[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]








    FISCAL YEAR 2024 DEPARTMENT OF HEALTH AND HUMAN SERVICES BUDGET

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 29, 2023

                               __________

                           Serial No. 118-17


     Published for the use of the Committee on Energy and Commerce 

                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov 
                             _________
                              
                 U.S. GOVERNMENT PUBLISHING OFFICE
                 
54-361 PDF               WASHINGTON : 2024 
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                        
                    COMMITTEE ON ENERGY AND COMMERCE

                   CATHY McMORRIS RODGERS, Washington
                                  Chair
MICHAEL C. BURGESS, Texas            FRANK PALLONE, Jr., New Jersey
ROBERT E. LATTA, Ohio                  Ranking Member
BRETT GUTHRIE, Kentucky              ANNA G. ESHOO, California
H. MORGAN GRIFFITH, Virginia         DIANA DeGETTE, Colorado
GUS M. BILIRAKIS, Florida            JAN SCHAKOWSKY, Illinois
BILL JOHNSON, Ohio                   DORIS O. MATSUI, California
LARRY BUCSHON, Indiana               KATHY CASTOR, Florida
RICHARD HUDSON, North Carolina       JOHN P. SARBANES, Maryland
TIM WALBERG, Michigan                PAUL TONKO, New York
EARL L. ``BUDDY'' CARTER, Georgia    YVETTE D. CLARKE, New York
JEFF DUNCAN, South Carolina          TONY CARDENAS, California
GARY J. PALMER, Alabama              RAUL RUIZ, California
NEAL P. DUNN, Florida                SCOTT H. PETERS, California
JOHN R. CURTIS, Utah                 DEBBIE DINGELL, Michigan
DEBBBIE LESKO, Arizona               MARC A. VEASEY, Texas
GREG PENCE, Indiana                  ANN M. KUSTER, New Hampshire
DAN CRENSHAW, Texas                  ROBIN L. KELLY, Illinois
JOHN JOYCE, Pennsylvania             NANETTE DIAZ BARRAGAN, California
KELLY ARMSTRONG, North Dakota, Vice  LISA BLUNT ROCHESTER, Delaware
    Chair                            DARREN SOTO, Florida
RANDY K. WEBER, Sr., Texas           ANGIE CRAIG, Minnesota
RICK W. ALLEN, Georgia               KIM SCHRIER, Washington
TROY BALDERSON, Ohio                 LORI TRAHAN, Massachusetts
RUSS FULCHER, Idaho                  LIZZIE FLETCHER, Texas
AUGUST PFLUGER, Texas
DIANA HARSHBARGER, Tennessee
MARIANNETTE MILLER-MEEKS, Iowa
KAT CAMMACK, Florida
JAY OBERNOLTE, California
                                 ------                                

                           Professional Staff

                      NATE HODSON, Staff Director
                   SARAH BURKE, Deputy Staff Director
               TIFFANY GUARASCIO, Minority Staff Director
                         Subcommittee on Health

                        BRETT GUTHRIE, Kentucky
                                 Chairman
MICHAEL C. BURGESS, Texas            ANNA G. ESHOO, California
ROBERT E. LATTA, Ohio                  Ranking Member
H. MORGAN GRIFFITH, Virginia         JOHN P. SARBANES, Maryland
GUS M. BILIRAKIS, Florida            TONY CARDENAS, California
BILL JOHNSON, Ohio                   RAUL RUIZ, California
LARRY BUCSHON, Indiana, Vice Chair   DEBBIE DINGELL, Michigan
RICHARD HUDSON, North Carolina       ANN M. KUSTER, New Hampshire
EARL L. ``BUDDY'' CARTER, Georgia    ROBIN L. KELLY, Illinois
NEAL P. DUNN, Florida                NANETTE DIAZ BARRAGAN, California
GREG PENCE, Indiana                  LISA BLUNT ROCHESTER, Delaware
DAN CRENSHAW, Texas                  ANGIE CRAIG, Minnesota
JOHN JOYCE, Pennsylvania             KIM SCHRIER, Washington
DIANA HARSHBARGER, Tennessee         LORI TRAHAN, Massachusetts
MARIANNETTE MILLER-MEEKS, Iowa       FRANK PALLONE, Jr., New Jersey (ex 
JAY OBERNOLTE, California                officio)
CATHY McMORRIS RODGERS, Washington 
    (ex officio)   
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     1
    Prepared statement...........................................     4
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     6
    Prepared statement...........................................     8
Hon. Cathy McMorris Rodgers, a Representative in Congress from 
  the State of Washington, opening statement.....................    10
    Prepared statement...........................................    12
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................    16
    Prepared statement...........................................    18
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................    20
    Prepared statement...........................................    22
Hon. Tony Cardenas, a Representative in Congress from the State 
  of California, opening statement...............................    23

                               Witnesses

Xavier Becerra, Secretary, Department of Health and Human 
  Services.......................................................    24
    Prepared statement...........................................    27
    Submitted questions for the record \1\

                           Submitted Material

Inclusion of the following was approved by unanimous consent.
Bulletin of February 17, 2023, ``Health Care-Related Taxes and 
  Hold Harmless Arrangements Involving the Redistribution of 
  Medicaid Payments,'' Centers for Medicare and Medicaid 
  Services, Department of Health and Human Services..............    85
Statement of the Academy of Physicians in Clinical Research......    91
Report of the Texas Department of Insurance, ``Senate Bill 1264 
  2021 midyear report,'' July 2021...............................    92
Statement of Hon. Sheila Cherfilus-McCormick, March 29, 2023.....   105
Article of March 28, 2023, ``A Minnesota family's desperate 
  search for care reveals state's mental health crisis,'' by 
  Christopher Snowbeck, Minnesota Star Tribune...................   107
Report of the Government Accountability Office, ``Rural Hospital 
  Closures: Number and Characteristics of Affected Hospitals and 
  Contributing Factors,'' August 2018 \2\

----------

\1\ Mr. Becerra did not answer submitted questions for the record by 
the time of publication. The questions have been retained in committee 
files and are available at https://docs.house.gov/meetings/IF/IF14/
20230329/115628/HHRG-118-IF14-Wstate-BecerraX-20230329-SD003.pdf. 
Replies received after publication will be retained in committee files 
and made available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=115628.
\2\ The report has been retained in committee files and is included in 
the Documents for the Record at https://docs.house.gov/meetings/IF/
IF14/20230329/115628/HHRG-118-IF14-20230329-SD003.pdf.

 
    FISCAL YEAR 2024 DEPARTMENT OF HEALTH AND HUMAN SERVICES BUDGET

                              ----------                              


                       WEDNESDAY, MARCH 29, 2023

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:03 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Brett Guthrie (chairman of the subcommittee) presiding.
    Members present: Representatives Guthrie, Burgess, Latta, 
Griffith, Bilirakis, Johnson, Bucshon, Hudson, Carter, Dunn, 
Pence, Crenshaw, Joyce, Harshbarger, Miller-Meeks, Obernolte, 
Rodgers (ex officio), Eshoo (subcommittee ranking member), 
Sarbanes, Cardenas, Ruiz, Kuster, Barragan, Blunt Rochester, 
Craig, Schrier, Trahan, and Pallone (ex officio).
    Staff present: Alec Aramanda, Professional Staff Member, 
Health; Sean Brebbia, Chief Counsel, Oversight and 
Investigations; Jolie Brochin, Clerk, Health; Sarah Burke, 
Deputy Staff Director; Corey Ensslin, Senior Policy Advisor, 
Health; Kristin Flukey, Professional Staff Member, Health; Seth 
Gold, Professional Staff Member, Health; Grace Graham, Chief 
Counsel, Health; Nate Hodson, Staff Director; Tara Hupman, 
Chief Counsel; Peter Kielty, General Counsel; Emily King, 
Member Services Director; Chris Krepich, Press Secretary; Molly 
Lolli, Counsel, Health; Clare Paoletta, Professional Staff 
Member, Health; Olivia Shields, Communications Director; 
Michael Taggart, Policy Director; Lydia Abma, Minority Policy 
Analyst; Jacquelyn Bolen, Minority Health Counsel; Waverly 
Gordon, Minority Deputy Staff Director and General Counsel; 
Tiffany Guarascio, Minority Staff Director; Stephen Holland, 
Minority Senior Health Counsel; Saha Khaterzai, Minority 
Professional Staff Member; Una Lee, Minority Chief Health 
Counsel; Juan Negrete, Minority Professional Staff Member; Greg 
Pugh, Minority Staff Assistant; Rick Van Buren, Minority Senior 
Health Counsel; and C.J. Young, Minority Deputy Communications 
Director.
    Mr. Guthrie. The subcommittee will come to order.
    Mr. Secretary, welcome. A former colleague, welcome here 
today.
    The Chair will recognize himself for an opening statement.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

    Today we are here to discuss the fiscal year 2024 budget 
for the U.S. Department of Health and Human Services.
    First I want to say I have great concerns about the budget. 
After driving up inflation and Federal spending, the President 
put forth the largest budget request in our Nation's history of 
almost $7 trillion. In the HHS budget specifically, the Centers 
for Disease Control and Prevention gets a significant increase 
in funding. And the question we have to ask is, why should 
taxpayers give higher levels of funding to the CDC when public 
trust has been eroded in the CDC due to politicized responses 
to the COVID-19 pandemic?
    The CDC--and we all need to work together to give serious 
reforms to restore the public trust, and need to get back to 
its core mission.
    The HHS budget also has unfunded mandates on State Medicaid 
programs.
    The President also touts his budget increases Medicare 
solvency for another 25 years. This will be done through 
increases in taxes on American households and more price 
controls to forcibly set prices for pharmaceutical drugs. These 
efforts will ultimately backfire and lead to even fewer 
lifesaving cures for our seniors.
    On fentanyl, the President recently stated, and I quote, 
``MAGA House Republicans' proposals would slash funding for 
border security, a move that could allow nearly 900 pounds of 
fentanyl into our country.'' Clearly, the President has failed 
to check the Customs and Border Patrol's website before 
releasing his budget proposal.
    Under the President's watch, Customs and Border Patrol has 
seized over 11,000 pounds of illicit fentanyl at our southwest 
border. That is just in the first 6 months of this fiscal year 
and represents nearly the total amount seized in all of fiscal 
year 2022. These are just fentanyl seizures, not what is 
actually being trafficked without being seized by the Customs 
and Border Patrol. At the same time, drug overdoses eclipsed 
107,000 in 2021, the highest ever in the United States. More 
than 70,000 of these deaths were from synthetic opioids, such 
as fentanyl.
    The President's budget uses the word ``fentanyl'' twice, 
compared to the--in the HHS budget, compared to 42 times it 
mentions climate change. This is unfair to the thousands of 
families across the country who have lost loved ones to 
fentanyl poisoning. I call on the administration to join us in 
supporting a classwide ban on fentanyl-related substances. The 
HALT Fentanyl Act would do this, and it was passed out of this 
committee less than a week ago with bipartisan support. It is 
long past time we permanently schedule all fentanyl-related 
substances in schedule I.
    The administration also has--talks about working on health 
equity. Well, however, the Centers for Medicare and Medicaid 
Services recently declined to cover an entire class of FDA-
approved Alzheimer's treatments for Medicare patients. This 
significantly reduced access to care for minority and rural 
patient populations with no other options to treat this 
treacherous disease.
    The Biden administration has also proposed cutting 
healthcare benefits for millions of Americans who receive 
health insurance through ACA exchanges. And most recently, the 
Biden administration proposed slashing Medicare payments for 
drugs approved through the accelerated approval pathway, which 
have significantly improved access to care for cancer patients 
over the past decade.
    I was hoping that this budget might offer a focus on 
policies where we can work together. This committee held a 
bipartisan, very informative hearing yesterday on healthcare 
affordability, and most--and transparency--and highlighting the 
ways we can improve and empower patients through greater price 
transparency. This budget fails to mention price transparency. 
It is a real missed opportunity, considering all the bipartisan 
support for greater transparency across the healthcare system. 
I invite the Secretary to work on all of us on this committee 
on this issue.
    In closing, I thank you for being here. I know that we may 
disagree on some of the things that we are talking about today, 
but we do agree that we want people to have access to better 
healthcare. And to that end, I believe we can work together on 
these pressing issues in a bipartisan fashion, and I hope that 
we can work together.
    [The prepared statement of Mr. Guthrie follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Guthrie. And I will yield back. The Chair now 
recognizes the ranking member of the subcommittee, Ms. Eshoo of 
California, for 5 minutes for an opening statement.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Eshoo. Thank you, Mr. Chairman.
    Good morning, Secretary Becerra. Welcome back to the Health 
Subcommittee. You are always welcome here.
    My thanks to you, to the Biden administration for your work 
over the past year to improve our Nation's healthcare system. 
Premiums under the Affordable Care Act are at an all-time low, 
and enrollment is at an all-time high. So I say bravo. A 
record-breaking 16.3 million Americans signed up for health 
coverage under the ACA, including more than 3.6 million 
Americans who are newly insured. And 4 out of 5 enrollees 
qualify for plans that cost $10 or less a month. These are 
stunning figures.
    And while there may not be applause on one side of the 
aisle here, I think there is applause across the country with 
the American people. We are very proud of that.
    We have also made progress on fighting the fentanyl 
overdose crisis. The number of providers able to prescribe 
buprenorphine for opioid use disorder has increased by 19 
percent, and naloxone prescriptions filled in pharmacies has 
increased by 37 percent in the past year alone. For 6 months in 
a row there has been a steady decrease or flattening in 
overdose deaths. They are--no one can be satisfied with 
whatever the number is, but that the number is decreasing is an 
improvement. Why? Because access to treatment saves lives.
    President Biden's fiscal 2024 budget request builds on 
these achievements and addresses the remaining gaps in our 
healthcare system. To continue lowering costs, the budget 
proposes making permanent the enhanced premium tax credits that 
were extended to 2025 in the Inflation Reduction Act, expands 
surprise billing protections to ground ambulances, and caps the 
monthly cost of insulin at $35 for Americans with group and 
individual market coverage. We got that through. Everyone in 
the country, whether they are young, middle-aged, or Medicare 
beneficiaries, will enjoy that critical benefit of capping 
insulin at $35 a month.
    Importantly, the budget provides a historic $46.1 billion 
to address the overdose crisis. This funding will go toward 
efforts to get people like--to get people the evidence-based 
care they need, reduce the supply of illicit drugs like 
fentanyl, and go after drug traffickers to stop overdose 
deaths.
    The President's budget outlines a strategy to use over 
$13.8 billion to improve our Nation's mental health, including 
increasing the availability of crisis care and achieving full 
parity, which we have struggled, with between physical and 
mental healthcare coverage.
    The budget also invests $50.5 billion in pandemic 
preparedness, including $20 billion in mandatory funding to 
prevent and address current and emerging public health threats.
    Finally, President Biden has proposed increasing the 
Medicare tax rate to 5 percent for those making over $400,000 a 
year and closing loopholes. These reforms will make the 
Medicare trust fund solvent beyond 2050 to ensure older 
Americans can really retire with dignity and security.
    Instead of looking toward the future, I--what I hear--the 
House Republican leadership reportedly want to cut 2024 
discretionary spending back to the 2022 level. These cuts would 
decrease access to the essential government functions each of 
our constituents rely on.
    So I look forward to hearing from you--we all do--Mr. 
Secretary, both on the impact of these cuts and working with 
you and your team to build on the progress of the last 2 years 
to improve our Nation's health and our overall well-being. When 
people are healthy, we have a stronger nation. So we have a 
responsibility to keep investing in that.
    So thank you for what will be, I am sure, your instructive 
testimony.
    [The prepared statement of Ms. Eshoo follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. And I yield back, Mr. Chairman.
    Mr. Guthrie. Thank you. The gentlelady yields back. The 
Chair now recognizes the chair of the full committee, Chair 
Rodgers, for 5 minutes for an opening statement.

      OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A 
    REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON

    Mrs. Rodgers. Thank you, Mr. Chairman. Today's hearing on 
the President's budget for the Department of Health and Human 
Services comes at a time when we need to return hope and 
optimism to America again so people can leave--live fuller, 
happier, and healthier lives.
    We need to come together to stop the fentanyl crisis and 
save lives.
    We need to rein out-of-control government spending to 
reverse President Biden's inflation crisis, so people can 
afford healthcare.
    We need to help build and support strong communities so 
people are less lonely, less anxious, and restore a sense of 
purpose and belonging for our children.
    There must be accountability from the administration, too, 
for too many ways that they have made the crisis worse, 
especially the authoritarian COVID-19 policies.
    Secretary Becerra, the President's budget should reflect 
the solutions we need to make people's lives better. 
Unfortunately, that is not what we are seeing.
    Regarding fentanyl, as Mr. Guthrie said, the President's 
budget only mentions this twice. It is unacceptable, given more 
people are dying from fentanyl poisoning in America, the 
number-1 killer of 18 to 45-year-olds.
    This committee has heard from several parents, such as 
Molly Cain, who emphasize their children are not suffering from 
a substance use disorder, but that their teenager purchased a 
pill off of Snapchat or bought cocaine, not knowing it was 
laced with fentanyl, and died. Your budget request for 
increased funding for medication-assisted treatment, while 
important, doesn't seem like it would have prevented these 
individuals from dying from fentanyl poisoning. This is perhaps 
the greatest threat facing our communities. But your budget 
doesn't reflect all aspects of the terrifying reality of this 
crisis.
    Regarding healthcare cost, this committee came together 
just yesterday in a bipartisan way to explore ways to lower 
healthcare costs with more price transparency and more 
competition. This is a top priority for those we serve, yet 
your budget says nothing regarding bipartisan efforts to 
implement and enforce the transparency efforts brought forth 
during the Trump administration.
    In addition to lowering cost, this administration needs to 
take restoring trust in public health agencies more seriously. 
The buck stops with you. You oversee our public health and 
preparedness policies under CDC and NIH. As I have said, these 
agencies need to do the hard work of restoring trust with the 
American people and comply with our oversight before they ask 
for more money and more authority.
    The NIH, in many cases, has failed to be a steward of the 
American taxpayer dollars or ensure lab safety. It has 
stonewalled this committee's request for information that we 
are constitutionally entitled to, and it refuses to completely 
answer questions about what sort of risky gain-of-function 
research it may fund or what role the National Science Advisory 
Board for Biosecurity is playing to keep Americans safe.
    Similarly, the CDC has created a crisis of confidence, so 
much so that the CDC Director Walensky has undertaken a full-
scale reevaluation and reorganization of the agency. This is 
because its guidance was used to justify mandates that have 
more parents now questioning routine vaccination. Its guidance, 
influenced by teachers unions, kept schools closed to justify 
mask mandates on kids. We know these weren't decisions based 
upon the best science, data. Now our children are paying the 
price academically, physically, emotionally. Like NIH, the CDC 
does not need more authority. It needs robust oversight.
    Secretary Becerra, let me be clear: We expect better. The 
American people are eager for a brighter future. We expect a 
high degree of cooperation from you on policies that will help 
improve their health and their quality of life. And I hope that 
you leave today with a greater sense of the urgency, the 
urgency that I feel and every member of this committee feels to 
address these problems, and do it in a bipartisan fashion.
    We are committed to bringing the Republicans and Democrats 
together, together to address fentanyl, together to address the 
need for public health--trust in our public health agencies 
like CDC and NIH, and together, as we did yesterday, on price 
transparency that would really help restore the doctor-patient 
relationship and bring down the cost of healthcare. That is our 
goal. We are committed to doing it together, and we thank you 
for being here today, and there is more to come. Thank you.
    [The prepared statement of Mrs. Rodgers follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Guthrie. Thank you. The gentlelady yields back. The 
Chair now recognizes the ranking member of the full committee, 
the gentleman from New Jersey, Rep. Pallone, for 5 minutes.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairman Guthrie. I want to thank 
Secretary Becerra for being with us today to discuss the 
President's fiscal year 2024 budget request for Department of 
Health and Human Services.
    But I have to start out by saying I hear my GOP colleagues 
criticize the President's budget, but they don't have one. They 
don't have one. There is all--every reason to believe that we 
are never going to see one from them. And, you know, they 
talk--they criticize the fact that--they talk about Alzheimer's 
research, fentanyl, price transparency. Well, why don't you go 
to the House Republican leadership and say that they should put 
a budget together that has more money for Alzheimer's research 
or more money for fentanyl enforcement or price transparency?
    I mean, I have to say, I don't really think you should be 
criticizing something without an alternative. And there isn't 
one. And there's a lot of reasons there isn't going to be one.
    So thank you for being here and defending something that 
exists. And if the criticism is that they don't like something 
that is in it, then let--you know, I know you are not going to 
do that, but I am going to say, well then, let us see what you 
have as an alternative, Republicans, which we're not seeing.
    Let me just say--I don't want to repeat all the great 
things that the Biden administration and congressional 
Democrats delivered for the people in the last year. But thanks 
to the--but I am going to say a few things. Thanks to the 
Inflation Reduction Act, we finally allowed Medicare to 
negotiate prescription drug prices. We have the Medicare--the 
cap on insulin. We built on the ACA. We have now 16.5 million 
Americans who signed up for coverage through the ACA 
marketplaces. Expanded subsidies are driving costs down. An 
average family is saving $2,400 a year in premiums.
    The President's budget also increases the number of drugs 
Medicare selects for negotiation, extends the $35 monthly cap 
for insulin to people with private insurance, and makes 
permanent the ACA-enhanced premium subsidies. So this 
administration is addressing the affordability issue, which is 
so crucial to the--to Americans.
    The Biden budget also proposes to finally ensure that all 
low-income individuals have access to the benefits and 
protections of Medicaid, regardless of the political decisions 
made by the Governors and legislatures. North Carolina just 
became the latest State to recognize that Medicaid expansion is 
not only morally necessary but also a sound economic decision.
    And I am also pleased to see that the budget would expand 
access to home- and community-based services, because if people 
stay at home and out of hospitals and out of nursing homes, we 
save money.
    The budget would also require all States to provide 
Medicaid coverage to all low-income women for 12 months 
postpartum. We have a maternal mortality crisis. We need to do 
that.
    There is a lot of progress in other areas, such as 
enhancing public health programs. I am encouraged to see that 
the budget prioritizes funding for important public health and 
workforce programs. It invests in pandemic preparedness and 
biodefense to ensure that we are prepared for future 
challenges.
    Now, the Biden administration lays all this out, but I 
don't know what the other side is doing because they have no 
budget. But there is a leading Republican proposal that would 
cut trillions of dollars from Medicaid, including repealing 
Medicaid expansion. It would rip away health insurance from 17 
million people by doing that. And these proposed Medicaid cuts 
are going to hurt everybody.
    The Republicans have also talked about eliminating the ACA 
expanded tax credits and subsidies, and more people would then 
be uninsured.
    Now, let me explain. The burden on the healthcare system 
when States don't expand Medicaid or when the Federal 
Government ACA subsidies are cut is severe. Red States that 
have not expanded Medicaid are seeing their hospitals starved 
for funding because of the number of patients receiving 
uncompensated care. Medicaid isn't just important to cities. It 
is important to hospitals and nursing homes or community health 
centers in rural areas, in Republican districts.
    So all these things that we are hearing--we don't really 
know if they are--you know, what they are doing because there 
is no budget. But all the things that we are hearing are going 
to hurt that they want to cut: Medicaid in particular, ACA. So 
these are going to starve the healthcare system.
    And I know that, you know, on the one hand we hear the 
Republicans say, ``Oh, we have to reduce spending,'' but then 
on the other hand they talk about more spending for other 
things. So unless I actually see something as what the 
administration has proposed that really reduces the deficit and 
expands coverage and makes things more affordable, I have no 
reason that a Republican proposal would accomplish any of those 
things. And I fear, from what I hear, that, in fact, it does 
the opposite, if it ever--if we ever even see it.
    [The prepared statement of Mr. Pallone follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Pallone. So thank you again for being here.
    And I yield back, Mr. Chairman.
    Mr. Guthrie. The gentleman yields back.
    The Chair reminds Members that, pursuant to committee 
rules, all Members' opening statements will be made part of the 
record.
    Are there further opening statements?
    The Chair recognizes Dr. Burgess for 3 minutes for an 
opening statement.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Mr. Chairman.
    And Mr. Secretary, thank you for being here this morning. 
Several times since the beginning of this year I have reached 
out to your office, hoping that we could get a chance to talk 
about more than the things I can discuss in the 5-minute 
question period. Unfortunately, I have not been able to secure 
such a meeting. The comment from your office is you are 
unavailable for the foreseeable future. I hope that we can, in 
fact, get together at some point and talk about a number of 
these things, because they are absolutely critical.
    One of the things that has come up over and over again in 
my world is what is happening to--it is one thing to have 
coverage, but if you have got no one to deliver the care it 
becomes extremely problematic. So some of the things that are 
happening to our providers, to our doctors based on 
reimbursement, is really going to set us up for big-time 
failure down the road, regardless of the state of coverage.
    So price-setting provisions in the Inflation Reduction Act, 
physicians are going to see a reimbursement cut as the maximum 
fair price replaces the average sales price in Part B. Part B-
administered medicines primarily affect--affecting oncologists, 
neurologists, rheumatologists, infused drugs that are given in 
a doctor's office. Those reimbursement rates are going to be 
significantly cut under the maximum fair price. No one really 
knows what that is. It is actually set by you, which is another 
reason I would very much like to have a conversation about it.
    But at a time when the country is facing physician 
shortages, policies that result in physicians being reimbursed 
less for the care they are already giving, that is not going to 
lead to appropriate physician interaction.
    I don't know that this administration realizes the 
circumstances that doctors are facing every day. It is not just 
that they have seen reimbursement cuts year over year over 
year. It is now that they have got 6, 8, 9 percent inflation to 
deal with. They still have to pay their office staffs. They 
still have to pay their rent. Their electricity bills are going 
up. The cost of living for them is going up, and they simply 
cannot afford to stay in practice.
    So what happens is doctors will say, ``I cannot afford to 
see a Medicare patient.'' That is a tragedy. And then, of 
course, some doctors are simply saying, ``This has become too 
difficult. The Government has made the practice of medicine too 
hard, and I am going to stop.'' And that is a real tragedy. We 
are in a position in this country where we cannot afford to 
lose additional providers.
    So again, the policies of the administration, policies of 
your agency, are actually adding to this. So at the end of the 
day, I hope that you will continue to engage with the physician 
community on this. I hope you and I will be able to have 
further conversations on this. And beyond that, I look forward 
to today's conversation.
    [The prepared statement of Mr. Burgess follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Burgess. Thank you, Mr. Chairman. I yield back.
    Mr. Guthrie. The gentleman yields back. Anybody on the 
Democratic side?
    The Chair recognizes Mr. Cardenas from California for 3 
minutes.

 OPENING STATEMENT OF HON. TONY CARDENAS, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mr. Cardenas. I am glad we have the opportunity to discuss 
these important issues on this committee today, and I want to 
thank you, Chairman, and the ranking member, as well. I want to 
welcome the opportunity for us to have a nice, honest, robust 
discussion with Secretary Becerra, and I just look forward for 
us to getting to the real issues.
    It sounds like some people think that we are going to solve 
all the world's problems in this hearing, and that is not going 
to happen. But we are going to cover some good ground, and 
hopefully we can have some robust, honest discussions.
    Mr. Ruiz. Yield to me.
    Mr. Cardenas. I will yield to Dr. Ruiz.
    Mr. Ruiz. Yes, I appreciate the moment. The pandemic was 
mentioned, and I think it is important to highlight the 
differences that occurred during the Trump administration and 
the Biden administration.
    We definitely need to have a comprehensive approach to 
examining actions taken in the earliest days of the public 
health crisis. From the beginning, President Trump and his 
administration did not act with the urgency needed to reduce 
transmission, communicate honestly with the American people, 
and equip our schools with the resources they needed. Instead 
of working to efficiently manufacture PPE, scale up testing, 
promote basic public health measures like masking and social 
distancing, President Trump chose to politicize this virus, 
calling it a hoax and downplaying its severity, saying it would 
go away like the flu.
    But as the coronavirus reached pandemic proportion, public 
officials of all political persuasions had to act to suspend 
in-person learning, and social distancing, and promoting the 
mask wearing. And so President Biden took a different approach: 
swift action to develop evidence-based guidance for schools and 
work and throughout our society, and all hands on deck, and to 
get schools back safely and responsibly, and the results speak 
for themselves.
    For example, in schools alone, 1 year after President Biden 
was sworn into office, our efforts more than doubled the number 
of schools open for full-time, in-person learning to 95 
percent. And schools didn't just reopen, they stayed open. 
Today more than 99 percent of schools in the United States have 
safely and responsibly reopened for in-person learning. This is 
a direct result of the American Rescue Plan's targeted 
investments in childhood education to keep students healthy and 
safe while they learn.
    In fact, key funding from the American Rescue Plan is 
already at work--since schools were mentioned--rebuilding 
schools' crumbling infrastructure, upgrading their ventilation 
systems, and getting students the resources they need. And so 
this is a key component that I know that the all-hands-on-deck 
government response by President Biden and oftentimes led by 
Secretary Xavier Becerra with the equity focus to make sure 
that the hardest hit, the hardest-to-reach communities were 
front and center to do the outreach necessary to save lives, 
reduce transmission was a key component of why we are back to 
where we are now.
    And so, with that, I applaud the administration. There is a 
lot of work to do. There is--a lot of the pandemic experience 
weighs heavy on a lot of people's experiences, and we need to 
help our children now with solutions.
    And with that, I yield back my time----
    Mr. Cardenas. I yield back. Thank you, Mr. Chairman.
    Mr. Guthrie. The gentleman yields back. Any other opening 
statements on the Republican side?
    Any further on the Democrat side?
    Seeing none, our witness today is the Honorable Xavier 
Becerra, Secretary of Health and--Department of Health and 
Human Services.
    I appreciate you being here. I know you understand the 
lighting system, so I won't explain that.
    We will now recognize you for 5 minutes for your opening 
statement.

 STATEMENT OF XAVIER BECERRA, SECRETARY, DEPARTMENT OF HEALTH 
                       AND HUMAN SERVICES

    Mr. Becerra. Chairman Guthrie, Ranking Member Eshoo, 
Chairwoman Rodgers, and to Ranking Member Pallone, and to all 
the members of this committee, thank you for the invitation.
    A lot has happened in a year since I last spoke to you 
about budgets. More than 16 million Americans have secured --
and Congresswoman Eshoo, 16.4 million; we added that 0.4 
instead of 0.3--16.4 million Americans have secured health 
insurance through the Affordable Care marketplaces. That is, as 
you have heard, an all-time high. Altogether, more than 300 
million Americans today now carry insurance to cover their 
healthcare. That, too, is a historic high.
    The President's new lower-cost prescription drug law has 
capped insulin at $35 per month and made preventative vaccines 
like the flu, COVID, shingles, which I hear about a lot, 
available for free under Medicare. Moving forward, this new law 
gives us the right to finally negotiate lower prescription drug 
prices for Americans.
    To cap it off, the Biden-Harris administration has safely 
and effectively executed the largest adult vaccination program 
in U.S. history, achieving nearly 700 million shots in arms 
during the COVID pandemic without charge.
    The FY 2024 budget proposes $144 billion in discretionary 
funding and $1.7 trillion in mandatory funding for HHS. It 
positions us to tackle the urgent challenges we face, including 
a growing behavioral health crisis and future public health 
threats.
    It also funds operations and mission-critical 
infrastructure needed to build a healthier America, moving the 
Nation from an illness-care system to a wellness-care system.
    An illness-care system leaves our most vulnerable families 
behind. A wellness-care system invests in providing the full 
spectrum of healthcare to all Americans.
    Illness care allows the price of prescription drugs to 
skyrocket. Wellness care starts by prescribing fruits, 
vegetables, and exercise. It treats food as medicine.
    Illness care requires you to get a referral by your family 
physician to see a specialist for mental health services. 
Wellness care, well, it lets you get mental healthcare the 
minute you walk through the door of your family physician's 
office.
    Illness care forces hard-working Americans to deplete their 
life savings in order to get long-term care that they need. 
Wellness care invests early in long-term care, like in-home 
care, so our older adults and Americans with disabilities can 
thrive at home and in their communities.
    Our budget, the President's budget, invests in wellness 
care. It includes funding for health centers, the National 
Health Service Corps, teaching health centers, and other areas 
that provide critical support to Americans. And it should 
continue without interruption.
    We also invest more than $330 billion to prepare us for the 
next COVID or public health crisis, including $1 billion to 
replenish our Nation's Strategic National Stockpile.
    On behavioral health, too many of our loved ones are dying 
from suicide or overdose. So we increase access to crisis care, 
we grow the behavioral health workforce, and we beef up 
substance use services.
    We are also gearing up to handle more than 6 million 
additional contacts from people who are experiencing mental 
health crisis. We do that through 9-8-8, the three-digit 
suicide prevention lifeline we stood up last year.
    This budget covers 2 million adults left out of Medicaid by 
their home States and extends tax credits that make healthcare 
more affordable for millions of Americans.
    It would also ensure that expanded postpartum Medicaid 
coverage for a new mom and her baby is here to stay.
    The President's budget not only strengthens Medicare for 
our--today's seniors, but protects and strengthens it for the 
next generation.
    We also take care of our family members in this budget we--
by investing $600 billion in child care and preschool programs 
and $150 billion to strengthen Medicaid home and community-
based services.
    This budget funds Cancer Moonshot and ARPA-H. It invests in 
title 10 family planning programs so essential to so many of 
our families. And it delivers on commitments made as part of 
the National Strategy for Hunger, Nutrition, and Health.
    And important to me as a former attorney general, it 
bolsters our healthcare fraud and abuse detection and 
enforcement work.
    Finally, the President's budget honors our responsibilities 
to Indian country, with more than $2 billion in new resources 
in 2024.
    This budget reflects the President's values. It reflects 
our values and commitments. It helps begin to move from a 
nation focused on illness care to one about wellness care. And 
most importantly, it ensures health and wellness are within 
reach for all Americans.
    On behalf of the women and men of HHS, we look forward to 
working with you.
    [The prepared statement of Mr. Becerra follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Becerra. And with that, Mr. Chairman, I yield back.
    Mr. Guthrie. Thank you. The gentleman yields back. We will 
now move to questions.
    And before we get started, to respect the Secretary's 
time--I think at 1:00 you have a hard stop--and to respect our 
Members--everybody have the opportunity to ask a question--at 5 
minutes I am going to gavel. So everybody understand--don't ask 
your question with 3 seconds left, because we are going to 
respect everybody's time to move forward.
    So having said that, we will get started now, and I will 
recognize myself for 5 minutes.
    So, Mr. Secretary, last year when you were here we talked 
about scheduling fentanyl, and you said, and I quote, ``I 
wouldn't''--I asked you if you were for permanently scheduling 
fentanyl analogues, and you said, ``I wouldn't get ahead of the 
agencies that actually do the science.''
    So the Drug Enforcement Agency has testified before this 
committee. We had our hearing, and they said their number-one 
priority this session is scheduling of illicit fentanyl, making 
it permanent scheduling, their number-one legislative priority. 
Do you agree with the DEA that this should finally--we should 
finally permanently schedule fentanyl-related substances as 
schedule I drugs?
    Mr. Becerra. The FDA has spoken on this. And yes, we do 
want to see it scheduled. We don't want to have to continue to 
see Congress reauthorize this. And so we hope that we will be 
able to work with you on that----
    Mr. Guthrie. And subject to mandatory minimums?
    Mr. Becerra. Well, that is where we can have that 
conversation, because we are interested in discussing a 
comprehensive approach on how we deal with fentanyl and drug 
overdose.
    Mr. Guthrie. We want to as well, but I just don't 
understand why somebody selling a derivative of fentanyl should 
be treated less than somebody selling fentanyl. I can't 
understand that.
    Mr. Becerra. I--we can discuss----
    Mr. Guthrie. I--no, go ahead.
    Mr. Becerra. Yes, and the Department of Justice would be 
more than willing, I think, to discuss some of these issues 
about mandatory sentencing and mandatory minimums.
    What I can tell you is from HHS's perspective. What we need 
to do is make sure we are helping do the research that will 
help us find the cures, the treatments that are necessary.
    You probably heard the news today that the FDA has now 
announced that Narcan will now be provided over the counter, so 
any consumer can go in and purchase it. That will save lives. 
So we are doing the things that will help keep people alive, 
and we look forward to working with you on a comprehensive 
approach.
    Mr. Guthrie. Well, thanks. Thanks. I want to move to the 
IRA.
    On--we had H.R. 19, which--it wasn't bipartisan, I won't 
say, but every provision in it had a bipartisan solution, 
because we all want lower drug prices. We had a hearing 
yesterday on drug--on healthcare costs. We want to deal with 
it.
    When the IRA passed last year, one of our main concerns was 
the innovation, and CBO said that it would lead to 15 fewer 
cures over the next 30 years in a modest estimate compared to 
others. But the official CBO score--and we have already seen 
examples, I think, of a couple of--in 4 months already--drugs 
in phase one and phase three, I believe, an eye--a rare eye 
disease, and also a cancer drug have an R&D cut.
    And so our concern--do you believe that--so my question is, 
do you believe that CMS should consider the divestment in 
certain therapies that could eventually lead to the development 
of cheaper alternatives as the agency makes decisions on 
setting the price of certain therapies?
    Mr. Becerra. And CMS will be having further conversations 
with the Hill on exactly how we are going to move forward on 
the price negotiation.
    What I think you are going to find is that they are going 
to try to move towards a more competitive system that allows us 
to get the best price for those drugs but not let drug 
companies gouge the American consumer. There is no reason why 
we should continue to see Americans paying 2 to 3 times more 
for drugs here in America, when those same drugs are sold in 
other parts of the world for so much less.
    Mr. Guthrie. We agree. That is why we want to expose the 
price that people pay, the price it takes to make it, the price 
that goes to the system. So we agree on that.
    But we are concerned about--and we have already heard that 
there are big pharmaceutical companies--and people point out 
they have made billions of dollars over the last couple of 
years, and we are not here defending that.
    What I am saying, though, most innovation comes from small 
businesses, a lot of them from Stanford in California, small 
people who make--start businesses, they are researchers and 
they start their own businesses, and they really need venture 
capital to move forward. I am not talking about a handful of 
pharmaceutical companies. They really come up with our--moving 
forward.
    And so they have already talked to us and said the venture 
capital is concerned about the 13-year, 9-year--the small 
molecule and the other, and now you are talking about going to 
5, and expanding more drugs.
    So when you were talking about that in your discussion in 
making this proposal, did the idea of lack of innovation --we 
had a hearing on it last year, and people--and we have had 
people in this committee say, ``We are willing to trade some 
innovation for cheaper prices.'' Did you all discuss the lack 
of innovation when you had these hearings?
    Mr. Becerra. Mr. Chairman, without a doubt. Everyone has 
discussed innovation. Everyone wants to make sure that we have 
a competitive industry. Everyone wants to make sure that we 
have a domestic production of the best drugs that the world can 
produce. And so all of that is part of this process.
    The legislation that passed actually provides a safe harbor 
for a lot of those innovative companies so they can continue 
forward. It makes sure that we don't take on every particular 
prescription drug for price negotiation right away. And what we 
are going to try to do is make sure that not only do we 
stimulate more innovation and more production, but we do it in 
a way that keeps the price fair so that there is still a profit 
for the company producing the drug. They deserve to earn a 
profit.
    But gouging is not acceptable. And--would agree that there 
is gouging going on. And that was the purpose of this new 
prescription drug law, to lower the price of those prescription 
drugs that we know--there is no reason why we couldn't have had 
insulin for $35 a month 10 years ago, 20 years----
    Mr. Guthrie. We just have to expose the price. You are 
right. So I am calling myself down, I guess, on that.
    [Laughter.]
    Mr. Guthrie. I yield back to myself, and my time is 
expired. I recognize the gentlelady from California for 5 
minutes.
    Ms. Eshoo. Thank you, Mr. Chairman. And not to mention the 
games that are played with patents by the drug industry. I just 
have to throw that in there.
    It is great to see you here, Mr. Secretary. Yesterday our 
subcommittee held an important bipartisan hearing on 
transparency in healthcare. It has been mentioned. Our expert 
witnesses testified on the importance of shedding light on 
fraud, on waste, on abuse that really poisons the healthcare 
industry and hurts patients. So based on their remarks, I think 
that--I assume that all of my colleagues should be able to 
support your agency's actions to audit Medicare Advantage plans 
to recover overpayments.
    Now, I remember years and years and years ago at this 
committee on the issue of waste and fraud that there were 
individuals whose cases had been adjudicated. They were on 
their way to prison. This was the private sector ripping off 
the public sector in Medicare. It was billions and billions of 
dollars. And they testified as to how they did that. It was so 
highly instructive, obviously, I still recall it very well 
today.
    So you mentioned in your testimony that you are doing 
audits to save taxpayer dollars. There are ads on TV saying 
that President Biden is cutting payments to Medicare. Can you 
set the record straight on this, and how much you estimate 
those audits are going to cost?
    I know it is something in the--there is money in your 
budget for that.
    Mr. Becerra. Congresswoman, thank you for the question.
    The reason we are doing the audits is because now we have 
collected enough data to actually show us how some of this--the 
money that we provide, taxpayer money, in Medicare is being 
spent. And what we are finding is that there is a lot of 
overbilling. And we are trying to recoup that money, because 
when we recoup it we put more money into the Medicare program 
to put back into the services and benefits that Medicare 
beneficiaries will receive.
    The program will cost us a fraction of the billions of 
dollars that we will recoup in these audits. And so we are 
hoping to move forward. But the difficulty we have is that 
there are millions being spent to date--tens of millions of 
dollars are being spent to date on these commercials, 
deceptively speaking to Medicare beneficiaries--scaring them, 
quite honestly--because there are billions at stake. And that 
is a pretty wise investment, if you think about it. They are 
trying to save billions of dollars in returning money to the 
Medicare program, and it is only going to cost them some 
millions of dollars in commercials.
    Ms. Eshoo. Yes. So in other words, let's be for fraud and 
abuse because it is my plan. Hell of a line.
    Mr. Becerra. Yes. We are going to continue forward, and----
    Ms. Eshoo. Good, good.
    Mr. Becerra. We have to.
    Ms. Eshoo. I am with you 1,000 percent on that.
    It has been reported that the House Republican leadership 
plans to cap 2024--fiscal year 2024 discretionary spending. 
What I would like to know is, how many fewer grants would that 
mean that NIH would be able to support?
    Mr. Becerra. Congresswoman, we estimate that if some of 
these proposed cuts--and again, we have not seen the budget, 
but what we have heard are some of the proposed cuts--NIH 
probably would face a cut of about, well, billions that would 
cost us about 5,000 grants that are done by NIH researchers.
    Ms. Eshoo. Five thousand NIH grants?
    Mr. Becerra. Five thousand.
    Ms. Eshoo. Would that include funding for Alzheimer's, for 
instance?
    Mr. Becerra. It could include Alzheimer's, cures for 
different diseases. The research that is being done by NIH is 
to fund and find cures for diseases. So some 5,000 grants would 
probably have to be rescinded or not put out.
    Ms. Eshoo. You know, this debate about how much money--and 
it is a worthy debate, it is a very important one--I would link 
the dollars to keep building on the progress that the United 
States of America continues to make. And when you pull back, it 
pulls back on the progress.
    So this is not just an accounting exercise, this is about 
our collective society and what kind of a--you know, what the 
progress is, and what we need to invest in.
    Bravo on ARPA-H. I am thrilled. That was a bipartisan 
effort here, and I am glad they are up and running and doing 
business.
    Mr. Guthrie. The----
    Ms. Eshoo. Thank you.
    Mr. Guthrie. The gentlelady's time is expired. The Chair 
now recognizes Dr. Burgess from Texas for 5 minutes for 
questions.
    Mr. Burgess. Thank you, Mr. Chairman.
    Again, Mr. Secretary, welcome. Good morning. Yes, ARPA-H, 
important. I hope you will look favorably on the State of Texas 
to locate it at an area that has already proven an ability to 
provide what you are looking for with some of the work the 
State has done on cancer prevention and research.
    So you have had a busy week, and you have been to a fair 
number of committees, both on this side of the Hill and the 
other side of the Hill. There seems to be a narrative emerging 
that HHS is attempting to convince Congress that there has been 
a much higher volume of claims under the No Surprises Act, a 
higher volume of claims submitted for independent dispute 
resolution than anyone could have predicted.
    So your responses to Senator Harris--I am sorry, Dr. Harris 
of Maryland, Senator Bennet from Colorado, and Dr. Wenstrup of 
Ohio, and you cited the sheer volume of claims and asserted 
that some were frivolous, implying that providers are not 
acting in good faith. Now I have providers calling me literally 
every day and stating that they are winning much more often 
than they lose during the arbitration process. Their win rate 
is over 75 percent. Unfortunately, because of the HHS backlog, 
only 3 percent of the submissions have made it through the 
process.
    So what is the deal here? Are the claims that are being 
submitted really not actually necessary? And it is hard to 
square that with the fact that so many are decided in favor of 
the intervener.
    Mr. Becerra. And Congressman, thank you for asking the 
question, because I am going to connect the final dots to the--
what you just said.
    Those physicians who are having success are, as you said, 
they are going to start to see a slowdown in the adjudication 
of those claims. The reason they are going to see a slowdown is 
because neither you nor I or anyone who actually had the wisdom 
to propose and enact the No Surprises Act believed that we were 
going to have the volume of submissions of claims.
    I guarantee you, you did not believe that in the first 8 
months we would have 164,000 claims submitted.
    Mr. Burgess. Yes. If I could just reclaim my time, first 
off, I want to point out I voted against the No Surprises Act 
because I was worried about this exact thing.
    But when Texas--Texas, as you know, had their own version 
of the No Surprises Act that was passed in the State of Texas. 
The first year they saw 45,000 claims in the first year. In the 
first 6 months of 2021, the very 6 months where you all were 
beginning to implement the No Surprises Act at the agency, they 
had another 50,000 claims.
    And, Mr. Chairman, I am going to ask that the Texas Senate 
bill--evaluation of the Texas Department of Insurance be 
inserted for the record.
    Mr. Guthrie. So ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. But your Department estimated--so that is 
100,000 claims, basically, in the first year. And your 
Department estimated the annual number of submissions would be 
17,000 nationwide for the whole year. I mean, did you not look 
at the data that had already been accumulated in a single State 
that had implemented a similar law in the year and a half 
before yours started?
    I mean, I can only draw the conclusion that you didn't look 
at the data that was available. And then to turn around and 
blame providers for your Department not being prepared for the 
volume of claims--it just doesn't square with me.
    And for everything I have heard so far this week, I believe 
that to the extent that this process is a failure, it is a 
failure because of poor planning on the part of HHS and 
mismanagement of the law passed by Congress. So instead of 
blaming providers for the Department's mistakes, I hope going 
forward we can focus on resolving the backlog. When 75 percent 
are decided in favor of the person who brought the claim, but 3 
percent are getting through, we got a real problem. And again, 
it comes back to keeping doctors involved.
    Let me just shift gears and ask you a question, because it 
came up in other testimony. You stated you were unfamiliar with 
statistics reported by The New York Times that HHS has been 
able to contact over 85,000 unaccompanied alien children who 
have been released from HHS custody. Are you now familiar with 
that 85,000 figure? And are you aware of where it--from where 
it comes?
    Mr. Becerra. Congressman, I am aware of where it comes. It 
is not a statistic. It is a number that New York Times came up 
with.
    Mr. Burgess. But the fact remains there are children that 
you cannot identify where they are that have gone through your 
system. And it seems to be the throughput is the critical 
thing, not the child. And that is bothersome to a lot of us on 
this committee.
    Mr. Becerra. No, see, there is a misunderstanding about 
what we are supposed to do, and what we are then able to do 
once a child is placed.
    If you take a look at the law that was passed by Congress, 
Congress gave HHS the responsibility, the authority to provide 
the custody and care of a unaccompanied child----
    Mr. Guthrie. I know you want to answer. We are out of time. 
I need to move----
    Mr. Burgess. I look forward to your answer.
    Mr. Becerra. I look forward to clarify the 
misunderstanding. Maybe I will have a chance later on.
    Mr. Guthrie. Absolutely.
    Mr. Burgess. I will submit that to you in writing, because 
it is important.
    Thank you, Mr. Chairman.
    Mr. Guthrie. Mr. Sarbanes, you are recognized for 5 minutes 
for questions.
    Mr. Sarbanes. Thank you very much, Mr. Chairman.
    Secretary Becerra, welcome. As you know, a strong, well-
trained workforce is critical to ensuring a high-quality 
healthcare delivery system that can deliver all the necessary 
care for all patients today and be prepared for future public 
health crises.
    While nearly every industry is facing workforce challenges 
across the country, I want to focus today on how President 
Biden's budget addresses those faced by the healthcare 
workforce. According to HRSA's most recent workforce estimates, 
current demand for healthcare providers, especially primary 
care physicians and mental and behavioral health providers, far 
outpaces supply. And without meaningful action to turn the 
tide, this gap is only projected to widen over the next decade.
    We have already seen how shortages at every level can 
impact access to care for individuals in Maryland. For example, 
we are facing long emergency room wait times and a mental and 
behavioral healthcare crisis that is particularly acute for 
pediatric patients. While these are complex problems that 
require comprehensive solutions, a key part of those solutions 
is addressing shortages in primary mental health and skilled 
nursing care, so that every patient can access the level of 
care they need at the time they need it most.
    The President's budget certainly reflects an understanding 
of the importance of these investments in a healthcare 
workforce, and would provide robust funding for programs that 
have a proven track record of strengthening our healthcare 
provider pipeline and delivery system.
    For example, the budget includes, as you know, $2.7 billion 
for HRSA's workforce programs, including a $548 million 
increase in funding for the National Health Services Corps, 
additional resources for graduate medical education and other 
training programs, and $28 million for a new program to address 
healthcare workforce shortages.
    Mr. Secretary, can you speak a bit more about these 
investments, particularly the new program to address workforce 
challenges, and how they will work together to build a stronger 
provider base that can meet the needs of every community?
    Mr. Becerra. Congressman, thank you for the question, and 
thank you for championing the ability for Americans to stay in 
the healthcare workforce and to increase the numbers.
    We are doing what we can in the budget to actually support 
the--an increase in our workforce, whether it is the healthcare 
workforce or, as you see in the President's budget, for the 
child care workforce, because we know that the needs are dire.
    What we also are trying to do is figure out how to best 
direct the next generation of healthcare workers. So our 
National Center for Health Care Workforce Analysis is trying to 
collect some of that information, the data that will tell us 
where the shortages are, not just geographically but by 
profession. And so we are going to do everything we can to give 
States the best guidance because they are the ones that 
ultimately certify and license individuals, and we want them to 
know where their needs will be, coming into the future.
    Mr. Sarbanes. Thank you very much. And I appreciate you 
talking about the data, the importance of collecting 
information on where the shortages are. That can inform 
recommendations about a national policy to address shortages 
within the healthcare workforce.
    Congressman Blunt Rochester and I again have led a letter 
this year to the House Appropriations Committee requesting $11 
million for the National Center on Health Workforce Analysis 
that you mentioned for fiscal year 2024. And, as you know, that 
center releases a lot of really critical information about the 
supply-and-demand challenges. And increasing its funding is, I 
think, very critical to help this committee to help your 
Department and agency make the smartest decisions we can 
possibly make when it comes to investing in our healthcare 
workforce.
    Building upon the American Rescue Plan and the Inflation 
Reduction Act's historic reforms to lower healthcare costs for 
Americans, we have got to look at this workforce shortage. Let 
me freestyle a little bit with you here right now a bit more on 
this. Do you think we could put together a kind of broad 
national health workforce strategy that brings various partners 
together who may not have collaborated previously?
    For example, we look in Maryland at these shortages around 
nursing. We know that we even are lacking instructors for 
nursing programs. So we have got some community colleges that 
provide nursing. They are now going to hospitals and saying, 
``Can you give us some of your nursing supervisors on a part-
time basis to come in and be instructors?'' All hands on deck. 
What can that look like as a national policy from your 
perspective in the healthcare arena?
    Mr. Becerra. Congressman, we are already looking at it. 
HRSA is undertaking a number of efforts. They are talking to 
States and those in the profession about best practices. We are 
also using SAMHSA----
    Mr. Guthrie. You are going to have to wrap up. I am sorry. 
We are trying to keep your--on time, so our Members can ask 
questions.
    Mr. Sarbanes. We will continue the conversation.
    Mr. Guthrie. I gaveled myself down, so I am going to --
Chair McMorris Rodgers, you are recognized for 5 minutes.
    Mrs. Rodgers. Thank you.
    Mr. Secretary, last week this committee advanced my bill, 
the Protecting Health Care for All Patients Act, which would 
ban QALYs and other similar measures in Federal healthcare 
programs. And I am grateful for the hard work of your team to 
modify the bill language to resolve all outstanding issues and 
help us towards a shared goal of removing discrimination in 
Federal health programs.
    Prohibitions on QALYs and other similar measures already 
exist in Medicare and the Inflation Reduction Act. Since we 
already have an additional ban in place for Medicare, do you 
think it would be appropriate to ban these measures in all 
other Federal care programs like Medicaid?
    Mr. Becerra. Madam Chair, can--ban what?
    Mrs. Rodgers. QALYs.
    Mr. Becerra. Oh, I know that we already have them banned in 
Medicare. We do not use them.
    Mrs. Rodgers. Thank you.
    Mr. Becerra. And I believe that there is an----
    Mrs. Rodgers. Thank you. I am going to take back--
reclaiming my time--I have a lot to get through here.
    Some questions were raised about Equal Value Life Years 
Gained. Do you view the Equal Value Life Years Gained metric as 
discriminatory?
    Mr. Becerra. Congresswoman, we don't use those kinds of 
measures.
    Mrs. Rodgers. OK, thank you.
    Mr. Becerra. I am not sure what the reference is to.
    Mrs. Rodgers. OK, very good. Thank you. Secretary Becerra, 
can you tell me how many additional resources you provided to, 
in the words of President Biden's Executive order on promoting 
competition, ``support existing price transparency initiatives 
for hospitals, other providers, and insurers''?
    Mr. Becerra. I think my answer is probably going to go 
longer than you would like, but we are engaged in quite a few 
activities with regard to price transparency, and I could go 
through a list of them.
    I could also tell you how we are trying to engage real soon 
with companies on price negotiation to get the best price for 
pharmaceutical drugs.
    Mrs. Rodgers. OK, just reclaiming my time, if it is a 
priority, why has there only been 2 penalties issued to 
hospitals in more than 2 years, despite numerous academic 
third-party studies, your own agency demonstrating significant 
noncompliance?
    Mr. Becerra. Are you talking about the price--I mean, the--
yes, the price transparency laws that are in effect?
    Mrs. Rodgers. Yes.
    Mr. Becerra. Madam Chair, as you recognize, that that law 
was only implemented recently by this administration. It is 
taking a while. The industry has to come forward and come up 
with plans on how they are going to show their prices.
    Mrs. Rodgers. OK.
    Mr. Becerra. It differs by region----
    Mrs. Rodgers. OK, thank you, thank you. We are going to go 
to work on this, and we are going to work on this together, and 
we are going to get it done. OK.
    I wanted to move on to Medicare. The administration 
recently proposed Medicare Advantage changes that will reduce 
risk adjustment payments to plans. You have characterized these 
changes as reducing overall overpayments to plans. Do 
reductions in these types of Medicare payments constitute a cut 
to Medicare?
    Mr. Becerra. These insurance companies will get more money 
this year than they got last year. That is not a cut.
    Mrs. Rodgers. OK, thank you. In my opening statement I 
alluded to site-neutral payments, a bipartisan policy that 
would reduce Medicare spending in what seniors pay by having 
Medicare pay the same for services regardless of location. If 
lowering payments to plans isn't a cut, would you characterize 
such a policy as a cut to Medicare site-neutral payments?
    Mr. Becerra. Obviously, different regions have different 
pricing. We have to make sure that what we are doing is doing a 
fair evaluation of what the cost of a service or product is----
    Mrs. Rodgers. OK.
    Mr. Becerra [continuing]. In healthcare services.
    Mrs. Rodgers. So thank you, I appreciate that. We found an 
area of agreement, I think.
    President Biden, Speaker McCarthy, and us were agreeing on 
not cutting Medicare. And it appears that we can agree on some 
payment reductions that don't constitute cuts. So would you 
commit to working with us on bipartisan approaches to address 
payments that are higher than they might need to be?
    Mr. Becerra. Absolutely.
    Mrs. Rodgers. OK, thank you.
    Just last week, CDC released 25 newly documented 
statistical, numerical errors in its COVID-19 data. Eighty 
percent of these errors exaggerated the severity of the COVID-
19 situation. And it is especially concerning that--the impact 
that this had on children. Ninety-four percent overstated the 
risk to children. In less than 50 percent of these instances 
did CDC ever fully correct the error.
    So can you speak to this report on errors and commit to 
specific actions you will take to ensure that these are 
corrected?
    Mr. Becerra. The CDC has always attempted to be as 
transparent as possible. The information, the data they provide 
is essential for----
    Mrs. Rodgers. OK.
    Mr. Becerra [continuing]. States and our consumers.
    Mrs. Rodgers. Thank you. So we will work on that together 
too.
    And then finally, I just want to close by saying I am 
concerned about, you know, on one hand we have the 
administration talking a big picture on curing cancers, 
fighting Alzheimer's, and yet, unfortunately, we see where the 
action contradicts that goal. In an unprecedented action to 
restrict Medicare patients from accessing FDA-approved 
treatments across the board, no matter the promising data or 
the results, are disappointing to millions of patients with 
Alzheimer's and their families who are looking for hope.
    And we are going to continue to press you on this, because 
when these--when we finally get these breakthrough drugs, we 
must make them available to the people that are dependent upon 
these drugs to give them hope.
    And I will yield back, Mr.----
    Mr. Guthrie. Thanks. The gentlelady yields back. The Chair 
yields back, and the Chair now recognizes the ranking member 
for 5 minutes for asking questions.
    Mr. Pallone. Thank you, Chairman Guthrie. Before I get to 
my questions, I would just ask unanimous consent to submit to 
the record the GAO report from August 2018 titled, ``Rural 
Hospital Closures Number and Characteristics of Affected 
Hospitals and Contributing Factors,'' which analyzed data from 
the North Carolina Rural Health Research Center and CMS and 
found, I quote, that ``from 2013 through 2017, rural hospitals 
in States that had expanded Medicaid as of April 2018 were less 
likely to close, compared with rural hospitals in States that 
had not expanded Medicaid.''
    And this, of course, goes to my point that not expanding 
Medicaid or cuts to Medicaid are really going to starve the 
healthcare systems in rural areas, and impact red States in a 
major way.
    Mr. Guthrie. Without objection, so ordered. 1A\1\
---------------------------------------------------------------------------
    \1\ The report has been retained in committee files and is included 
in the Documents for the Record at https://docs.house.gov/meetings/IF/
IF14/20230329/115628/HHRG-118-IF14-20230329-SD003.pdf.
---------------------------------------------------------------------------
    Mr. Pallone. Thank you, Mr. Chairman. I am very proud of 
the historic achievements included in the Inflation Reduction 
Act, which I know Secretary Becerra mentioned, particularly the 
authority for the Secretary to negotiate lower drug prices for 
certain high-priced, single-source drugs as well as to cap drug 
prices that increase faster than the rate of inflation in 
Medicare Part B and D.
    Additionally, IRA will cap out-of-pocket costs of Medicare 
Part D at 2,000 a year, beginning in 2025, and beneficiaries 
are already starting to see the benefits of capping insulin 
copayments at $35 a month, as well as no-cost vaccines in Part 
D.
    So a few questions, if you can answer quickly so I can get 
to them all: Why are these--why were these provisions so 
important? And are you already seeing the positive impact of 
these changes on the ground, such as the savings generated from 
the insulin and vaccine provisions, Mr. Secretary?
    Mr. Becerra. Mr. Chairman, we are seeing immediate impact. 
I can tell you that, every place I have gone since January 1st, 
I am approached by a senior who has mentioned how it is 
incredible that they paid only $35 for their insulin. And in 
December I remember one lady specifically, it was about 112 or 
117 dollars that she said she had paid in December. She was so 
startled that she went to the insurer and said, ``I think you 
undercharged me for the--for my insulin.'' And when they told 
her, no, that is the new price, she was ecstatic.
    And so that is what I am running into. I have had people 
tell me stories about having to pay close to $200 for a vaccine 
on shingles. One in three Americans will at some point 
experience shingles. You don't want to experience it. And it is 
an expensive vaccine for folks on fixed incomes. It can--it 
takes a big bite out of their budget. And so to find out that 
today, as a result of the new prescription drug law, the 
Inflation Reduction Act, they are paying nothing, it is great 
for--great news for them.
    Mr. Pallone. Now, can you again talk briefly--because I 
have one more question after this--can you talk about whether 
legislation extending the protections from the Inflation 
Reduction Act to the commercial market could be helpful in 
achieving the goal of, you know, reducing drug prices as well?
    Mr. Becerra. Without a doubt. There is no reason why 
Americans should be paying two or three times more for their 
prescription drugs than people around the world for the same 
drug, and sometimes manufactured in the U.S. And so the ability 
to negotiate for a fair price is something that will reward all 
Americans.
    Mr. Pallone. Now, the budget notes that additional savings 
can be achieved by increasing the number of drugs selected for 
negotiation. Can you talk about why the administration supports 
legislation to increase the number of drugs subject to 
negotiation, and how this would both increase savings to 
Medicare beneficiaries and improve Medicare solvency?
    Mr. Becerra. The legislation--we are thankful for the 
legislation--allows us to move forward with the first 10 drugs. 
We identified them this year. And by 2024, 2025, negotiate--by 
2026 Americans are receiving the fruits of that negotiation and 
lower drug costs. And then every year after the first year, it 
will increase another 10 to 15.
    The President believes that there are more than 10 drugs. 
There are, obviously, quite a number of drugs that are 
overpriced, and that if we move faster we save Americans more 
money, and we also save the Medicare program more money.
    Mr. Pallone. Well, thank you, Mr. Secretary. I am very 
supportive of this. And I believe that negotiating the price 
for more negotiating--negotiation-eligible drugs will allow 
more beneficiaries taking high-cost, sole-source drugs to see 
the benefits of this law. And I hope to continue to work with 
you on these efforts to build on the IRA and expand savings for 
seniors as well as those insured in private insurance.
    And, you know, I know I keep saying the same thing, but, 
you know, you are here talking about something that exists, 
which is the President's budget. And I know that, you know, 
Republicans are talking about increasing spending, cutting 
things. But until they actually give us a budget, you know, it 
is very--it is nice that they come here and criticize you and 
the President, but there is no alternative for us to see coming 
from the other side.
    So with that, I yield back, Mr. Chairman.
    Mr. Guthrie. The gentleman yields back. The Chair now 
recognizes Mr. Latta for 5 minutes for questions.
    Mr. Latta. Well, thank you, Mr. Chairman, and thanks for 
calling today's hearing.
    And, Mr. Secretary, thanks for being with us. I would like 
to go back to what the chairman had started in his opening 
statements, some questions on fentanyl. My seatmate and friend 
from Virginia, we have the HALT Fentanyl Act that would make 
sure that--for once and for all, that fentanyl is going to be a 
schedule I drug. And I just want to make sure that you are on 
board that fentanyl should be a schedule I.
    Mr. Becerra. Congressman, as I have said to the chairman 
and others, FDA agrees that we need to continue the scheduling 
of fentanyl. I leave it to FDA to make those decisions on how 
they should be scheduled. And FDA would also say we need a 
comprehensive approach when we deal with either fentanyl or 
other drugs that are killing Americans.
    Mr. Latta. Well, that is important because, again, we had 
roundtables and hearings in here. I think it is important to 
point out that one of the terms I try not to use anymore is the 
word ``overdoses.'' It is poisoning, especially when we are 
talking fentanyl. When we look at the over 71,000 people who 
died last year in this country because of fentanyl, it is 
poisoning. We had one sheriff actually say that when these drug 
cartels know what they are putting in these pills and sending 
them north, it is not poisoning anymore, it is murder.
    And so I would like to just go to a--some statements that 
you have, and just ask a couple of questions.
    You said NIH will continue to invest over $1.8 billion in 
research on opioid misuse, addiction, and pain disorders, 
including the Helping to End Addiction Long-Term, HEAL, 
Initiative. Now, the question I have is--because again, I am 
not sure exactly when this has been put into place and how long 
it has been going. But as we see the trend of fentanyl 
poisoning and also all drug overdoses and other sorts going up 
in this country to about 107,000 in 2022, that--the question 
then is that--is this effective?
    Because, again, in this committee, because we do have broad 
jurisdiction, when we talk about things that's online and drugs 
that are coming into this country, we are being told by law 
enforcement and the DEA and everyone else that when drugs are 
coming across this border, that the cartels are making a 
fentanyl-laced pill for a dime that are killing Americans, and 
they are making 30 to 40 dollars off each of these pills.
    And so, as was pointed out earlier, that when you have 18-
to-45-year-olds as the leading cause of death now is--looking 
at the either fentanyl poisoning or some other type of a drug 
overdose, are the initiatives of this $1.8 billion being 
effective right now?
    Mr. Becerra. Congressman, thank you for the question.
    I think $1.8 billion is a major investment. If in the 
wisdom of this body you wish to give us more resources, I 
guarantee you we will make good use of them. But I understand 
that there is a conversation about cutting, not increasing on 
your side of the aisle. So I hope that what you are----
    Mr. Latta. Well, let me ask--because again, we had 
testimony from, you know, parents of lost loved ones. And the 
question--and the problem is, again, as I said, these pills are 
flowing across the border, and then they are getting in on--
through the internet. And pretty soon we can't even track where 
they came from.
    But when somebody buys one of these pills, a younger 
person, they are thinking they are getting, you know, X, Y, Z, 
and it turns out a fentanyl-laced pill, what is the Department 
doing to warn Americans?
    Because again, with that $1.8 billion, you could do a lot 
of information out there as to what is going on, warning 
people, kids especially, don't buy anything on the internet.
    And the reason I bring this up--it has been a few years 
ago, but I sponsored the track-and-trace legislation. And what 
that legislation did was to make sure, from the time that a 
drug was manufactured to the time it was delivered, we would 
know every stop that it was--that it wasn't counterfeited or 
adulterated along the way. So, you know, that is--and that is, 
hopefully, for a prescription drug or something else that is 
flowing naturally and legally through, that people know what 
they are going to get.
    But how--warning people online--that are online today 
buying these pills that it is not a counterfeit or a knockoff, 
this drug could have--or this pill could have fentanyl in it 
that will kill you. And this is the problem, when you see the 
numbers going up.
    And so that is my question on this, you know--we--on 
research and misuse and addiction and pain disorders, but how 
are we getting the word out that, people, don't do this?
    Mr. Becerra. Congressman, much of that work is actually 
done not by NIH, but by SAMHSA, our substance use and mental 
health agency, which deals with that. And they are working with 
States and local entities that are actually doing the work on 
the ground to support some of those efforts to inform and to do 
the surveillance.
    They are also taking on best practices using evidence-based 
practices. For example, fentanyl strips are now being made 
available. We are finally supporting that at a national level, 
because we know it saves lives.
    You heard the news today that Narcan is now going to be 
available over the counter. The FDA has made that announcement. 
So we are doing the things that we can at the Federal level to 
support the work that is done on the ground at the local level.
    Mr. Latta. My time is expired. I yield back.
    Mr. Guthrie. The gentleman yields back. The Chair now 
recognizes Mr. Cardenas for 5 minutes for questions.
    Mr. Cardenas. Thank you, Chairman Guthrie, and also Ranking 
Member Eshoo, for having this important hearing. And I 
appreciate the opportunity to discuss in front of the whole 
world, Secretary Becerra, what we are doing proactively in many 
areas, and I really appreciate the budget that the President 
has put forth.
    And I am thrilled to see that the President has emphasized 
in his budget request--placed on funding for 9-8-8 and the 
broader continuum of crisis care in America. The 9-8-8 Suicide 
and Crisis Lifeline is saving lives by providing urgent and 
timely responses to individuals in crisis. It is a key starting 
point for the crisis continuum.
    But it is not enough to just have someone to call--when you 
call--when someone calls 9-8-8, we also need someone to come 
and somewhere to go when an individual requires greater mental 
health support. I am particularly excited to see requests for 
robust funding for mobile crisis response grants so that 
trained mental health professionals can be the first responders 
to mental health emergencies.
    And I would imagine that--I would hope that my colleagues 
who represent much of rural America are excited about the 
opportunity to have mobile crisis response grants put out in 
every corner of this country, especially in rural America.
    Secretary Becerra, why maybe, in your opinion, is it so 
critical to have a robust crisis care infrastructure in our 
country?
    Mr. Becerra. Congressman, thanks for the work that you have 
done over the years on this issue.
    The reason it is so important to have a crisis care system 
is because people don't have a mental health crisis just from 
the hours of 9 to 5. There has to be a place for them to go 
after hours. They have to know that when it hits, there will be 
someone there to catch them. And the--a 24/7 crisis care center 
is the best way to make sure not only do we save lives but keep 
people from harming themselves.
    Mr. Cardenas. And I want to make it clear. I think you and 
I are talking a little bit inside baseball. When you and I are 
talking about crisis, we are talking about mental health 
crisis.
    Right now in America--or before last year--if there was a 
crisis moment in America, maybe somebody was off their meds and 
their mother called 9-1-1, who would show up? Maybe there would 
be a healthcare professional show up. But 99 percent of the 
time it was the law enforcement officer who--even they and we 
all agree they are not trained to deal with mental health 
issues. We need mental health professionals to show up to the 
moment, so that we can actually help the situation instead of, 
unfortunately, have a critical moment where it even gets worse.
    So when it comes to mental health in America, we are making 
improvements, and 9-8-8 is, in fact, a big step in the right 
direction. And hopefully, Americans will take 9-8-8 for 
granted, like people expect that when they call 9-1-1--and it 
happens everywhere in the country--someone comes when they call 
9-1-1, and that is what 9-8-8 is about.
    What resources are still needed to build out our crisis 
infrastructure when it comes to mental health and ensure that 
everyone, regardless of circumstance, can access crisis 
services, including the LGBTQ+ community and individuals and 
people with disabilities, and those whose primary language is 
not English?
    Mr. Becerra. Congressman, on 9-8-8 I will just mention we 
need to get States further invested in it, because this is not 
a national program. Only because the President and Congress has 
been so willing to help the States have we been able to make it 
work so well. But if the States have to make commitments to 
have permanent, stable funding for 9-8-8 in their 
jurisdiction--and so that means a lot of work.
    We need--we are expanding access under 9-8-8 in languages 
other than English because we know a lot of folks need that 
communication. We are doing a call that is specific--a line 
that is specific for veterans. And so we are going to try to 
make sure we are approaching as many people as we can, 
including our LGBTQI-plus community, as well.
    Crisis care, we need to fund further crisis care so that it 
is available 24/7. We have to make sure that there is followup 
service when someone does reach out and make the call. And so 
we are working as hard as we can to make sure certified 
community behavioral health centers receive the support to be 
able to expand.
    Mr. Cardenas. Locally in every community, correct?
    Mr. Becerra. That is correct.
    Mr. Cardenas. OK. So when somebody calls 9-8-8, they are 
not in California talking to somebody in--five States over, or 
what have you. Make it local, make it robust.
    And you are absolutely right, 9-1-1 is, in fact, a local-
funded program supported by the Federal Government.
    Mr. Becerra. Yes.
    Mr. Cardenas. But it is primarily supported by locals.
    Mr. Becerra. By--the workforce, as well. We are working to 
expand the workforce because, if there is a shortage in the 
healthcare workforce, it is even more acute in the mental 
health and substance use workforce.
    Mr. Cardenas. Absolutely. And in order for us to have more 
mental health force workers ready and to fill those positions 
and do that work, we need to make sure that the local schools 
and the local activities are actually educating people, so they 
can actually be in that position.
    My time having expired, thank you so much, Mr. Secretary.
    I yield back.
    Mr. Guthrie. Thank you. The gentleman yields back. The 
Chair now recognizes Mr. Griffith for 5 minutes for questions.
    Mr. Griffith. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary. Mr. Secretary, many of us on both 
sides of the aisle are concerned about the workings of the 
Office of Refugee Resettlement, ORR.
    When the Oversight and Investigations Subcommittee holds a 
hearing on ORR to address our questions and our concerns and 
looking for answers, are you willing to come to the 
subcommittee to testify, yes or no?
    Mr. Becerra. Absolutely. Absolutely, Congressman.
    Mr. Griffith. Thank you very much.
    Mr. Becerra. Hopefully we can work out a good time. Just 
make sure I am available.
    Mr. Griffith. Yes, sir, and we will work on that.
    Also, Mr. Secretary, on another subject, the President 
recently signed into law a bill that passed unanimously in both 
the House and the Senate to declassify information related to 
COVID-19 origins and the Wuhan Institute of Virology. When do 
you think HHS will be able to comply with the law?
    And I am not saying to anybody--I don't want anybody to 
misinterpret that I think you all are tardy, because this has 
been, like, a week.
    Mr. Becerra. Yes.
    Mr. Griffith. But I am just curious as to what kind of a 
timeline there is.
    Mr. Becerra. Thank you. Thank you for clarifying. We will 
try to move swiftly, because we are as anxious to get 
information out there as you are. There are a lot of entities 
around the world who aren't being transparent. We want to make 
sure we are transparent.
    Mr. Griffith. Let's switch gears and talk about some of the 
entities that aren't being so transparent.
    According to an article in the May 20th, 2021, China Daily, 
Minister Ma Xiaowei of the National Health Commission of the 
People's Republic of China said during a phone call with you 
that China was willing to deepen cooperation with the United 
States in fighting against COVID-19--the COVID-19 pandemic. 
What cooperation has China's National Health Commission 
provided?
    Mr. Becerra. Congressman, what I can tell you is I hope 
that those words ring true, that they will try to be more 
transparent and more collaborative, because we still are 
seeking information from China and--about their research and 
about the information they have about the first infections that 
they saw of COVID in their country.
    Mr. Griffith. Yes, this is very critical, and it is not 
just because we want to beat up on the lab or beat up on 
anybody else, but we have to have this data to try to figure 
out what we can do to try to prevent a future problem of a 
similar nature. Would you agree?
    Mr. Becerra. There is no way you are going to trace the 
origin or figure out how to address these and find remedies 
unless you have all the comprehensive information that lets you 
determine what is driving this.
    Mr. Griffith. In that regard, have you had communications 
with Minister Ma since May of 2021?
    Mr. Becerra. I have not, and it has been difficult to keep 
those communications going. We have made requests. We have done 
it directly and through the World Health Organization, and we 
are hoping that we will continue to see words that talk about 
doing more together.
    Mr. Griffith. And speaking of the World Health 
Organization, have they been cooperative? Because early on, it 
looked like they were kind of running interference on behalf of 
the Chinese, and I am just wondering if that has gotten any 
better.
    Mr. Becerra. I would say that the WHO and the director 
general have been making efforts to try to secure information 
from China. And I believe that they have tried to be as 
transparent as they can. They have done a good job of bringing 
so many countries together to deal with COVID.
    And all of us are seeking as much information from whatever 
the source is--not just from China--that we can get, so we can 
figure out where we go from here from--with COVID.
    Mr. Griffith. All right. I appreciate that. Mr. Secretary, 
last year Republican leaders McMorris Rodgers, Mr. Guthrie, and 
myself wrote to you asking you to provide more transparency 
about your meeting calendar. You declined to provide the 
information.
    However, other cabinet Secretaries have publicly posted 
their calendars on the websites of their departments to dispel 
questions about your level of engagement on HHS matters and to 
build public confidence. Will you commit to making your work 
calendar publicly available, like other cabinet Secretaries do?
    Mr. Becerra. Congressman, we will provide the information 
like my work schedule and so forth as those requests come in 
and as the law requires.
    Mr. Griffith. Yes. And I look forward to the ORR meeting 
that I referenced earlier, because there are a lot of questions 
that we want to get to. The New York Times article is 
concerning.
    Further, as you know, last year I raised issues about the 
vetting process for where we are sending these children. I want 
to look into that more because I think on both sides of the 
aisle we want to make sure--we may not agree on how they got 
here, how they crossed the border, but once they are here we 
have an obligation to make sure these children are in safe 
environments, where they are not being abused or exploited. You 
would agree with that, would you not?
    Mr. Becerra. A hundred percent.
    Mr. Griffith. All right. And I look forward to working with 
you to try to make ORR better and to figure out what we can do 
to live up to at least a minimal standard of security for these 
children.
    Thank you, Mr. Chairman. I yield back.
    Mr. Becerra. Thank you.
    Mr. Guthrie. The gentleman yields back. The Chair 
recognizes Dr. Ruiz for 5 minutes for questions.
    Mr. Ruiz. Thank you.
    Mr. Secretary, it is good to see you. Thanks for being here 
today.
    As you know, I am committed to protecting Medicare for 
seniors in my district and across the country, and to build on 
the policies that we passed last Congress to make healthcare 
more affordable. This includes the Inflation Reduction Act, 
which lowers drug prices for American seniors.
    The President's budget discussed today further improves 
seniors' access to lifesaving care by further lowering 
prescription drug costs for our seniors. On the contrary, 
Republicans have repeatedly tried to cut Medicare, and leading 
Republican plans have proposed to slash Medicare funding and 
increase the age for Medicare eligibility. Under the Republican 
plan, seniors would be subject to thousands of dollars in 
additional out-of-pocket costs.
    Secretary Becerra, can you briefly discuss how slashing 
Medicare funding would harm seniors?
    Mr. Becerra. Congressman, I think everyone knows how much 
Medicare has lifted seniors out of poverty, how Medicare has 
saved lives. And to now see the chance of that progress eroded 
would be devastating. That is why the President came out with a 
budget that actually not only protects all those benefits, all 
those services for today's seniors, but assures that it will be 
there for the next generation as well.
    Mr. Ruiz. Thank you. And so can you expand on how the 
administration intends to protect seniors and lower their 
healthcare costs?
    Mr. Becerra. Well, first, you have--everyone now is aware 
of the $35 cap per month of insulin. That is a tremendous 
saving. I mentioned earlier the money that is now being saved 
by no out-of-pocket costs for preventative vaccines. That is 
saving a lot of Americans a lot of money.
    We are now beginning to watch the pricing that the drug 
companies put out for their drugs if they go beyond the rate of 
inflation. The law that you helped pass, Congressman, lets us 
tell those companies, ``You owe back money to the Medicare 
system because you charged more than the rate of inflation for 
your prescription medication.''
    And as you know, in the next coming years we will be able 
to negotiate the prices of prescription medication.
    Mr. Ruiz. Thank you.
    You know, in addition to affordability, I am also concerned 
with access. Medicare physician pay and its impact on patient 
access to care remains a major issue for my constituents. In 
fact, adjusted for inflation in practice costs, Medicare 
physician pay actually declined 26 percent from 2001 to 2023, 
or by 1.8 percent per year, on average.
    Nonpartisan government stakeholders are recognizing the 
damaging impact these cuts are having on patient access to 
care. The 2021 Medicare Trustee Report states that ``absent a 
change in the delivery system or level of update by subsequent 
legislation, the trustees expect access to Medicare 
participating physicians to become a significant issue in the 
long term.''
    To help address this growing problem, I am working with my 
friend and colleague, Dr. Bucshon, on legislation to provide an 
annual Medicare payment update tied to inflation as measured by 
the Medicare Economic Index, the MEI.
    Even the March 2023 MedPAC report to Congress includes 
recommendations that Congress increase the 2024 Medicare 
physician payment rate above current law with an inflation-
based payment update tied to the MEI.
    It is critical that we move away from a system where every 
year there is uncertainty over potential cuts, threatening 
access for seniors across the country.
    Secretary Becerra, can you discuss the pressing financial 
instability facing physician practices, including the threat of 
yearly cuts combined with rising costs?
    Mr. Becerra. Congressman--and I know you know this well, as 
a physician--my wife, who is a physician also, will talk to me 
about this, and I know several members of this committee are 
physicians. It is tough. I mean, the workforce is strained. 
That is not different for doctors or nurses or other health 
professionals.
    We want to encourage people to go into these professions. 
We saw with COVID how important it is. And what I will tell you 
is I now will speak to you as a former Member of this chamber 
going through this exercise every year of trying to figure out 
physician payments. It is not just a headache, it is a real 
threat to how physicians can plan their life forward.
    And so I hope Congress is able to work in a way that gives 
us a--some certainty for physicians and others moving forward 
of what they can expect in terms of payment. You know, I wish I 
could tell you we could do more, but we are constrained because 
we have to be budget-neutral in whatever we do. So if we are 
going to increase payments in one place, we have to decrease 
them in another place.
    And so I think physicians around the world--around the 
country will tell you, come up with a better system.
    Mr. Ruiz. I agree. Thank you, and I look forward to 
continuing our work together on these important issues.
    Mr. Guthrie. Thank you. The gentleman yields back, and I 
recognize Mr. Johnson for 5 minutes for questions.
    Mr. Johnson. Well, thank you, Mr. Chairman, and thank you, 
Secretary Becerra, for joining us today.
    You know, fiscal responsibility is an issue that, 
unfortunately, is easily forgotten here in the Beltway--inside 
the Beltway. It is too easy to spend money that doesn't belong 
to you. And the idea of small government and not spending 
outside of your means is a sentiment in very short supply these 
days here in this city.
    Earlier this month, President Biden released a $1.7 
trillion budget that does nothing to change the frightening 
debt track that the United States is on. In fact, the 
administration continues to tout the fact that they are cutting 
roughly 10 billion in mandatory spending over the next year. 
But what is the catch? It is spending that is solely related to 
the COVID emergency.
    So I hate to bust the bubble, but you don't get to take 
credit for cutting spending on a pandemic that the President 
has personally claimed is already over. This spending should 
have ended a long time ago, but facts never seem to stop this 
White House from continuing its spending addiction.
    Today I am going to focus my questions and comments on the 
East Palestine train derailment and chemical fire that has 
upended the lives of my constituents in this small, rural Ohio 
village. A little less than 2 months ago, a train carrying 
hazardous materials derailed in East Palestine, Ohio, in my 
district, resulting in a controlled release of toxic chemicals, 
evacuation, and massive environmental cleanup. No family should 
ever be faced with this type of hardship caused through no 
fault of their own.
    And right now the biggest concern for these residents and 
for me is the long-term health and viability of their 
community. So, Secretary Becerra, earlier this month you said 
the administration would have a whole-of-government--I quote, 
``whole-of-government''--response to the train derailment. 
Could you explain how that involves HHS, and what you are doing 
on the ground in East Palestine?
    Mr. Becerra. Congressman, thank you. And if there are other 
things that we can do on this issue for the people of East 
Palestine, please let us know.
    Mr. Johnson. Thank you.
    Mr. Becerra. We want to be there as much for you and your 
constituents as we can.
    Mr. Johnson. OK.
    Mr. Becerra. But we know those families need----
    Mr. Johnson. Tell us what you are doing. I am sorry for 
interrupting you, but he is going to gavel me down in 5 
minutes.
    Mr. Becerra. We were one of the first on the ground. CDC 
was on the ground. We were doing the assessments, going door to 
door to find out what people were experiencing. That 
information we compiled in the data, because we wanted to find 
out what the health effects might be for the families there. So 
we were on the ground quickly, talking to hundreds of people 
there that were surrounding the incident.
    We also knew that there was a community health center that 
was providing most of the healthcare immediately to some of 
those families that needed help. We provided an emergency grant 
of $250,000 to that health center so they could continue to 
provide that extra care that they were not expecting to have to 
do.
    And so we continue to be on the ground. We work with the 
EPA and others within the Federal Government. I have been in 
touch with the health director at--for the State of Ohio, for 
the State of Pennsylvania. We will be in touch, but please let 
us know if there is more we can do. We are ready.
    Mr. Johnson. It is my understanding our local health 
department is continuing its own response efforts. And you just 
mentioned that you are coordinating with them to ensure there 
is no duplication of efforts, right?
    Mr. Becerra. We work with them. We don't do the--we try to 
support what they do.
    Mr. Johnson. OK. What is the process your agency is using 
to communicate information to healthcare providers, 
particularly in regards to highly vulnerable populations such 
as children, pregnant women, and the elderly?
    Mr. Becerra. We work with the State's health department and 
with your local health departments, because we are not the ones 
that are on the ground all the time, and we respect the work 
that they do and the relationship they have with the community. 
So we try to support in whatever ways they ask.
    Mr. Johnson. OK. And finally, currently there has been only 
one SAMHSA and one HRSA grant provided to on-the-ground efforts 
there in East Palestine. Are you using HRSA's already existing 
current emergency authority to issue these grants?
    Mr. Becerra. That is how we got some of the immediate 
funding to that community health center. And as I said, we put 
out the call, we have let them know, ``Let us know if we can be 
more helpful.'' I say that directly to the health director for 
the State, and we are ready to try to do what we can.
    Mr. Johnson. OK, thank you very much.
    Mr. Chairman, let it be noted I answered your call: Thirty 
seconds I am yielding back.
    Mr. Guthrie. Thank you. The gentleman yields back. The 
chairman recognizes Ms. Kuster for 5 minutes for questions.
    Ms. Kuster. Thank you, Mr. Chairman.
    And welcome, Secretary Becerra. Great to be with you today.
    The Department of Health and Human Services plays a pivotal 
role in protecting the well-being of our country, and this 
budget proposal reflects that. We all know COVID-19 took a 
harsh toll on the healthcare workforce, and I was glad to see 
the fiscal year 2024 budget support for workforce programs 
across HRSA and the CDC supporting the current workforce and 
investing in the future.
    We expanded the capacity of healthcare workers throughout 
the pandemic by adopting telehealth as an important tool. 
Telehealth not only allows a patient to receive care in the 
comfort of their own home, but it also empowers providers to 
use their skills in communities that need it most. And it is 
particularly important in a rural district like mine.
    Secretary Becerra, how can telehealth be used beyond the 
public health emergency to work across State lines, expanding 
access to rural and underserved areas?
    Mr. Becerra. Congresswoman, thank you for your work in this 
area, because it has become so essential to have access to 
healthcare through telehealth.
    Perhaps some of the greatest gains we have seen in COVID is 
behavioral health. We were having a lot of folks who, for 
reasons of stigma and other reasons, were not using services 
for mental health. And what we found is that having access to a 
physician or a provider at your home through telehealth made 
you more likely to participate, more likely to make your 
appointment. And so we hope that people recognize at a time 
when 9 in 10 Americans believe that America is experiencing a 
mental health crisis, that telehealth is indispensable.
    We need to continue to work with you because those 
authorities for flexibility on telehealth which you extended to 
the end of 2024, you can't have that cliff and all of a sudden 
have all those flexibilities expire. And so we need to work 
with you. We need to work with States to make sure we figure 
out if there is a possibility of having a cross-State provision 
of healthcare services, because right now a physician license 
in one State doesn't have a license to practice in another 
State. Telehealth has no borders. And so we have to figure that 
out as well.
    Ms. Kuster. Thank you. The budget also reflects this 
administration's commitment to ending the mental health and 
substance use disorder crisis. We made great strides last 
Congress, passing the bipartisan Restoring Hope for Mental 
Health and Wellbeing Act with a vote of 402 to 20. I think it 
was probably the most bipartisan vote we took.
    While this was important progress, we know that there is 
still a lot of work to be done, particularly in better serving 
the hard-to-reach populations. I look forward to working with 
my colleagues on reintroduction of my bipartisan bill, the 
Humane Correctional Health Care Act, that will end the Federal 
rule that prohibits Medicaid from paying for care for people 
who are incarcerated.
    I am also excited that Representative Tonko is 
reintroducing the Medicaid Reentry Act to allow for Medicaid 
coverage for 30 days prior to release, and I look forward to 
supporting Mr. Trone's legislation to allow Medicaid to cover 
pretrial detainees in the Due Process Continuity of Care Act.
    Medicaid is the largest public payer of behavioral 
healthcare, and it is essential that we defend the integrity 
and funding for this essential program as a bedrock of the 
Federal budget. Right now, people across New Hampshire are 
rallying behind the Medicaid program as the State considers 
making expansion permanent on a bipartisan basis. And I know 
there are a number of Republican States that have just made 
Medicaid expansion.
    Medicaid expansion has been an unqualified success. It has 
extended health insurance to millions of low-income people, 
helping to make them healthier and more economically secure. I 
am concerned about how some of the discussed cuts to Medicaid 
would affect deeply vulnerable individuals, particularly people 
with disabilities, seniors, and children with complex medical 
conditions.
    Could you describe what some of the consequences would be 
if the Federal Government suddenly cut funding for Medicaid 
expansion?
    Mr. Becerra. Well, Congresswoman, Medicaid has become the 
provider of healthcare for not just low-income Americans but 
for many middle- or lower-to-middle-income Americans who can't 
afford sometimes healthcare on their own.
    And if we were to see cuts to Medicaid, well, let's just 
put it this way. There were 8--close to 19 million Americans 
who received healthcare through Medicaid that was expanded. 
Forty of the 50 States have expanded their Medicaid program. 
That is about 19 million Americans. If we were to cut those 
things, you would quickly see millions of Americans return to 
the rolls of the uninsured.
    And I mentioned how we have never seen so many Americans 
have access to healthcare through their own insurance as we see 
today, more than 300 million. It would be devastating to move 
backwards instead of trying to get the rest of the country, the 
30 or so million Americans who still are not covered.
    Ms. Kuster. Secretary, my time is up, but I just want to 
point out that that would have a devastating impact on our 
workforce as well.
    Mr. Becerra. Yes.
    Ms. Kuster. So I yield back.
    Mr. Guthrie. The gentlelady yields back.
    Ms. Kuster. Thank you so----
    Mr. Guthrie. The Chair now recognizes Ms. Harshbarger for 5 
minutes for questions.
    Mrs. Harshbarger. Thank you, Mr. Chairman, and thank you, 
Secretary, for being here today. I want to delve right in and 
touch on a couple of issues which we have common ground on, and 
then some where there may be some disagreement.
    In one of our previous conversations we have talked about 
how pharmacy benefit managers have exploited the lack of 
transparency, created conflicts of interest, distorted 
competition, reduced choices for consumers, and ultimately 
increased the price of drugs. They are really putting the 
screws on independent pharmacists, by the way, and you know 
that, sir.
    Is there anything in the President's budget that would 
address or reform the PBM industry to make prescription drugs 
more affordable? And that is just a yes or a no.
    Mr. Becerra. It is--I have to qualify, because most of that 
reform would not be done through the budget. It would be done 
through the rules that we set. But we are absolutely trying to 
do reform and transparency.
    Mrs. Harshbarger. Well, I think we could work together on 
that, because there is strong bipartisan support in Congress--
--
    Mr. Becerra. Great.
    Mrs. Harshbarger [continuing]. To do that, especially on 
this committee.
    Mr. Becerra. I look forward to it.
    Mrs. Harshbarger. Let me turn to another topic that, to me, 
is an immediate threat, and it is about mail order of oncology 
drugs.
    Recently HHS, through frequently asked questions, 
implemented a prohibition on community cancer clinics from 
mailing their patients medicines directly, forcing patients to 
come into the clinic. Now, HHS waived this restriction through 
the public health emergency, but it is set to take effect again 
in May. And this is extremely disruptive to cancer care, and I 
have talked to these oncologists personally.
    And I want to follow up with more details in a written 
letter, but do I have your commitment to work with me and other 
concerned Members in Congress to resolve this issue?
    Mr. Becerra. Absolutely, you have my commitment.
    Mrs. Harshbarger. OK, fantastic. We will get that letter to 
you.
    Now let me move on to something you might not--well, you 
are probably familiar with, and I want to ask you a couple of 
things about the Federal workforce under your Department. Now 
you have about 83,000 Federal employees under the Department. 
Is that correct?
    Mr. Becerra. I am sorry?
    Mrs. Harshbarger. You have about 83,000 Federal employees--
--
    Mr. Becerra. Correct.
    Mrs. Harshbarger [continuing]. Under your Department.
    Mr. Becerra. That is correct.
    Mrs. Harshbarger. And about 4,000 of those employees work 
at CMS headquarters in Woodlawn, Maryland, correct?
    Mr. Becerra. I would have to check the number, but I will 
assume that you have a correct number.
    [Photo displayed.]
    Mrs. Harshbarger. OK. Well, I have--I want to show you this 
photo, and I am sure that you are absolutely familiar with this 
photo. It is an empty parking lot at CMS headquarters in 
Woodlawn, Maryland. This photo was taken on a Monday, March 
20th at 10:40 a.m.
    And Mr. Secretary, I assume that a good number of people 
will drive to the headquarters at CMS. And why is the parking 
lot empty, and on a Monday morning at 10:40 a.m.?
    My question is, do you have a breakdown of how many 
employees at CMS do telework on a regular, consistent basis, 
sir?
    Mr. Becerra. Congresswoman, we are working full-time. We 
have been working full-time since the pandemic. The fact that 
so many Americans have a vaccine that they have been able to 
use to save their lives----
    Mrs. Harshbarger. Well, can I stop you just a second? Would 
you give me the data on that?
    Mr. Becerra. I can certainly get you data on----
    Mrs. Harshbarger. Yes, that would be----
    Mr. Becerra [continuing]. On the workforce, and we will----
    Mrs. Harshbarger. Absolutely.
    Mr. Becerra [continuing]. Can try to respond to some of 
those questions.
    Mrs. Harshbarger. I would love to know how many people are 
working from home.
    I see in the President's budget CMS is requesting thousands 
more dollars for office rent. And my question to you is, why 
should we even consider more funding for office rent when you 
don't know how many people are showing up at the office?
    And there's also other areas in your Department that--you 
are potentially looking to get rid of property. You know, and 
this is--let me tell you this. This is what the American people 
see. They see an image or a situation that does not resemble 
good government. And it is not only outrageous to many Members 
in Congress, but it also is like a slap in the face to the 
Americans and the taxpayers that are coming to work and showing 
up, day in and day out, sir, because it is--that is their job, 
is to be on site. And we know, we have looked at studies, 
people are more productive when they show up in person. And I 
am a healthcare provider, and I have been for 37 years. I have 
to show up to do my job.
    So let me turn to one other thing. And--well, I may have a 
little bit of time--and it is about the future of Medicare. In 
a recent Washington Post editorial called ``President Biden's 
Medicare Solvency Plan,'' and I quote, ``political messaging, 
rather than a serious approach,'' and it places the entire 
burden of ensuring Medicare solvency on popular--on unpopular 
drug companies and high-income--implying incorrectly that 
structural reforms are unnecessary.
    And I will just say this. When a Democratic administration 
loses the faith of the Washington Post editorial board, you 
know things are not going in the right direction, sir.
    Would these Medicare proposals do anything to prevent 
Medicare costs from growing at a far faster rate than GDP?
    Mr. Becerra. Congresswoman, the fact that the President not 
only maintains benefits and protects them but also can do that 
for the next generation will be a great savings for all 
Americans who can have guaranteed healthcare when they need it.
    Mrs. Harshbarger. Well, I am out of time, sir, and I have a 
few other questions, but I will get those to you in writing.
    Thank you, sir, and I yield back.
    Mr. Guthrie. I now recognize the gentlelady from 
California, Ms. Barragan, for her 5 minutes.
    Ms. Barragan. Thank you, Mr. Chair.
    Thank you, Mr. Secretary, for being here today to testify. 
Thank you for all of your work, and thank you for joining the 
Congressional Hispanic Caucus on the road to talk about youth 
mental health and everything in the administration that you are 
doing to address youth mental health. I am sure we will be 
seeing you to continue on the road to talk about all of the 
accomplishments that we have been able to do in the last 2 
years that were--the people are going to barely start to feel. 
So thank you for that.
    There is an area which we have talked about before, and I 
want to take a moment here to recognize the amazing advocates 
that are sitting in purple behind you with the Alzheimer's 
Association. I stand with them in support of improving access 
to FDA-approved Alzheimer's drugs. And I know that you have 
heard it from me before, but I disagree with CMS's coverage 
decision to tightly restrict coverage for an entire class of 
FDA-approved Alzheimer's drugs. And I continue to just say I 
think there is a huge disconnect when the FDA can approve a 
drug and that CMS will not cover that drug.
    Just recently the VA also announced that they were going to 
cover one of the drugs that CMS won't cover, which is 
lecanemab. And so it seems to me there is just some real 
disconnect that we are trying to get to the heart of to see how 
we can fix that. It is one of the reasons that my colleague Dr. 
Joyce and I introduced the Access to Innovative Treatments Act. 
Our bill would ensure CMS fairly considers coverage for 
innovative drugs and therapies.
    And so this is an issue I am going to continue to work on. 
My mother has Alzheimer's. She is 82.
    We also know Alzheimer's is one of the biggest threats that 
we have, especially in our Latino communities who are at risk 
of developing this. And I think when we talk about budgets and 
we talk about cost, it is also going to have a huge dollar 
impact, you know, on our budget and access to care and 
healthcare.
    One of the good things, I think, that came out of what 
Democrats were able to do in the last couple of years is 
investing over $100 billion over 10 years for Medicaid home and 
community-based services. I want to thank you for that. That is 
something that Congress needs to continue to do, so that people 
like my mother who have Alzheimer's can stay in their home, 
which they know is the most familiar place, which helps them in 
their development.
    Mr. Secretary, I want to move on to a topic that is in the 
public now and is so critical, and that is the Medicaid 
unwinding. I want to thank you for your leadership on this, and 
thank you for your leadership in keeping Americans covered. As 
a result of your hard work, more Americans have healthcare 
coverage today than ever before. Uninsured rates are at an all-
time low.
    However, this achievement may be at risk. In just a few 
days, States will resume reviewing all Medicaid enrollees' 
eligibility, a process called Medicaid unwinding, on April 1st. 
Last August, HHS estimated that 15 million people could lose 
their Medicaid if the program operates as it did in the past, 
including nearly 5 million Latinos who are at risk. More than 
half of the people of color estimated to lose coverage will 
remain eligible for Medicaid.
    In response to these staggering numbers, Congress enacted 
strong beneficiary protections, required additional 
transparency from States, and authorized powerful new 
enforcement tools for HHS to use to protect our most vulnerable 
citizens.
    Furthermore, more than 60 members of the Congressional Tri-
Caucus, which is made up of the CHC, the CBC, and the Asian 
American Caucus, sent you a letter urging you to protect access 
to healthcare coverage during the unwinding.
    My question, Mr. Secretary: How do you plan to oversee 
States to ensure that they are complying with the law?
    And how will you commit to act swiftly to protect Medicaid 
beneficiaries if it is clear that a State is improperly 
disenrolling individuals?
    Mr. Becerra. Congresswoman, first, thank you for the work 
you are doing on this. We--I look forward to the partnership, 
because you are right. There is no reason why someone who is 
eligible to receive insurance should lose it and not have 
access to medical services simply because they did not get 
connected in time.
    A year ago--I think about--maybe even more than a year ago, 
I wrote a letter to all the Governors in our country, saying at 
some point we are going to be moving on from the public health 
emergency, and Medicaid will have to unwind, and people may 
lose their coverage, so let's start working together to 
prepare, because States, as you know, administer the Medicaid 
program for the Federal Government.
    We have since been following up with those Governors. I now 
write them every month, so they know where they stand. We don't 
want any Governor to say, ``Oh, I didn't realize that hundreds 
of thousands or millions of my residents were going to lose 
their coverage.''
    I am holding a copy of the letter I sent to our Governor in 
California, Governor Newsom. That was dated March 7th. This is 
a letter that every Governor--very similar--gets to tell them 
where they stand. We are going to bird dog this, and I want to 
say especially to those of you who supported the law that gives 
us more authority to oversee how----
    Mr. Guthrie. The time is expired.
    Mr. Becerra [continuing]. That unwind occurs to make sure 
that every State is responsible----
    Mr. Guthrie. Sorry, Mr. Secretary, the time is expired. So 
we are about almost a minute over, I apologize. So the Chair 
now recognizes Mr. Bilirakis for 5 minutes for questions.
    Mr. Bilirakis. Thank you, thank you, Mr. Chairman. I 
appreciate it very much.
    Mr. Secretary, I want to talk to you today about the health 
concerns plaguing the youth of our Nation. We have seen an 
influx of illicit fentanyl and other dangerous illicit 
substances coming across the southern border, all while we have 
an unprecedented mental health and substance abuse crisis.
    Our children are being poisoned by drugs that flood across 
our southern border. And I always say that fentanyl is a weapon 
of mass destruction. Many of these children do not realize that 
they are even encountering illicit fentanyl. Many utilize 
social media platforms to purchase pills that they believe are 
pharmaceutical grade but in fact are laced with fentanyl. And I 
know this has been mentioned before, but it is worth being 
mentioned again, that is for sure.
    The HHS budget suggests expanding the CDC's--and I quote--
What Works in Schools Program, centered around health education 
for middle and high school students. In this program the CDC 
has provided health education curriculum tools for schools to 
utilize--to help meet the health needs of students. This 940-
page document never mentions fentanyl or opioids, not a single 
time. For that matter, illicit fentanyl is only mentioned once 
in your HHS budget document, only twice in the President's 
budget. And I know that the chairman mentioned this, as well.
    Is there confusion at HHS about the deadly impact of 
illicit fentanyl when it comes to drug overdose deaths? Please, 
sir.
    Mr. Becerra. Congressman, I have heard the mention of a 
reference once or twice in the budget. I would say to you that 
we are addressing fentanyl not once or twice in the budget, but 
10 billion, 900 million times, because that is the amount of 
money that we are committing to fight drug overdose and 
fentanyl and opioids. And so we are in that mix. We don't have 
to say the word to be in the mix.
    And what we are trying to do is work with our communities 
locally to make sure they know that they will be supported by 
the Federal Government when it comes to addressing drug 
overdose, whether it is opioids, whether it is fentanyl. We 
want to be there with them.
    Mr. Bilirakis. OK, I will get on to the next question.
    Last year you told me--when I asked about the status of 
Medicare's transitional coverage of emerging technologies rule 
and also expressed concern about CMS acting as a second 
gatekeeper to the FDA, particularly due to the agency's 
misguided NCD decision on Alzheimer's treatments, you told me 
that the two agencies have two separate but distinct missions, 
but they were committed to working together to help provide 
seniors with new potential treatment options.
    Unfortunately, in the year since, we saw you--that exact 
opposite. Unfortunately, the exact opposite has occurred. And I 
know my colleagues have mentioned this, as well. CMS doubled 
down on its policies and blocked coverage for the entire class 
of these treatments when it comes to Alzheimer's.
    How is it possible for CMS to prejudge an entire class of 
drugs as not being reasonable and necessary for seniors after 
the FDA approves these very drugs to treat a safe and 
effective--for Medicare patients with Alzheimer's, the primary 
audience for these drugs?
    And this is hope for Alzheimer's patients. It is hope for 
our families and caregivers. So please, sir, answer the 
question, and let's reverse this ruling by CMS. I mean, isn't 
FDA responsible for making these decisions?
    Mr. Becerra. Yes, Mr. Chairman, thank you very much.
    And for all Americans who are interested in this subject, 
not just because a family member has Alzheimer's but just 
because this is the kind of thing that could hit their family 
at any time, I want to make sure we are clear. We are 
following, Congressman, the law that you all have passed--maybe 
not you today or in the last few years, but the law that is in 
the books treats FDA and CMS differently. The standards that 
apply to FDA are different from the standards that CMS must 
apply.
    And so it wasn't that CMS prejudged or that it didn't 
follow what FDA did and said, it is that the CMS is not, by 
law, under the laws that Congress passed, supposed to just 
follow FDA or judge based on what FDA does. CMS, like FDA, must 
collect the evidence to make decisions.
    FDA makes the initial decision: Is this a drug that should 
be put out into the market for American consumers to have 
access to? Is it safe and effective?
    CMS has a different standard by law, established by 
Congress----
    Mr. Bilirakis. What is that standard?
    Mr. Becerra. Reasonable and necessary is probably the 
shortcut way of saying what CMS must look at for purposes of 
determining whether it will provide access to a particular 
treatment or medication.
    Mr. Guthrie. Great, thanks. Time has expired. I let you go 
on because we are all interested in that, and I know a lot of 
people in this room are interested in that as well. So we 
appreciate it.
    Dr. Schrier, you are now recognized for 5 minutes.
    Ms. Schrier. Thank you, Mr. Chairman.
    And thank you, Secretary Becerra. Thank you for being here 
today. Thank you for the work you have done to make healthcare 
more affordable and accessible for the American people. And 
thank you specifically for coming to my district to visit a 
school-based health clinic, which is pretty remarkable. And I 
want to thank you for including support for school-based health 
centers in your budget.
    Today there are so many things to focus on, I thought I 
would focus on healthcare access from a couple of perspectives.
    First, in your testimony you discussed the importance of 
expanding and retaining the healthcare workforce. In the wake 
of the pandemic we have seen early retirements, resignations, 
mostly in doctors and nurses, and these shortages are already 
being felt in rural areas and underserved areas.
    I saw that there is funding in the budget for innovative 
approaches to train up some other parts of our healthcare 
system, which is great. But I just want to focus on the 
importance of graduate medical education needing a bigger 
pipeline in order to respond to physician shortages. And I know 
it is a lengthy training, but you have got to start somewhere.
    I have been working on bipartisan efforts to enhance both 
the rural and pediatric workforces. One of my recent bills with 
my colleague Representative Harshbarger is the Rural Physician 
Workforce Protection Act, which aims to put more providers in 
residency programs in rural areas because where people train, 
as you know, they stay.
    I was wondering if you could talk about your plans to 
strengthen GME, and also if you could touch on pediatric 
graduate medical education.
    Mr. Becerra. First, I have to say what you just said is 
music to our ears at HHS. We believe that where a physician 
trains probably will determine where that physician practices. 
And so, therefore, to the degree that we can drive through the 
graduate medical education programs these graduate slots, these 
residency slots into communities like rural communities, low-
income communities, we have a chance of ensuring that they will 
stay there to practice. And so we support that.
    Our Public Health Service Corps, we are sending more people 
into communities that are disadvantaged. We pay your education 
for 4 years of medical school or nursing school, and then you 
commit to 5 years of service in an underserved area, a rural 
community, otherwise. So we are going to try to----
    Ms. Schrier. Thank you. Music to my ears.
    Mr. Becerra. Yes.
    Ms. Schrier. You know, I wanted to--just this week in a 
meeting I heard that there are some new restrictions on 
residency funding so that that cannot be used to have 
residents, say, at an urban hospital do some of their rotations 
in rural areas unless there is special set-aside funding. So if 
you could just take a look at that, that would be counter to 
what we want to do in rural America.
    Mr. Becerra. OK.
    Ms. Schrier. Let's see. I also wanted to talk about 
retaining the workforce that we have. I want to associate 
myself with the comments made by Dr. Ruiz about the continuing 
threats of Medicare cuts and how that impacts the workforce. 
And we just ask that, at a minimum, we don't cut and, ideally, 
have it keep up with inflation, because there is definitely a 
squeeze.
    Mr. Becerra. And Congresswoman, recognize that we have to 
live with a neutral process.
    Ms. Schrier. Yes.
    Mr. Becerra. So if we increase in one place, we have to 
decrease somewhere else. We don't have a choice. We need you to 
change that.
    Ms. Schrier. Maybe that neutrality is the problem. I am 
happy to talk with you about that and to work on that.
    Let's see. I also wanted to talk about Medicaid 
reimbursement, which is even lower than Medicare reimbursement. 
And I have a bill, the Kids Access to Care Act, which boosts 
Medicaid to Medicare reimbursement, which I am working on. And 
I hope you will pay attention to that too.
    And lastly, this is a big thank you just about the 
importance of the Affordable Care Act and the subsidies that we 
included in the Inflation Reduction Act that have really made a 
difference at the kitchen table for my constituents. Premiums 
are at an all-time low. Enrollment is at an all-time high. In 
part of my district in a rural area, 82 percent of people on 
ACA plans saw their premiums reduced by an average of $450 a 
month, and that matters at the kitchen table. So I want to 
thank you.
    I am short on time, but if you want to touch on the 
importance of making those subsidies, those tax credit 
enhancements permanent, I would love to hear a couple of words.
    Mr. Becerra. Congresswoman, it is all about peace of mind. 
If you know that you can take your child to the hospital when 
it is necessary and you don't have to fear going bankrupt or 
not being able to pay the mortgage, it is peace of mind. And 
every American should have that. There is no reason why some 
families in America can't make that decision the right way, 
which is give my child the care he or she needs.
    Ms. Schrier. Thank you.
    Mr. Becerra. Thanks.
    Ms. Schrier. I yield back.
    Mr. Guthrie. I thank--the gentlelady yields back. The Chair 
recognizes Mr. Hudson for 5 minutes.
    Mr. Hudson. Thank you, Chairman.
    Mr. Secretary, thank you for joining us today. I have a 
number of questions, so I think I will jump right in.
    For the last several years, FDA has allowed certain e-
cigarettes and vaping products with pending premarket tobacco 
application to be sold. Unfortunately, FDA has failed to 
publicly communicate in a transparent manner which of these 
products have filed a PMTA and therefore are allowed to remain 
on the market. The result is marketplace confusion and a 
related proliferation of illegal vapor products on store 
shelves.
    In addition to the agency's failure to provide regulatory 
clarity to consumers and retailers on what products may be 
lawfully on the market, FDA's Center for Tobacco Products is 
also facing an unprecedented backlog in new product 
applications.
    While I understand that CTP is still in the process of 
reviewing applications for both PMTAs and nontobacco nicotine 
products, some applicants are experiencing historic wait times 
on hearing back from the center on the status of their 
applications. This does affect consumer and industry confidence 
in the administration's ability to bring innovative, next-
generation products to the market.
    Mr. Secretary, does the administration have any plans to 
use your enforcement discretion to remove these illegal e-
cigarette and vapor products, a majority of which come from 
China, from the market?
    And additionally, will this administration commit to ending 
the confusion surrounding the legality of these products?
    Mr. Becerra. Congressman, I look forward to working with 
you on this subject, because if I were to ask you how many 
applications do you think FDA received to put a vaping product 
on the market, what would you say?
    Mr. Hudson. Hundreds.
    Mr. Becerra. Hundreds? Over--I think it was 5 million.
    Mr. Hudson. Wow.
    Mr. Becerra. And so that has been the issue. We have--we 
were flooded with applications, some really not worth the paper 
they were written on. But this way they could try to escape 
having direct action taken against them, enforcement action.
    And so what I can tell you is FDA has disposed of well over 
90--I think close to 98 percent of all of those claims. They 
are moving hard. It is just that you haven't seen that because 
so many of them they had to dispose of were essentially 
frivolous. Now we are being sued because there are companies 
that don't like the determinations we have made.
    So I would look forward to working with you, because we are 
doing everything we can to get some of these products, which 
you and I know have no reason to be on that shelf, a grocery 
shelf, we need to take them off. So I look forward to working 
with you on that.
    Mr. Hudson. Absolutely. I commit to working with you on 
that. Thank you.
    What is CTP's plan to mitigate the current backlog, though? 
I mean, I realize it is larger than I thought it would be, but 
do you--what is your plan for----
    Mr. Becerra. The backlog--there is no--the backlog is not 
so much a backlog, it is we are being delayed by litigation. We 
can't move forward on a particular product.
    The larger companies are the ones that are putting lots of 
attorneys in front of us and suing us. They are the ones that 
have the majority of the products. And because we are in 
litigation, because we are being sued, we are--it essentially 
puts a halt on a lot of our enforcement. But we have taken 
recent enforcement actions. We are working with the Department 
of Justice to help us enforce on those actions.
    And as I said, I would love to have that conversation with 
you, because we could use some help in letting the public know 
what is really going on out there.
    Mr. Hudson. Yes, great.
    Well, switching gears in the little bit of time I have left 
here, I had the honor to work with my colleague Anna Eshoo on 
reauthorization of the Pandemic and All-Hazards Preparedness 
Act, and we look forward to working with you in a bipartisan 
manner on this important reauthorization.
    A recent GAO analysis tracking COVID-19 funding and 
spending found Congress has appropriated nearly 350 billion to 
the Public Health and Social Services Emergency Fund, also 
known as PHSSEF. This funding was intended to support and 
improve the Nation's preparedness and response for COVID-19 and 
other public health emergencies. According to the report, as of 
January 31st there remains about 20 billion in unexpired and 
unobligated funds within this fund.
    Just this morning, the Bloomberg reported, based on a 
breakdown directly from the White House, that over 98 percent 
of the money from COVID relief bills, including this fund, had 
been committed, leaving about 4.5 billion. I then learned from 
the Appropriations--my Appropriations counterparts this morning 
that there's actually approximately 5 to 6 billion unobligated 
as of March 20th.
    Could you help us provide a little bit of clarity here? I 
think this committee deserves a little bit more information on 
an accounting, a summary of what is obligated, what is not, and 
what HHS's plans to allocate and distribute all this unspent 
money is.
    Mr. Becerra. Yes, and Congressman, I commit to follow up 
with you on this, because I know we are going to run out of 
time.
    But what I will say is, first, thank you for the leadership 
you have shown on the--because I think what we are trying to do 
is build that infrastructure.
    We can get back to you on the actual dollars that are left. 
Ninety-six percent of all of the COVID dollars have already 
gone out the door. The 4 or so percent that remain, 4 to 6 
percent that remain, are unobligated but are in the pipeline to 
be, you know, signed on the dotted line. So there is not a lot 
of money that is uncommitted. Unobligated makes it sound like 
it is not yet committed. It really is.
    But I can talk to you. We can go through the numbers. But 
what I would really love to talk to you about is how we follow 
up because what we need to do is strengthen our domestic 
production. We have to secure our supply chains. And I suspect 
you know all of these things, so I would be interested in 
soliciting your support.
    Mr. Guthrie. Thanks----
    Mr. Hudson. Absolutely. I look forward to working with you.
    And Mr. Chairman, thank you. I yield back.
    Mr. Guthrie. The gentleman yields back. The Chair 
recognizes Ms. Blunt Rochester for 5 minutes.
    Ms. Blunt Rochester. Thank you, Mr. Chairman.
    And thank you, Secretary Becerra. Good to see you. Thank 
you for joining us in Delaware to focus on child mental health 
and for joining us today to discuss the President's fiscal year 
2024 budget for the Department of Health and Human Services.
    I am pleased that a few of my colleagues have touched on 
workforce issues, which underscores how important we think this 
is. But I want to focus specifically on the nursing workforce.
    With over 5 million people nationwide, nursing is the 
Nation's largest healthcare profession. Therefore, a robust 
nursing workforce is critical for improving health, economic 
security, and equity in our country. During the COVID-19 
pandemic, the already overstretched nursing workforce struggled 
with a host of new and intensifying challenges. And now they 
are leaving the profession in record numbers.
    Secretary Becerra, the President's budget outlines several 
proposals to reduce healthcare workforce shortages, including 
the nursing workforce. Can you discuss why innovative 
approaches to strengthen retention and address healthcare 
workforce shortages are necessary?
    Mr. Becerra. Congresswoman, it is hard to have good 
healthcare if you can't find a good healthcare professional. 
And we have already had lots of discussion about how it has 
become tough, whether physicians, nurses, other healthcare 
professionals. And so we are going to be in this game for a 
while because we need to support these efforts.
    We are providing additional funding for the National Health 
Service Corps, which as you know helps put professionals in 
some of our most disadvantaged communities. We are increasing 
graduate medical education funding. We are providing 
scholarship and loan repayment programs for clinicians who 
return to practicing in underserved areas. We are beefing up 
primary care physicians. We are doing quite a bit.
    Ms. Blunt Rochester. Great, thank you. I am concerned that 
the nursing landscape is evolving more rapidly than our current 
methods of data collection and analysis. And I am also 
concerned that we don't have a centralized, dedicated body to 
study and advise on ongoing nursing workforce trends as they 
occur.
    What is the administration proposing to ensure that 
policymakers, healthcare leaders, and educators have up-to-date 
and actionable information on emerging nursing trends?
    Mr. Becerra. We are in the process of fielding the National 
Sample Survey of Registered Nurses, which will give us the data 
we need to figure out where we are, what we need to do. We are 
going to work with HRSA to try to make sure that we put 
resources into those areas that help us beef up the workforce, 
and we look forward to working with you.
    Ms. Blunt Rochester. And how is the administration working 
with and supporting State-based entities like nursing workforce 
centers that use a local lens to address the nursing shortage 
within their respective States?
    Mr. Becerra. Well, they are our principle guides, because 
they know where we have to put the resources, where folks have 
to be. And so we intend to work closely with them.
    Ms. Blunt Rochester. Thank you for that answer. I believe 
that improved Federal and State coordination is needed to 
monitor nursing shortages, coordinate strategies to alleviate 
the pressures on the nursing workforce, and advise 
stakeholders. I am glad to share that Congresswoman Young Kim, 
Senator Merkley, and Senator Tillis and I introduced the 
bipartisan Nursing Workforce Shortage--Nursing Workforce Center 
Act to do just that. I look forward to working together with 
you on this and other healthcare issues.
    Switching gears, health centers are a critical part of the 
healthcare safety net, treating a sicker, poorer, and more 
diverse population than most other healthcare providers. The 
President's budget includes several proposals to improve the 
reach of health centers by expanding mental health and 
substance use disorder care, increasing hours of operation, and 
funding new access points for high need areas.
    Can you describe the President's proposal and explain to us 
why enhanced funding will increase access to affordable, 
comprehensive, and high-quality primary care services?
    Mr. Becerra. Congresswoman, as you know, some of the real 
champions and stellar performers during COVID were our 
community health centers. They stepped forward and provided 
care to people who didn't have insurance, who couldn't access 
regular care through a physician's office or a hospital. And 
they did the large work when it came to saving lives in COVID.
    We have put additional resources, quite a bit of money into 
these centers, the 1,400 or so health centers around the 
country. They service tens of millions of Americans, and they 
are proven, they are successful. We are going to continue to 
fund them. We are increasing funding. We want them to get more 
into behavioral health. They are limited in their funding, so 
sometimes they can't do certain services, but we hope we can 
help them get there.
    Ms. Blunt Rochester. I am really pleased, again, to see the 
expansion of also hours and access, because that is really 
important, too.
    And I want to thank those who are here today from the 
Alzheimer's, our patient advocates, and others. We look forward 
to continuing the partnership.
    Thank you, Mr. Chairman, and I yield back.
    Mr. Guthrie. Thank you. The gentlelady yields back. The 
Chair recognizes Dr. Bucshon for 5 minutes.
    Mr. Bucshon. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary. As my colleagues heard yesterday, 
one of my legislative priorities is to increase transparency 
and accountability in the 340B program. In a letter from 2020, 
you described the 340B program as, and I quote, public--``for 
public hospitals, community health centers, and others serving 
indigent patients.'' Do you still believe that?
    Mr. Becerra. I do.
    Mr. Bucshon. Great. I am sure you may have read the New 
York Times article--and there's other articles and other 
sources from--this was from last September--describing how 
certain large hospital systems have bought up 340B-eligible 
entities in low-income areas and then used this location to 
obtain 340B eligibility in their facilities in more prosperous 
areas, and essentially pocket the profits with--and fail to use 
this money to help the patients as the program was intended.
    Do you agree that the 340B program participants should be 
accountable for how they use savings from the program?
    Mr. Becerra. Absolutely.
    Mr. Bucshon. In 2018, as attorney general for California, 
you sued Sutter Health, one of the largest hospital systems in 
the State, alleging that Sutter aggressively bought up 
hospitals and physician practices and exploited that market 
dominance by raising prices. Certain Sutter hospitals, 
including Sutter Davis, Sutter Medical Center Sacramento, and 
Alta Bates Summit Medical Center, participate in the 340B 
program. If Sutter was failing to meet your expectations as a--
and I quote--``public hospital community health center or other 
provider serving indigent patients,'' should it continue to be 
a 340B-designated facility?
    Mr. Becerra. I----
    Mr. Bucshon. That is complicated question, I understand.
    Mr. Becerra. Yes, yes, but I am glad you asked it, because 
what we don't want is to find that there is opaqueness, there 
is little transparency in how money is being used, that 340B 
doesn't have the transparency we need.
    What I will tell you, with Sutter Health we found that they 
were engaged in practices that were stifling competition----
    Mr. Bucshon. Sure.
    Mr. Becerra [continuing]. Increasing prices.
    Mr. Bucshon. Yes.
    Mr. Becerra. What we--that is not what we want. And we want 
to make sure that, on 340B, we are not driving pharmacists out 
of business. We are making sure community clinics can receive 
the medicines they need. We are going to do what we can to make 
it more transparent.
    Mr. Bucshon. Yes. I mean, the whole point of that line of 
thought right there that I had was to show that you really just 
don't know whether they should--whether they are acting well in 
340B or not, because there is no transparency, right?
    Mr. Becerra. That is right.
    Mr. Bucshon. In 2014, Kathleen Sebelius, then Secretary of 
the Department of Health and Human Services for the Obama 
administration, testified before the Senate Finance Committee 
on the President's fiscal year 2015 budget. In response to a 
question on 340B she said--and I quote--``it had been expanded 
beyond its bounds.''
    At that point there were 9 billion in sales in the 340B--at 
the 340B price. In 2021 there were 44 billion in sales at the 
340B price. The number of covered entity sites has more than 
doubled since 2014 to 50,000 sites. And now more than half of 
all hospitals in America participate in the 340B program, 
according to MedPAC.
    I do want to say, though--I failed to mention that--I am a 
huge supporter of 340B, if done properly. My community 
hospitals need this program. My intent is to make it 
transparent, so that it doesn't continue to struggle and 
jeopardize their participation.
    But it seems to me that, logically, such an expansion would 
also mean exponential growth in the amount of charity care and 
other patient benefits. You would think. That was how the 
program was intended, right? But that is just not the case that 
we have seen over the last 8 years. So what are your thoughts 
on that?
    Mr. Becerra. So we are trying to do reforms in 340B. We 
need your help to have statutory authorities to make some of 
these changes. We know that there has been a lot of lawsuits 
filed because of 340B.
    What I will simply say to you, compliance, transparency, 
two crucial aspects of making sure----
    Mr. Bucshon. You need legislative action for most of that, 
some of that?
    Mr. Becerra. A great deal of it.
    Mr. Bucshon. Yes, well, I am working on that.
    I want to talk briefly about the No Surprises Act. As you 
know, this took the patients out of the picture. They no longer 
get surprise medical bills from out-of-network providers, which 
is a tremendous success.
    However, as you probably might imagine, I was disappointed 
in the implementation from the agency, which I feel didn't 
follow congressional intent. I know the people on Capitol Hill 
that didn't get their way tried--now are trying to do it 
through the agencies. I know that. So I would just--I don't 
have much time, but, you know, I would hope that, you know, the 
intent of the law was to have a balanced approach between the 
providers and the insurance companies.
    And I recently heard in the IDR situation the--you know, 
the dispute resolution, that even though providers are winning 
those cases, we still don't have insurance companies actually 
paying after they have lost. So we need to see what we can do 
to make sure that that happens.
    With that, I yield back.
    Mr. Guthrie. Thank you. The gentleman yields back. The 
Chair recognizes Ms. Craig for 5 minutes for questions.
    Ms. Craig. Thank you so much, Mr. Chairman, and thank you 
so much, Secretary Becerra, for taking the time to answer our 
questions about HHS's proposed budget. It is so good to see you 
again.
    I had to step out for a few minutes of our hearing, but I 
am just wondering, did my colleagues on the Republican side of 
the aisle issue a budget while I was away?
    Mr. Becerra. No, Congresswoman.
    Ms. Craig. OK. OK, good. I just want to make sure I was up 
to date.
    I want to use my time today to discuss the mental health 
and substance use disorder crisis currently facing our Nation.
    I represent the 2nd congressional district of Minnesota. 
Our State is home to some of the most recognizable names in 
healthcare, including the Mayo Clinic and a host of medical 
technology companies. We consistently rank in the top 10 of all 
States for access to and quality of care, and we have recently 
emerged as a beacon of reproductive and gender-affirming care 
in a country where States have grown increasingly hostile 
toward the concept of individual choice and freedom.
    In short, in Minnesota we have a lot to be proud of.
    But as--even as Minnesota operates on the cutting edge of 
healthcare, I am hearing from my constituents that mental 
health and substance use disorder-related crises are only 
rising. Often our law enforcement officials, our healthcare 
workers, and our teachers are being forced to intercede outside 
of their areas of expertise to de-escalate dangerous 
situations. And it is causing a malicious cycle of mental 
stress for both them and the people in their care.
    According to a recent analysis published in the Minneapolis 
Star Tribune, which I would like to ask to be entered into the 
hearing record----
    Mr. Guthrie. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. Craig. The number of behavioral and mental health 
patients transferred from hospitals in the Twin Cities area to 
out-of-State facilities more than doubled from 66 in 2017 to 
154 in 2021.
    Further, hospital-based mental healthcare workers are in 
short supply, with 80 percent of Minnesota counties designated 
as areas with a mental health shortage.
    From 2011 to 2021, the age-adjusted death rate due to 
opioid overdose in Minnesota increased from 5.3 per 100,000 to 
17.9 per 100,000, more than threefold.
    I am proud of the bipartisan work we have done on the 
Energy and Commerce Committee to improve mental health across 
the Nation. I believe we have to attack these overlapping 
national crises head on through a comprehensive, whole-of-
government approach.
    So Secretary Becerra, can you describe how the Department 
coordinates with other agencies like the Office of National 
Drug Control Policy and the Drug Enforcement Administration?
    Mr. Becerra. Congresswoman, thank you for the question and 
for the work that you have done on this issue.
    Because drugs fall under the jurisdiction of Health and 
Human Services as medicines and because they fall under the 
jurisdiction of the Department of Justice when it comes to 
enforcement of our laws, drug laws, we have a joint effort that 
takes place on some of these matters.
    Oftentimes we find that, in trying to move in a direction, 
for example, making medications more available, that it might 
be listed as harmful drugs or drugs that can be abused. We find 
that law enforcement and the health sector don't always see eye 
to eye. DoJ, DEA, ONDCP, Office of National Drug Control 
Policy, all of us working together with HHS and others, we try 
to make sure that we are consistent in the way the Federal 
Government handles this.
    For HHS, we want to make sure we are concentrating on 
health and making sure that whatever we do with our policy on 
drugs, it provides for the best outcome, healthcarewise. And so 
we work with our different agency partners to make sure we can 
move forward. That is why, for example, on the X waiver, we 
were able to make it possible for physicians to actually 
prescribe treatments that could help someone survive an 
addiction--at the same time, wouldn't put themselves in 
jeopardy of being accused of actually trying to feed a drug 
habit.
    Ms. Craig. Mr. Secretary, I just want to end with I am 
incredibly pleased to see--request 190 million in increased 
funding for 18,000 new behavioral health providers and expand 
Medicare coverage of and the payment for additional behavioral 
health professionals. We appreciate your continued focus on 
these areas that are going to help support underserved 
communities and, in particular, rural areas.
    So appreciate it, and thank you for coming.
    Mr. Becerra. Thank you.
    Ms. Craig. I yield back.
    Mr. Guthrie. Thank you. The gentlelady yields back. The 
Chair now recognizes Mr. Carter for 5 minutes.
    Mr. Carter. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for being here. It is always good 
to see you. Mr. Secretary, as you are aware, we have had quite 
a bit of consolidation in healthcare----
    Mr. Becerra. Yes.
    Mr. Carter [continuing]. Here in the recent years, 
including and certainly not limited to in pharmacy and in drug 
pricing. And I am very concerned about that. I am very 
concerned that now we have three PBMs, 3 PBMs that control 80 
percent of the market. And those PBMs, all three of those, are 
owned by an insurance company. The insurance company not only 
owns the PBM, but it also owns the pharmacy. That vertical 
integration is something that I have been asking in the 8 years 
that I have been in Congress for the FTC to look at. Finally, 
last summer, they agreed to do 6(b) study, and they are looking 
at that now.
    But it is not just in drug pricing. It is in healthcare 
altogether. It is also with hospitals. There have been almost 
1,800 hospital mergers between 1998 and 2021, leading to about 
2,000 fewer hospitals in this country than we had before. This 
consolidation in healthcare is such a problem.
    We had the CBO here before us and before this committee, 
before the Energy and Commerce Committee. We had the director 
of the CBO, the Congressional Budget Office, as well as about 
20 of his staff members. And I asked them pointedly the 
question: ``Give me one example--one example--of where 
consolidation has saved money.'' Nothing. None of them could 
give me one example of where consolidation had saved money.
    Now, look, you have been a member of this august body, and 
you understand we all want the same thing, regardless of which 
side of the aisle you are on. We want affordable, accessible, 
quality healthcare.
    And I know that the administration, the Biden 
administration, has repeatedly said that competition--they want 
more competition across all industries in America. Given that, 
can you tell me what HHS's proposed budget does to address 
healthcare vertical integration and consolidation?
    Mr. Becerra. And Congressman, I will mention that when I 
was attorney general I took on hospital consolidation in 
California. It is a problem. It is not coordination of care. It 
is the consolidation which leads to less care that we are 
concerned about.
    HHS doesn't have the direct jurisdiction to deal with 
consolidation as you speak. That is more in the jurisdiction of 
the Department of Justice and the FCC. But we do try to make 
sure that care is coordinated, but not in a way that removes 
competition.
    Mr. Carter. I would submit to you--and I mean this 
sincerely--I don't know that there has been another agency in 
the Federal Government that has failed the American people more 
than the FTC has in allowing this consolidation to take place, 
not only in drug pricing, not only with the insurance companies 
owning the PBM, owning the pharmacy, with spread pricing, with 
everything that is going on--and you are aware of it, you know 
what is going on.
    There was a study done by the Berkeley Research Group--and 
granted, it is a little bit aged now, but it was last year, in 
March of 2022. It showed that only 33 percent--only 33 
percent--of the price of a drug goes to the pharmaceutical 
manufacturer, which begs the question, where does the other 67 
percent go? It goes to the people who--to the middleman. We 
have got to address that. It is so clear and such an abuse.
    And then we see the egregious practices that are taking 
place with the PBMs. I have got a bill now, the Help Copays 
Act, that--they are not allowing a credit from a manufacturer 
to go toward their deductible. They do not allow that. It is 
just awful.
    Let me switch gears for just a second. In October of 2022 
on social media--a social media post, after swearing in the new 
Director at the National Cancer Institute, you tweeted, 
``Cancer knows no bounds, and neither should our efforts to 
prevent cancer deaths. Together, we will advance Cancer 
Moonshot.''
    As you know, in the IRA there was a part in there that 
dealt with drug pricing. And you are aware of that and, I am 
sure, trying to implement it and administer it now. The CBO has 
said that that is going to result in 15 fewer cures in the next 
30 years.
    How can you say that we are going to advance Cancer 
Moonshot when we are eliminating, potentially, 15 cures in the 
next 30 years, a cure that could be the cure for Alzheimer?
    Mr. Becerra. Congressman, I actually disagree with that. I 
think you are going to see more than 15 new cures come on the 
market over the next several years, as a result of the 
legislation that we have.
    Mr. Carter. Then why did CBO say that? I didn't say it, CBO 
said it.
    Mr. Becerra. That is a question you would have to ask CBO.
    Mr. Carter. So you disagree with that?
    Mr. Becerra. I disagree.
    Mr. Carter. Unbelievable. Thank you, Mr. Secretary, for 
being here.
    Mr. Becerra. Thank you.
    Mr. Guthrie. The gentleman's time has expired. The Chair 
now recognizes Mr. Crenshaw for 5 minutes.
    Mr. Crenshaw. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for being here. I want to follow 
up on that, because it bugs me.
    I thought it was actually 30 drugs that the CBO estimated 
would not exist, and plenty of other estimates have much, much 
higher. We have already seen--we have talked to industry--we 
have already seen the dollars drying up from investing in what 
they would call higher-risk investments. That would definitely 
be Alzheimer's.
    So drug companies are going to do--because of this price 
cap rule, what they are going to do is they are going to invest 
in ``safer investments.'' So the drug companies will be fine. 
They will be fine. Do you know who won't be fine? Alzheimer's 
patients who want that cutting-edge drug. That is a fact. And 
you guys can sit there comfortably in your position on this, 
because you know that we can never prove the counter-factual, 
because there is another element of history that we will never 
know about. And it is very, very frustrating.
    But I want to talk about your budget. So one thing that 
concerns me--and the chairman mentioned it--is the President's 
budget mentions climate change 42 times, mentions fentanyl 
twice. What is the leading cause of death for adults aged 18 to 
45?
    Mr. Becerra. Congressman, I would mention that while we may 
have mentioned the word fentanyl, we put $10.9 billion more 
than I think any administration has to----
    Mr. Crenshaw. All right, let's--I appreciate that. I am not 
sure what that money is going towards, but----
    Mr. Becerra. We can----
    Mr. Crenshaw. It is opioid. I mean, the answer to my 
question--you didn't answer my question, but it is opioids, so 
I will just answer it for you. It is opioid overdose, right? 
And most of that is fentanyl. We lose about 100,000 people or 
more to opioid overdose. Almost 80,000 that is fentanyl 
directly related. You can't even compare that kind of number to 
climate change. Not even close.
    If we want to actually compare--let me ask you, actually. I 
mean, is HHS in charge of regulating carbon emissions? Am I 
missing something here? Why do you guys have an Office of 
Climate Change and Health Equity funded in this budget?
    Mr. Becerra. Congressman, I think it is a proven fact that 
the impacts of climate change are affecting the health of 
Americans and people around the world.
    Mr. Crenshaw. How have you quantified that?
    Mr. Becerra. Excuse me?
    Mr. Crenshaw. How have you quantified that?
    Mr. Becerra. I can get you some of the research that has 
been done. I can show you some of the communities that have 
been affected. We can do any number of ways to quantify it 
that--you can let me know.
    Mr. Crenshaw. I have a way of quantifying it. Here, I will 
help you out.
    So in the last--since 1900, deaths from--due to nature have 
plummeted by over 90 percent. They have actually plummeted over 
70 percent just since Biden took office. So weather accounts 
for somewhere around 0.07 percent of worldwide deaths, 0.01 
percent in the United States. And that is with the--by the way, 
with the population increasing, like, tenfold.
    So there is a completely negative correlation there, and we 
are pretending like it is a crisis, and we are scaring people 
to death about it. And you are telling hospitals that they 
should be going to net zero.
    Of all of the locations in America that I would want to 
have reliable energy sources because people are on life 
support, I think hospitals would be one of them, right? And if 
hospitals go to net-zero emissions, what kind of effect is that 
going to have on our temperature in 100 years?
    Mr. Becerra. A hospital is one of the major--well, the 
healthcare sector is one of the major contributors to pollution 
in the world.
    Mr. Crenshaw. What? How did you--how do you quantify that?
    Mr. Becerra. We can get you the information that shows that 
the healthcare sector, because of its production of lots of 
different--and uses of lots of different chemicals, the fact 
that it is a very widespread industry, it does have a major 
impact on the climate.
    Mr. Crenshaw. And so you are just going to get rid of these 
chemicals?
    Why don't we get rid of plastics too, the plastics that are 
used for medical devices that save people's lives, is that a 
good idea?
    Mr. Becerra. I think most people would say to you that 
there is a use for plastics, but we don't have to have so much 
plastic in the world that it is causing major degradation of 
our environment.
    Mr. Crenshaw. What you are saying is terrifying. What you 
are saying will harm people. I mean, high-quality plastics are 
used in an extraordinary way for cutting-edge medical devices. 
They are used in everything in a hospital.
    What percentage do you think our healthcare sector 
contributes to overall carbon emissions?
    Mr. Becerra. Well----
    Mr. Crenshaw. You said it was significant. You said it is 
one of the most significant. So what is the percentage? Do you 
have a ballpark?
    Mr. Becerra. Of the industry that--of the----
    Mr. Crenshaw. So you just said the healthcare industry is 
one of the biggest contributors to carbon emissions. So do you 
have a ballpark percentage of what that might be?
    Mr. Becerra. I don't have it in front of me, but I can get 
you that information.
    Mr. Crenshaw. I think it is probably less than a percentage 
point. I mean, I see these numbers all the time, especially on 
this committee. Transportation is a big one, right? Power 
production is a big one. The healthcare sector is a big one? 
That is what you are saying?
    Mr. Becerra. The healthcare sector is a big one.
    Mr. Crenshaw. How much money are you guys wanting to spend 
on this in your budget?
    Mr. Becerra. Spend on what?
    Mr. Crenshaw. On this office.
    Mr. Becerra. It is a small fraction of the entire budget. I 
can tell you the exact amount if you give me time to look 
through the book.
    Mr. Crenshaw. I only have 7 seconds, but thank you.
    I yield back.
    Mr. Guthrie. The gentleman yields back.
    So no one on the Democratic side?
    The Chair recognizes Dr. Dunn for 5 minutes for questions.
    Mr. Dunn. Thank you very much, Mr. Chairman.
    Many sectors of our healthcare industry today are, frankly, 
in crisis. Last year the Democrats passed inflationary spending 
policies that are squeezing American families to their limit. 
Today they are facing tough decisions on whether they buy food, 
gas, or medicine.
    Artificially subsidizing the Affordable Care Act 
marketplace at the expense of the taxpayers and forcing price 
fixing on our innovators are two examples of top-down 
government policies that distort the market and fails the 
American people.
    This next-year White House fiscal year 2024 HHS budget 
calls for continued propping up of the ACA. It makes no mention 
of expanding health savings accounts or alternative insurance 
frameworks that would actually meet individual needs. So that 
leaves the ACA as often the only choice for consumers. I think 
seeing these top-down price controls mean that the government 
bureaucrats will choose which medicine patients will have 
access to. So this is taking choices away, rather than giving 
choices to patients.
    Mr. Secretary, under the IRA small-molecule drugs will be 
the first subject to price negotiations after 9 years, while 
biologics at 13 years. Economic analysis of this has 
suggested--and we have talked to the pharmaceutical companies--
that this will eviscerate investment in small-molecule drugs. 
Can you look into the crystal ball of the future and tell us 
which diseases and which patients are not going to get their 
medicines because of this?
    Mr. Becerra. Congressman, thank you for the question. And 
while I won't use a crystal ball, what I will tell you is that 
Americans are going to save a lot of money by having to pay 
lower prices for the prescriptions that they need.
    Mr. Dunn. I think they are just not going to have the 
medicines to take. That would be my opinion.
    But 90 new therapeutics approved just since 2020, 26 of 
those were for cancer, and all of those were primarily small 
molecules, all right? So therefore, innovation in the cancer 
space is going to be hit hard in the future. That is a 
prediction that our economic analysis and the pharmaceutical 
industry has been making loudly.
    Keeping with theme of drug development, Mr. Secretary, 
another concern is that we are not producing the drugs that we 
need, the drugs we use daily, whether at home or in doctor's 
office or hospital here in America. For more than a decade, 
China has been the largest producer of APIs in the world. And I 
won't go into the statistics of it, but even before the 
pandemic, in 2019, the Department of Defense acknowledged in 
testimony before the U.S.-China Economic and Security Review 
Commission the national security risk of Chinese dominance of 
global API markets.
    Mr. Secretary, given how important domestic drug 
manufacturing is to ASPR's National Health Security Strategy, 
what is the Department doing to incentivize domestic supply of 
production of API and API substrates as well?
    Mr. Becerra. Congressman, thank you for the question. I 
think this is one of those issues where there is bipartisan 
support.
    We are trying to increase the domestic production. We are 
trying to make sure the supply chains aren't disrupted. We make 
some investments in the budget to make sure that there is the 
capacity for us to incent the production of a lot of the kinds 
of things that we saw during COVID, basic things from masks to 
also having the materials for vaccines, have that material made 
available through the U.S. domestic manufacturing sector, and 
we are hoping that we will get the support to do that with 
Congress.
    Mr. Dunn. Well, so I certainly hope that--I want to ask you 
to go back and take a look at the FDA's approval process of 
manufacturing, as well, because it gets bogged down. Even if 
you have a plant, you can't use the plant. It is--that is a 
problem that our industry is facing now.
    What is HHS doing to prepare us against future pandemics, 
epidemics, biologic attacks?
    Mr. Becerra. We continue, through NIH, to do the research 
on the next generation of vaccines and treatments. We continue 
to see CDC reach out to our State partners to make sure that we 
can collect the information that not only lets us detect and 
surveil, but also to spread the information on best practices. 
We continue to have ASPR working to deal with COVID as it 
stands today, our preparedness and response agency. They are 
the ones that are still tracking what goes on with COVID. And--
--
    Mr. Dunn. We are running out of time, Mr. Secretary, but I 
want to make a comment. I want to add to it.
    I saw action--well, was a doctor in the Army, worked at the 
Chemical Biological Warfare Headquarters up at Fort Detrick, 
and know something about surveillance of these organisms all 
across the--we did not do a lot of the things that we can do, 
that we know how to do, that we are actually pretty good at in 
terms of surveillance diagnostics.
    And again, I want to say the small molecule therapeutics, 
which are really, really critical, we can't just depend on 
vaccines. That is way too one track, one minded.
    So with that, I see my time is expired, and I will yield 
back, Mr. Chairman.
    Mr. Guthrie. Thank you. The gentleman yields back. The 
Chair recognizes Dr. Joyce for 5 minutes.
    Mr. Joyce. Thank you for yielding, Mr. Chairman.
    And Mr. Secretary, I would like to turn to the Orphan Drug 
Act and its impact on patients. Rare disease and cancer 
patients have benefited from the development of over 600 new 
treatments since its enactment. Despite these advancements, 
there are still too many patients living with rare diseases and 
cancers that still have no treatments available to them.
    Unfortunately, Democrats' so-called Inflation Reduction Act 
threatens the continued success of the Orphan Drug Act. 
Specifically, it does not protect therapies that treat two or 
more orphan diseases from the law's price-setting scheme. As a 
result, we already know of two companies that have cited the 
IRA as a reason not to continue rare disease drug development.
    As a physician, I believe that we must do more, not impede 
the pipeline of new life-altering therapies for patients living 
with rare diseases and cancers.
    Secretary Becerra, can you please expand on the commitment 
from yesterday's hearing at Ways and Means on how you will 
specifically utilize the guidance and the rulemaking process 
under the IRA to ensure that these patients aren't robbed of 
the future of cures?
    Mr. Becerra. Congressman, thank you for the question. And 
absolutely, that would--that is the goal, to make sure that we 
are putting as many innovative and curative medicines out there 
for Americans to be able to buy.
    The difficulty is they are not able to afford so many of 
those medicines. And so this law would do nothing to impede the 
innovation, the research. What it would simply say is, once you 
have got a drug out there, make sure you are charging a fair 
price. And a fair price would mean----
    Mr. Joyce. The pharmaceutical----
    Mr. Becerra [continuing]. Profit off of your----
    Mr. Joyce [continuing]. Have already stopped--they have 
already announced to us that they are going to decrease their 
ability to do that research and development into new lifesaving 
medicines.
    Mr. Becerra. Why would they say they are going to decrease 
their investment?
    Mr. Joyce. I think my questions will reveal that answer.
    The guidance process for the IRA that you designed greatly 
discourages input----
    Mr. Becerra. How does----
    Mr. Joyce [continuing]. Patients, and physicians.
    Mr. Becerra. And how does----
    Mr. Joyce. You gave them hardly any time to submit--no 
clear direction on treatment alternatives and outcomes that you 
are interested in, and then you won't tell them how, if at all, 
you consider their input until months after a final decision, 
months after a final decision was made.
    Will you commit today to use the input that you get from 
patients and from doctors?
    Mr. Becerra. Oh, absolutely. But, Congressman, you have 
misinterpreted the law. We don't tell any company what they can 
and cannot do. We simply say, when it comes time to put it on 
market, let's make sure you are charging a fair price. Let's 
negotiate for----
    Mr. Joyce. Under your guidance, what is the earliest that 
individuals, physicians, patients will hear from you on how you 
use their input?
    And would you consider additional steps to engage with them 
during the process?
    Mr. Becerra. We will begin the process this year, where we 
will announce which are going to be the first 10 drugs that 
will be negotiated. We will go through a very public and 
transparent process, and we hope the pharmaceutical industry 
will join us in trying to make that transition.
    Mr. Joyce. And what about patients? What about patients? 
What about physicians?
    Mr. Becerra. The public--patients are the public, and we 
want them----
    Mr. Joyce. And what timeline will your response be when 
they submit their concerns to you?
    Mr. Becerra. Ongoing----
    Mr. Joyce. And outline a process that--they will receive 
that before the final decision is made?
    Mr. Becerra. That--yes, the public----
    Mr. Joyce. Thank you. I appreciate that commitment.
    Mr. Becerra. But Congressman, I don't understand how we are 
stopping a company from making investments. All we are saying 
is, once you have created that drug, let's negotiate to get the 
best price for Americans.
    Mr. Joyce. Well, I think there is a case in point right in 
front of us, and sitting right behind you today.
    While testifying last week about CMS's decision to limit 
coverage of new Alzheimer's disease therapies to clinical 
studies, you made a distinction between the FDA's process and 
CMS review process. You responded, quote, ``CMS has to remain 
consistent in the way it treats any drugs.''
    How many other times has Medicare refused to cover or 
impose CED requirements on an FDA-approved drug administered 
according to its label, for medically appropriate use?
    Mr. Becerra. Yes, and Congressman, that approach is 
misguided, because it doesn't take into account the laws that 
you all put in the books that make--that tell CMS how to 
operate. CMS is following the laws that Congress passed.
    Mr. Joyce. Are there any other medications that have these 
restrictions?
    We both know that the answer is zero. There is no other 
medication. In fact, CMS actions are unprecedented, 
representing the first time Medicare has refused to cover an 
FDA-approved therapy administered, according to its label, for 
medical appropriate use. And the barriers imposed by the CED 
mean that people living in rural areas and other medically 
underserved communities like my district in Pennsylvania will 
face huge restrictions to access.
    Mr. Secretary, how many national coverage determinations 
have been issued under coverage with evidence development 
paradigm, which I understand first came into existence in 2005?
    Mr. Becerra. Congressman, you misrepresented what CMS has 
done. CMS did provide a pathway for coverage. As more evidence 
comes in, that pathway probably will expand.
    And recognize that CMS must follow the laws that Congress 
imposed upon it.
    Mr. Joyce. But right now patients in rural areas who do not 
have access to tertiary facilities are not eligible to receive 
this important life-altering medicine.
    Mr. Becerra. Congressman, I would suggest that you change 
the laws that tells CMS how it can operate, because we are 
implementing the law that Congress passed.
    Mr. Joyce. But CMS has not done that with any other 
approvals.
    Mr. Becerra. CMS is following the laws that you all put in 
the books.
    Mr. Joyce. But why restrict one medicine, which has such a 
huge impact on so many American patients and citizens, families 
who care for individuals with Alzheimer's, why exclude this one 
specific disease?
    Mr. Becerra. It is not excluded. There is a pathway. It 
could expand.
    Mr. Joyce. When I go home to the patients in my community, 
that pathway has been blocked.
    I realize my time has expired, and I would ask you to take 
consideration to allow all patients to have access to FDA-
approved drugs.
    Thank you, Mr. Chairman, and I yield.
    Mr. Guthrie. Thank you. The gentleman yields back. The 
Chair recognizes Mrs. Trahan for 5 minutes for questions.
    Mrs. Trahan. Thank you, Mr. Chair.
    Good afternoon, Mr. Secretary. Thank you for being here 
today.
    As we navigated the deadliest pandemic of our generation, 
the U.S. made tremendous progress in our fight against COVID-
19. As a founding member of the Congressional Pandemic 
Preparedness Caucus and as this committee prepares to 
reauthorize the Pandemics and All-hazards Preparedness Act this 
year, it is critically important that we take an all-of-
government approach to expand our pandemic preparedness 
efforts.
    We must look at our response systems through fresh eyes, 
and get creative on how we protect the health of the Nation 
moving forward. For example, in response to 9/11, Congress 
established ASPR, stood up BARDA, and required the development 
of a National Health Security Strategy. As we come out on the 
other side of COVID, we must again apply the lessons of a 
costly crisis by updating our preparedness and response 
structures and recalculating the resources necessary to 
robustly fund our pandemic preparedness efforts.
    HHS has relied heavily on industry to develop medical 
countermeasures. These public-private partnerships saved 
millions of lives through vaccine development when HHS, with 
essential support from the Department of Defense, launched 
Operation Warp Speed. However, I am concerned that HHS doesn't 
have the capacity to achieve similar success in the future with 
current budget constraints. Unless appropriately resourced, 
ASPR can only go so far to support the development and 
manufacturing of scale--at scale for future vaccines and 
therapeutics against unknown viral threats that can lead to a 
devastating pandemic.
    While taking a look at HHS's budget justification for 
fiscal year 2024, I am curious to hear why the administration 
generally included funding to address longstanding, established 
threats in their discretionary requests but concentrated 
funding to address emerging, unknown threats in the mandatory 
request.
    So, Mr. Secretary, if we are unable to fund these mandatory 
components this Congress, is it fair to say that we will remain 
vulnerable against unknown viral threats like we saw with 
COVID?
    Mr. Becerra. Without the preparation, without the resources 
to prepare, without the resources to employ the best practices 
that we know, we are vulnerable for--to further attacks from 
disease, for other ways that could cost the life of many 
Americans.
    Mrs. Trahan. Thank you.
    In December 2022 the Department of Defense issued a new 
approach for research, development, and acquisition of medical 
countermeasures and test products, which moves away from an 
acquisition focused on a set list of known threats. The revised 
strategy pivots toward a new emphasis on broad spectrum MCMs as 
a first wave of protection against novel and emerging threats, 
paired with capabilities to rapidly develop a second wave of 
narrow spectrum MCM as the threats are identified and 
characterized.
    Is HHS thinking about the threat to the public at large in 
a similar manner?
    And if so, does the budget request provide sufficient 
funding to provide broad spectrum MCMs to achieve this 
flexibility capacity?
    Mr. Becerra. We have a request that would let us address 
the public health threats that are coming before us. It is not 
all we need. We will need more over the years. But this at 
least allows us to continue the work that NIH, ASPR, our 
unified effort across the government are working on to try to 
have that preparation in place.
    We would love to see more domestic preparation done, so we 
are ready to deal with it here domestically if we need a 
particular material or medicine. We are trying to make sure 
that we are prepared with a stockpile, a strategic national 
stockpile that can address needs. We want to make sure that we 
are prepared for any supply chain issues that could result if 
we have international disruption.
    And so the monies that you see in our budget are geared 
towards making sure we continue the work that is being done. 
But long term, it is going to take much more than that.
    Mrs. Trahan. Thank you. I think I have time to switch gears 
for one other question, because you are probably aware that 
last Congress I authored the Bio Preparedness Workforce Pilot 
Program, and it is a new loan repayment program at HRSA aimed 
at incentivizing individuals to enter infectious disease 
healthcare professions in underserved areas. I am pleased that 
the pilot was enacted last year as part of the omnibus and that 
the President's budget request included an increase in funding 
for HRSA to support the health workforce.
    Mr. Secretary, do you believe we need a strong infectious 
diseases workforce to improve the Nation's pandemic 
preparedness?
    And will you work with us to fund and implement the Bio 
Preparedness Workforce Pilot Program in order to boost 
recruitment into infectious disease careers in underserved 
communities?
    Mr. Becerra. I absolutely agree. Thank you for your 
leadership on this, and we look forward to your success and 
providing the resources.
    Mrs. Trahan. Thank you.
    Thank you. I yield back.
    Mr. Guthrie. The gentlelady yields back. We have--the 
committee has a bill on the floor, and I understand there is 
one Member rushing back, if that is OK, because we are a little 
ahead of time, if that is OK with you.
    Mr. Becerra. That is fine.
    Mr. Guthrie. Dr.--we have got a physician coming back to--
and if she is here in a minute or so--we won't hold you up, if 
not.
    But so--while we are doing that, I have documents submitted 
for the record. There has been a list distributed amongst the 
minority and majority for documents that both sides of the 
aisle want to submit for the record.
    And without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Guthrie. Thank you.
    Voice. We probably need to call it.
    Mr. Guthrie. Let me see if she is within 30 seconds. If so, 
we will stay. I appreciate the opportunity--I appreciate you 
doing that.
    As you know, when you are at the end of the line, you have 
got a time when--you have been there before, right?
    Mr. Becerra. I have been there, Mr. Chairman.
    Mr. Guthrie. Well, thank you. I appreciate the offer. And 
while we are waiting, I am not taking more time for--unless you 
want time, as well.
    We really--there are some opportunities for us really to 
work together, particularly on price transparency. And I think 
that we are going to do that. That was an excellent hearing 
yesterday, I think, from both sides of the aisle. And we really 
want to get to the healthcare costs and get to the bottom. And 
so----
    Mr. Becerra. Mr. Chair----
    Mr. Guthrie. I will give you some time, too, since I am 
taking it, but----
    Ms. Blunt Rochester. Well, thank you, Mr. Chairman. I 
didn't expect to have additional time, but I will----
    Mr. Guthrie. I----
    Ms. Blunt Rochester. Well, I will take it, and really just 
say thank you again for all of your work and focus on improving 
the health outcomes for the American people.
    And I now am going to give 1 second for the gentlewoman to 
get herself seated and situated, and doctor to doctor, I will 
turn it back over to the chairman.
    Mr. Guthrie. I will turn it back--and just a point of 
personal privilege, we have some guests you see in the room 
with us today concerned about the CMS rule. And I could comment 
on it, but that gets into a new set of questions. So I am not 
going to do that.
    But if Congress does have something in the law that is 
preventing you from moving forward with that, which I am not 
sure that is actually the--I mean, I understand that the 
process is set up, but if we need to improve something, let us 
know, and we will----
    Mr. Becerra. Yes, the standards are different, and that is 
where I think people don't recognize that FDA and CMS operate 
under different standards. And we have to follow that guidance 
that we have in the law. Congress could change that, but we 
have to follow those different standards for the different 
agencies.
    Mr. Guthrie. Well, I appreciate it. I don't want to get in 
more questions on that, so I am going to yield to Dr. Miller-
Meeks, and that will be our last questions for the set of 
questions.
    Dr. Miller-Meeks, you have 5 minutes.
    Mrs. Miller-Meeks. Thank you, Mr. Chair.
    And Secretary Becerra, thank you for testifying before the 
committee today.
    HHS's Budget Summary document asks for a 5.2 billion 
increase in healthcare fraud and abuse control program funding, 
specifically listing cutting-edge data analytics to detect 
trends and outliers. In a Senate Finance Committee hearing, you 
mentioned that the President's fiscal year 2024 budget request 
bolsters HHS's healthcare fraud and abuse detection and 
enforcement work.
    Furthermore, HHS's OIG, Christi Grimm, stated in her 
confirmation hearing that she is committed to expanding HHS 
OIG's use of sophisticated data analytics, including leveraging 
artificial intelligence and machine learning to proactively 
monitor and address fraud, waste, and abuse in the HHS 
programs.
    Both in the Healthy Future Task Force for the Republicans, 
as chair of the Modernization Committee, I talked a great deal 
about artificial intelligence and its use in detecting waste, 
fraud, and abuse in the Medicare system. I am currently 
drafting legislation that would require Medicare to use 
advanced algorithmic technologies such as artificial 
intelligence, machine learning, and predictive modeling to 
combat fraud, waste, and abuse in the fee-for-service program.
    Estimates of healthcare fraud range from 50 billion to 300 
billion annually. And unfortunately, OMB and GAO have 
identified Medicare as an at-risk for improper payments. 
According to a 2015 OIG report, every dollar invested in AI 
fraud detection yields $5 of savings, highlighting the need to 
invest in this technology.
    I support the use of AI in improving program integrity but 
want to ensure that AI technology is not misused to deny 
legitimate patient claims. Mr. Secretary, how can we apply 
lessons and AI innovations from the commercial and Medicare 
Advantage space to root out fraud, waste, and abuse in Medicare 
fee-for-service?
    And will you commit to working with me to responsibly 
strengthen HHS's fraud reduction capabilities?
    Mr. Becerra. Congresswoman, we would absolutely look 
forward to working with you, because everyone is still trying 
to figure out how we can make the best use of AI and, as you 
said, use it for the right purpose, where we can probe, but not 
for the wrong purposes, where we might exclude people from 
care.
    So I very much would look forward to working with you, 
because we know there is a lot of fraud that is going on within 
the Medicare system.
    Mrs. Miller-Meeks. Yes. As a provider, there is fraud 
within all of our systems, and we don't want to deny legitimate 
patient claims, we want them done in a timely fashion, and we 
don't want to delay provider reimbursement.
    Let me also echo the sentiments of other individuals and 
other Representatives in this chamber this morning. I took care 
of my mother with Alzheimer's the last 2 years of her life. And 
I would say that for CMS to deny coverage of a medication that 
has been shown and approved by the FDA that could benefit those 
with Alzheimer's, I think there, you know, we can--you said 
that we don't want to cut spending in Medicare because we want 
to provide people access to care. And I would say we can ration 
care, and that is another name for cutting spending.
    I also want to, as a physician, express my displeasure at 
CMS's rule on surprise billing. We were very specific in the 
law. I was not one of those Members of Congress but followed 
that very closely, was very supportive of the legislation that 
was passed. And it was done in such a way to make sure that the 
rulemaking process followed what we were passing in 
legislation.
    As a provider, as a doctor, you know, we feel that the 
comments we have had back from HHS and CMS have been less than 
satisfactory. And I would strongly recommend and encourage you 
to revisit the rule on surprise billing and make sure we are 
protecting providers and patients.
    Thank you very much. I yield back.
    Mr. Guthrie. I thank the gentlelady for yielding back, and 
Mr. Secretary, that concludes all Members' questions.
    We really appreciate your time and your effort to be here. 
I know you have seen it from both sides, and hopefully you have 
had a nice morning. We appreciate it very much and appreciate 
you being here and, like I said, look for the opportunity to 
work together.
    I will remind Members they have 10 business days to submit 
questions for the record, and I ask the witness to respond to 
our questions promptly. There were several times when you said 
you would get back. We just--we don't want to be here next year 
going, ``You said last year you would get back with us,'' so we 
would appreciate just prompt response for that. And I know you 
will do that, and we appreciate it.
    And Members should submit their questions by the close of 
business on April the 12th.
    And without objection, the subcommittee is adjourned.
    [Whereupon, at 12:56 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

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