut Medicaid by
$1.5 trillion over 10 years and turning the vital program into
a block grant to the States. Yet, shoring up Medicaid and
strengthening that program is perhaps the single best thing we
can do to expand access to mental health and substance use
treatment services.
As I am sure you know, Medicaid is the single most
important financing source of mental health services in this
country. Medicaid covers approximately a quarter of all adults
with serious mental illness. The Medicaid program covers many
inpatient and outpatient mental health services, such as
psychiatric treatment, counseling, and prescription
medications. And Medicaid coverage of mental health services is
often more comprehensive than private insurance coverage.
Medicaid also covers 4 in 10 non-elderly adults with opioid
addiction, and those with Medicaid coverage are twice as likely
as those with private insurance or no insurance to receive
substance use treatment.
Your rhetoric on mental health and addiction is not matched
by your actions. Cutting the very insurance coverage that
treats these people for ideological reasons, the coverage that
provides critical mental health services and substance use
treatment, will not help us address these critical issues.
Secretary Azar, do you agree that Medicaid is a critical
tool in helping individuals with mental health conditions or
substance use disorders? I just want a yes or no.
Mr. Azar. Yes, we do believe Medicaid is important for
those individuals.
Ms. Matsui. OK. Secretary Azar, will you commit to not
taking any further action in this administration, as your
predecessor and CMS Administrator already have, that would
negatively impact the coverage that people with mental health
or substance use disorders rely upon?
Mr. Azar. Well, we actually, with our budget, are proposing
changes that I think refocuses on the key core populations of
Medicaid as opposed to just providing insurance to able-bodied
potentially-working adults. So I actually think the budget lets
us focus on these people with substance use disorder and mental
illness, the disabled, those that really need it, instead the
perverse incentives that we have got right now.
Ms. Matsui. Well, I don't agree with you there. I also
believe, too, that it is very difficult to get mental health
services, and the population that needs them are certainly ones
that don't game the system. They really are people who really
need the services. And mental health and substance use services
are so critical, and Medicaid is the means by which most of the
population receives these services.
Mr. Azar. If I could just point you to one thing in the
budget that I hope you will support. It is we propose extending
Medicaid for postpartum pregnant women for up to one year who
have suffered from substance use disorder. So I do hope we
could advance that.
Ms. Matsui. That is really wonderful, but I am still
talking about the vast population that needs the Medicaid
services for mental health services.
And let me just say this: that I want to reiterate the
concerns of Ranking Member Walden regarding the protected
classes. I have gotten many of my constituents coming forward
and saying that they are really very concerned regarding the
step therapy. They have medication that they already know
works, and to think that they have to go back again and go
through the steps, that would really bring them back to a place
they don't want to be.
And I have run out of time already. So I just want to make
that point. Thank you.
Ms. Eshoo. You yield back. I thank the gentlewoman.
I think the issue that Ms. Matsui just mentioned, and Mr.
Walden, and I think both sides hold the same view. So we need
to move forward and correct that situation.
I now would like to recognize my friend from Illinois, the
gentleman from Illinois, Mr. Shimkus, for 5 minutes.
Mr. Shimkus. Thank you, Chairman Eshoo.
Secretary Azar, thanks for being here.
Chairman Eshoo and I cosponsored a bill last Congress
called the REVAMP Act. We have worked to address antibiotic
drug resistance for over a decade with colleagues on both sides
of the aisle. We have secured some wins, not the least of which
is the GAIN Act.
Mr. Secretary, can you tell me what your administration is
doing to address this concern?
Mr. Azar. Yes. So we actually announced what we called the
AMR Challenge in September of last year at the United Nations
General Assembly, which is a CDC Foundation initiative where we
received commitments from, I think, over a hundred NGOs and
private sector entities to commit around appropriate
utilization.
I am focused right now around AMR on what I view as a
potential market failure issue there on antimicrobial
resistance developing next-generation antibiotics, because here
is the problem we have: we want new antibiotics, but, for AMR
purposes, we need them not to be used. So that it almost
presents a project bioshield-like scenario where we, as the
Government, need to actually think about our role there as a
purchaser to get developed and park antibiotics that are
needed. That is the issue.
Mr. Shimkus. I appreciate the way you finished up that,
because what we always hear quite a bit is: how do you
incentivize the private sector to produce a product that you
hope they don't use? And that is kind of what we have been
trying to deal with here.
I wasn't here for Dr. Burgess' questioning, but he talked
about alternative payment methods. I am a big fan of Medicare
Advantage Plans. I understand the move and some discussions in
some areas about Medicare for All. But how can using
alternative payment methods affect quality and cost in the
Medicare Advantage world?
Mr. Azar. So I actually think we have been often thinking
about things the wrong way when we think about, for instance,
the Centers for Medicare and Medicaid innovation and our
demonstration authorities. We tend to think of Fee-for-Service,
the traditional Medicare, as where we need to innovate, and
then, Medicare Advantage would just follow. Well, the
competitive structures with Medicare Advantage and their
customer responsiveness, and frankly, their ability to run
plans--these are insurance companies; it is what they do. They
know how to run insurance and integrated benefits and deliver
outcomes that are quality outcomes.
I have been trying to change our mentality to think about
MA as more of the leading edge of innovation, and perhaps Fee-
for-Service is a fast follower there.
Mr. Shimkus. Yes, let me follow up with that. What about
waivers to the Stark and Anti-Kickback Statutes? Do you see
that addressing it in that space might be helpful?
Mr. Azar. Yes. So we actually have--it is called the
Regulatory Sprint, which is an effort that our Deputy Secretary
has been leading, looking at how the Anti-Kickback Statute
interpretations and Stark laws could be barriers to
integration, collaboration, and coordination. Because to get
the kind of outcomes we want to pay for value, we have to stop
paying just each individual provider in a procedure-based rifle
shot and pay together, and have them work together, but we have
the laws that say don't work together.
So we have to look at it. We have to protect against fraud.
We have to protect against abuse. But we have got to open up
and make sure we allow that collaboration outside of common
ownership structures.
Mr. Shimkus. Thank you.
When we knew about the hearing, we opened up to our social
media for people to maybe direct a question or two to you. And
Melody Tucker from Charleston, she actually submitted a whole
bunch, like 30 of them. So I am not going to go through them
all; we don't have time to do that. But one of the questions
she had was--I am just going to read it the way she sent it--
``Will salaries of healthcare providers, including physicians
and professional/paraprofessional staff, be determined by the
Government?'' And she is in the reference to the Medicare for
All debate. Would you see that as--and she goes on with saying,
``If so, how is Medicare for All not socialized medicine?''
Mr. Azar. Well, I think there is a real risk with Medicare
for All that it become, depending on the plan, that it become a
single-payer system. And if it is a single-payer system, one
eventually may want to move maybe to actually own the providers
that are under that, as we see with other countries' socialist
systems around healthcare. And so, yes, that would end up with
a system where we would, Congress or HHS would set salaries for
providers. I hope we don't ever get to that point, but I do
think that is a risk of single-payer systems. We have seen it
in other countries.
Mr. Shimkus. I appreciate that.
Madam Chairman, my time has expired. I will just yield
back.
Ms. Eshoo. I thank the gentleman. I now have the pleasure
of recognizing the gentlewoman from Florida, Ms. Castor.
Ms. Castor. Thank you, Madam Chair.
And thank you, Secretary Azar, for appearing before us
today on the Trump budget.
After reviewing the Trump budget, I know my neighbors back
home in Florida would want me to ask you, why does the
administration continue to undermine the law that protects them
from discrimination by insurance companies for preexisting
conditions? And they would want me to ask you, why does the
administration continue to saddle families with higher
healthcare costs, copayments, and premiums? And let's get into
the specifics here.
Your Department finalized a rule to expand short-term,
limitation-duration health plans. These junk plans are not
required to comply with the comprehensive consumer protections
of the Affordable Care Act. Junk plans undermine protections
for people with preexisting conditions. They increase costs.
They leave American families with fewer financial protections
and expose them to fraud.
So yes or no, are you aware, and did you consider in
rulemaking, that these junk plans discriminate against
Americans with preexisting conditions?
Mr. Azar. The short-term, limited-duration plans do not
have to comply with the Affordable Care Act's full
requirements, and we need to be sure people understand that.
Ms. Castor. I will take that as, yes, you were aware?
Mr. Azar. Some plans may and I believe are covering
preexisting conditions; some are not. And that needs to be
fully disclosed.
Ms. Castor. Did you know, are you aware that--so, you are
aware that these plans can exclude coverage for preexisting
conditions or decline to offer coverage to individuals with
preexisting conditions? Yes or no?
Mr. Azar. That is correct.
Ms. Castor. Yes.
Mr. Azar. That is correct. And that is why people need to
be fully aware of that, if they go into buying them.
Ms. Castor. No, I think what should happen is that we
should adhere to the law of the land, that we do allow
discrimination against our neighbors with preexisting health
conditions. That is what the law says.
Mr. Azar. If that was the law of the land, then President
Obama violated during his entire Presidency.
Ms. Castor. Secretary Azar, yes or no, are you aware, and
did you consider in rulemaking, that these junk plans exclude
coverage for basic healthcare services, such as
hospitalization, treatment for substance use disorders, or
prescription drugs? Yes or no?
Mr. Azar. Short-term, limited-duration plans may exclude
coverage.
Ms. Castor. So yes?
Mr. Azar. That is exactly why they can be more affordable
options for some people.
Ms. Castor. So the Department also concluded that expanding
junk plans will, and I quote, ``increase premiums and cause an
increase in the number of individuals who are uninsured. Other
nonpartisan estimates, including the CBO, have also projected
that expanding junk plans will increase premiums.'' So yes or
no, are you aware, and did you consider in rulemaking, that
expanding junk plans will lead to higher premiums in the
individual market?
Mr. Azar. Did consider that. The CMS actuary had some
analysis around that. But, given that we now pay for the
insurance for everybody in the individual market--we are
subsidizing, I think, over 87 percent of people's premium
acquisition--nobody should be leaving subsidized insurance to
buy one of these plans. If we are buying you a full insurance
package, I don't know why you would leave and buy a short-term,
limited-duration plan out of your own pocket.
Ms. Castor. Well----
Mr. Azar. It doesn't make any sense to me, but----
Ms. Castor. Let me say, the CBO was very clear on this.
They projected premiums will increase by at least three percent
due to your junk plan rule. And other studies, including one of
out of the Urban Institute, they have projected higher premium
increases across the board as well.
Mr. Azar. Well, the rule----
Ms. Castor. You are going in the wrong direction.
Mr. Azar. Well----
Ms. Castor. Families need relief. And what is happening is
you have sabotaged--allowing these junk plans is hurting
everybody. And we had expert testimony last week from folks
that are implementing in many States that said as much.
Your Department also finalized a proposal in the final rule
that would allow junk plans to be renewed for up to 36 months.
This was not presented in the proposed rule, and stakeholders
did not have an opportunity to provide input in rulemaking. Why
did HHS sidestep the rulemaking process and finalize a major
policy change that was not presented in the proposed rule?
Mr. Azar. I don't believe we did, and my memory is that we
asked the question whether there was legal authority for
renewability, but I am not confident of that. But I thought we
had asked that question, but I am not aware of any legal
infirmity in the administrative processes there.
Ms. Castor. So you are saying the Department's general
counsel provided a legal opinion on the renewability provision?
Mr. Azar. No, I am saying that I thought we had asked for
comment in the Notice of Proposed Rulemaking around the
question of renewability. I may be mistaken. My memory is----
Ms. Castor. Would you please share those documents with the
committee?
Mr. Azar. No, I am saying we asked the question to the
public as to whether--and asked for comment. You were asking
about whether something was fairly included in the Notice of
Proposed Rulemaking.
Ms. Castor. Yes. Could you provide those documents that you
said you provided to the public and any of the legal opinions
or questions----
Mr. Azar. It would be in The Federal Register because it
would be--what I am saying is I think in the Notice of Proposed
Rulemaking we asked that question. I may be mistaken.
Ms. Castor. So you are saying you would not provide those
documents if----
Mr. Azar. I don't think you are listening to what I am
saying, which is that it is in the Notice--I believe in the
Notice of Proposed Rulemaking we asked the question, and----
Ms. Castor. But your Department's general counsel's legal
opinion would not be in The Federal Register. Would you please
provide those documents to the committee?
Mr. Azar. We would have to review that under a request for
privilege and decide, and determine whether that is appropriate
to share.
Ms. Castor. I don't believe that you did.
Ms. Eshoo. The gentlewoman's time has expired. I now would
like to recognize the gentleman from Kentucky, Mr. Guthrie.
Mr. Guthrie. Thank you.
Thank you, Mr. Secretary. Just a couple of things before I
get to my questions.
I believe short-term duration plans were legal under the
previous administration?
Mr. Azar. That is correct. For the entirety of the Obama
administration, they existed for 12 months, up until just the
waning hours of the Obama administration, when they cut them
back only to three months to try to drive people into the
exchange market.
Mr. Guthrie. All right. Thanks.
Also, we are talking about per-capita caps, and I worked on
this in the previous Congress. And I remember having a letter--
and it was entered in the record when we had a hearing--that
each member, Democrat member of the Senate who had been serving
at the time, who was still serving, who were serving in the
1990s--I think it was '96--signed a letter for per-capita
allotments through Medicaid and Medicare--Medicaid. I'm sorry.
And former committee chairman Henry Waxman, in a 1996
congressional hearing, said that, ``the Federal Government
would maintain its commitment to sharing the costs of providing
basic healthcare and long-term coverage to vulnerable
Americans.'' And he correctly pointed out that ``States would
have both incentives and the tools to manage Medicaid more
efficiently.'' He did say that, obviously, the Federal
assistance would have to change if there was increases beyond
the control of States--hurricanes, floods, outbreaks of
contagious diseases. But that was something that, in the '90s
at least, was more bipartisan.
Let me just get to--I had a lady who came into my office
the other day. A lot of us have people that come regularly with
different groups with diseases, and she has ovarian cancer, and
it touched my heart. But her biggest struggle, when I was
talking to her, was about her daughter--she had her
grandchildren because her daughter had an opioid addiction.
With everything she was going through, that was really on her
heart and mind, and we talked about the opioid bill that we
passed. I know that it is supported in this budget.
And I particularly had an area called Comprehensive Opioid
Recovery Centers Act, which would give comprehensive coverage.
It became Section 7121 of H.R. 6. And could you talk about that
specific section, if you have that information, and
implementation of it moving forward, or just the overall
implementation of H.R. 6 as well?
Mr. Azar. I would be happy to get back to you. I am afraid
I don't have details on that particular aspect of the
implementation. We are, obviously, thankful to you and this
committee and Congress for the SUPPORT Act and the tools that
it provided us on the opioid epidemic.
Nearly every part of HHS is involved in implementing the
SUPPORT Act. It is such a comprehensive piece of legislation.
We are driving forward under the direction of our Assistant
Secretary for Health, Admiral Brett Giroir, and trying to make
sure we meet all deadlines in implementing all the various
provisions of the Act.
Mr. Guthrie. Thank you very much.
And also, I wanted to just kind of ask you this: The House
Republicans strongly believe that it is important that we
ensure protections for individuals with preexisting conditions.
And this is a commitment by you and President Trump, correct?
Mr. Azar. That is correct. The President has made clear he
will sign no legislation that would change the Affordable Care
Act that does not protect preexisting conditions. His budget
mandates that, that if Congress were to pass it, the $1.2
trillion American Healthcare Grant to States would have to have
effective risk-pooling mechanisms or other genuine protections
for preexisting conditions, which we have actually worked with
States to do. I have granted, I believe, seven waivers to
States under the Affordable Care Act to create reinsurance
pools that have actually brought premiums down from 9 to 30
percent as a result of these preexisting conditions pooling
mechanisms.
Mr. Guthrie. Thank you.
And also, under the Obama administration, premiums in the
individual market increased every year. But President Trump has
enacted several deregulatory reforms, and premiums have
decreased. Is this true?
Mr. Azar. That is absolutely true. Premiums, for the first
time in the history of the Affordable Care Act, actually went
down almost two percent from 2018 to 2019, and we saw the first
increase in the number of plans since 2015. These are directly
attributable to steps that we have taken to try to stabilize
the marketplace, including the first thing that we did on it
was a marketplace stabilization rule that were the things the
insurance industry said we need to be able to run a
predictable, actuarially, non-gamed system.
Mr. Guthrie. Thank you.
Mr. Azar. So we think we have a way to try to protect, to
make the premiums lower and choices better.
Mr. Guthrie. OK. Thank you.
There have been proposals for Medicare for All, a single-
payer, government-run Medicare for All bill. A 158 million
Americans receive their insurance through their employer or
their unions. What would happen to these 158 million employees
if we passed Medicare for All, from the proposals you have
seen?
Mr. Azar. So CMS's data is actually 174 million Americans
have their insurance through their employers. And under the
plans, at least some that I have seen, your employer insurance
would immediately go away because it would be outlawed; you
would have to go on Medicare. Even plans that don't mandate
that immediately would eventually cause the private sector
plans to go away because you would create such a financial
advantage for the Medicare plans, which I think pay 40 percent
less to providers by law. They end up paying 40 percent less
than commercial plans. It would effectively drive all private
plans out of business. So one way or the other, the different
iterations would lead to 174 million Americans not having the
insurance they have today.
Mr. Guthrie. Thank you.
My time has expired. I yield back. Thank you.
Ms. Eshoo. I thank the gentleman. I now have the pleasure
of recognizing the gentleman from New York, Mr. Engel.
Mr. Engel. Thank you, Madam Chair.
And thank you, Mr. Secretary, for being here today.
Fifteen months ago, the Republican tax scam bill passed and
was signed into law. And I said at the time, and it is even
more true today, the impact of that legislation has led to
exploding deficits, and therefore, also has led to the
President's budget calling for a 12 percent decrease in the HHS
budget. This budget continues to promote the long-sought goal
of dismantling the Affordable Care Act by another failed
attempt at so-called repeal and replace the law and weakens
protections for people with preexisting conditions. This would
leave millions of Americans without meaningful health
insurance.
Over 10 years, this budget calls for a $1.5 trillion cut in
Medicaid and a $500 billion cut in Medicare, partially offset
by inadequate investments in health plans which bypass consumer
protections. The cut in Medicaid is approximately $1 in $4
spent today, resulting in millions of Americans losing their
coverage.
The budget does provide a very modest $291 million towards
what the President call halting the spread of HIV. As chairman
of the House Foreign Affair Committee, I am particularly
opposed to cuts in funding for global AIDS programs. There is a
22 percent cut in PEPFAR, used to treat millions
internationally, mostly in Africa, a program started by
President George W. Bush. There is also a proposal to water
down the U.S. contribution in the global fund to fight AIDS,
TB, and malaria from $1.35 to $1.1 billion.
Inexplicitly, we also see budget slashes to the CDC of
nearly 10 percent. Funding for the NIH takes a 12 percent cut
of $4.5 billion, with the National Cancer Institute absorbing
most of that hit. Can you imagine that?
Now, Mr. Secretary, this HHS budget is completely
unacceptable and is a direct threat to the health and well-
being of all Americans. I have a couple of questions.
I would like to ask you, Mr. Secretary, yes or no, can you
guarantee that cutting almost $26 billion from hospitals that
serve low-income and uninsured individuals will not result in a
reduction in services, endanger access to vulnerable
populations, or contribute to hospital closures?
Mr. Azar. I am not sure which particular cut to hospitals
you are referring to in $26 billion. If it is the Medicare
changes on hospitals gaming the system by jacking up private
practice rates when they buy a physician practice----
Mr. Engel DSH payments is what I am referring to. Under
this formula, some of the largest DSH cuts will be on States
like mine that chose to expand Medicaid, while States that
rejected Medicaid expansion will get much smaller cuts. So will
the additional DSH cuts you are proposing continue this policy
of punishing states that expanded Medicaid with steeper
hospital costs?
Mr. Azar. Correct me if I am wrong, but I thought the point
of the Medicaid expansion, actually, was tied to DSH payments
going down. That was part of the funding mechanism in it. I may
be mistaken, but I think that is actually part of the
original--what President Obama and the Congress enacted, and we
are sort of carrying through on that, I believe.
Mr. Engel. Well, yes, how do the cuts in the CDC and NIH
budgets promote lifesaving research for those Americans
desperate for a cure?
Mr. Azar. The cuts at CDC and NIH were a challenge and it
is a starting point. With a tough budget environment, these are
difficult choices. We have tried to prioritize, and I
understand you or others will disagree with those choices. And
we are happy to engage in an ongoing discussion. It is a
starting point for that.
Mr. Engel. Well, the choice I am really against is the
choice that gives tax breaks to very wealthy people in exchange
for what we are seeing right now in this budget, hurting the
poor and the middle-class and their ability to have adequate
healthcare.
You have hospitals in my district and all the surrounding
districts that serve a high number of Medicaid patients, and
the uninsured are a critical part of our healthcare
infrastructure. They ensure that our most vulnerable citizens
have access to the care they need when they need it most. And
these hospitals rely on funding. I know you know this. For the
Medicaid Disproportionate Share Hospital, a DSH will help keep
their doors open and their lights on. And Medicaid DSH payments
help support hospitals across the country in all types of
communities, urban and rural. And at the end of this year,
hospitals will face substantial cuts to their DSH funds if
Congress doesn't act.
So the President's budget, the way I look at it, doesn't
propose to reduce or delay these cuts. Instead, it doubles down
and proposes increasing the size of these cuts over a longer
period of time. And by your own objections, this would result
in $25.9 billion in cuts to Medicaid DSH on top of a $44
billion in DSH allotment reductions under current law. I don't
see how hospitals will be able to sustain cuts of that size.
Could you please explain to me how that would be possible?
Mr. Azar. Again, I believe that is inherent in the
Affordable Care Act's structure. And in terms of uncompensated
care, I thought that the Medicaid expansion and the Affordable
Care Act were supposed to get rid of the uncompensated care. I
mean, we can't keep the old system and have the new system on
top of it and keep paying the same amount of money. That is at
least our perspective in the budget.
Mr. Engel. But let me just say, Madam Chair, and then, I
will end, to me, it doesn't matter as long as we are not
pulling away help that people need now. It seems to me that,
from these cuts, there is no way that you can call it any other
thing, but we are taking money away and many, many more people
will be left uninsured and will have no help. And to me, that
is not the way we should be going, providing tax cuts for the
wealthy in exchange for everybody else getting screwed.
Ms. Eshoo. I thank the gentleman. I now have the pleasure
of recognizing the gentleman from Virginia, Mr. Griffith, 5
minutes for questioning.
Mr. Griffith. Mr. Secretary, in trying to answer some of
the questions just a minute or two ago, you were talking about
the DSH payments and some of the bigger hospitals buying up
small satellites in order to be able to get DSH payments they
wouldn't otherwise be qualified for. Did you want to expand on
that?
Mr. Azar. I am afraid on the DSH payment issues I have to
get back to you on that. If you have a question on that, on
detail, I would be very happy to get back to you there.
Mr. Griffith. That is fine.
In regard to having socialized medicine and have it the
same parameters as the current Medicare system, where you
referenced that the medical folks are paid 40 percent less
under Medicare, have you all done any studies on how many
healthcare providers would leave the field?
And let me tell you why I ask that question. My mother is
88 years old, and obviously, she has been on Medicare for a
while. Recently, her primary care physician retired. She
started making phone calls and made a couple of calls and found
that the doctors that she called were not taking any new
Medicare patients because of the reduced payments that they
were going to get. And she just decided she would work with her
older doctors who were the specialists that dealt with the
areas of concern, instead of having a primary care physician.
So she is actually getting less care now than she got before.
And it made me think that perhaps, at a 40 percent
reduction, a fair number of healthcare providers, particularly
those who might have other means of supporting themselves,
might just go do something else. Have you all done any studies
on that?
Mr. Azar. I am not aware of any studies that have been
conducted yet. I think that is a fruitful area for inquiry. We
ought to look at that.
We certainly see that with European socialist systems,
though, that you get the better providers or hospitals who will
often opt out of the socialist system because of underpayment.
And what you get is a two-tier system. You will have basically
an essential medicine, essential services systems, and then,
you have others who can buy up in a private sector system,
alternative providers and hospitals in there. That is not to
say that these are bad healthcare systems, but it is a two-tier
system.
Mr. Griffith. And with our current system where a lot of
people get it through their employer, it doesn't matter whether
you are the CEO or the guy working the line or the lady working
the line; you get the same system. And now we are headed toward
a system that might actually have two tiers, where the people
with the money can get that specialist, but the people who are
working on the factory floor may not be able to get that
specialist. Is that correct, yes or no?
Mr. Azar. I am extremely concerned about a two-tier system
like that.
Mr. Griffith. And so, that is a yes?
Mr. Azar. Yes, that is a yes. And let's protect everybody.
Mr. Griffith. My time is slipping away from me. Just let me
say this as you all look at things. We have got to figure out a
way to do reimbursements for telemedicine across the board
because telemedicine can save us money in the long term and
provide better care in rural districts like mine. And I am a
big proponent. And any way I can help you with that, I would
greatly appreciate it.
Also, you all have been looking at the DIR fees, the direct
and indirect payments to pharmacists. It seems to me it is an
inequitable situation that we have now, where, months later, a
pharmacist who has sold a drug--and I have lots of these across
my rural district, community pharmacies. They are not big
companies. They are little, small, mom-and-pop operations. And
they get notice that they owe tens of thousands of dollars six
months after they have already filled the prescription. You
can't go back to the patient and say, ``Oh, by the way, I told
you it was a $20 drug. It turns out it was a $30 drug.'' You
just can't do that, and the pharmacists are having to eat that.
You all are working on that, and I appreciate that.
You all, last year, in a Senate hearing, you stated that
you were going to direct your agency's Office of Inspector
General to conduct a study on these DIR fees and how these fees
specifically impact community pharmacists. Has that study been
completed and, if so, when do you expect to release the
results?
Mr. Azar. I believe it well underway and I hope it will
come out quite soon.
Mr. Griffith. All right. I appreciate that.
I also want to talk about durable medical equipment,
prosthetics, orthotics, and supplies, et cetera. Competitive
bidding programs have been put on hold. I appreciate that. One
of the concerns in a rural area is that you may only have one
or two suppliers, and while the equipment might be available to
somebody if they drive down the mountain in 45 minutes to an
hour, but sometimes these folks aren't capable of doing that.
And we are squeezing out the folks who would actually take the
equipment to them.
In that regard, the agency now has plans to include non-
invasive ventilators in the durable medical equipment program.
Those, obviously, assist people that can't breathe on their
own. Can you explain the rationale and clinical criteria used
in the decision to include non-invasive ventilators in the next
round of bidding?
Mr. Azar. Sure. The Social Security Act gives us authority
to phase in items that begin with the highest-cost and the
highest-volume items or services and those items that we
determine have the largest savings potential. And so, all of
the items that we have selected for competitive bidding are
high-cost, high-volume items with a very large savings
potential.
We have got a comprehensive monitoring program, and it has
shown that beneficiary access and health status outcomes have
been preserved under the program. We have been very concerned
about the impact in rural. That is why we made the
modifications that we did, I believe, midyear last year, and
then, carrying forward, to attempt to ensure fair reimbursement
and fair competition for rural areas especially.
Mr. Griffith. I appreciate it, and yield back, Madam Chair.
Ms. Eshoo. I thank the gentleman. I now have the pleasure
of recognizing the gentleman from Maryland, Mr. Sarbanes, for 5
minutes of questioning.
Mr. Sarbanes. Thank you, Madam Chair.
And thank you, Secretary Azar, for being here.
I just wanted to make sure the record was clear on a couple
of things. In response to Congresswoman Castor's questions with
regard to the junk plans, I just want to point out that, while
with respect to the renewability question of these plans it
does look like the Department went through the normal course in
terms of the NPR and allowing public comment there with respect
to the extension of these plans to 36 months, that did not come
until the final rule was proposed. And in that sense, it
sidestepped the kind of transparency that I think we have a
right to expect. So that is the first thing.
The second thing I wanted to note is you have been asked a
number of times about the cuts to NIH, and you really don't
have a good answer for that, because I think it is indefensible
and there is going to be a lot of continued inquiry in that
regard. Because we want to stay on the cutting edge in terms of
researching and finding cures to these life-threatening
diseases that afflict so many Americans across the country.
But I wanted to talk specifically about the opioid crisis
and address the impact of the pharmaceutical manufacturer
marketing efforts with respect to the crisis. On February 26th,
a Washington Post article titled, ``Inside the House of
OxyContin,'' detailed the actions of Purdue Pharmaceuticals and
their owners, the Sackler family, in marketing opioids as safe
and effective to the medical community. It highlighted, the
article did, that Purdue pioneered direct-to-physician
marketing and used this approach to lead a marketing strategy
to persuade providers that opioids were both safe and effective
for long-term use, despite a lot of scientific evidence to the
contrary.
One member of the Sackler family was quoted from an email
in 1996 saying, quote, ``This strategy has outperformed our
expectations, market research, and fondest dreams.'' End quote.
Twenty years later, we are dealing with the consequences of
this marketing strategy. And I don't need to remind my
colleagues that opioid deaths hit a record high in 2017 with
70,000 recorded opioid deaths that year.
So how is HHS going to hold pharmaceutical manufacturers
accountable for drug-marketing strategies that are boosting
profits while harming our communities? Could you speak to that,
please?
Mr. Azar. Congressman, thank you for raising it. It is
really important because, you are right, that is a big part of
how we got into this opioid crisis, were the practices in
getting legal opioids out there and getting them out in primary
care and getting them extensively overprescribed. Is it five
times, I think, the European average in terms of legal opioids?
We have been aggressively working on that. We have actually
gotten opioid, legal opioid prescribing down 22 percent, and on
a morphine molecular equivalent, down 27 percent so far since
January of 2017.
The President has directed, and the Justice Department has
been working. We will support fully the Justice Department in
going after any manufacturers who engaged in illegal or
unethical conduct. DOJ joined in the litigation by the States
against these manufacturers, and that process is ongoing. But,
certainly, we will take any cases anywhere the evidence goes. I
share your concern. We are deeply disturbed, and we see the
foundation of this crisis in the legal opioid use that started,
I think, back in the '90s.
Mr. Sarbanes. Well, I do think we need to step back and
systematically look at what these marketing strategies are and
decide whether we are going to lean against them going forward.
What is the standard of scientific evidence at HHS and FDA
in terms of what is required from pharmaceutical manufacturers
when approving drug applications, especially in the case of
opioids?
Mr. Azar. New drug applications, I want to defer to my
colleagues at FDA. So I would say my current belief, but,
please, I will ask my colleagues, and we will correct it if I
get it wrong.
Usually, for an on-label indication, you would require two
double-blind controlled studies, randomized clinical trials, to
support a labeled indication. And then, for other information
that you would provide about the drug, I believe it is a
substantial evidence test, but I----
Mr. Sarbanes. I am worried that whatever the standards are
that are being applied are not achieving the goals that the
public would want to see in terms of kind of rigorous decisions
about what is safe and what is not safe. And you may have heard
that the former FDA Commissioner, David Kessler, is concerned
that opioids are being used in a way that was never proven to
be safe or effective, particularly the decision on FDA's part
to expand the label use of opioids to allow long-term use,
which is something that probably should not have happened.
So as I close, I just want to say that I think HHS and FDA
have to put a plan in place for retroactively reviewing the
safety and efficacy of existing opioid projects. Let's go look
at what is happening right now because it could be continuing
to fuel this opioid crisis. So it is not just retrospective
here. This is about making decisions going forward that can
help us get out of this crisis.
With that, I yield back my time.
Ms. Eshoo. I thank the gentleman. I now would like to
recognize the gentleman from Florida, Mr. Bilirakis.
Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so
very much.
And welcome, Mr. Secretary. Appreciate it.
I want to talk about Medicare Part D. When Congress created
Medicare Part D, it did so with the belief that private sector
organizations which are already administering employer-
sponsored drug benefits could be used to administer a Medicare
drug benefit. We now have Medicare Part D, where drug plans
compete against each other to provide the lowest price to
beneficiaries. It is probably the only Federal program that
consistently comes in under budget with premiums that have
remained largely unchanged. And I know this has been going on
for years. It is a very successful program.
In my district, we have 191,000 seniors, and about 80
percent of them are on either Medicare Part D or they
participate in a Medicare Advantage program with a drug
benefit. Some people have talked about changing Part D and
having the Government negotiate drug prices. Do you think the
Government can negotiate a better deal than what the plans have
been able to negotiate over the past 15 years? Again, we want
what is best for our constituents. We want low drug prices, and
I know you do, too, and the President as well. So that is the
question. Again, do you think the Government can negotiate a
better deal than what the plans have been able to negotiate
over the past 15 years?
Mr. Azar. I do not believe that we could do a better job
negotiating than these pharmacy benefit managers do, absent
creating a highly-restrictive, uniform formulary for every
senior citizen in America. And that is what Peter Orszag, the
head of the Congressional Budget Office and President Obama's
OBM Director, concluded also. These PBMs have significant
market power. They negotiate discounts, where we let them, that
are comparable to European OECD levels of discounting, is my
understanding and experience.
But we would have to create a single formulary. We would
have to say that, every senior, you may have this drug; you may
not have this drug. We have heard the bipartisan concern even
today on step therapy and utilization management within
protected classes. Imagine the outcry if we were to say to all
seniors, ``You may have''--and I will just pick a drug--``You
may have HUMIRA; you may not have Enbrel.'' That is the only
way I could get better savings than the PBMs are able to
negotiate.
And I think a lot of the concerns would be here. I am not
sure a lot of folks who ask us for that negotiation understand
the implications from a beneficiary choice and access
perspective. I am happy to have that discussion with both sides
of the aisle on this, because we want to solve the drug pricing
crisis. We want to solve that, but we want to solve it in the
right way, with patients at the center.
Mr. Bilirakis. All right. Thank you very much, Mr.
Secretary.
Again, yes, you are right. I mean, your heart is in the
right place. The President's heart is in the right place.
Everyone, we want lower drug prices, but, again, also choice
and accessibility are so very important for our seniors.
I assume that you have reviewed the Medicare for All
proposal?
Mr. Azar. I have seen and heard about different iterations
of it, sir.
Mr. Bilirakis. Yes, yes. So how would the Medicare for All
proposal affect the successful Medicare Part D program, in your
opinion?
Mr. Azar. It would take it away because Medicare Part D is
a private-plan-administered program with private insurance, is
my understanding, at least of some of the versions of that.
Mr. Bilirakis. Yes, and, in my opinion, it is not perfect,
and we are going to close the donut hole. But it has been a
very successful program. I hear from my seniors all the time.
Medicare Advantage is very popular in my district. Fifty-
three percent of our seniors are on Medicare Advantage. They
really love the program. How would Medicare for All affect the
Medicare Advantage Program?
Mr. Azar. I believe Medicare for All, under at least some
versions of the Medicare for All program, that Medicare
Advantage would disappear because it is a private insurance
program administered by the Government. But I believe it would
go away and all would go onto a Medicare Fee-for-Service, the
old-style 1960s Medicare that people are increasingly not
choosing because they want the more private sector, flexible,
choice-full benefit package of Medicare Advantage.
Mr. Bilirakis. Well, thank you very much. It would be a
real shame if we lost that.
Mr. Azar. Thank you.
Mr. Bilirakis. Thank you very much. I yield back.
Ms. Eshoo. I thank the gentleman. I now would like to
recognize the gentleman from Oregon, a wonderful member of this
committee, Mr. Schrader.
Mr. Schrader. Thank you very much. I appreciate this.
Thank you for being here today, Mr. Secretary. I appreciate
it very much.
I am not particularly a big fan of the budget that is
rolled out for HHS, to be honest. We are a big fan of the ACA.
This would repeal it, and the Medicaid program gets cut, cuts
to research, those types of things.
But I try to look at the silver linings here, and the
prescription drug costs suggestions merit, I think, some good
look-sees. In particular, generics are saving us $250 billion a
year. It is a big area. I prefer, like my good colleague from
Florida, market-based solutions in terms of how we encourage
competition, as probably the best way to go about that.
And in the generic space, we currently give manufacturers
180 days exclusivity when they file for a new generic drug, but
there have been some problems with that, with that exclusivity.
Sometimes they don't just get around to marketing the drug in a
timely manner, and that exclusivity drags out well beyond 180
days, basically, blocking others from getting into the
marketplace and further reducing costs for the consumer.
So a couple of questions, if I may. One is, how often does
a first filer block competition from subsequent generic
manufacturers, and how long does that parking actually seem to
last? Any examples recently?
Mr. Azar. So my understanding is that, on average, we see
about five of those instances a year where you will have that
first-to-file, essentially, squat on their 180-day exclusivity.
And on average, that leads to about a 12-month delay in
generics coming to market. So it is a very significant access
and financial issue.
Mr. Schrader. All right. Any recent examples of that?
Mr. Azar. I don't have a particular company or product in
mind. We could try to get that to you. But those are the
average numbers there.
Mr. Schrader. All right. Well, it would be great to get
that information, some real-life examples.
And what is the motivation, basically, what is the
advantage for these manufacturers to park their exclusivity,
which seems sort of obvious, but what you seen?
Mr. Azar. Well, there could be instances where they simply
can't make the drug. There are often manufacturing problems. So
somebody gets approved, but they are not able to bring it
across the finish line and manufacture. But there may also be
instances where there is a deal, where there is a deal between
the generic company and the branded manufacture to forestall
the starting of that 180-day clock, so that the branded company
can keep selling the branded drugs.
Mr. Schrader. I see. I see.
Mr. Azar. It is a likely potential source of great abuse on
access to generic medicines for our people.
Mr. Schrader. Yes, and I think the goal would be,
hopefully, to provide opportunity for folks to get into the
market as soon as possible. Maybe some changes can be made, so
that a second generic that comes to market in a timely manner
would start triggering a clock.
Mr. Azar. And the President's budget has that proposal in
there. And I appreciate your leadership and Congressman
Carter's leadership supporting reform here that would fix this
real abuse of our generic system.
Mr. Schrader. Last question is, some people argue that the
forfeiture of that exclusivity that is currently in statute
provides enough protections against the parking issue that we
are talking about here. I understand there have been some
problems, frankly, enforcing that forfeiture portion.
Mr. Azar. Yes. I think the evidence would be to the
contrary, that, in fact, we are seeing this as a real problem.
And getting rid of that abuse by having the clock start as soon
as the drug is available from an approval perspective, and if
they don't launch as soon as there is a second drug available
to come on, that clock should start or other different
solutions. So the forfeiture provisions that are there are,
obviously, not quite sufficient. We need to fix this 180-day
clock issue.
Mr. Schrader. Very good. Very good. Well, I appreciate your
interest in that issue, and hopefully, it is one of many areas
we can work together on.
Mr. Azar. I hope so.
Mr. Schrader. Thank you very much, and I yield back, Madam
Chair.
Ms. Eshoo. I thank the gentleman. And we are going to have
a legislative hearing tomorrow on the very issue that you just
raised with the Secretary. I hope that we have good bipartisan
support on addressing that abuse.
I now would like to recognize the gentleman from Indiana,
Dr. Bucshon.
Mr. Bucshon. Thank you.
And welcome, Secretary Azar, to our subcommittee.
I do agree with one of my colleagues on the other side that
my constituents do need relief, but it is from the high
deductibles and premiums created the ACA and the following
years after that.
Secretary Azar, I was pleased to see the administration's
focus on the 340(b) program again this year in the budget,
specifically, a call to require transparency regarding the use
of program savings by 340(b) entities. This goes hand in hand
with the important work done by this committee, the Energy and
Commerce Committee, last Congress in the Oversight Subcommittee
in highlighting the need for 340(b) reform, and also, in
exploring specific legislative proposals aimed at strengthening
the program.
I was proud to sponsor a bill last Congress that would
introduce common-sense data collection for 340(b) entities
previously facing no oversight. It is very concerning to me
that a significant number of hospitals in the 340(b) program
may be providing low levels of charity care, despite the rapid
growth in the program, recently, mostly through the acquisition
of child sites, and face no requirements to report on their use
of 340(b) savings.
The first question I would have, would you support
including a charity care requirement as a condition of
eligibility for the program?
Mr. Azar. I would have to look at that and see what the
administration position would be there. In our budget, of
course, we do propose that, to get the benefit of savings from
our reimbursement change----
Mr. Bucshon. Correct.
Mr. Azar [continuing]. That you would have to provide, I
believe, at least one percent charity care.
Mr. Bucshon. One percent.
Mr. Azar. So to be a beneficiary of the budget neutrality
from the outpatient changes, you would have to do that. So we
are at least partway there already.
Mr. Bucshon. OK. Do you think that we should have a minimum
charity care level met across all hospital networks at the main
hospital, but also within their network?
Mr. Azar. Well, it's certainly----
Mr. Bucshon. It is a complicated question.
Mr. Azar. The rationale on 340(b) is that you are providing
that type of care. And so, it is something we need to be
looking at. I am happy to work with you on that.
Mr. Bucshon. I appreciate that.
And based on your budget, would you agree that HRSA needs
more authority to create clear and enforceful standards for the
340(b) program?
Mr. Azar. Absolutely. We need regulatory authority. We need
oversight authority. We need transparency in 340(b). And we
need a user fee program, so that those benefitting from 340(b)
pay for the oversight that we need to provide over their use of
the program.
Mr. Bucshon. Thank you for that answer. And could you also
agree that we need to require all 340(b) covered entities to
report savings achieved from the 340(b) program and their uses?
Mr. Azar. I think that type of transparency could be very
useful. That is not, obviously, a formal statement of
administration position, but we are generally in favor of that
type of transparency.
Mr. Bucshon. I understand. Thank you again for addressing
340(b) in your budget.
And I yield back.
Mr. Burgess. Will the gentleman yield?
Mr. Bucshon. The gentleman will yield to the ranking
member, yes, I will.
Mr. Burgess. I thank the gentleman for yielding.
This is such an important topic. Of course, this committee,
the Subcommittee on Oversight and Investigations did do a
significant amount of body work and produced a report last
Congress that I encourage people to look at.
But, Mr. Secretary, there was something that occurred along
the way in the 340(b) genesis that got us to this point. And
that was the ability of a contract pharmacy to participate in
the 340(b) program. Do you have any thoughts as to whether or
not that is adding to our difficulties?
Mr. Azar. It is adding to the difficulties and the issues
around integrity of the program and just original purpose. And
I do think it would be great if this committee could look into
this question. It was a well-meaning idea at the start, which
was, if a hospital doesn't want to run its own pharmacy for
low-income patients when they come in, let somebody else run
it. OK, that made perfect sense. But, then, it became, well,
what if they need something a little closer to home? So extend
the contract pharmacy out to pharmacies maybe in the
neighborhood of the patients of that hospital. It has now
become an industry. It has begun an industry of contract
pharmacy, of basically shared profit between the pharmacies and
these hospitals. It is worth looking at it to see the extent to
which it is fulfilling the original purpose and what Congress
really intends 340(b) to be about. I leave that to you all. But
I do think it is worthy of being on your agenda.
Mr. Burgess. Yes, and I completely agree, and to the extent
that mergers and acquisitions might evolve out of those 340(b)
contract pharmacies, it is worthy of our discussion.
So I thank the gentleman for yielding. I will yield back to
you.
Mr. Bucshon. I yield back.
Ms. Eshoo. I thank the gentleman. I now have the pleasure
of recognizing the gentleman from New Mexico, Mr. Lujan.
Mr. Lujan. Thank you very much, Madam Chair.
Secretary Azar, yes or no, were you given advance warning
of the Department of Justice's decision to not defend the law?
Mr. Azar. I am sorry, you are speaking, I assume, about the
Texas litigation? I just want to be sure I--you said ``the
law''. I just want to make sure the law we are talking about--
--
Mr. Lujan. Yes, Mr. Secretary.
Mr. Azar [continuing]. Is the Affordable Care Act?
Mr. Lujan. Yes, Mr. Secretary.
Mr. Azar. Yes, I knew the filing that was going to happen
on behalf of the United States.
Mr. Lujan. How were you notified of the Department of
Justice decision? Did you receive a phone call, an email, or a
written letter?
Mr. Azar. Our Department is involved in consultations
regarding the filing of litigation in which the Department has
interest or is a party. And so, we have communications with the
Justice Department.
Mr. Lujan. You had a phone call or was it an in-person
meeting? Was it a letter? Was it a----
Mr. Azar. The nature of the discussions that I have
regarding deliberations on filing of the position of the United
States in litigation in this case are not ones that I can have
full discussion about.
Mr. Lujan. You can't say? I understand that you have
already refused to share those documents, but you can't say if
it was a phone conversation or an in-person meeting?
Mr. Azar. Our Department has discussions with the Justice
Department and other officials regarding the position in highly
significant cases of litigation on the position of the United
States. And, yes, I had a----
Mr. Lujan. Mr. Secretary, did you personally have those
conversations?
Mr. Azar. I did, indeed.
Mr. Lujan. Look, it is simple. If the District Court ruling
stays, millions of Americans would lose their health coverage,
healthcare costs would skyrocket, and lifesaving healthcare
would become unaffordable for American families. Secretary
Azar, yes or no, did your Department conduct an analysis to
evaluate the effects of the Department of Justice's position on
consumer cost and coverage?
Mr. Azar. I don't know if we did at the time, and as I
spoke with Chairman Pallone earlier, we are working to gather
up, if we do have analytics around impacts of the court
decision in the case, we are working to provide those to the
committee.
Mr. Lujan. Can you commit to providing that, then, to the
committee? That is something you will do?
Mr. Azar. I asked my team to find any materials like that
and provide those to the committee, that type of analytics, and
to provide those to the committee. Absent some problem--and I
think they have communicated with committee staff to that
regard--absent something I am not aware of, I want to make sure
you get that information.
Mr. Lujan. So, Mr. Secretary, surrounding the initial
questions that I asked as well, why is it that there is a
reluctance to share that information with the committee?
Mr. Azar. To share the analytics? I have----
Mr. Lujan. Not the analytics, Mr. Secretary. Why is it that
there is a reluctance from you to share the information,
pursuant to the conversation surrounding the Department of
Justice's decision to not defend the law in the Texas case?
Mr. Azar. Well, obviously, discussions of individual
Cabinet members at a certain level regarding positions of the
United States in litigation are historically over the course of
the history of this country highly-privileged, sensitive
discussions, especially with pending litigation.
Mr. Lujan. Well, Mr. Secretary, I think that there is a
decision that was clearly made associated with positions of the
administration. The question that I have, and why I am asking
the questions that I am, is in your Senate confirmation
hearings you repeatedly stated that you were committed to
enforcing and upholding the Affordable Care Act. Is that
correct?
Mr. Azar. I absolutely am. As long as it is the law of the
land, I will in my administrative authorities work to make it
work for the American people, in my judgment, as best I can.
Mr. Lujan. Well, Mr. Secretary----
Mr. Azar. But that is not a statement of whether something
is constitutional or not.
Mr. Lujan. Mr. Secretary, if I may, the administration has
made an unprecedented decision to throw away the responsibility
to defend the Affordable Care Act and law.
Mr. Azar. So I want to be very clear. Our policy position,
as an administration and mine, is to protect preexisting
conditions. You are speaking about a legal piece of litigation
the Justice Department leads on. We want preexisting conditions
protected. Our budget actually has a concept about how we can
do that with a replacement of the Affordable Care Act. I am
happy to work with this Congress on alternative ways and
approaches. The President has made it very clear he will never
sign any new legislation replacing the ACA that he does not
believe does protect people who have preexisting conditions.
Mr. Lujan. Well, Mr. Secretary, I am glad that you brought
attention to the fact of the policy related to people with
preexisting conditions because you and I very well know that
the Trump administration has specifically disavowed ACA
provisions that guarantee coverage and protect people with
preexisting conditions. I think that that is ignoring what has
occurred. Your testimony today seems to be ignoring positions
that have been taken by this administration, that you,
yourself, said you would uphold in court.
Mr. Azar. I think you are probably referring to short-term,
limitation-duration----
Mr. Lujan. No, no, no. I know what I am referring to, Mr.
Secretary.
Mr. Azar. It is totally transparent----
Mr. Lujan. And I think that it is critically important that
we understand what is occurring here today and what is not
occurring. And I certainly hope that you will reverse your
refusal to share documents with this committee.
And with that, Madam Chair, I yield back.
Ms. Eshoo. I thank the gentleman.
We have three votes on the floor. So the subcommittee will
stand in recess until immediately after votes.
We still have several members that are in line to question.
I have 14 members. There are three that waved on, but that is
still a large group.
So, Mr. Secretary, it is a chance for you to take a
stretch, relax for a few minutes, figure out how you might
answer the questions that are to come.
And we will return as soon as votes are completed.
Thank you.
[Recess.]
Ms. Eshoo. I call the subcommittee back to order.
Thank you, Mr. Secretary, for your patience.
And we will move on with questions. It is a huge pleasure
because she has been such a wonderful partner in so many
things--the gentlewoman from Indiana, Mrs. Brooks, for 5
minutes of questions.
Mrs. Brooks. Thank you, Madam Chairwoman.
And, Secretary Azar, we have talked about this in the past,
the Pandemic and All-Hazards Preparedness Act, a program that,
while we have reauthorized it once again in this Congress--and
I really want to thank the chairwoman, Congresswoman Eshoo, who
worked with me both last Congress and this Congress to get this
across the finish line here in the House once again--it has not
yet been reauthorized. We have not yet been able to get it
through the Senate.
It is supported by a host of public health groups, the
Alliance for Biosecurity. And when we kicked off the
Congressional Biodefense Caucus together, you participated and
spoke at that Biodefense Caucus. And I thank you for speaking
about the importance of PAHPA. During your remarks, you
mentioned that you were involved in the writing in 2002 of the
Bioterrorism Act. And I want to commend you because it appears
that in the Public Health Services Emergency Fund there is, for
the most part, either level funding or some increased funding
relative to Pandemic and All-Hazards Preparedness.
But can you share with us the negative impact of PAHPA not
being authorized? And if we cannot get this through the
Senate--there are several programs that actually expired in
2018; I won't go into those--but what does this do for our
private partners in the very critical public-private
partnership in the Medical Countermeasures Enterprise?
Mr. Azar. Well, thank you, Congresswoman Brooks, for your
support of PAHPA and for your advocacy of the bioterrorism
front.
We are committed to reauthorization of PAHPA. We are
committed to protecting Americans, and reauthorization of PAHPA
is an important part of that.
There are several expired provisions that HHS does need to
be able to continue the important work in this area. There is a
FOIA exemption. There is an antitrust exemption. There is a
National Advisory Committee on Children and Disasters. And
there is a provision for temporary reassignment of Federally-
funded personnel.
And the expiration of these provisions does endanger our
security and the broader Medical Countermeasures Development
Enterprise that we have. These medical countermeasures are
dependent upon a very unique and fragile U.S. Government-
industry partnership in this cradle-to-grave enterprise.
Specifically, if a pandemic were to occur, BARDA, which is our
research and development agency, would currently be unable to
negotiate and bring together certain critical medical
countermeasures manufacturers due to a lack of antitrust
exemptions. That is just one example of how we are at risk
right now.
Mrs. Brooks. And I think because it is not commonly
understood, that is because BARDA does sit with different
manufacturers of vaccines to have a discussion. Is that
correct?
Mr. Azar. Exactly. We can convene competitors under the
antitrust exemption, and they can speak freely in ways that
they otherwise wouldn't be able to.
Mrs. Brooks. And that provision has expired?
Mr. Azar. That has expired.
Mrs. Brooks. OK. So right now, they cannot convene that
type of meeting if we were to have an unusual or a pandemic and
have those discussions?
Mr. Azar. If we had a pandemic and needed to scale-up
production immediately for a pandemic flu vaccine, right now we
would not be able to engage in those collaborative private-
public partnership discussions across industry.
Mrs. Brooks. Right. Thank you.
With respect to the funding, I certainly see that the
National Disaster Medical System has actually been plused-up
from $57 million in FY19 to $77 million. If I am not mistaken,
that is bringing in medical providers from around the country
to help us in cases of disaster, of which we have seen quite a
bit. Is there anything you would like to say about that? And
then, we also went down, though, a bit on the Hospital
Preparedness Program by $7 million.
Mr. Azar. Right. So the National Disaster Medical System is
a bedrock of our preparedness and response program. So these
are individuals who have day jobs, doctors, emergency medical
technicians, veterinarians even, who work with us and allow us
to surge in. For instance, you will see these people when you
are at various events. Like the State of the Union, a lot of
the medical professionals that are here are actually NDMS
members here to protect you and me when we are here for
national security events like that. And so, it is a vital,
important program, and I am very glad that we have a proposal
to continue the investment with them.
Mrs. Brooks. Can you talk very briefly about the other
provision that expired and the National Advisory Committee on
Children and Disasters?
Mr. Azar. So this is, of course, just getting advice from
the best advisors out there on how we can focus on children in
disasters. There are very unique needs and threats for children
in the disaster situation, trauma, mental health, and we do
want to get the best advice possible. PAHPA enables that.
Mrs. Brooks. Well, thank you. We look forward to working
with you to help us get that over the finish line in the
Senate.
Mr. Azar. Thank you.
Mrs. Brooks. Thank you. I yield back.
Ms. Eshoo. I thank the gentlewoman. It is a pleasure to
recognize the gentleman from Massachusetts, Mr. Kennedy, for 5
minutes of questioning.
Mr. Kennedy. Thank you, Madam Chair.
Mr. Secretary, thanks for being here. Thanks for your
patience as we went over to vote.
Last fall, Mr. Secretary, it was reported that your agency
was considering establishing a legal definition of sex under
Title IX. According to The New York Times, the memo would
narrowly define gender as a biological condition determined at
birth, and any dispute about one's sex would have to be
clarified using genetic testing.
Mr. Secretary, is that memo real?
Mr. Azar. So there was litigation, I think it was at the
end of the Obama administration, and a Federal court actually
enjoined enforcement of--I think this is the Section 1557. Is
that the provision that you are talking about?
Mr. Kennedy. Yes, but does the memo exists? The New York
Times said this memo exists.
Mr. Azar. I am not going to comment on whether some
preliminary memo exists. We are working on complying with the
court's order to come up just how do we--the court said that
the Obama administration's regulation was invalid. And we will
just work to faithfully implement that across relevant
agencies.
Mr. Kennedy. Can you give us a copy of that memo? Can you
give us a copy of that memo then?
Mr. Azar. We will certainly look at that. I don't know. If
it is an internal memo like that, if it is appropriate to
disclose----
Mr. Kennedy. It is potentially going to impact millions of
Americans in not disclosing that, or at least hundreds of
thousands----
Mr. Azar. I wouldn't necessarily assume that is operative
continued thinking, that whatever was in any previous
document----
Mr. Kennedy. Thank you.
So moving on, sir, do you believe that healthcare is a
right for all Americans in this country?
Mr. Azar. I believe that we have an important duty, all of
us, this committee and this administration, to make healthcare
as affordable as possible for all Americans.
Mr. Kennedy. So in a less than a year, nearly 20,000 low-
income people in Arkansas, sir, have lost their healthcare
because of a work requirement that your agency approved. At the
same time, the unemployment rate in Arkansas has barely budged.
Is that a successful policy implementation?
Mr. Azar. So at the request of the Arkansas Government, we
did approve a community engagement waiver program with them.
The individuals who have fallen off that program, we do not yet
have data as to why they fell off the program.
Mr. Kennedy. Have we asked them? Have you asked them?
Mr. Azar. Yes. We are working with them. That is part of
the data gathering. That is part of the learning process.
Mr. Kennedy. And when do you expect to have that data back?
Mr. Azar. I don't know if it is timely for that. It is
quite new. It is quite new in its implementation. So tracing
the data out to see that individuals, as you said, who advance
into work with an employer insurance, and hence, do not qualify
for Medicaid anymore, need Medicaid anymore, we just don't know
at this point.
Mr. Kennedy. Mr. Secretary, so in your agency's budget you
propose implementing mandatory work requirements for Medicaid
beneficiaries, not knowing what the impact will be across every
single State. And according to some estimates, upwards of 4
million Americans can lose access to healthcare, 83 percent of
whom would only lose coverage because of onerous reporting
requirements. You just said you are not sure why people are
losing it. Yet, you have now said that you want to extend that
to every single State. What is the logic in that?
Mr. Azar. The logic behind that is we believe that it is a
fundamental aspect for able-bodied adults, if you are receiving
free healthcare from the taxpayer, it is not too much to ask
that you engage in some form of community activity engagement,
work training. That is consistent with TANF and the important
welfare reforms that were bipartisan. The administration's
budget proposal would actually harmonize these across all
public welfare programs.
Mr. Kennedy. Mr. Secretary, your mission is to try to make
sure that everybody gets access to healthcare in this country.
Can you point me to one study that says that work requirements
make people healthier? One?
Mr. Azar. We believe that individuals who have employment
have healthier outcomes. I don't have the data to cite. We have
used that in litigation, though.
Mr. Kennedy. Sir, you run an agency responsible for
healthcare for millions of Americans. Healthier people working
does not mean that work requirements make people healthier. I
assume you understand that?
Mr. Azar. Well, we are dealing with--because of the Obama--
--
Mr. Kennedy. Is that true, yes or no?
Mr. Azar. Could you repeat the question?
Mr. Kennedy. Healthier people working is not the same thing
as work making people healthier? Is there any single study you
can point to, yes or no, that shows that work requirements make
people healthier?
Mr. Azar. I would have to provide that in writing to you,
if we have that.
Mr. Kennedy. I look forward to the answer. Thank you.
You are aware of studies in Ohio and Michigan that show
that Medicaid expansion actually helped beneficiaries obtain
jobs or remain employed? Are you aware of that, the studies?
Mr. Azar. Medicaid can be a hand-up for individuals to help
them with transitioning into work. The goal of all these
programs should be to help people become independent, and that
is all of our goal.
Mr. Kennedy. Except the data that you are looking at seems
to indicate that there are tens of thousands of people that are
losing healthcare in a policy that you want to extend across
the country without answering why.
Mr. Azar. Well, we don't know if they lost their--if they
fell out and stopped complying with the work or community
engagement requirements because they are actually secured jobs
and, they just didn't need to keep applying.
Mr. Kennedy. And does cutting Medicare and Medicaid by $1.5
trillion actually make this program easier to extend healthcare
to more people?
Mr. Azar. So what we want to do is we want to remove the
Medicaid expansion for able-bodied adults----
Mr. Kennedy. The budget indicates, Mr. Secretary----
Mr. Azar [continuing]. And focus the program on the aged,
blind, disabled----
Mr. Kennedy. Yes or no, you are cutting these programs by
$1.5 trillion?
Mr. Azar. Our proposal does have a $1.4 trillion, I
believe, cut over 10 years to Medicaid, yes.
Mr. Kennedy. And so, I would imagine that cutting a program
by $1.4 trillion doesn't actually make the program, strengthen
the integrity of the program or make it easier for people to
gain access to insurance.
I would like to finally conclude with the basis for my
comments on this, which is it is the perspective of at least
this Member of Congress, and I think other colleagues of mine,
that Medicaid work requirements are against the Social
Security--the very statute that incorporates Medicaid, Section
115 of the Social Security Act, and are illegal.
I yield back.
Ms. Eshoo. I thank the gentleman. Now I would like to
recognize the gentleman from Oklahoma, Mr. Mullin, 5 minutes of
questioning.
Mr. Mullin. Thank you so much.
Let me go back to the work requirements for just a little
bit. Social Security is something that people paid into because
they work and it is deducted out of their paycheck, and it is
something they have earned. It is not an entitlement. It is
something that they were required to pay into. And so, it is
supposed to be there.
If I am not mistaken, the work requirement, it only targets
individuals that are abled individuals--able-bodied individuals
means there is no disability; there is not a reason why they
can't work. It is able-bodied individuals that are single with
no dependents. Isn't that correct?
Mr. Azar. Able-bodied individuals. I don't know about the
single. They would need to be able-bodied and you wouldn't have
pregnant women, and I believe with all of our waivers they have
ensured that there is an exclusion of, for instance, women who
have young children.
Mr. Mullin. Right, with no dependents, right.
Mr. Azar. Trying to be very simple about it.
Mr. Mullin. And the proposal that I looked at was able-
bodied individuals with no dependencies.
Mr. Azar. I would need to check if that is in the budget.
That is certainly the theme of what we approved with waivers,
has been ensuring that it is very common sense--individuals who
there is no issue why they couldn't go do volunteer work or job
training.
Mr. Mullin. Right. And one of the things you were saying is
you don't have the data because a lot of these able-bodied
individuals, they were able to go get jobs and we have employer
healthcare that could be covering them? There is no statistics
out there to say one or the next. But if they dropped off, they
probably went and got a job. Just like my employees, since I
have had my very first employee back in '97, I provided
healthcare for them. There is no need for them to be on there
at that point, is that correct?
Mr. Azar. Right. If the program has enabled--if the booming
economy, the historic low unemployment rate, and this program
has enabled individuals to secure jobs where they get employer
insurance----
Mr. Mullin. Right.
Mr. Azar [continuing]. They don't need to be on Medicaid
anymore. That seems to be a win for taxpayers and a win for
them, a win all around.
Mr. Mullin. Sure. I mean, listen, we have got 7.3 million-
plus job openings right now. We are all competing, all
employers like myself, we are competing for that employee, and
benefits sometimes is what puts it over the top.
So I commend you for giving Arkansas and other States the
ability to run their State as they see fit. Because we have got
to put more people in the workforce. Otherwise, we are just
going to be holding our economy back. So thank you so much for
doing that and explaining it.
Let me turn my attention right now to 42 CFR Part 2. Are
you familiar with that, sir?
Mr. Azar. I am, yes.
Mr. Mullin. As you know, last year, we worked pretty
tirelessly here in the House, had hearings on it. We were able
to get it out of this committee to the floor. It passed
overwhelmingly with bipartisan support, 357-to-57. And
unfortunately, it goes to the Senate and dies, which so many
great things do. And so, we are now faced with the real
possibility that we are costing people's lives at this point.
We have doctors that aren't able to really see the full
patient's history. And we understand that HHS may be working on
some rules that could help soften this a little bit. Is that
correct?
Mr. Azar. So we have been very public about the fact that
we have heard the concerns from you, from patients, from family
members about----
Mr. Mullin. Physicians?
Mr. Azar. Physicians, law enforcement, just around the care
for people with serious mental illness and substance use
disorder, and are they getting what they need or are our
regulations artificially standing in the way, while still
trying to protect their privacy needs? So yes, we are working
on proposals where we might try reform there, and also, of
course, we appreciate the work of Congress in looking to
reconcile Part 2 with HIPAA's requirements. And thank you for
your leadership and work on this issue.
Mr. Mullin. It is vitally important. I think it has hit
home to most people around the country right now, especially
with the drug abuse that is taking place and the amount of
opioids that are out there on the streets. So I appreciate it.
Is there anything that we can help you with that HHS might be
considering with 42 CFR Part 2?
Mr. Azar. I would say certainly continuing Congress'
efforts to look at reconciling Part 2 to HIPAA, to make sure
that we have uniform standards. There is just so much confusion
out there. And that is one of the things that I hear a lot, is
with these privacy provisions, they are important privacy
provisions, but you get a lot over-lawyering at hospitals and
schools----
Mr. Mullin. Right.
Mr. Azar [continuing]. And otherwise, that basically tell
people, no, you can't do this; no, you can't do that.
Mr. Mullin. So true. Over-lawyering, I like that word.
Mr. Azar. We try to correct it with FAQs. But, as you said,
people's lives are actually at risk. If parents don't know
their kid is suffering from an opioid addiction, that is a
problem. If a patient goes back into the hospital and the
providers don't know they are a recovering opioid addict, and
they give them opioids and put them back on it in a procedure,
that is a problem.
Mr. Mullin. Right. I couldn't agree with you more.
I don't have time to get to my IHS questions, but I do want
to work with you in getting some of the recommendations that
have been recommended for IHS. It is in disarray, especially
with what just came to the light with the physician, the
pediatrician who has been abusing the patients for over 25
years, and there was a lot of missteps and opportunities to get
him out. So we would love to work with you, and then, maybe see
if we can implement just some standard SOPs through IHS and
help modernize that system.
Mr. Azar. I look forward to that. Thank you.
Mr. Mullin. Thank you so much for your time.
I yield back.
Ms. Eshoo. I thank the gentleman. I would now like to
recognize with pleasure the gentleman from California, Mr.
Cardenas, 5 minutes for questions.
Mr. Cardenas. Thank you, Secretary Azar. Welcome to the
People's House, and thank you for coming today, for the
opportunity to ask questions, and more importantly, to finally
receive some of the answers in full view of the American
public.
There are certainly many topics to select today, but I want
to spend some time focusing on an administrative policy that
shocked the nation in the not-so-distant past, the policy of
separating children from their families. Just recently,
Secretary Nielsen testified before Congress on this same
policy. But I am particularly interested to hear from you,
Secretary Azar, considering your position leading the agency
whose mission statement, as you said in your opening statement
today, is: ``to enhance and protect the health and well-being
of all Americans by providing for effective health and human
services by fostering sound, sustained advances in sciences
underlying medicine, public health, and social services.''
That being the case, I am interested to hear what, if
anything, was done to protect these children and what is being
done to address these ill effects on the children and their
physical and mental condition. So my first question is, in
cases where a parent is separated from a child because of
criminal conduct or safety-related concerns, what evidentiary
standard is required to justify the separation? And what
written guidance or policy, if any, is provided to your
Department by DHS personnel making these determinations when it
comes to the child's welfare and expertise that comes out of
your Department?
Mr. Azar. So we do not separate children.
Mr. Cardenas. Correct, but, then, after that----
Mr. Azar. Right, the decision to separate would be made
over generally at DHS, and it would usually be CBP, sometimes
ICE, over there.
I do know there are standards in the TVPRA, the Trafficking
Victims Protection Act, that certain felonies--where a felony
conviction is required there, but I would have to defer to DHS
on what the contours are. We don't actually have a say in what
the standards are necessarily that they would use.
We get children, and hopefully, we get as much information
as possible why they are coming to us, either across the border
or coming from a family unit.
Mr. Cardenas. Thank you. Reclaiming my time, what I am
trying to get at here is HHS is better qualified with expertise
to deal with children, especially when they are separated from
their family. DHS doesn't do that as well as you do. They turn
them over to you, is that correct?
Mr. Azar. That is correct, yes.
Mr. Cardenas. OK. So the root of my question is this: that
having been the case, and thousands and thousands of children
having been turned over to HHS from DHS, is HHS engaged in
advising DHS, so that they can make better decisions in the
interest of the physical and mental health and well-being of
that child?
Mr. Cardenas. So I think that is a very fair question. I
don't think we are fully engaged in the sense that they have
their agents who have to make judgment calls on individual
cases. They have their standards internally. I don't have
those. I would, obviously, welcome the opportunity for HHS's
child welfare professionals to provide advice and assistance to
DHS in making those calls and setting standards for their SOPs.
We may have done so. I apologize, if it is happening, I don't
want to slight the process. But we would be very happy always
to be engaged in that.
Mr. Cardenas. And also, if HHS has been engaged in
dialoging with DHS on these matters, if you could forward any
of that to us, so we can understand the collaboration that is
going on. So that, hopefully, should these separations ever
continue--and it is my understanding that some children are
still separated from their parents--that we would at least
expect that in the United States of America, with all the
resources and expertise we have, they would be minimizing the
effects on these children's physical and mental well-being,
adverse effects on their well-being. So if there is any
information showing that that dialog is going on, to me, that
is good. We would love to know what that is.
Mr. Azar. Yes. Thank you. I mean, it is very important
question and concern.
Mr. Cardenas. Thank you.
Mr. Azar. I appreciate your doing that.
Mr. Cardenas. OK. And also, has HHS already instituted
policies, protocols, and procedures to limit harm to children
and their families during these separations? In other words,
since these separations have become so public and the numbers
have grown most recently, has HHS changed or instituted new
policies? Because we are in a paradigm shift right now with the
numbers being higher than they have probably ever been before
in American history.
Mr. Azar. So we have dramatically improved the information-
sharing practices, the IT systems between the Departments, so
that we can track and make sure that we always have it very
easy to keep the kids connected to the parent. We want to make
sure they are in touch all the time. OK?
All of our children who are separated, in one form or
another, they all are under mental health evaluation. Within 24
hours, they all get mental health evaluations. And I think we
continue to learn how to deal with the particular traumas and
mental health issues associated with being away from one's
parents, whether back in Guatemala or in ICE custody. And so, I
think we continue to try to be a learning organization and
improve the quality of care for these kids while we are
entrusted with them.
Mr. Cardenas. My time has expired. Thank you, Madam Chair.
Ms. Eshoo. I thank the gentleman. Now it is a pleasure to
recognize the gentleman from North Carolina, Mr. Hudson.
Mr. Hudson. I thank the Chair.
Mr. Secretary, thank you for being here today what is
almost three and a half hours now because of our vote. But I
really appreciate you making yourself available for so much
time.
Your leadership at HHS has been exemplary. And in general,
I really appreciate the efforts you are making on behalf of the
American people to make healthcare more accessible and more
affordable. I want to put that on the record in case my
questions today make it appear that I only have concerns.
But the first being that, on February 15th, I sent a letter
with 22 of my colleagues, three of which are here today, to
Commissioner Gottlieb in regard to recent proposal by the FDA
on menthol cigarettes and e-cigarette sales in convenience
stores. It was reported on March 1st that Commissioner Gottlieb
presented his plan to the White House. Yet, the FDA has still
not responded to serious concerns raised by colleagues and me
about this proposal. Will you commit to getting FDA's response
back to our letter before HHS moves forward with this proposal?
Mr. Azar. We have different elements in what was publicly
discussed by the Commissioner regarding both e-cigarettes, and
then, there was a separate issue of menthol additives. And I am
sorry you haven't had a response yet from Commissioner Gottlieb
on that. I don't want to delay any process that may be
underway, though, to take action, especially on this issue of
the e-cigarette epidemic that we have. This is a real public
health crisis with the access and the attractiveness to our
teenagers and even middle school kids. And so, I don't want to
do anything that might delay that process. It really is we are
very, very concerned about this e-cigarette issue and what is
happening to our kids.
Mr. Hudson. Well, sure. And even if you share the goal of
wanting to keep these out of the hands of kids, I think it is
still important for us to understand the process and what kind
of rules you are proposing. So we would appreciate a response.
Mr. Azar. Anything that we do in this space would be
subject, of course, whether it is rulemaking or good guidance
practices, would be a public process with comment and feedback
to make sure we are striking the right measure. We have to make
sure with e-cigarettes--they can be a very important public
health tool for getting adults who are addicted to combustible
tobacco off of that. It is better to be on an alternative
nicotine-delivery product than to be on combustible tobacco.
But, at the same time, we can't allow it to become an on ramp
to nicotine addiction or eventually combustible tobacco use by
our middle school kids and teenagers, and just the utilization
is soaring through the roof of those products there. So that
balance, we will get feedback on that, and we will get input on
that, on how to strike that right balance because it needs a
balance.
Mr. Hudson. I agree with that, and I think the industry,
for the most part, except for some bad actors out there, and
also, a concern about shipments from China of illegal product
and counterfeit product, I think those are all things we need
to work on, and I think we can agree to work on together.
But I think the data shows this is a safe alternative. And
so, the process is flowing one way where we are seeing people
come off combustible tobacco to the vapor-type products, and we
are not seeing the reverse as the case. And so, I do think it
is a public health improvement and would appreciate being in
the loop as much as we can, as you move forward and look at
that.
The second issue, I saw in the budget proposal HHS is
proposing that FDA begin collecting user fees from the e-
cigarette industry to support regulation of the products. In
general, I think FDA has demonstrated how beneficial user fees
can be, especially in the drug and device space, to provide
much-needed resources that an agency responsible for regulating
one-fifth of every dollar spent by Americans. In the tobacco
space, however, FDA has not had the same relationship. The
Tobacco Control Act has been the law for a decade. Yet, FDA has
approved zero products through the Modified Risk Tobacco
Product pathway. Is it your intention that these new resources,
through a user fee, would begin a new period of approval at
FDA?
Mr. Azar. Yes, that is the purpose of extending the user
fees to the e-cigarettes as alternative tobacco products, would
be to provide us the resources to enable us to build out the
regulatory architecture and approval processes for these
products, which we have executed regulatory forbearance on to
date.
Mr. Hudson. Right. I appreciate that.
The last issue, changing course a little bit, the President
has pledged in the State of the Union to eliminate new HIV
infections by 2030, as a far-reaching and important goal for
U.S. public health. The financial resources proposed in
yesterday's budget release speaks to the President's commitment
to improving diagnosis, testing, and linkage to care for HIV. I
commend the President for taking such a monumental effort and
hope to do what I can to support his plan.
Given this goal, though, I must ask about a problem a
number of my constituents that are HIV patients have raised
with me. Medicare Part D provides for protected classes where
Medicare must generally cover all drugs within that class. With
HIV drugs being one of the current six classes--I am running
out of time here--but my basic question is, how does HHS intend
on balancing the goal of introducing cost-control measures such
as prior authorization and step therapy with elimination of new
HIV infections by maintaining patient adherence to working drug
regimens in the HIV space?
Mr. Azar. I am happy to get back to you in writing on that,
for the chairwoman, if that is OK.
Mr. Hudson. Sorry about that. An important issue, but I
would appreciate the response.
Mr. Azar. It is. It is a very important issue. Thank you.
Mr. Hudson. Thanks.
Ms. Eshoo. I was expecting a long answer from the
Secretary. He is able to get back to you.
I thank the gentleman for his questions. And now, I have
the pleasure of recognizing the gentleman from Vermont, a high-
value member of this committee, Mr. Welch.
Mr. Welch. Thank you very much.
Secretary Azar, thank you so much for being here.
You know, there are two things about healthcare. One is
access related to cost, and the other is cost. There are two
ways to bring down the overall cost of healthcare, restrict
access or lower cost. And I am opposed to cutting access, but I
am determined to work with you on your efforts to lower costs.
And I want to say something. I believe that President Trump
on prescription drug prices is intent on bringing down the
cost. I believe you are. I thank you for your meeting. I
believe you are committed to doing that. I know Chairwoman
Eshoo is, and I believe Ranking Member Burgess and our ranking
member, the entire committee who is here, Mr. Upton is. So we
have got a chance.
A couple of things. You have got some good things in the
budget. It calls a statutory demonstration authority for up to
five State Medicaid programs to test the closed formulary. And
we can address that later.
It proposes to authorize you to leverage Medicare Part D
plans in negotiating power for certain drugs covered under Part
B. So I support those.
And the proposals you have made in the budget, they are in
the budget, yes, about opposing delay tactics, where I think
some of my colleagues like Mr. Carter, who has got a lot of
experience in this, are totally supportive. My goal is for us
to do those things, ideally do them together, because I think
that will increase our prospects of success in the Senate, and
a bipartisan approach on that would really be helpful.
So I do have a couple of questions, just to see your
position on a few other things. You do support, as I understand
it, ending pay for delay. Is that the case?
Mr. Azar. We do. In fact, our budget has a unique pay-for-
delay provision in it, in that if you do a pay-for-delay
agreement, you would actually be penalized in the Medicare Part
B system, yes.
Mr. Welch. Right, and that is really good. And you want to
curb the REMS abuses?
Secretary Azar. Absolutely do. So the CREATES Act, I am
working with you on that.
Mr. Welch. Right. And the product hopping that has been
occurring is another way. Are you opposed to that as well?
Mr. Azar. I want to make sure I am understanding the
product----
Mr. Welch. It is the abuse of citizens--it is product
hopping, the citizen petitions----
Mr. Azar. Oh, the citizen issues, yes, we want to crack--
yes.
Mr. Welch [continuing]. And other forms of evergreening.
Mr. Azar. Yes, we want to crack----
Mr. Welch. I mean, that is just manipulating the market.
Mr. Azar. We want to crack down on any forms of
manipulation or evergreening of patents and exclusivity beyond
what the original deals were, absolutely.
Mr. Welch. All right. And the President also indicated that
he wants to require the drug companies to disclose the price of
the products they are advertising----
Mr. Azar. Yes.
Mr. Welch [continuing]. Something Jan Schakowsky and our
committee is championing.
Mr. Azar. Right.
Mr. Welch. Now, on this question of negotiation, you raised
earlier what is the dilemma. If you want to get real savings,
you need a strict formulary, and that restricts patient choice.
But if you have no formulary, the cost is so highs it restricts
patient access.
And the way we approached this in Vermont is we did have a
formulary created by physicians and pharmacists like Mr.
Carter, but there was a failsafe. So that if the doctor said,
``Peter, you just need the other drug,'' that would get me
outside of the formulary.
Are you open to exploring some ways to try to address I
think the shared concern about not having a formulary restrict
appropriate access, but to get the benefits of lower costs that
would spread out across the system for all of us?
Mr. Azar. So I agree with you that the simple fact is, if
you don't have a formulary and the ability for someone, the
middleman, the pharmacy benefit manager, to control and move
share, they can't jam pharmaceutical companies for discounts
and rebates. They need power.
Mr. Welch. Right.
Mr. Azar. They have got to be able to move. That is what
our proposals in Part D and Medicare Advantage have been about,
is how do we create power against the pharma companies to get
discounts. But with the competition of D and MA, you can still
choose. If the patient doesn't like the approach that one plan
is making, they can choose a different----
Mr. Welch. Right, but there has got to be that balance.
Mr. Azar. Yes, these are difficult calls, absolutely.
Mr. Welch. Right, but what I am trying to say here is that
we share the desire for the patient to get what the doctor
thinks----
Mr. Azar. Yes.
Mr. Welch [continuing]. The patient needs. But we want to
get overall cost savings. So let's work together to try----
Mr. Azar. Absolutely.
Mr. Welch [continuing]. To address that concern.
The other thing is high-cost specialty drugs don't have any
competition, and the PBMs don't have any leverage, what you
were just talking about, to use competition to lower net
prices. Would you be open to negotiation to lower drug prices
in these cases where competition simply doesn't work?
Mr. Azar. So I am happy to work with you on ideas that keep
the patient at the center. We propose foreign reference pricing
in Part B----
Mr. Welch. Right.
Mr. Azar [continuing]. Where we don't have a competitive
mechanism for pricing. And we are happy to look at different
approaches that create proxies for effective pricing there.
Mr. Welch. OK. I yield back.
But thank you very much, Secretary Azar.
And I hope, Madam Chair, that we are able to make some
concrete progress with our Republican colleagues on this.
Ms. Eshoo. I agree with you.
Now I would like to recognize the gentleman from Georgia,
the patient Mr. Carter, for 5 minutes of questioning.
Mr. Carter. Thank you, Madam Chair.
And, Mr. Secretary, thank you for being here.
Mr. Secretary, as you know, for the past four years, I have
been the only pharmacist currently serving in Congress, and I
currently remain the only pharmacist.
Prescription drug prices have been something that is
extremely important to me and something that I have
concentrated on. And I want to thank you for your work, and
thank you, and your staff, in particular, particularly John
O'Brien, who has done an outstanding job in helping us.
This is something you are familiar with. You are familiar,
having been a CEO of a pharmaceutical manufacturer, and that
certainly gives you a unique insight. But I have dealt with it
in over 30 years of practicing pharmacy and seeing the
evolution of the middleman, of the pharmacy benefit managers,
the PBMs, and the abuses that I feel like that they have had
over the years.
And now, the administration is finally addressing that. I
can't tell you how much that means. And, Mr. Secretary, I feel
like this will be your legacy, and I think it is an honorable
legacy. And I want to thank you for that, and this
administration as well, as was mentioned. This administration
has made this a top priority, and I think it will be one of
their legacies. There could not be a more honorable legacy, in
my opinion, after having practiced pharmacy for 30 years and
seeing the impact that high prescription prices has on people.
I have seen it at the front counter. I have witnessed it. I
have seen senior citizens have to make a decision between
buying medicine and buying groceries. I have seen mothers in
tears because they couldn't afford medications for their
children. This is very serious and something that is
bipartisan.
Representative Schrader mentioned earlier a bill that we
are working on in a bipartisan fashion, the BLOCKING Act, that
will be brought up next week. That is something that is very
important. We have to do away with the abuse of the generic
manufacturers to delay this system like this.
Two things have been proposed by HHS. One has to do with
DIR fees. DIR fees are atrocious. Two weeks ago, I got a text
from a pharmacist who showed me where they had been charged,
his pharmacy has been charged over $300,000 in DIR fees for the
year. Only this morning, I got another text from a pharmacist
who owns seven drugstores, $500,000 in DIR fees. Mr. Secretary,
you can't stay in business in that kind of business model. It
is just not feasible.
Moving the discounts to the point of sale, I have always
said that the most immediate and most significant impact we can
have on prescription drug pricing is to have transparency. This
will help bring about transparency. Only this morning, United
Healthcare announced that they are going to move this into the
private sector as well. This is exactly what we need. This is
exactly what we have been fighting for. That is why I want to
thank you for this.
I find it interesting that, in the rebate rule, that HHS
and OIG, they have asked for three different scores. That is a
little bit unusual, isn't it? Can you explain what has come
about with that?
Mr. Azar. Yes, absolutely. So the reason there are multiple
scores in the proposed rule--and we wanted to be transparent
about it, so we published them--is our actuary from CMS came
out with a score. And you are trying to predict the behavior of
private market actors, and I am sorry, actuaries are well-
meaning, but they don't predict how businesses and private
actors will behaviorally change. You all see that with CBO and
so-called lack of dynamic scoring around legislation. We have
the same issue on regulations.
And so, we wanted to get these different perspectives of
what might happen in the marketplace. I firmly believe that, if
we can work together to get this rebate rule out, we will bring
$29 billion of savings to seniors at the point of sale at
pharmacies, starting January 1st. And I believe that we will
keep premiums stable in Part D because it is a highly-sensitive
marketplace to premium, and I believe the Part D plans will
manage that effectively. I think it will get list prices down.
It is, I think, the best tool we can have to completely change
how drugs are priced in this country for the benefit of our
citizens.
Mr. Carter. I couldn't agree with you more, Mr. Secretary.
I just thank you for that and thank you for your efforts in
this. And I hope you will continue on with this. This is
exactly the route we need to be taking and exactly the
direction we need to be having.
Moving very quickly to the 340(b) program, look, we don't
want to end the 340(b) program. It is a good program, but it
needs some guardrails on it, and we understand that. And that
is what we are trying to do, is just tighten it up, get some
accountability, some transparency, make sure it is going where
it was supposed to be going. We are not saying that anybody is
cheating. We are just saying that it is not being done in the
way that we intended it to be done. Your comments on that?
Mr. Azar. We would love to be a partner with Congress and
this committee on how we can bring that kind of transparency,
oversight, and keep 340(b) effective for the purposes it was
intended.
Mr. Carter. Thank you, Mr. Secretary. Again, I want to
thank you for your work, thank your staff for their work, the
administration for this. This is about the patient. This will
bring about lower cost for patients. It will bring about more
accessibility, more affordability, and better healthcare in
America. Thank you, Mr. Secretary.
Mr. Azar. Thank you.
Ms. Eshoo. I thank the gentleman. I now am pleased to
recognize Mr. Ruiz from California for 5 minutes of
questioning.
Mr. Ruiz. Thank you. Thank you, Madam Chair.
Secretary Azar, I am an emergency physician. And from the
Coachella Valley farm worker community where I grew up to the
hospitals where I worked as an emergency medicine physician, to
the alleys and parks where I practiced street medicine, I have
seen so many examples of how inadequate access to healthcare
has devastated families, communities, and local economies.
Passage of the Affordable Care Act, including Medicaid
expansion, has dramatically improved access to care. According
to California Healthcare Foundation, Medicaid enrollment in the
Inland Empire region of California, where my district resides,
increased by 57 percent in less than two years after Medicaid
expansion.
Instead of enacting policies that would shore up healthcare
coverage, this administration has worked to undermine the ACA.
In addition to selling junk health plans, dramatically rolling
back enrollment outreach efforts, and refusing to make cost-
share reduction payments, this budget continues to try to
repeal the ACA, turns Medicaid into a block grant program, and
imposes barriers like Medicaid work requirements.
In my district and across the nation, the effects of the
budget would result in increased premiums, increased out-of-
pocket costs for consumers, and more people without insurance.
According to data from Georgetown University, in my district 1
in 4 adults are covered by Medicaid and 58 percent of children
are covered by Medicaid or CHIP. Cutting this coverage is
unacceptable, and I will stand up for my constituents and the
millions of Americans across the country that rely on these
programs.
In addition, Secretary Azar, I would like to discuss the
administration's final rule on the Title X family planning
program issued late February that would make it more difficult
to access essential services like birth control, HIV and STD
testing, women's and men's healthcare, and pregnancy testing
for individuals in underserved areas. This rule would directly
hurt four Title-X-funded health centers in my district and
thousands of my constituents who are served by them, often in
underserved areas.
Let me explain. The final rule prohibits Title X providers,
like those in my district, from referring their patients for
abortion services, despite being allowed under current law and
even if the patient specifically requests it. Never mind that
Title X already cannot fund any abortion. But that means
doctors won't be able to provide the best medical advice to
their patients.
It also requires all Title X grantees to have strict
financial and physical separation from any activities that fall
outside the program scopes. That means a facility where 97
percent of the services are for prevention, cancer screenings,
oral contraceptives, STD screenings, would not be able to
receive Title X funds. They would have to, in order to receive
these funds, build an entirely different facility, which is
costly, cost-prohibitive, and they wouldn't be able to do that.
What most likely will happen, if this is allowed to go forward,
is these clinics will shut down, making breast exams, pap
smears, and other critical healthcare services unavailable for
those who need it.
So I want to get your sense, Secretary Azar. Do you believe
that the Title X program has successfully served as a source of
critical, preventative care for patients?
Mr. Azar. The Title X program is very important. It
provides important resources, contraceptive and comprehensive
family planning for individuals. And that is why we fully
funded it.
Mr. Ruiz. Great.
Mr. Azar. But we also want to ensure the fiscal integrity
of the program.
Mr. Ruiz. So let me ask you, then why has the
administration chosen to move forward with changes to the
program that would drastically alter how the current program
operates and how patients can receive care?
Mr. Azar. By definition, in the example you just gave,
Federal taxpayer money is being used to support the provision
of abortions. It is subsidizing that. If they wouldn't be able
to run that business independently, absent our Title X money,
it means that we are subsidizing that.
Mr. Ruiz. But those monies cannot go towards abortion.
Mr. Azar. Then they should be able to separate----
Mr. Ruiz. Those monies help for breast exams, pap smears,
and other preventative services. That is what they use those
monies for. It is illegal for them to use that money for
abortions.
Can you explain why you believe that withholding necessary
information from patients, from doctors, even when specifically
requested, even if a patient specifically requests, ``What are
your referrals? Where can I go if I am considering an
abortion?'', et cetera, is appropriate under medical ethics?
Mr. Azar. So under the final rule, we allow, as the statute
allows, non-directive counseling, including related to
abortion, and the provider is allowed to provide a list of
service providers, including those that do provide abortions,
but they are not allowed to just pick up the phone and actually
directly refer them over.
Mr. Ruiz. OK. Do you believe this rule will increase access
to care for patients served by Title X?
Mr. Azar. I think we actually may see an influx of
additional providers willing to come in and be part of Title X.
And these are fiscal integrity provisions----
Mr. Ruiz. So in terms of access, in terms of a young
woman's ability to get their pap smears going to an underserved
area where the only providers are those receiving Title X
funds, 98 percent of the services are for oral contraception,
family planning, counseling, and breast exams, as well as pap
smears, et cetera, for cancer prevention, you think by
defunding them or making it hard for them to function in their
clinic, when they are the only clinic in that community, is
going to increase healthcare access for women?
Mr. Azar. Not allowing them, through the Title X program
affiliate, to support abortions----
Mr. Ruiz. I would take that as a----
Mr. Azar [continuing]. Shouldn't be a problem. It shouldn't
impact their operations.
Mr. Ruiz. But it will. That is the whole point of this
conversation, is that it will. It creates barriers for those
individuals who provide 98 percent of their services for basic
primary care to deliver on those services.
Ms. Eshoo. The gentleman's time has expired. It is an
important conversation. Thank you, Mr. Ruiz.
I would like to now recognize the gentleman from Montana,
Mr. Gianforte.
Mr. Gianforte. Thank you, Madam Chair.
Secretary Azar, thank you for coming before the committee
today.
I want to note for the record that, after hours of
testimony, you look fresh and energetic. I appreciate your
endurance.
I have four topics I want to touch on quickly, if I could.
Many in Montana, especially our rural communities, struggle
with meth and opioid abuse. The rural nature of Montana makes
it challenging to ensure these individuals have access to
treatment. The President's budget request $120 million for the
Rural Communities Opioid Response Program, which supports
treatment and prevention of all substance use disorders in the
highest-risk rural communities. Could you touch briefly on how
this program will help focus resources on reducing meth and
opioid abuse, particularly in underserved communities?
Mr. Azar. Absolutely. Thank you.
And we are very concerned about not just the opioid issues,
but any type of substance use disorder, especially in our rural
areas. So that is why the program, Congress, on a bipartisan
basis, enacted with the Rural Communities Opioid Response
Program last year is so important. In '95, one year, our core
planning awards were made to support rural communities to
identify opioid use disorders in their communities and develop
plans to resolve these issues. And we are going to introduce
additional awards in FY 2019 that we hope will yield large-
scale organizational and infrastructure improvements at the
rural and State level. And we also were going to develop a
program just for rural and critical access hospitals, as well
as Medicaid-certified rural health clinics, in an effort to
expand MAT in rural communities.
Mr. Gianforte. Yes. OK. Thank you. And our office stands
ready to help----
Mr. Azar. Thank you.
Mr. Gianforte [continuing]. Particularly with rural.
I want to switch topics. Suicide is among one of the
leading causes of death in the United States, exceeding the
rate of death for car accidents. Unfortunately, Montana has the
highest rate of suicide per capita in the country. What is the
administration doing to help us reduce the deaths from suicide?
Mr. Azar. Yes. So on serious mental illness and mental
healthcare, we have invested, I believe it is over a billion
dollars in the budget that is dedicated towards serious mental
illness. Suicide, as you know, is the 10th leading cause of
death for adults, the second leading cause of death for our
youth. As SAMHSA, our largest mental health program, the
Community Mental Health Services Block Grant, actually provides
formula funding to enable States for serious mental illness and
emotional disturbance. The Community Mental Health Services
Block Grant is funded at $722 million. Our total mental health
budget is actually $1.506 billion just in SAMHSA. And our
suicide prevention program is $74 million. And another very
interesting program is the Assertive Community Treatment for
Adults with Serious Mental Illness. That is actually increased
to $15 million, allows a much more interactive approach to
individuals who are facing risk of mental illness and suicide.
Mr. Gianforte. OK. I appreciate your attention there. It is
critically important to us back in Montana.
Switching topics again, 18 percent of Montanans are over
the age of 65. Your budget would allow these seniors to expand
their ability to have health and medical savings accounts.
These are options that are widely supported and encourage
people to save for their healthcare needs. Can you just briefly
detail how this works and why it is a good idea?
Mr. Azar. So what we want to do is expand the ability of
individuals to use tax-free savings to assist them in building
the healthcare that they want. So for instance, in our health
savings account proposal, we want to allow you to save more
money. We want to allow the health savings account to be used
not just for high-deductible plans, but really any plan that
achieves a 70 percent actuarial evaluation. It is a technical
insurance term. But it basically would allow HSAs to be used
more frequently, expanding the use of, I think the old Archer,
the Medicare Savings Accounts, to expand. It has been a fairly
small program. We want to just create more options, especially
in rural areas, and to take the money and be able to seek out
alternatives that meet your needs.
Mr. Gianforte. My last question, and you will be happy to
hear it is a yes/no question, an easy one. Montana farmers grow
a diverse range of crops. Last Congress I signed onto a bill
that would allow industrial hemp farming. And the bill was
signed into law as part of the farm bill. Now that hemp is
legal, I am glad that the FDA has begun thinking about how to
regulate CBD. Dr. Gottlieb had stated that the FDA planned to
hold a public meeting on CBD regulation in April. Is the FDA
still planning on having this hearing now that we have had a
change in leadership?
Mr. Azar. Yes.
Mr. Gianforte. OK.
Mr. Azar. Yes.
Mr. Gianforte. So that is still going to occur?
Mr. Azar. It is. It is an important issue. We have got to
figure out how we deal with CBD oil and the constituent element
issues around marijuana. So absolutely, yes.
Mr. Gianforte. Great. Well, I want to thank you once again
for your hard work. We have to work together across the aisle
to get healthcare costs down and maintain access, and I
appreciate your leadership.
And with that, I yield back.
Ms. Eshoo. I thank the gentleman. Now it is a pleasure to
recognize the gentlewoman from New Hampshire, a new member of
Energy and Commerce and the Health Subcommittee, Ms. Kuster.
Ms. Kuster. Thank you very much, Madam Chair.
And thank you, Secretary Azar, for your patience with us.
This has been a long day for all of us.
The ACA helped millions of Americans enroll in affordable
comprehensive coverage. The law, Section 1332, provides States
with the flexibility to experiment with health reforms, but the
law makes clear that States seeking 1332 waivers must provide
comprehensive affordable coverage to a comparable number of
residences under the ACA.
I have a few yes-or-no questions on 1332 waiver guidance.
Simply yes or no, are you aware that the guidance could
substantially raise costs for Americans with preexisting
conditions?
Mr. Azar. The guidance is guidance. We would have to see an
individual request from a State. Nothing in the guidance
changes the ACA. It just says that to States, please come in
with plans if you want to enroll.
Ms. Kuster. Well, these would be preexisting conditions. If
they did not have coverage, would you agree that it would be
more expensive?
Mr. Azar. We are not able to approve any plans that waive
preexisting conditions coverage under 1332. I think that is
rock solid, is my understanding.
Ms. Kuster. Are you aware that the guidance could
substantially increase consumers' out-of-pocket costs and
monthly premiums?
Mr. Azar. The guidance cannot do that. A State plan would
have to come in with a request, and that would certainly be
something that we would evaluate as part of that process. The
guidance is simply saying to States, you can come in with
plans; we will look at them. There is no commitment to
approve----
Ms. Kuster. Well, would you acknowledge that insurance
companies could substantially reduce the benefits that the
product would cover?
Mr. Azar. I don't know that, under 1332, we are able to
waive the essential benefits coverage. I would have to check on
that to get back to you on that.
Ms. Kuster. Do you think it is appropriate to spend
taxpayer dollars on junk insurance plans rather than
comprehensive coverage for Americans?
Mr. Azar. So one Washingtonian's view of junk could be to
somebody in rural New Hampshire their lifeline of some form of
insurance that they couldn't afford. Twenty-nine million
Americans still are lacking insurance, and we are trying to
make other options available for people. Short-term, limited-
duration is one, expansions to HRAs. No one has talked about
this, which could actually add 10 million people into the ACA
exchanges through the HRA regulation that we have proposed. So
we are just trying to make more and more options available, so
people can choose----
Ms. Kuster. Well, can you explain why HHS has sidestepped
the full rulemaking process in promulgating its guidance?
Mr. Azar. Yes. The 1332 guidance was promulgated actually
using, I believe, the identical processes that the Obama
administration used in putting out their 1332 guidance.
Ms. Kuster. Did your Department's general counsel provide a
legal opinion on the guidance, including on the statutory
guardrails and whether the guidance should be subject to the
APA?
Mr. Azar. I don't know, but I presume so, because any
action coming out would normally be subjected to legal review.
But it was put out exactly the same as Obama put out.
Ms. Kuster. Will you commit to sharing this analysis with
the committee? I am focused on your administration. Would you
commit to sharing this analysis with the committee?
Mr. Azar. We will look at it and determine if it is
appropriate to share in terms of privilege.
Ms. Kuster. And you will get back to the committee on that?
Mr. Azar. Absolutely.
Ms. Kuster. And the statutory text is clear that a State
waiver must meet these four guardrails specified in the law. Do
you agree that any State waiver has to meet the guardrails
specified in statute in order to be approved by your
Department?
Mr. Azar. Well, of course. We have to act consistent with
the statute, and we will do so.
Ms. Kuster. And if a State submitted a waiver application
that would provide less comprehensive or less affordable
coverage to its State residents, would your Department approve
it?
Mr. Azar. I think we laid out in the guidance an
alternative way of looking at the comprehensiveness aspects.
What we found was that the previous administration had so
interpreted the comprehensiveness aspects that no States were
actually, whether red, blue, whatever, were willing to come in
with requests because it was so confining and lacking in
flexibility, and we thought violated the 1332----
Ms. Kuster. Well, will you commit to upholding the law and
only approving 1332 waivers that meet the guardrails specified
in the statute?
Mr. Azar. We certainly will only do so to meet the
guardrails in the statute. We may in candor, though, you and I,
our administrations may differ on what it means in terms of,
what it may mean in terms of the comprehensiveness.
I just want to correct something, if I could. Essential
health benefits are actually waivable in the guidance. I
misstated that. I mis-recollected. So I do want to clarify. I
have been informed that essential health benefits would be
waivable, and that is why it opened the door to short-term,
limited-duration plans.
Ms. Kuster. OK. I am going to switch gears now, if I could
reclaim my time.
Mr. Azar. Sorry. Sorry for the error there.
Ms. Kuster. Is it true that your request in the budget cuts
$52 million from the SAMHSA mental health programs?
Mr. Azar. There may be a part of it that does, that does
cut a part of the program that we find less effective.
Ms. Kuster. And $31 million from substance abuse treatment
programs?
Mr. Azar. Well, I mean, we can play these games. There is
$1.5 billion of serious mental illness and mental health
programs within SAMHSA that we are requesting funding in the
budget.
Ms. Kuster. But, for example, the ONDCP has been cut
completely? Or that is funded?
Mr. Azar. First, ONDCP is not part of SAMHSA. What happened
is, the one program which SAMHSA already administered, I
believe the funding for that was actually moved over to SAMHSA
to regularize how that is administered. I believe that was----
Ms. Kuster. I am sorry, my time is over. I am just trying
to follow this bouncing ball, because I think SAMHSA actually
is losing over $160 million for this program, with this trick
of moving the ONDCP funding.
But I yield back.
Ms. Eshoo. I thank the gentlewoman. I am now pleased to
recognize the gentleman from Missouri, Mr. Long, 5 minutes for
questioning----
Mr. Long. Thank you, Madam Chairwoman. Thank you.
Ms. Eshoo [continuing]. And a few seconds of something
lighthearted.
Mr. Long. I'm sorry?
Ms. Eshoo. And a few seconds of something lighthearted.
[Laughter.]
Mr. Long. I will tell you, it has been a long day. I will
tell you that. I don't know how much of that I have got in me
right now.
But I had another subcommittee hearing most of the day, why
I was late getting in here, and I hope I don't repeat anything
that was said earlier.
But, Secretary Azar, I want to thank you for being here
today. And I understand you have been here some four hours now.
I want to commend you for all your hard work from all of us
that you do.
And I also want to recognize President Trump for proposing
a fiscally-responsible budget which reflects the reality of the
Budget Control Act. Can you detail what your priorities are and
how you worked to restrain spending, in light of the current
law?
Mr. Azar. Thank you very much, Congressman.
As you know, we are trying to submit a budget that complies
with the cap's agreements. We have submitted a budget that
tries to comply with the caps, the budget caps, that the
Congress and President Obama actually put into statute. And so,
to do that, it requires tough choices.
So the prioritization that we used in looking at our
budget, working with OMB and the White House, has been, first,
fiscal discipline. So make sure that we are contributing across
the board to the overall functioning of the budget. The second
is ensuring responsible stewardship of taxpayer dollars. We
actually eliminate 90 programs that we find to be ineffective
or less effective than others, supporting and prioritizing
direct service delivery. So where are we actually providing
healthcare or human services to people as opposed to capacity-
building, and providing flexible funding to States and others,
rather than just categorical programs. So those would be some
of the ways.
Obviously, there are some other areas like opioid funding
that we have prioritized, ending the HIV epidemic that we have
really prioritized funding, and bioterrorism preparedness, of
course.
Mr. Long. Yes, I always say that, of the 435 congressional
districts, there is 435 of us that will swear that our district
has the worst opioid epidemic in the country. So it is a huge
problem.
As you are well aware, the Community Health Center Fund
expires on September 30, 2019, and the budget proposes to
continue funding them at $4 billion in mandatory resources for
each of the fiscal years 2020 and 2021. How do Community Health
Centers serve as a gateway to integrated care for individuals
for mental illnesses and substance disorders?
Mr. Azar. The Community Health Center Program is absolutely
vital to our efforts around substance use disorder, mental
health, primary care provision. So, as you mentioned, the
budget that we have on the Health Center Program, in that
budget, in the FY 2020 proposal, we continue the $544 million
of ongoing annual investment and expanded mental health and
substance use disorder services related to the treatment,
prevention, and awareness of opioid abuse, which were initially
awarded in FYs 2016 through 2019.
Mr. Long. OK. Community Health Centers are increasingly
using telehealth, which is very important to rural districts
like mine, to better meet patients' needs, especially in those
rural areas where residents face long distances between home
and healthcare providers, and sometimes it is just not worth
it. The elderly don't want to drive 70 miles to get services,
or 100 miles, or whatever the case may be. Do you see the value
in allowing more use of telehealth in health centers?
Mr. Azar. I am passionate believer in telehealth,
especially as part of how we need to bring services to rural
areas and other underserved areas. The HRSA Telehealth Network
Grant Program is part of that, which provides funding. But we
want to keep working with Congress to find other ways to help
address the rural healthcare crisis in the country and the
underserved crisis. Telehealth has to be a part of that.
Mr. Long. HHS developed the reimagine HHS plan to increase
the efficiency of the Department. Could you talk a little more
about this plan and how it can improve the functioning of HHS's
programs?
Mr. Azar. Thank you very much. So with Reimagine HHS, what
we did is, it is essentially taking the President's management
agenda and looking at this $1.3 trillion agency with 80,000
people, and we talk to our career people. I have got just
tremendous respect over the two decades that I have been around
HHS and the career officials we have at our Department. And we
did a bottom-up process asking them, if you could run HHS
differently, what would you do differently?
And so, first, we want to make HHS the best place to work.
We want high employee engagement. We want people to feel very
fulfilled in the important mission of our work.
We want to improve NIH's operations. So part of Reimagine
HHS is to create, essentially, regional hubs within NIH where
we can optimize several platform services there, not a single
service provider for all of NIH, but create some collaborative
hubs that will save money and, hopefully, improve efficiency
and improve quality.
We want to reform our acquisition processes, so that we can
buy smarter.
Just a couple of examples of good common-sense ways to run
a massive department better using the genius of our own career
people.
Mr. Long. OK. I am going to have to stop you there. I don't
have any time left, but if I did, I would yield it back.
Ms. Eshoo. That was generous.
[Laughter.]
He is known for his generosity.
The patient gentlewoman from Illinois, Ms. Kelly----
Ms. Kelly. Thank you, Madam Chair.
Ms. Eshoo [continuing]. Robin Kelly.
Ms. Kelly. Thank you.
I think we can all agree that, regardless of political
affiliation, we should all want to ensure that children have
access to healthcare. After years of decline, recently, the
number of uninsured children in this country has been
significantly increasing. In 2017, the first year of the Trump
administration, according to the American Community Survey
conducted by the Census Bureau, the number of uninsured
children increased by 276,000. And according to HHS's data, in
2018, the number of children enrolled in Medicaid and CHIP
declined by nearly 600,000. There is no data showing that the
number of children enrolled in private health insurance
coverage increased by 600,000 over the same period. So it is
pretty clear that hundreds of thousands more children will be
uninsured.
Since all of this is happening on your watch, I have a
couple of questions. Your CMS Administrator, Seema Verma, likes
to say that Medicaid will always be around for those who truly
need it. But, according to these numbers, there are a
significant number of children who are losing health coverage
under Medicaid and CHIP, and many children going uninsured.
Secretary, just yes or no, are low-income children included
in your definition of those how truly need Medicaid?
Mr. Azar. Absolutely. They are one of the core populations
of Medicaid, of course, as well as our SCHIP program.
Absolutely, the low-income children are a core of that, of the
traditional--I mean, that is part of what we want to do, is
really make sure we are not losing our focus on some of the
core populations Medicaid was built for, and low-income
children, absolutely.
Ms. Kelly. What does the President's budget propose to stem
the increase and return uninsurance rates among children to the
historically low rate that the President inherited in 2016?
Mr. Azar. So we haven't, to my knowledge--and if we have, I
would like to know; if there is something that we have done in
regulation, or otherwise, in Medicaid that is impacting that
and access to Medicaid for low-income children, please let's
talk about that.
Ms. Kelly. OK.
Mr. Azar. I would like to know that.
Ms. Kelly. OK.
Mr. Azar. And then, we can build interventions around that.
So I would like to solve the problem. I am glad you are
highlighting this for my attention, and I am happy to work with
you on that.
Ms. Kelly. OK. We would love to.
In some States, you have approved waivers to take away
health coverage from parents who failed to work a certain
number of hours each month. We know from research that, when
parents have health insurance, their children are more likely
to be covered. Another yes-or-no question. Can you guarantee
that no children will be affected by their parents' coverage
loss in those States?
Mr. Azar. Children should not be impacted by any of the
work requirement or community engagement programs that I am
aware of in terms of the waivers that we have granted. Even if
the parent were to come off, they would have been qualified as
able-bodied under Medicaid expansion populations. I want to
double-check on that, though, if I could get back to you there.
I would be very surprised if that would impact child coverage,
but I just want to make sure that I am being accurate with you.
If I could get back to you on that, to be sure----
Ms. Kelly. I would appreciate it.
Mr. Azar [continuing]. If you don't mind?
Ms. Kelly. And just changing a little bit, I was asked by
some young people to ask this. Menthol cigarettes have had a
particularly devastating impact on young African-Americans.
Seven out of ten African-American youths smoke menthol
cigarettes. You prohibit tobacco companies from using cherry,
strawberry, and other flavors to attract kids. It has been four
years since the FDA announced that it would issue a proposed
rulemaking on menthol. Can you assure me the FDA will soon
issue a proposed rule to prohibit menthol cigarettes?
Mr. Azar. So I share your concern about menthol as an
additive in tobacco. I share the public health concern about
attractiveness, especially in the African-American community,
and some of the data that we've seen around possible fostering
of addiction or attractiveness there. We want to make sure we
are gathering all the public health information on this. And
so, I do anticipate that we continue to run processes to learn
here. I don't know that the first step would be a regulatory
action as opposed to initiating a process to make sure we get--
we have to build the public health base very solid with
evidence on rulemakings in that space.
But I know your concern. I share your concern. Commissioner
Gottlieb shares that concern. He addressed that in some public
comments he made recently. And so, we want to keep moving on
that. But I don't know the exact mechanism that the next one
would be.
Ms. Kelly. I will report your answer back.
Mr. Azar. Thank you.
Ms. Kelly. I yield back the rest of my time.
Ms. Eshoo. OK, let's see. Now I would like to recognize the
gentlewoman from California, a new member of the full committee
and this subcommittee, Ms. Barragan.
Ms. Barragan. Thank you, Madam Chairwoman.
Mr. Azar, thank you for being here today.
Have you had a chance to visit the Homestead detention
facility in Florida?
Mr. Azar. I have, yes.
Ms. Barragan. When was that?
Mr. Azar. It would have been about a month or a month and a
half ago that I visited.
Ms. Barragan. Do you remember when you visited the
facility, roughly, how many children were being housed there?
Mr. Azar. Actually, I may have that information. It should
have been relatively stable. I don't have the actual census in
front of me now. I don't want to speculate on a number.
Ms. Barragan OK.
Mr. Azar. I just don't have that in front of me at the
moment.
Ms. Barragan. And the Homestead facility, it is a temporary
shelter, is that correct?
Mr. Azar. It is what we call a temporary influx shelter.
What we do, because the inflow of unaccompanied alien children
across the border is so unpredictable, we build permanent
shelters.
Ms. Barragan. Right, but this is a temporary one?
Mr. Azar. And we have temporary influx to give us flux
capacity, but we keep working to try to add permanent capacity,
because we would much prefer permanent capacity to temporary
influx, absolutely.
Ms. Barragan. OK. So when it is temporary, there is no
requirement to get a license from the State of Florida, is that
correct?
Mr. Azar. So the temporary influx shelters are not subject
to State licensure, but they are subject to all of ORR's
regulatory requirements, yes.
Ms. Barragan. Well, the permanent facilities have different
requirements, is that right?
Mr. Azar. A permanent facility actually does have to be
licensed by the State----
Ms. Barragan. OK.
Mr. Azar [continuing]. As a temporary influx to be----
Ms. Barragan. I just want to make sure we are clear. The
permanent facilities actually do have regulations that are
followed. The temporary ones don't have to follow those same
regulations as the permanent ones?
Mr. Azar. They do not have to be State licensed. They still
have to follow all of the ORR's regulatory and practice
requirements for----
Ms. Barragan. Right, and they are different. I just want to
note for the record----
Mr. Azar. And they are subject to Florida's regulatory----
Ms. Barragan [continuing]. That they are different, and a
temporary has different requirements than a permanent one?
Mr. Azar. That is correct.
Ms. Barragan. OK. Why are we running emergency unlicensed
facilities when there has been no unexpected surge of
unaccompanied minor arrivals?
Mr. Azar. No unexpected surge? We have had 120 percent
unaccompanied alien children coming into this country in
February over last year. I am sorry, we are in a crisis. We----
Ms. Barragan. There is no surge, though, sir. If you take a
look at your own numbers, in February 26, 2019, I was told
there were 1600, per your own--actually, it is your own release
that I have here. Sixteen hundred unaccompanied minors were
housed there. There have been many, many more in the past, and
there has been no surge to really need a temporary facility in
which children really are being treated differently.
Let me ask you, Mr. Secretary, about your visit when you
were there. When you visited there, did you get to see the
rooms that are really cold, where immigrants are being packed
like sardines there? Did you see that when you were there?
Mr. Azar. I saw dormitory rooms that had, I think there
were 10 beds in the rooms, that had air conditioning. You are
in southern Florida. They had air conditioning.
Ms. Barragan. So did you not see----
Mr. Azar. Sometimes the kids do complain that we keep the
temperature a little cold.
Ms. Barragan. Sir, I am asking you a very specific
question. In your assessment when you went to go see there, did
you see children being packed into these cold rooms?
Mr. Azar. Of course not.
Ms. Barragan. So you did not see what other people are
seeing? You did not see 70, up to 250, kids in these rooms?
Mr. Azar. Oh, so if what you are referring to is not the
dormitory, the age 17 part of the facility on, I think it is
the north campus, does have congregate living for the 17-year-
olds, I believe it is. And they are in a large, open area. And
interestingly, I asked about exactly the thing you are asking.
And what I was told--it may be incorrect--was that the kids
actually prefer, that 17-year-olds actually prefer that more
open, congregate setting, social setting.
Ms. Barragan. Do we let the kids decide if they want to--
how they want to sleep? My understanding is that, beforehand,
most kids would sleep in rooms of 12. Now you have children in
these large rooms that sleep up to 70 to 250 kids. From my
reports that I have seen, it is inhumane, the way kids are
being treated there. It is inhumane that they are being
situated there. They are certainly not a family setting. Would
you say it is a family setting there?
Mr. Azar. I would just dispute inhumane. I met with the
student council representatives and----
Ms. Barragan. Do you feel like it is a family setting
there? Everything I have heard is that it is like a prison. And
the kids, they form lines and----
Mr. Azar. I have got to tell you, you know, these--I hope
I----
Ms. Barragan. Do you think that is an inaccurate
assessment?
Mr. Azar. It disgusts me when people refer to the grand----
Ms. Barragan. Mr. Secretary, I am just asking you a very
simple question.
Mr. Azar. We are talking there----
Ms. Barragan. Do you think it is like a prison setting or
do you disagree?
Mr. Azar. No, I do not. No, I do not.
Ms. Barragan. You do not think it is like a prison setting?
Mr. Azar. No, I do not.
Ms. Barragan. OK. I want to ask you really quickly, sir,
because I know my time is expiring here, do you agree that
anytime that a child is abused in the care of ORR, that is one
too many children?
Mr. Azar. Any child abused is one too many children abused,
absolutely.
Ms. Barragan. OK. There have been reports of thousands of
children who have had sexual abuse incidences in ORR custody.
Do you know of any where there have been against staff?
Mr. Azar. I am sorry, where what? Any where?
Ms. Barragan. Any complaints where they have been against
staff?
Mr. Azar. Against staff?
Ms. Barragan. Yes.
Mr. Azar. Against ORR staff?
Ms. Barragan. Yes.
Mr. Azar. Absolutely not. ORR doesn't----
Ms. Barragan. You don't know of one incident?
Mr. Azar. ORR itself does not take care of the children. We
have nonprofit grantees who take care of children.
Ms. Barragan. But they are under your----
Mr. Azar. No, but you asked about ORR staff. The grantees,
we have received in the past four years over 4,000 complaints,
including in the Obama administration, about a thousand sexual
misconducts. Of those, 178 over four years involved allegations
of children regarding staff members, adult-minor sexual abuse,
all of which are reported to authorities and investigated. We
will actually be putting a report out soon showing a very high
rate of those being unsubstantiated, but we take each one
deadly seriously, absolutely,
Ms. Barragan. Well, they are under your jurisdiction, sir.
Ms. Eshoo. The time has expired. I thank the gentlewoman.
And now, I would like to recognize the gentlewoman from
Delaware, Ms. Blunt Rochester, for 5 minutes of questioning.
Ms. Blunt Rochester. Thank you, Madam Chairman.
And thank you, Secretary, for being before our subcommittee
today.
Mr. Secretary, I get a lot of visits in my office. Even as
recent as today, I had folks come in from the American College
of Obstetrics and Gynecology. I had women from the sorority
Delta Sigma Theta. There is a lot of concern, No. 1, about the
budget proposals, everything from NIH funding to Medicare and
Medicaid cuts.
But one of the big things that people focused on was the
real rollbacks to the Affordable Care Act and what people have
witnessed as, from day one, actions that the administration and
your Department have taken that have made it much harder for
Americans to access and afford the vital health insurance
coverage that they rely on.
The administration has undermined the health insurance
market by cutting off cost-sharing reductions, gutting ACA
marketplace enrollment periods and outreach, reducing funding
for the Navigator program, while promoting the sale of short-
term, limited plans, also known as junk plans, which don't
comply with the ACA consumer protections, don't provide
adequate healthcare coverage or financial protections for
families.
And so, my question, the first question is, Mr. Secretary,
your Department recently proposed a rule that would change the
formula for the ACA subsidies. Your Department's own analysis
acknowledges that the proposed policy would increase premiums
for 7 million individuals and cause hundreds of thousands to
lose coverage. Mr. Secretary, in deciding to propose this
policy, did you consider the fact that it would increase
premiums and out-of-pocket costs for millions of Americans? And
that is just a yes-or-no question.
Mr. Azar. I want to make sure I am understanding what you
are asking about. I think you might be talking about the notice
with the premium indexing? Is that what you are referring to?
Because, with the notice on premium indexing, it had been
indexed just to employer increases in premiums. We proposed,
actually, index the premium contribution based on a metric that
would include employer as well as the individual market
premiums, as the basis for what the individual maximum required
contribution towards insurance coverage is. So I think that is
what you are referring to.
Ms. Blunt Rochester. But is it correct that it would
increase premiums for 7 million individuals?
Mr. Azar. The indexing, by increasing the index, it would
increase for some individuals.
Ms. Blunt Rochester. So yes? So the answer is----
Mr. Azar. I don't know the 7 million, but it would
increase, yes, the indexing increases to account for that.
Ms. Blunt Rochester. OK. So 7 million people.
Mr. Secretary, your Department also requested comment on a
policy that would end the practice of automatically re-
enrolling consumers in the marketplace. The Department
acknowledges that 2 million Americans rely on automatic re-
enrollment. Approximately 2 million individuals could lose
coverage if the Department terminates this policy. So you are
basically getting rid of one of the easiest pathways for
Americans to get health coverage.
The Department has also made a concerted effort to make it
more difficult for people to obtain coverage in the exchanges
by drastically reducing funding for outreach and education
activities, as we mentioned, gutting the Navigator program and
limiting the time of enrollment, ultimately, giving consumers
less opportunities and less time to make informed choices.
Secretary Azar, can you commit to ensuring that Americans
wishing to enroll in coverage are well-informed about the
opportunities to enroll?
Mr. Azar. I think they are, and we see those results, I
believe, through the enrollment numbers, which show actually a
fairly consistent pathway on enrollment numbers year over year.
And we saw, I think, historic levels of 90 percent satisfaction
with call center interactions. We didn't even have to use the
waiting room in the call center, I think for the second year in
a row. I think we are----
Ms. Blunt Rochester. Well, I am just going to jump in for a
quick minute because I don't have that much time. But I know
that it has been a challenge for folks to do the outreach. And
I know that the budget in the past was cut by 90 percent for
marketing and outreach. And so, if you could share with us
specifically, with that kind of cut, what do you propose to
reach out to folks?
Mr. Azar. So we have had that, consistent with last year
and this year, we have had more limited Federal spending around
outreach. And what we have done is relied on the private plans,
who have every incentive to get people enrolled in their plans
to do so. And we have seen very efficient and effective
enrollment seasons where I believe they have stayed relatively
consistent, certainly in light of economic indicators. And so,
I think it is actually working. They are bearing the burden, as
they should----
Ms. Blunt Rochester. You mentioned, also, something about
enhanced disclosure. I am sorry, I only have 10 seconds. For
the so-called junk plans, can you talk about what does an
enhanced disclosure actually mean?
Mr. Azar. We have required that they very clearly disclose
that this is not compliant with the Affordable Care Act EHB
provisions.
Ms. Blunt Rochester. It is just inconsistent to cut off the
marketing and outreach, but at the same time you are
acknowledging that you need enhanced disclosure and more
information to people. So my goal is that we would really make
it more available to people, easier for them to get automatic
enrollments, and more time for people to make informed choices.
And thank you for your patience as well, for being here.
Ms. Eshoo. I thank the gentlewoman for her excellent
questions. Now I would like to recognize the gentleman from
Illinois, Mr. Rush, for 5 minutes of discussion. And then, we
will be moving to the second round of questions, and there are
designated members that will participate in that.
Mr. Rush, 5 minutes.
Mr. Rush. I want to thank you, Madam Chairman.
Secretary Azar, studies have found that short-term,
limited-duration health plans, often referred to as junk plans,
engage in deceptive marketing tactics and insurance brokers who
are selling these plans fail to provide consumers with detailed
plan information.
I would like to share a story that a patient, Sam Bochar, a
29-year-old patient from Chicago wrote in a testimony submitted
to this subcommittee earlier year at a hearing entitled,
``Strengthening our Healthcare Systems: Legislation to Reverse
ACA Sabotage and Ensure Preexisting Conditions Protection''.
Sam enrolled in a junk insurance policy after an insurance
broker misled him about the benefits covered under the plan.
Sam had been experiencing back pain. After enrolling in a junk
insurance plan, Sam was diagnosed with cancer. His insurer
refused to pay for his treatment, claiming that the cancer was
a preexisting condition that was not covered because, Sam
should have known that cancer was the cause of his back pain.
He was left with almost a million dollars in medical bills.
Mr. Secretary, your Department acknowledged that consumers
who purchase junk plans and, then, get sick or, quote,``develop
chronic conditions could face financial hardship as a result''.
End quote.
Mr. Secretary, yes or no, do you think that it takes this
country in the right direction to go back to the days when a
policy could be rescinded if you get sick or you get declined
for preexisting conditions? Yes or no?
Mr. Azar. We don't believe that. We believe people should
have the option to have their preexisting conditions covered.
The short-term, limited-duration plans, though, are helpful for
the 29 million Americans who got shut out of the Affordable
Care Act market.
Mr. Rush. Thank you, Mr. Secretary. All right.
A study by the Georgetown University Health Policy
Institute found that many consumers enrolling in these
deceptive plans are led to believe they are purchasing
comprehensive policies, what, in fact, they are not. Plain and
simple, these plans are nothing but garbage. The same study
found that brokers often fail to disclose to consumers the junk
plans are not comprehensive coverage and would deliberately
steer consumers toward junk plans. For example, brokers selling
junk plans over the phone pressure consumers to quickly
purchase these plans without providing written information,
including information on the benefits covered.
Mr. Secretary, are you aware and did you consider in
rulemaking that these plans often engage in aggressive
marketing, and that means people do not understand what they
are buying? Yes or no?
Mr. Azar. So yes, we enhanced the protections compared to
what the Obama administration had around the short-term
duration plans that they had in their rulemaking.
Mr. Rush. Mr. Secretary, are you aware that insurers of
these junk plans currently engage in the practice post-claims
underwriting, as the insurance Commissioner of Pennsylvania
testified before this subcommittee?
Mr. Azar. These plans are subject to State law and
regulation. So that would be that insurance Commissioner's
issue on how to regulate these plans.
Mr. Rush. Secretary Azar, someone with insurance should not
have to worry about filing for bankruptcy or not having access
to lifesaving treatment. These junk plans are not about
consumer choice and freedom. These products are a risk to
people's health and to their economic security.
Thank you, and I yield back the balance of my time.
Ms. Eshoo. As previously discussed with the minority, we
will now move to a second round of questions, which the
Secretary has agreed to, from three Democratic members and
three Republican members.
I now would like to recognize Ms. DeGette of Colorado.
Let's see, how much time? Five minutes? I recognize her for 5
minutes in this round.
Ms. DeGette. Thank you very much, Madam Chair, for
recognizing me.
Mr. Secretary, as you know, I am the Chair of the Oversight
and Investigations Subcommittee, and we had hoped to have you
here for our hearing that we had on the border separations, but
we are glad to have you now.
I wanted to just ask you a couple of questions about the
zero tolerance policy, instituted on April 6th, 2018, under
which nearly 3,000 children were separated from their parents.
Secretary Azar, were you consulted prior to the issuance of
this policy or informed it was under consideration?
Mr. Azar. I was not aware that that policy was under
consideration before the Attorney General announced it on
April--was it April 6th, or so?
Ms. DeGette. Now wouldn't you normally be, since HHS has
the Office of Refugee Resettlement which would be taking these
children, wouldn't it be normal to consult HHS before
instituting a policy like this?
Mr. Azar. I would have hoped so.
Ms. DeGette. But they didn't talk to you beforehand?
Mr. Azar. Not to me, no.
Ms. DeGette. If you had been consulted, what would your
recommendation have been?
Mr. Azar. I think it is very hard now, looking back with
all that we have been through, to do 20/20 backwards. You know,
it is easy to Monday morning quarterback.
Ms. DeGette. Do you think you may have said it was a good
idea?
Mr. Azar. I hope that I would have raised the significant
child welfare issues, the significant issues around program and
reputational----
Ms. DeGette. But you are not sure if you would have?
Mr. Azar. I just want to be fair to my colleagues and
everyone else. It is very easy in retrospect to say----
Ms. DeGette. But wait, let me ask you this: when did you
learn about this? When did you learn about this policy?
Mr. Azar. So this policy, let's be clear, the Attorney
General, on April 6th, announced zero tolerance.
Ms. DeGette. That is right.
Mr. Azar. And then, I believe it was March 7th, announced
the implementation of the zero tolerance and 100 percent
referral.
Ms. DeGette. Well, March 7th is before April.
Mr. Azar. May, I am sorry, May 7th. May 7th, zero tolerance
and----
Ms. DeGette. But when did they start taking the kids from
the parents?
Mr. Azar. I don't know when they first started. I learned
about the fact of the zero tolerance, of course, when it would
have been in the press April 6th.
Ms. DeGette. But when did you, as the head of HHS, learn
that the children were starting to be taken from their parents
and put into the custody of your agency?
Mr. Azar. If you wouldn't mind, I will be happy to tell
you. So April 6th, I would have seen it in the media or learned
about it.I very quickly fell ill and was in the hospital for
several weeks of hospital-at-home care in the month of April.
Around when the Attorney General made his announcement of
implementation May 7th, I would have known about the fact that
that was coming out. But I want to be clear. I did not connect
the dots that zero tolerance and 100 percent referral meant
implications for our program, nor was there any indication from
discussions with me.
Ms. DeGette. Well, when did you learn of that?
Mr. Azar. It would have been in the days and weeks
following the announcement on May 7th.
Ms. DeGette. May 7th?
Mr. Azar. Yes. As we started seeing kids and seeing media
stories around that.
Ms. DeGette. Did you talk to the Attorney General, or
anybody else, about that?
Mr. Azar. I did not speak to the Attorney General himself
about that, but there were various meetings----
Ms. DeGette. Who did you talk to about it?
Mr. Azar. We would have talked to the Department of
Homeland Security.
Ms. DeGette. Who did you, Secretary Azar, talk to?
Mr. Azar. Talked to when and about what?
Ms. DeGette. In the weeks after May 7th about this policy.
Mr. Azar. In the weeks after May 7th, our immediate concern
was taking care of these kids.
Ms. DeGette. So no, no, no. Who did you talk to in the
weeks after May 7th about this policy?
Mr. Azar. I would have talked to, I would have spoken with
the Secretary of Homeland Security routinely, the White House,
the interagency policy process around immigration policy.
Ms. DeGette. And what did you tell them at that time your
agency's view was towards this policy?
Mr. Azar. So our focus was on how do we take these kids in
and deal with the issues----
Ms. DeGette. So you didn't register an objection to it at
that time?
Mr. Azar. I did not.
Ms. DeGette. OK. Now Commander White came before the
Oversight and Investigations Subcommittee. He told us he raised
concerns with HHS leadership about the family separation
policy. Did you know of Commander White's concerns?
Mr. Azar. I did not. In fact, I, unfortunately, did not
know Commander White until I brought him in to help with this
problem in June.
Ms. DeGette. OK. And you don't recall him ever telling you
or you never learned that he was expressing concerns throughout
the agency?
Mr. Azar. No, and----
Ms. DeGette. OK. Can I just say, this is the frustration
for us because he was there; you are here. We have asked for
documents. Mr. Pallone is going to talk to you about it. But I
would appreciate it if we could get those email communications
to find out what the agency knew. You can work with us on that.
Mr. Azar. We are certainly working on it. I believe we
produced several thousands already, and we will keep working
with you on a rolling basis on producing materials.
Ms. DeGette. Thank you.
One last thing. There was an article in The New York Times
on the 9th of March, and it said that the separations are still
happening; there are 245 children that have been removed since
the policy was reversed. And it also says that staff members
have raised questions with Border Control agents about what
appear to be little or no justification. Do you have any
knowledge of that?
Mr. Azar. Yes, I do. And if I could answer?
Ms. DeGette. If you can please answer?
Mr. Azar. So separations have always happened, and they
continue to happen under the TVPRA as well as just child
welfare principles. So DHS will send us children where there is
a felony conviction. Under the TVPRA, there are certain ones,
especially violent crimes, where there is a concern about child
welfare, where an individual claim to be a parent but isn't a
parent. So we get those.
In addition, my understanding is we get a small number of
children at this point still where local officials use their
discretion to prosecute the parent for a felony violation of
immigration laws, only felony. We may have received some where
it appears it was based only on a misdemeanor offense and
prosecution. That is not the policy, is my understanding. I
think our people, sometimes we don't always get full
information why they were separated and sent to us. And so, I
think, in fairness, some of our people have expressed concern
about some cases saying, ``Why is this child being sent to us?
I don't quite know and understand why you separated them. And
does it''----
Ms. Eshoo. I think your time has expired.
Mr. Azar. All of that. All right.
Ms. DeGette. Thank you. Madam Chair, I would just ask
unanimous consent to place this New York Times article in the
record. And also, we will be sending follow up questions. I
would appreciate if the Secretary could answer them.
Ms. Eshoo. So ordered.
Ms. Eshoo. Now I would like to recognize the gentleman from
Kentucky, Mr. Guthrie, for 5 minutes.
Mr. Guthrie. Thank you, Madam Chair. I appreciate it very
much.
And just to reiterate what was said, because I was going to
point this out, the decision to separate parents from their
children, the immigration enforcement decisions are made by the
Department of Justice and carried out by DHS. My understanding
is HHS hasn't separated a single child. And while I do support
strong enforcement of our borders by DHS and the Justice
Department, I do not support separating families from their
children. I don't know of anyone here that supports separating
families from children. We want to keep children together.
In a previous hearing, there were some allegations brought
up about HHS, ORR, so within your Department. So I just want to
bring these up.
And so, recent reports have detailed allegations of abuse,
including sexual abuse, of minors in ORR facilities over the
past four years. This was an issue that this committee examined
in 2014, upon learning of abuse detailed and reports published
by the Houston Chronicle. I believe Dr. Burgess led that. And
we remain concerned about recent reports.
What is ORR's process for reporting and investigating
sexual abuse allegations? And does this process differ,
depending on if the allegations are between two unaccompanied
minors or versus an unaccompanied child and an adult staff
member?
Mr. Azar. Yes, thank you. And obviously, any allegation of
abuse or neglect against a child has to be taken very
seriously, and especially sexual misconduct or abuses,
absolutely unacceptable. And we want to work with you and make
sure our processes and procedures protect against that.
We received three types of sexual misconduct that fit into
that group of about 1,000 a year of reports that we have gotten
over the last four years, including in the previous
administration. There is inappropriate sexual behavior. That
can be as little as a child saying something inappropriate to
another child, inappropriate touching. It can be sexual
harassment. It could be child on child or, most seriously,
sexual abuse.
We received over the last four years, when we have had
about 180-289 thousand children in that period, 178 allegations
of sexual abuse of adult-on-child, staff member issues. Those
sexual misconduct allegations must be reported to ORR within
four hours. Sexual abuse cases must be reported to Federal,
State, Local law enforcement officials, child safety welfare
individuals, for investigation.
ORR received these investigations. We have put in place a
full-time prevention of sexual abuse coordinator in this
administration. We have put together a committee to review
allegations and ensure proper oversight. We receive reports on
any developments in the case within 24 hours. So we try to
aggressively pursue that. If we can improve our procedures, we
are welcome to be a learning organization and get better and
better at this. We do not want any of these cases ever to
happen.
Mr. Guthrie. To clarify, it was in another committee and
with a different Secretary. And I know you have answered some
questions in other departments. So they were asked about what
is going on in your Department. So I just wanted to clarify.
Recently, there has been some incorrect information
regarding who the allegations are made against. When we say
``staff,'' allegations against staff, does that mean HHS staff
or ORR staff or an appointee or a contractee's staff?
Mr. Azar. Thank you for asking for that clarification.
These are allegations, where it involves staff, it would be
staff of grantees. These are the nonprofit entities that run
the approximately 100 facilities that we have to care for
children. Obviously, still, we have oversight. We want a safe
environment. We have to investigate. So it is not to diminish
in any way responsibility that we have to ensure a safe
environment. But, to my knowledge, I am not aware of any
allegations against an actual HHS employee or ORR employee with
regard to these children.
Mr. Guthrie. When you see this--so, walk me through the
process of--I know it may not get to your level, but what
happens? I mean, what happens? So we understand how these
children are being protected. I know that you want, we all want
the children to be protected, and obviously, you do as well. So
how do you react when your cabinet--well, I won't say
``cabinets,'' what we call them in Kentucky--your Department
react when you have an allegation?
Mr. Azar. So the process, especially when we get a sexual
abuse allegation, is that the grantee is required to alert
immediately child protective services and State officials for
potential prosecution and investigation for child welfare. We
are alerted within four hours. That goes to this national
sexual abuse prevention coordinator.
We have in each of our grantee facilities actually a
hotline. It is like a telephone booth. If you visit our
facilities, you should see that, where a child may make a claim
of sexual misconduct through that reporting hotline to make
sure we learn of it immediately. Then, we conduct, of course,
the regular oversight, and we take, I hope we take swift,
appropriate, remedial action anytime there is a finding of
inappropriate conduct.
Mr. Guthrie. I believe there are three contractors--I am
probably out of time--but three contractors that the most
allegations have been against. Has anything happened with those
three contractors?
Mr. Azar. I would say most of the allegations you have
heard about involve a contractor in the Arizona area. In that
instance, we shut down before anything was public. There was a
pulling-hair incident that you might have seen a video of.
Before that was ever public, we actually shut that facility
down. We pulled our children out of it. We shut another
facility down, I believe, pulled children out of it. We stopped
placement of children in the other six facilities of that
grantee, revoked their licensure.
And for any facilities to come back online, they would have
to go through the State licensing procedure recertification, as
well as ORR being satisfied that the leadership, policies,
practices, everything had changed sufficiently for that,
because we really have to ensure the safety of our children.
Mr. Guthrie. OK. I thank the Chair for her indulgence.
And thank you for your answers. I appreciate that. Thank
you.
Ms. Eshoo. I thank the gentleman for his important
questions. Now the ever-patient, ever-present Ms. Schakowsky
from Illinois is recognized for 5 minutes.
Ms. Schakowsky. I thank the Chair for allowing me to wave
on. This is such an important issue.
According to the Government Accountability Office, months
before the Attorney General's April 2018 zero tolerance policy
memo was issued, the Office of Refugee Resettlement saw a
tenfold increase in the number of children who were separated
from their parents. Furthermore, ORR officials told GAO that, a
few months prior to the April 2018 zero tolerance memo, they
considered planning for a continued increase in the separated
children, but HHS leaders advised them not to engage in such
planning.
So, Secretary Azar, were you aware that ORR officials were
seeing a tenfold increase in the number of children who were
separated from their parents?
Mr. Azar. I was not. I wasn't actually aware of an issue of
separating children at the time really until we got into that
May timeframe.
Ms. Schakowsky. I heard what you said, but, according to
Commander White's testimony in front of this very committee,
the Oversight and Investigations Subcommittee, though, the HHS
leaders who told him not to plan for continued increase in
separated children were Scott Lloyd, the head of ORR, and
Maggie Wynne, your counsel for human services policy.
So, Secretary Azar, before the issuance of the zero
tolerance policy, did Mr. Lloyd or Ms. Wynne ever discuss
family separation with you?
Mr. Azar. Not to my knowledge. And I am disappointed that I
didn't know that. I am disappointed they did not tell me if
they were engaged in----
Ms. Schakowsky. And has there been any consequence for them
for not telling you something like separating children?
Mr. Azar. So the issue is what would we have done
differently, of course. I am concerned----
Ms. Schakowsky. Stop separating children is one idea.
Mr. Azar. First, we don't separate children. But the other
is----
Ms. Schakowsky. Whoa. Go back to that.
Mr. Azar. We don't at HHS separate children.
Ms. Schakowsky. I see.
Mr. Azar. We have never--we at HHS do not separate
children.
Ms. Schakowsky. I know.
Mr. Azar. We receive children sent to us.
Ms. Schakowsky. Yes.
Mr. Azar. And we just try to care for them the best we can.
Ms. Schakowsky. Stop the policy though?
Mr. Azar. I'm sorry?
Ms. Schakowsky. You could have stopped the policy in some
way, made a stink about it?
Mr. Azar. Correct. If I had been alerted to it, I could
have raised objections and concerns, absolutely. And I wish we
had had more knowledge flow, and I wish more people had been
engaged in these issues, absolutely. Of course.
Ms. Schakowsky. So once you found out about all this, have
you done anything at all in terms of raising this issue?
Mr. Azar. So once we found out about it in May, we
scrambled immediately towards dealing with the issues that we
were dealing with. What I told our team, I convened our team,
and I said, because I was seeing the same press stories you
were seeing, and I was very disturbed by it, I said, ``I want
every child to know where their parent is. I want every parent
to know where their child is. I want every parent and child in
regular communication, telephone or Skype. And I want us to
begin an immediate reunification process to get them outplaced
with sponsorship.''
Now we use reunification differently than the later Judge
Sabraw order. Reunification means placing, often with a level 1
or level 2 sponsor, in the homeland. And so, I pulled in our
Assistant Secretary for Preparedness and Response to add
logistics capabilities on top of our normal----
Ms. Schakowsky. Reclaiming my time, so tell me, Secretary
Azar, as this nation's top health official, after separation
began taking place, did you ever attempt to just put your foot
down and stand up for the children, and tell DOJ, DHS, or the
White House, that separation should be stopped?
Mr. Azar. All of that was preempted. The President, on
January 22nd, issued his Executive Order stopping separations.
And at that point, we moved immediately towards compliance with
the June 26th court order and reunifications. All of our
efforts were focused on that.
Ms. Schakowsky. Well, you say that, but did you read The
New York Times on Sunday?
Mr. Azar. As I mentioned to Congresswoman DeGette, the
separations that are currently occurring, to my knowledge--
again, I don't separate children--are the types of separations
that are normally happening for child welfare. They are from
felony violations for child welfare, lack of parentage. There
can be some felony prosecutions. I believe those are fairly
rare.
Ms. Schakowsky. OK. Well, let me quote. Let me tell you
what some of your staff said. Staff members have in some cases
raised questions with Border Patrol agents about separations
with what appears to be little or no justification.
Mr. Azar. And I am glad they are doing so, and I encourage
them to do so. We don't always get--sometimes there is law
enforcement sensitive information----
Ms. Schakowsky. So what are you doing? People, American
people are horrified by this. They see this, I see this as
State-sponsored child abuse, I would say even State-sponsored
kidnapping, children being taken away from their parents,
hundreds, maybe thousands of children. And it's continuing. I
want to know what you are doing, a sense of urgency to come
from you about what you are doing about stopping this.
Mr. Azar. I will not stop or advocate DHS to stop
separating children from individuals who present a harm for
child welfare. And if that is what is occurring, and that is
what should be occurring----
Ms. Schakowsky. OK, but you are the child welfare agency.
Mr. Azar. That is what I will stand up for.
Ms. Schakowsky. And you need to find out if these are
legitimate child--because----
Mr. Azar. And that is what I----
Ms. Schakowsky [continuing]. It is also said that some of
your staff found that the border agents said, ``No, we're not
doing anything about this. We are going to separate the
children.'' That is in that article. Read it.
Ms. Eshoo. The gentlelady's time has expired. The
gentleman, the ranking member of the full committee, Mr.
Walden.
Mr. Walden. From Oregon. Thank you, Madam Chair. I
appreciate it.
Mr. Secretary, thanks for being here and taking on these
tough questions. We appreciate it.
And I want to go back to part of this again to make clear
that your professionals do not separate children?
Mr. Azar. That is correct. We do not separate children.
Mr. Walden. And tell me, how many children show up at these
ORR facilities on a given day? I mean, you probably get some
count. And you don't control that flow, right?
Mr. Azar. We have no control over the flow of children to
us. We currently have 11,668 children in our care. We received
the other day, the last report we received, 229 children. We
have seen rates up----
Mr. Walden. In a given 24-hour period?
Mr. Azar. In a day. In a day. We are seeing rates--it is
surging--we are seeing rates upwards of 300 children coming
over a day now. It is 120 percent increase in unaccompanied
alien children crossing the border and being sent to us from a
year ago February. We are in a crisis situation.
Mr. Walden. And these children that are coming across, you
say unaccompanied?
Mr. Azar. Unaccompanied. This is a 12-year-old girl walking
across the border or a coyote shoving her across the border by
herself.
Mr. Walden. So they have been separated from their
parents----
Mr. Azar. Their parents separating them by sending them
here or they ran away on their own up to here. They are coming
here by themselves. They are unaccompanied. And then, our job
is to take care of them and try to find them some relative
that, hopefully, is here in the States that we can vet and
place them with that person who is responsible----
Mr. Walden. And in the prior administration, didn't we
learn that there were times where children, unaccompanied, were
put with the wrong people?
Mr. Azar. Yes. Yes. Unfortunately, we try to do as good a
job as we can vetting individuals, the family members and
others that we place as sponsors. But, yes, in the prior
administration, there was one instance that became quite a
cause celebre. The permanent Subcommittee on Investigations in
the Senate held inquiries around children that Senator Portman
was very focused on, children sent to sponsors in Ohio, who
ended up actually with traffickers and working as, essentially,
trafficked labor at an egg processing plant, if I remember
correctly.
Mr. Walden. So is that because they were pushed out of the
ORR system into the wrong hands too fast?
Mr. Azar. Obviously, the screening process and vetting
process on sponsors failed.
Mr. Walden. And have you changed anything to make sure that
is not happening on your watch?
Mr. Azar. So we try to ensure enhanced vetting of any
individual that we put children with. We have case managers
that work with us and with the grantees that take on these
children's cases. And we vet the individuals. We fingerprint
them. We fingerprint others as necessary, for instance, other
household members. We send them for FBI background checks. We
do common public record checks. I think we can check the child
abuse files on them. We learn immigration status on them
because that can be a relevant factor. For instance, placing a
child with someone who is in the middle of a removal
proceeding, that wouldn't be a stable environment. So we are
constantly trying to improve the quality of our vetting process
to place the children in a safe environment.
Mr. Walden. And during that whole process, do these kids
have the opportunity to talk to their families back in their
home countries?
Mr. Azar. Oh, yes. Yes. In fact----
Mr. Walden. How often?
Mr. Azar. I believe they are required to speak, to have the
opportunity to speak at least twice a week. And we try to----
Mr. Walden. They have to pay for those calls?
Mr. Azar. No. No, no. We pay for that. And they have
limited access to their attorneys, and they----
Mr. Walden. Do they get access to any kind of healthcare?
Mr. Azar. They get free healthcare, free mental healthcare,
free vision.
Mr. Walden. How often do they get mental health services?
Mr. Azar. They are assessed for their mental health needs
within 24 hours of arriving at an ORR intake facility.
Mr. Walden. Within 24 hours, they see a mental health
counselor?
Mr. Azar. Yes.
Mr. Walden. And how often do they get access to health
services?
Mr. Azar. They also receive that care immediately. I
believe within 48 hours they are vaccinated and receive the
suite of CDC vaccinations if they do not have documentation of
prior vaccination. And then, we provide ongoing healthcare,
including emergency services.
Mr. Walden. What about educational services?
Mr. Azar. We provide them with education services in all of
our facilities, and--yes.
Mr. Walden. Have you ever gone down to one of these
facilities and met with these kids?
Mr. Azar. I have, indeed. I meet with the children when I
am there. I met with the student council when I was down at the
Homestead facility.
Mr. Walden. Wait a minute. They have student councils?
Mr. Azar. They have an elected student council who----
Mr. Walden. And what are the student councils? Are they
free to tell you the good, bad, ugly?
Mr. Azar. I beg them, I beg them, tell me any complaints
and concerns that you have.
Mr. Walden. What are their complaints?
Mr. Azar. Well, there were three themes. The first thing
they said was, ``We miss our parents who sent us here.'' The
second thing they said was, ``We are grateful to America. We
are safe and secure for the first times in our lives.'' It is
actually heartwarming to see the gratitude on these beautiful
children's faces. It was just such gratitude. And even any
complaint they had, one girl wanted better sneakers. She felt
so guilty saying it because she feels such gratitude to this
country.
Mr. Walden. What about food?
Mr. Azar. They want pizza night. They want pizza night more
often. That's the most common thing they say. They don't like
our breakfast because they have to comply with the Federal
nutrition standards. And so, they do complain about the
breakfast.
Mr. Walden. They are like other teenagers then?
Mr. Azar. Yes.
Mr. Walden. Yes.
Mr. Azar. Yes, yes.
Mr. Walden. All right. My time has expired, Madam Chairman.
Thank you.
And, Mr. Secretary, thank you for being here.
Ms.Eshoo [presiding]. Thank you. Thank you very much, Mr.
Walden.
The Chair now recognizes the chairman of the full
committee, Mr. Pallone, for 5 minutes.
Mr. Pallone. Thank you, Madam Chair.
I just wanted to explore, Mr. Secretary, the lessons
learned from the family separation policy to see if we can
figure out what went wrong.
But, first, let me mention an issue of documentation. You
know, I am very frustrated with the lack of documentation on
this and other issues, as you know from my previous questions.
The committee sent you a letter nearly two months ago
requesting documents relating to family separations. What few
documents we have received, sir, have been largely
unresponsive. And in these cases, in these productions that we
have received from you, we have received little substance,
including very few communications from key HHS leaders.
One weekly production, in other words, documents, included
almost 800 pages, but only 14 of those pages was responsive to
our request. Another time, the weekly production consisted of
only seven pages of documents. And I think it is now fair to
ask, what is HHS hiding? Mr. Secretary, we have been working
with HHS in good faith, but our patience has really run out. So
what explains this slow production? Are there certain documents
you don't want us to see? I know, previously, you mentioned
executive privilege. Would you commit today to fully cooperate
with this investigation and produce all of our requested
documents related to family separations?
Mr. Azar. We are certainly working to do so. I believe we
have produced over 2800 pages of materials. We are doing it on
a rolling basis.
Mr. Pallone. But very little of it responds to our
questions, you know, on family separation.
Mr. Azar. I am not personally sitting and reviewing each
document that is going over. So I can't comment on that. I want
to be cooperative. I want you to get the materials you need to
do your job. There may be limited areas where we can provide
materials to you or have to have an accommodation, an
appropriate accommodation discussion. But your oversight is
appropriate. We want----
Mr. Pallone. Just please----
Mr. Azar. I assure you I want to do the lessons learned on
this. I want to learn how we can do better always.
Mr. Pallone. Well, just please get back to us with the
requested documents about family separation and responsive to
our request.
At our hearing last month on this topic, we heard from
child welfare experts about the decades of research showing
that family separations lead to toxic stress. There are often
long-term traumatic consequences. Countless other organizations
have spoken out about this harm.
Mr. Secretary, why was this misguided policy allowed to
engulf HHS and harm both children and their families and the
reputation of this critical program, if you would?
Mr. Azar. I share the concerns about child welfare, and I
especially share the concerns that Commander White, who spoke
to your committee--I have just the absolute highest respect and
regard for Commander White and the advice----
Mr. Pallone. Well, what is the reason why this was allowed
to continue without--I mean, you agree that it wasn't good.
Mr. Azar. The President's Executive Order on June 22nd was
able to short circuit that right as we were in the throes of
this. I focused immediately my energy on those three priorities
I talked about, which is just ameliorating harm as quickly as
possible, which was kids know where parents are; parents know
where kids are. Get them in contact and get them placed,
reunified or placed with sponsors as quickly as possible. And
then, the Executive Order came along, and all of our energies
switched over--that stopped--and switched over towards Judge
Sabraw's order and compliance, which was a full-court press to
do that. So I think the timing didn't really facilitate that,
but the concerns are absolutely valid around child welfare. I
share them. I said at the time nobody wants children separated
from their parents.
Mr. Pallone. No, I know, and I can't help, you know, there
is that quote on the wall at your headquarters from Hubert
Humphrey where he said, ``the moral test of a government is how
that government treats those are in the dawn of life, the
children; the twilight of life, the elderly; and the shadows of
life, the sick, the needy and the handicapped.''
I mean, you don't believe that this policy past the moral
test that Vice President Humphrey spoke of? I mean, you would
agree, right?
Mr. Azar. I absolutely share the concern about child
welfare, of separating children. I can't speak to the questions
of enforcing. There are significant issues, though, about
exempting someone. As long as Congress has the law on the books
making it crime to cross our border, there are significant
questions that this Congress has to focus on about exempting
somebody from those laws simply because they have a child with
them. That is a real concern.
Mr. Pallone. I understand, but----
Mr. Azar. As a lawyer, it is a concern I have.
Mr. Pallone. All I really want is an assurance today.
Because I don't know if I am the last person; I think I might
be. But can you assure us today that wholesale family
separations will never happen again under your watch?
Mr. Azar. I will certainly advocate for the child welfare.
There are three major concerns I have. One is child welfare.
The second is the operational concerns that you raised about
our program. The third is the reputational harm----
Mr. Pallone. I just want an assurance that this kind of
wholesale family separation is never going to happen again
under your watch. Can you just say, answer that?
Mr. Azar. Of course, I am not the President. I do not get
the final judgment.
Mr. Pallone. No, just you.
Mr. Azar. I can tell you my perspective is I will always
advocate for the child welfare concerns, the reputational
concerns, and the operational concerns of our program.
Mr. Pallone. No, I don't think that answers the question,
but whatever.
Thank you, Madam Chair.
Ms. Eshoo. I would just take a moment to remind the witness
that, if someone is coming across the border as a refugee, that
is a legal entry.
All right. The Chair would now recognize Dr. Burgess for 5
minutes.
Mr. Burgess. Thank you.
And thank you, Mr. Secretary, for spending the day with us.
I am going to mostly do the talking at this point. Feel
free to interject whatever you may wish.
First off, Madam Chairwoman, I am going to ask unanimous
consent to place into the record a newspaper article from
February 19th, 2019. The title of the article is, ``Texan
Republican Rejects Democrats' Criticism of the Homestead
Facility for Migrant Kids.'' I visited the facility, along with
four of your colleagues, in February.
You know, this was odd because they had a press conference
after the visit but wouldn't let me participate in the press
conference. So I actually called one of the reporters and
provided a different perspective from what was reported.
But I would like to place this article in the record.
Ms. Eshoo. Without objection, the article is admitted.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. I went to the Central American countries that
are primarily involved with most of the children that are
coming over. And just so people understand what is going on
here, a family will decide to send their child north because
perhaps they have other family members who have already made
the trip and they want their child to go north.
I actually asked Democrats to go with me on that CODEL. I
couldn't get anyone to accompany me.
One of the things that I learned that really concerns me is
that it costs $6 to $10 thousand for a child to make that
journey. That is no small sum of money in a country that is
relatively poor. And I asked the question, ``Where do they get
the money to make this journey?'' I was told that they borrow
it from the bank. They borrow it from the bank, putting their
home or their farm up as collateral. I don't know, this doesn't
sound like a good system to me.
Now part of that Homestead visit, I also went to the Bryan
Walsh Children's Village that the Democrats did not go. That is
a permanent facility that is down in Florida. One of the things
that struck me about the Bryan Walsh Children's Village is they
have got a big mural that they have drawn on the outside of one
of the buildings. It is a mural of a train with children
sitting on top of it. It is not like a ride at an amusement
park. This is ``la Bestia.'' This is how those children get
from Central America. They are brought by traffickers on the
top of a train through the deserts of Central Mexico and
deposited at our border.
They are, then, brought across the river in the case of
Texas. They are brought across the river by a coyote who leaves
them in a small lot of people, and then, hopes that Customs and
Border Patrol will find them before they dehydrate or burn
under the Texas sun.
It is not a good system that is being set up. And I cannot
imagine why people wouldn't want that system to not exist
anymore. Why would we continue to provide the magnet for people
to want to make that dangerous journey or, worse yet, send
their child on that dangerous journey?
Now, Secretary Azar, during a House Judiciary Committee
hearing on February 26th, there was, unfortunately, a gross
mischaracterization of the work being done at HHS to care for
unaccompanied alien children. And a member on the other side of
the dias on the Judiciary Committee stated that, ``ORR created
an environment of systemic sexual assaults by HHS staff on
unaccompanied alien children.'' Close quote.
So that accusation is false and it was made without this
member, to the best of my knowledge, having ever visited an ORR
facility. His comments discredit the efforts by ORR employees
to deal with problems, and these problems date back to a
previous administration. They weren't created when Donald Trump
took his hand off the Bible.
So Madam Chair, I have a letter that was written by
Jonathan Hayes to this member of the Judiciary Committee,
characterizing the remarks that were made and asking for an
apology. And I ask unanimous consent to insert this letter into
the record. And I would, further, ask that this committee ask
Representative Deutch to issue an apology to the men and women
at ORR and HHS who work every day to see that these children
are well taken care of.
And I will yield back my time.
But I do ask unanimous consent----
Ms. Eshoo [presiding]. That unanimous consent is not
approved.
Mr. Burgess. Is not approved?
Ms. Eshoo. Is not approved.
Mr. Burgess. You are not going to put this letter into the
record?
Ms. Eshoo. Is approved. I am sorry.
Yes, it is a letter condemning another member, and I am not
going to pursue taking the words down, but I am going to draw a
line and not accept it for the record.
Mr. Burgess. Madam Chair, could I appeal the ruling of the
Chair?
Ms. Eshoo. Let it remain--well, if you want to do that, you
may, but I am not going to put those words in the record. I
don't think they are fit for the record. And you have been in
this chair, Mr. Burgess, and I think that, were you to hear me
making that request, that you would do the same thing.
Mr. Burgess. If it is any consolation for you, they are
already in the record of the Rules Committee from yesterday.
Ms. Eshoo. All right. Well, are you finished with your
questioning?Azar. Madam Chairwoman? Madam Chairwoman?
Ms. Eshoo. Who is asking for----
Mr. Azar. Me, upfront.
[Laughter.]
Ms. Eshoo. Oh, I am sorry. I am sorry.
Mr. Azar. I am terribly sorry to interrupt.
If I could, I just wanted to clarify, I think in response
to Chairman Pallone, when we were speaking, I made reference to
approximately 2800 documents. My staff informs me I was
incorrect. It is approximately 2,080 pages. I just wanted to be
clear that they have corrected me. I made a mistake in my
statement there, and I wanted to be sure to get that on the
record. I am sorry about that. I apologize.
Ms. Eshoo. You have got good staff behind you----
Mr. Azar. I have got a good team.
Ms. Eshoo [continuing]. Giving you the notes to make the
correction.
Mr. Azar. Thank you.
Ms. Eshoo. So noted and appreciated.
Hardly anyone is left, but I still want to put out the
reminder that Members have 10 business days to submit their
additional questions for the record.
And, Mr. Secretary, there were many requests and you made
several offers to provide the information that was requested.
Please do that, and also respond promptly to the questions that
are going to be submitted to you by Members.
I just want to close this hearing. It has been a long one.
We thank you, Mr. Secretary.
It is the budget of our nation, and the budget of our
nation is a statement of our national values. And there have
been those that have supported some of the things that are in
the budget. You have also heard those that have spoken out
where they believe it doesn't meet our national values.
I would just ask you to do the following: and that is, to
go online and tap in President Ronald Reagan's last speech as
President of the United States. It is one of the most
magnificent set of remarks I have ever heard. It is a love
letter to immigrants. Call me after you have watched that, and
I want to have a discussion with you about it.
With that, the committee has concluded its business for
today and the end of the hearing.
Thank you.
[Whereupon, at 5:03 p.m., the subcommittee was adjourned.]
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