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


                      HEARING ON PRESIDENT BIDEN'S
                  FISCAL YEAR 2024 BUDGET REQUEST WITH
                       HEALTH AND HUMAN SERVICES
                           SECRETARY BECERRA

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

                                HEARING

                               BEFORE THE

                      COMMITTEE ON WAYS AND MEANS
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION
                               __________

                             MARCH 28, 2023
                               __________

                          Serial No. 118-FC06
                               __________

         Printed for the use of the Committee on Ways and Means
         

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                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
55-032                     WASHINGTON : 2024                     


                      COMMITTEE ON WAYS AND MEANS

                    JASON SMITH, Missouri, Chairman
VERN BUCHANAN, Florida               RICHARD E. NEAL, Massachusetts
ADRIAN SMITH, Nebraska               LLOYD DOGGETT, Texas
MIKE KELLY, Pennsylvania             MIKE THOMPSON, California
DAVID SCHWEIKERT, Arizona            JOHN B. LARSON, Connecticut
DARIN LaHOOD, Illinois               EARL BLUMENAUER, Oregon
BRAD WENSTRUP, Ohio                  BILL PASCRELL, Jr., New Jersey
JODEY ARRINGTON, Texas               DANNY DAVIS, Illinois
DREW FERGUSON, Georgia               LINDA SANCHEZ, California
RON ESTES, Kansas                    BRIAN HIGGINS, New York
LLOYD SMUCKER, Pennsylvania          TERRI SEWELL, Alabama
KEVIN HERN, Oklahoma                 SUZAN DelBENE, Washington
CAROL MILLER, West Virginia          JUDY CHU, California
GREG MURPHY, North Carolina          GWEN MOORE, Wisconsin
DAVID KUSTOFF, Tennessee             DAN KILDEE, Michigan
BRIAN FITZPATRICK, Pennsylvania      DON BEYER, Virginia
GREG STEUBE, Florida                 DWIGHT EVANS, Pennsylvania
CLAUDIA TENNEY, New York             BRAD SCHNEIDER, Illinois
MICHELLE FISCHBACH, Minnesota        JIMMY PANETTA, California
BLAKE MOORE, Utah
MICHELLE STEEL, California
BETH VAN DUYNE, Texas
RANDY FEENSTRA, Iowa
NICOLE MALLIOTAKIS, New York
MIKE CAREY, Ohio

                       Mark Roman, Staff Director
                 Brandon Casey, Minority Chief Counsel

                         C  O  N  T  E  N  T  S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Hon. Jason Smith, Missouri, Chairman.............................     1
Hon. Richard Neal, Massachusetts, Ranking Member.................     2
Advisory of March 28, 2023 announcing the hearing................     V

                                WITNESS

Xavier Becerra, Secretary, United States Department of Health and 
  Human Services.................................................     4

                    MEMBER QUESTIONS FOR THE RECORD

Member Questions for the Record to and Responses from Xavier 
  Becerra, Secretary, United States Department of Health and 
  Human Services.................................................   452

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                   PRESIDENT BIDEN'S FISCAL YEAR 2024
                     BUDGET REQUEST WITH HEALTH AND
                    HUMAN SERVICES SECRETARY BECERRA

                              ----------                              


                        TUESDAY, MARCH 28, 2023

                          House of Representatives,
                               Committee on Ways and Means,
                                                    Washington, DC.
    The committee met, pursuant to call, at 2:13 p.m., in Room 
1100, Longworth House Office Building, Hon. Jason T. Smith, 
[chairman of the committee] presiding.
    Chairman SMITH. The committee will come to order.
    Thank you, Secretary Becerra, for testifying today before 
the House Ways and Means Committee.
    The President's 2024 budget doubles down on harmful 
policies that will only make access and affordability of care 
worse, killing new medical innovation, false promises of 
Medicare solvency with real consequences, and more reckless 
spending on government subsidies for the wealthy.
    The President's new budget expands Democrats' harmful drug 
price control, which means higher prices for new medicines, 
according to the nonpartisan Congressional Budget Office.
    Regular folks will have less access to care and fewer new 
drugs, up to 342 fewer, according to one study, with medical 
researchers already announcing suspending work on treatments 
for eye disease and certain blood cancers.
    On top of fewer and more expensive medicines for seniors, 
President Biden's budget also cuts Medicare. For example, under 
current law Medicare faces 500 billion in cuts created solely 
by Democrats' spending spree. The President's new budget 
presents no plan to stop them and threatens seniors' hard-
earned benefits.
    It also proposed significant changes to Medicare Advantage, 
which may negatively impact the 31 million Americans who rely 
on the program. These seniors who prefer Medicare Advantage 
plans need assurance from the Administration that their cost, 
coverage, and access to care will not be impacted.
    Republicans are committed to protecting and strengthening 
Medicare, which is why last week all of the Republicans on Ways 
and Means and Energy and Commerce sent you a letter about this 
issue, and we look forward to your detailed response.
    Additionally, this budget continues welfare for the wealthy 
by proposing another $183 billion in new Obamacare subsidies 
for wealthy people making as much as $600,000 a year.
    These Washington subsidies are a cause of inflation, not a 
solution. I represent rural, working-class communities where 
access to health care is a major challenge. Health clinics and 
hospitals are struggling to keep their doors open to treat 
patients.
    The Biden Administration must prioritize better access to 
care for rural Americans.
    Thanks to the President's policy failures, our economy is 
still struggling, and his refusal to change direction will only 
further undermine Medicare and Social Security. In fact, a 
University of Chicago analysis shows the Presidents' low-growth 
policies will reduce Medicare and Social Security financing by 
nearly $900 billion, another direct threat to seniors' health 
and retirement at the hands of this Administration.
    This budget rehashes the same mistakes of more government 
price controls, false promises to seniors, and billions more in 
subsidies that drive health care inflation.
    House Republicans want to lower cost for working families, 
improve access to quality care, and protect Medicare. The Biden 
Administration should work with us to achieve these goals.
    Chairman SMITH. I am pleased to recognize the gentleman 
from Massachusetts, Mr. Neal, for his opening statement.
    Mr. NEAL. Thank you, Mr. Chairman.
    We want to welcome back to the Committee on Ways and Means 
the distinguished alum, another success story that comes from 
the Ways and Means Committee.
    It is an honor to have you here, Mr. Secretary. When you 
testified before us last year, our country was in the midst of 
an unprecedented economic recovery from the financial impacts 
of COVID-19.
    Today that progress continues, two years of consecutive 
economic growth, wages rising, and the strongest jobs record of 
any administration in history. And we have accomplished all of 
this while our colleagues on the other side have reported the 
idea that somehow we are in a recession, launching partisan 
attacks.
    We are raising the first generation of Americans that only 
know life with the Affordable Care Act. What a story this has 
turned out to be, and now it is baked into the American 
economy. At life's most vulnerable moments they do not have to 
fear any longer that their insurance company will cut off their 
coverage or be denied coverage because of cost or preexisting 
conditions.
    They only know health coverage is free from discrimination 
for those with preexisting conditions and women.
    In the last 13 years, we have given Americans peace of 
mind, and we are not going back. Democrats have supercharged 
the ACA over the last decade, lowering health care costs, 
reducing prescription drug prices for millions with the 
American Rescue Package and the Inflation Reduction Act.
    Republicans, on the other side, have repeatedly attempted 
to repeal without a replacement opportunity to the ACA.
    President Biden's fiscal 2024 budget shares the Ways and 
Means Committee Democrats' commitment to building on historic 
progress that the last Congress made. This budget responsibly 
invests in affordability and accessibility of care, giving 
Americans more breathing room while reducing the deficit.
    Simply put, this budget puts workers and families over the 
well-connected.
    Mr. Secretary, we hope that during this afternoon's 
opportunity, Republicans might unveil what their budget really 
looks like. We eagerly await that opportunity.
    This is how you build an economy from the middle out and 
the bottom up, further expanding Medicare's ability to 
negotiate drug prices, permanently extending premium tax 
credits, strengthening Medicare, improving its services, 
building on the American Rescue Plan's investments in 
childcare, and addressing America's mental health crisis, and 
closing our coverage gaps for Americans living in States that 
have not expanded it.
    Other Ways and Means priorities included in the President's 
budget are, investments in elder care and TANF emergency funds. 
We will protect our most vulnerable citizens. Democrats know 
that investing in health care and care of giving is an 
investment in our Nation's children, families, and economy.
    Many on the other side have attempted to send this health 
care system back to the grim days when tens of millions of 
Americans were without health insurance. That plot to repeal 
the ACA or the Inflation Reduction Act, while making deep cuts 
to Medicaid, would devastate millions.
    Their plan pulls from the same unsuccessful playbook that 
they have been pushing for the last 13 years, shifting costs 
onto patients, sending the health care system into chaos, and 
taking away protections relating to preexisting conditions.
    Our colleagues have made it clear where they stand, and let 
me tell you it is not with the American family if the companies 
who will profit hand over hand and fist over fist from 
lifesaving medications and the top one percent continue to get 
billions of dollars in tax cuts in exchange for health care 
coverage.
    Ways and Means Democrats have stayed the course, 
strengthening Americans' health care even as that coverage has 
been threatened to be taken away by the other side. Countless 
lives have been saved.
    In my opening statement I have used the opportunity to 
remind all of the success of the ACA, the success of Medicare, 
the success of Social Security, and just as importantly, a 
reminder that Medicaid has now become, as we have discussed in 
the past, a very important part of planning for long-term care 
for the American family. Fifty-seven cents on every Medicaid 
dollar now goes to long-term care.
    As you know, Mr. Secretary, we are delighted to have you 
here on the topics on which we agree, I am also going to use my 
question-and-answer period to talk about what this committee 
did of historic purpose with the whole idea of surprise 
billing.
    Mr. Brady and I fully were on the same page. We know 
exactly what we intended with the wording choice, and I hope 
that based on the conversations we have had and the court 
decisions that have been rendered that we will be able to 
travel down that path in the next few hours.
    Thank you, Mr. Secretary, for your presence.
    And thank you, Mr. Chairman.
    Chairman SMITH [continuing]. Thank you, Ranking Member 
Neal.
    Today's sole witness, former Ways and Means colleague and 
is the Secretary of the Department of Health and Human 
Services, Xavier Becerra.
    The committee has received your written statement, and it 
will be made part of the formal hearing record.
    You have five minutes to deliver your oral remarks. 
Secretary Becerra, you may begin when you are ready.

  STATEMENT OF THE HON. XAVIER BECERRA, SECRETARY OF THE U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Secretary BECERRA. Mr. Chairman, Chairman Smith, Ranking 
Member Neal, to all the members, thank you very much for the 
invitation. Great to be back in the room. I see my chair 
somewhere around there.
    A lot of things have happened in the year since I last 
spoke to you about budgets. More than 16 million Americans have 
secured health insurance through the Affordable Care Act 
marketplaces. That is an all-time high, to emphasize what 
Congressman Neal had mentioned.
    All together more than 300 million Americans now carry 
insurance to cover their health care. That is another historic 
high.
    The President's new lower cost prescription drug law has 
capped insulin at $35 per month and made preventative vaccines 
like flu, COVID, shingles available for free under Medicare.
    Moving forward, this new law gives us the right to finally 
negotiate for lower prescription drug prices for Americans.
    To cap it all 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 fiscal year 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 health care 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 health care the 
minute you walk through the door of your family physician's 
office.
    Illness care forces hardworking Americans to deplete their 
life savings to get that long-term care that they need, and 
this is the point that Mr. Neal was stressing. Wellness care 
will invest nearly as much as it can and as early as possible 
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 invests in wellness care. We invest more than 
$30 billion to prepare 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 and 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 six million 
additional contacts from the people who are experiencing a 
mental health crisis through 988, the three-digit suicide 
prevention lifeline we stood up last year.
    This budget covers two million adults left out of Medicaid 
by their home State and extends tax credits that make health 
care 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 
today's seniors but protects and strengthens it for the next 
generation.
    We also take care of our family members in this budget, 
investing $600 billion in childcare and preschool programs and 
$150 billion to strengthen Medicaid home and community-based 
services. This budget funds the Cancer Moonshot and APRA-H and 
invests in Title 10 family planning programs essential to so 
many of our families.
    It delivers on our commitments made as part of the National 
Strategy for Hunger, Nutrition, and Health. It opens more 
community health centers.
    And important to me as the former Attorney General, it 
bolsters our health care fraud and abuse detection and 
enforcement work.
    And of course, 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 and our values and 
commitments. It helps begin the move from a Nation focused on 
illness care to one about wellness care, and most importantly, 
it ensures health and wellness are within the reach for all 
Americans.
    On behalf of the women and men of HHS, we look forward to 
working with you and, Mr. Chairman, we thank you for the time.
    And I yield back.
    [The statement of Secretary Becerra follows:]

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    Chairman SMITH. Thank you, Secretary.
    As always, we want to make sure that all members have an 
opportunity to ask questions of the Secretary. Therefore, 
without objection, each member will be recognized for three and 
a half minutes to accommodate the Secretary's time.
    We will now proceed to the question-and-answer session, and 
I will begin.
    In the Inflation Reduction Act, Democrats gave your 
department $3 billion to implement a drug price setting scheme 
which will undermine innovation into lifesaving drugs and 
increase the cost of new medication.
    I, along with the Ranking Member of the Senate Finance 
Committee, Senator Crapo, as well as House Energy and Commerce 
Chair, Cathy McMorris Rogers, have requested detailed 
information on how your department plans to spend the $3 
billion.
    That was sent to you more than a month ago, and we only 
received your response just mere minutes before the hearing 
began today.
    Will you commit to keeping Ways and Means regularly 
informed by making appropriate HHS officials available to 
testify before this committee about the drug pricing scheme so 
that we can have more effective oversight over what I fear will 
be more government expansion and control?
    Secretary BECERRA. Mr. Chairman, we are absolutely 
committed to making sure that in implementation of this new 
prescription drug law that allows us to negotiate for better 
prices and increase competition, that we will absolutely keep 
this committee informed.
    Chairman SMITH. Thank you, Secretary.
    The President's budget claims to add 25 years of solvency 
to the Medicare Program, but it is all just budgetary sleight 
of hand.
    The President's budget does have $650 billion in new taxes 
on small businesses, but then you use that money to claim both 
shoring up Medicare's Trust Fund and deficit reduction.
    You are putting budget gimmicks over beneficiaries. The 
last time you claimed savings in Medicare through the Inflation 
Reduction Act's drug price setting program, you used that $300 
billion in savings to pay for green new deal policies, such as 
green vehicle tax credits.
    How can you assure the new revenue will be used for 
Medicare solvency when your own budget also claims these same 
tax increases will be used for deficit reduction?
    Secretary BECERRA. Mr. Chairman, what I can tell you is 
that the President is committed to make sure that he not only 
extends Medicare into the next generation, but he does it by 
protecting the benefits that curb Medicare beneficiaries' 
receipt.
    And the beauty of this is that because he does it in a way 
that does not hurt middle income Americans, we can make sure 
that as you continue to work, you are going to be ready to 
receive your Medicare ready and fully there to go for you.
    And so what I can say to you is that the President is the 
first President I know, and I sat at that dais for over 20 
years, the first President who has actually proposed a real 
plan to deal with Medicare to keep it strong for the years to 
come.
    Chairman SMITH. So that leads to my next question because 
he did not address this issue in regards to Medicare.
    During the Biden Administration's first two years, we have 
seen near $2 trillion in unpaid for, reckless Democrat 
spending, and according to pay-go law, this will result in more 
than $500 billion in cuts to Medicare over the next decade.
    To the detriment of seniors, your budget shows no plan to 
reverse these cuts. You simply ignore them and try to sweep 
them under the rug as if they are not happening.
    Why do you not account for these looming cuts in your 
budget?
    And what are you going to do to prevent them from taking 
place?
    Secretary BECERRA. Mr. Chairman, we can try to go through 
the numbers, but what I can tell you is that the President's 
budget actually reduces the deficit in the years to come, and 
what it does for Medicare is it preserves those benefits that 
we have become accustomed to seeing available to our family 
members, our parents, and our grandparents.
    And what I will tell you is this. The President made sure 
that he proposed a budget that not only would strengthen 
Medicare for the next generation, but at the same time--and the 
budget numbers show it--would be able to reduce the deficit 
long term by substantial numbers into the hundreds of billions, 
if not trillions.
    Chairman SMITH. But the budget does not say anything about 
the $500 billion in looming cuts from pay-go. Do you have 
anywhere in the budget that you would show that the President 
is going to make sure those cuts do not take an effect?
    Secretary BECERRA. So I will try to stay in my lane and 
speak to HHS budget elements and say to you that within 
Medicare, I can speak to you unequivocally that this budget 
protects every single benefit that the Medicare laws provide to 
seniors and those who are disabled.
    And it does so by making sure that moving forward into the 
next generation those very benefits are there for them as well.
    Chairman SMITH. Last Tuesday you received a letter from 
myself and all the Republicans on the Ways and Means Committee 
and Energy and Commerce Committee asking specific questions 
about proposed changes your department wants to make to the 
Medicare Advantage Program.
    Your department is claiming a one percent increase in 
Medicare Advantage payments for 2024. This calculation includes 
what is called the ``risk score trend,'' basically a metric 
that is supposed to project insurance plans' coding behavior 
throughout the year of care for their beneficiaries.
    Do you agree that the risk score trend, of which CMS 
projects to be three percent for 2024, is a forward-looking 
metric and is not factored into a plan's base payment?
    Secretary BECERRA. Mr. Chairman, today, after some 30 
years, almost 30 years of managed care within the Medicare 
system, we have data that helps us be able to project forward, 
and the projections that we are making are based on data.
    And that data is showing us that in many cases that we have 
been overpaying those insurance companies that are within the 
Medicare system. We are simply trying to make sure that we keep 
money in Medicare for Medicare beneficiaries.
    And no one, whether it is an insurance company or a 
provider, should make unreasonable profits at the expense of 
Medicare beneficiaries.
    And so we are just trying to make sure that we now use the 
data, the evidence that we have, to make sure that we move 
forward in the Medicare Program, whether it is the fee-for-
service program or the managed care program.
    Chairman SMITH. It is my understanding that this is a 
projected metric.
    Do you agree that your own agency, CMS, approves Medicare 
Advantage insurers' bids, excluding this risk score trend?
    Secretary BECERRA. Let me ask the question again. Now you 
are asking me to get into CMS' business. So I want to make sure 
I am----
    Chairman SMITH. Yes. Do you agree that your own agency, 
CMS, approves Medicare Advantage insurers' bids, excluding this 
risk score trend?
    Secretary BECERRA. So I will try to answer the best I can 
and certainly ask our Administrator to respond more directly 
and precisely.
    But we make sure that we follow both the statutory 
prescriptions that we have and all the regulations that are in 
place for the managed care program within Medicare when it 
comes to how we put out the reimbursement rates for those 
insurance companies.
    And what we are finding is, of course, that we are 
overpaying in many cases, and now we are trying to make sure we 
get some of that money back. It is in the billions.
    Chairman SMITH. It is my understanding that CMS excludes 
this in their evaluations. So excluding this risk score trend, 
Medicare Advantage insurers will have to set their premiums 
based on an expected two percent decrease in payments compared 
with last year, correct?
    Secretary BECERRA. We, in our plan, we do not require 
Medicare Advantage plans to cut any Medicare services that are 
provided within the confines of the law of Medicare.
    Chairman SMITH. So, Mr. Secretary, it is basic math. One 
minus three is a negative number. We have heard from many 
concerned groups that this proposal may lead Medicare Advantage 
insurers to increase premiums or decrease certain benefits, 
potentially impacting seniors and their access to care.
    I urge you to provide a diligent response to our questions 
that we sent you.
    One last thing. HHS, under President Trump, established a 
hospital price transparency rule that went into effect on 
January 1st, 2021, requiring hospitals to post publicly the 
cost of various medical services they provide.
    Unfortunately, there are major concerns regarding 
hospitals' compliance with the rule and whether the data is 
truly helpful for patients.
    What is the Biden Administration doing to ensure hospitals 
are abiding with not just the letter but the intent of that 
rule so that patients have greater transparency and insight 
into the cost of the procedures before they receive care?
    Secretary BECERRA. Excellent question, Mr. Chairman. 
Because we are trying to make sure that we move forward that 
new law, I think there are still some 30 percent of providers 
who have not yet complied. We are trying to move quickly.
    Part of it we have to recognize that these providers have 
never had to do that. All of them use different formulas to 
figure out what their cost structure would be. We are trying to 
get all of them to become more uniform, but that does not 
excuse for them not complying with the law.
    And so we are trying to be more aggressive in how we get 
them there. Hopefully it is with a carrot, but we have got the 
stick as well that you all provided us, and we will definitely 
try to do that.
    I look to you for some guidance as well because we want to 
make sure that as we get all these providers to be transparent 
in their pricing, we do it without hurting the little guys who 
do not have the kind of wherewithal that the big guys do to 
really get in that stream of things.
    And, by the way, on Medicare managed care program, Medicare 
Advantage, so-called Medicare Advantage, Mr. Chairman, our 
proposal increases the amount of money that those insurance 
companies will get from last year. How anyone can claim that 
there is going to be a cut I do not understand.
    The second thing is there is nothing that we are doing that 
would require any insurance company to cut any benefits to any 
American on Medicare. If they make those cuts, it is those 
insurance companies that are doing it, and it is on them, not 
on the laws or what we have done at CMS.
    Chairman SMITH. It is just a huge concern for 31 million 
Americans, and we are very concerned.
    Secretary BECERRA. Because it should be.
    Chairman SMITH. Because many of these Americans are worried 
that they are going to have cuts, and the way that we add it 
up, it appears that there is going to be a minus 2 percent cut.
    Secretary BECERRA. We have these deceptive commercials that 
are on TV. I think it is unfair.
    Chairman SMITH. We need to--yes. Well, this will not be the 
last we discuss this topic.
    Thank you, Secretary.
    Secretary BECERRA. Thank you, Chairman.
    Chairman SMITH. I recognize the gentleman from 
Massachusetts, Mr. Neal.
    Mr. NEAL. Thank you.
    Under President Biden and with your department's 
leadership, Mr. Secretary, we have seen an increase in the 
number of Americans with insurance coverage and a reduction in 
out-of-pocket costs and lowering insurance and drug costs due 
to both strengthening and the growth of the Affordable Care 
Act.
    Our legislative agenda on the Democratic side, including 
the Inflation Reduction Act is prevailing. Today more than 40 
million Americans owe their health coverage to the Affordable 
Care Act. That is how important this law is.
    Just last week the other side tipped their hand on some of 
their health care ideas. More of the same, allowing insurers to 
discriminate against patients with preexisting conditions 
including diabetes, shifting costs onto patients, and promoting 
tax accounts that benefit the wealthy.
    All of this instead of bolstering a law that is not only 
widely popular, but also what consumers want and need. That 
agenda would raise health care costs for families across the 
country.
    On average Americans with coverage through exchanges have 
saved $800 this year, thanks to the Inflation Reduction Act, 
and the other side would put those savings on the line, as we 
noted in this committee just recently.
    We still have not seen a Republican budget plan. They want 
us to get to work in balancing a budget, but they will not show 
us their plan.
    Make no mistake. Their proposals will have a hard time 
under the magnifying glass in standing up. They simply will 
punish the sick by making them foot higher bills.
    If going after workers is not enough, many of these 
physicians will go after seniors, and one of the first bills to 
repeal the life-changing drug pricing provisions of the 
Inflation Reduction Act, they would remove the power to 
negotiate drug prices from Medicare, eliminating the cap on 
out-of-pocket costs and insulin.
    Had the insulin cap been in effect in 2020, more than 1.5 
million Americans would have saved $500 that year, including 
free vaccines that will save the average American $70 as 
beneficiaries.
    I think we can agree they will attack family budgets 
through their plans.
    Finally, Mr. Secretary, let me take a note for a moment, by 
the way, to congratulate North Carolina on expanding Medicaid 
and the Affordable Care Act, a reminder that every child in 
Massachusetts has health insurance. Ninety-seven percent of the 
adults in Massachusetts have health insurance because of the 
ACA, and it polls regularly in the high 70 percentiles.
    Finally, you and I have spoken a number of times, Mr. 
Secretary, about surprise billing. Mr. Brady and I, the former 
Ranking Member, we know precisely what we intended with the 
language and the words that we chose. We have not only 
prevailed in this committee. We have prevailed on the floor of 
the House, on the floor of the Senate, and now in subsequent 
court cases.
    I hope that these implementation issues will be consistent 
with what this committee intended, and much of the confusion 
and expense has been a result of a department that is not 
fulfilling the wishes of what the committee intended here on 
this legislation.
    We need a commitment to indicate that we will continue to 
expeditiously air these issues and do precisely what this 
committee intended when we marked this legislation up. We saw 
it on both side as a huge accomplishment.
    And if you might in the last 14 seconds, Mr. Secretary?
    Secretary BECERRA. Yes, and I know we will talk about this 
more, but first I have to say thank you to you, Mr. Brady, and 
many of your colleagues who pushed this because at the end of 
the day, we still have work to do to make it work right, to 
your point.
    What we can guarantee you is that Americans as consumers of 
that health care service, as the patients are taken out of the 
food fight between the provider who gave the care and the 
insurance company who has to pay it, the most important thing 
you did was to make sure that as that fight continues, it is 
not patients who have to pay the price.
    Mr. NEAL. Thank you, Mr. Chairman. I yield back.
    Chairman SMITH. I recognize the gentleman from Florida, Mr. 
Buchanan.
    Mr. BUCHANAN. Welcome back, Mr. Secretary. It is great to 
see you.
    Secretary BECERRA. Great to see you.
    Mr. BUCHANAN. We did work out a lot of things together. So 
I appreciate that.
    I want to touch base on Alzheimer's drugs. I am in Florida. 
I have got the fifth oldest district in the country. So CMS 
decided they will not cover the Alzheimer's drugs.
    It just seems like every family is touched by this. To give 
someone an extra six months to a year even though the drug is 
maybe not quite where it needs to be is a big deal.
    But it basically essentially put them out of reach for six 
and half million Americans with Alzheimer's. Just two weeks 
ago, however, the Department of Veterans Affairs announced they 
would cover the latest cost for veterans.
    Sadly, CMS is still blocking access to this. In fact, CMS 
refused to even consider the decision even though the 
Alzheimer's Association is strongly, strongly supporting it. I 
have met with them.
    Given the VA decided to cover this drug, will you commit to 
working with CMS to try to reconsider that decision?
    Because it is devastating I will tell you now, I think, for 
a lot of people across the country, but especially in Florida.
    Secretary BECERRA. Congressman, there is nothing you said 
that I do not agree with. There is not probably one of us who 
has not gone through the circumstance where one of our loved 
ones, our parents, our grandparents, is going through 
Alzheimer's or some form of dementia.
    I have gone through it. My wife has gone through it. It is 
devastating, especially if like us you are the one who is 
providing a lot of that care.
    And I have said this to the advocates from the Alzheimer's 
Association. You keep pushing. You are doing everything right.
    And what I will tell you is that CMS is moving in the 
direction which I think will give a lot of Americans heart to 
believe that their loved one will have an opportunity to get 
recovery.
    Mr. BUCHANAN. Let me get another question in at least.
    Secretary BECERRA. Okay.
    Mr. BUCHANAN. Because we only get three and half minutes.
    Secretary BECERRA. I apologize.
    Mr. BUCHANAN. Also I just want to touch base on the year 
2024 in terms of Medicare Advantage. They are looking at a cut, 
2.3 percent. It will negatively impact 31 million people who 
have got Medicare. It is huge, over 50 percent, 55 percent of 
people who have Medicare Advantage.
    And they are looking at raising the price from $540 to 
$830, which is over a 50 percent increase. It is huge because a 
lot of the seniors, that is all they have. It is very 
important.
    Is that something you can consider to look into as well?
    Secretary BECERRA. So, Congressman, here I want to be 
really clear. We are not doing any of what you just said. I am 
not sure where you got that information, but we are increasing 
the amount of reimbursement we are getting to these insurance 
companies.
    If these insurance companies are claiming that they are 
going to have to cut benefits, it is because they do not want 
to provide them and they are more willing to take care of their 
profits over the----
    Mr. BUCHANAN. I will get you the information, the backup on 
that.
    Secretary BECERRA. Please.
    Mr. BUCHANAN. I read a letter with Chairman Smith 
interviewing Commerce Chairwoman Rogers and Health Subcommittee 
Chairman Guthrie. I would like to submit it for the record, 
asking direct questions about the impact this will have on 
seniors and how CMS determines these rates.
    Chairman SMITH. Without objection.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Secretary BECERRA. I look forward to getting it.
    Mr. BUCHANAN. With that I yield back.
    Secretary BECERRA. Thank you.
    Chairman SMITH. The gentleman from Texas is recognized.
    Mr. DOGGETT. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary, for your service.
    I think among the many positive provisions in the 
President's budget are those that are designed to strengthen 
Medicare.
    It is not enough to say we will not cut Medicare. It is 
taking the steps necessary to ensure that it is there not just 
for today's grandparents, but for tomorrow's grandchildren.
    And I think further comment from you is in order about 
Medicare Advantage. I remember, as you do because you were on 
the committee, when people came forward and told us how much 
money Medicare Advantage was going to save Medicare.
    Instead we find it to be one of the most profitable 
sections of the insurance business. I heard the suggestion 31 
million Americans are concerned. I think it is rather a few 
hundred insurance executives that are concerned that getting 
$1,500 on average per Medicare beneficiary paying that much 
more for Medicare Advantage than for traditional Medicare is 
just not enough for them.
    MedPAC, an independent agency that looks at these issues, 
has estimated that we spent about $27 billion in overpayment to 
Medicare Advantage this year alone.
    I have seen those misleading commercials you referred to, 
and I know our constituents are being bombarded with tales 
about all that is going to go wrong if the Administration's 
proposals are adopted.
    They are the same folks that get bombarded with one 
misleading advertisement and phone call after another trying to 
sell them on a policy that may well provide them lack of access 
to their physician at a time when they need it the most.
    Seeing what you have done to date, is it not correct that 
you are not cutting Medicare Advantage? You are not really 
getting back that $27 billion in overpayment. You are actually 
under your proposal increasing the payments that Medicare 
Advantage company will get in the next year by one percent.
    They are just unhappy that the increase they are getting is 
not as big as the overly generous increases of the past.
    Secretary BECERRA. Congressman, that is right. We are 
actually increasing the amount of payment that we are making to 
them from the previous year, and as my mother will ask me when 
she sees these commercials, she will call me and say, ``Can you 
tell me if I am in the right plan or not?''
    I tell here, ``Look. What would you expect from a 
commercial that is peddling a product to you? They want you to 
buy and so they try to pitch it to you in ways that will sell 
it.''
    And unfortunately, once some of these seniors lock into 
some of these policies, they realize they are not getting what 
they thought.
    Mr. DOGGETT. Well, I hope that in addition to what you do 
in terms of payment, that we will continue to see a vigorous 
examination of the false claims that are made to ensure that 
everyone who relies on Medicare Advantage and takes that 
approach gets what they are promised.
    Thank you very much.
    I yield back.
    Chairman SMITH. I now recognize Mr. Smith from Nebraska.
    Mr. SMITH of Nebraska. Thank you, Mr. Secretary and Mr. 
Chairman, as well.
    Thank you, Mr. Secretary, for joining us today.
    I would like to start by calling your attention to a letter 
I sent to you on March 10th, a February 25th, 2023, article in 
the New York Times and a subsequent report by the Washington 
Post that have raised serious concerns about the Office of 
Refugee Resettlement at HHS.
    Everything about this situation, from unaccompanied 
children at the border to the lack of sponsor vetting to the 
ORR losing track of these children, I have to say, is 
troubling. So I hope you will respond to my letter hopefully by 
April 15th as requested so we can ensure that HHS is able to 
address these issues.
    The COVID public health emergency is scheduled to expire on 
May 11th. I welcome this expiration. There are hundreds though 
of waivers, many of which have vastly benefitted patients 
around the country, which immediately sunset, immediately 
sunset with the PHE.
    These expirations have the potential to impact virtually 
every medical provider and patient but would have a 
disproportionate impact, I believe, on rural and underserved 
areas like my home district in Nebraska.
    For example, it appears that without intervention, the 
following regulations will return to full force on May 12th: 
the 96-hour and offsite provider telehealth conditions of 
participation for critical access hospitals; the three-day 
hospital stay rule for skilled nursing facility admittance; and 
the long-term care hospital waiver of site neutrality in IPPS.
    Mr. Secretary, should we have the concern that the return 
to full enforcement of these regulations will have impact on 
patient access to care?
    Secretary BECERRA. Congressman, absolutely. And we thank 
you for the extension to some of those telehealth opportunities 
that will expire at the end of 2024, but we need to do 
something permanently.
    Mr. SMITH of Nebraska. Okay. So I guess can we count on 
your support of efforts to make many of these provisions 
permanent that have proven to be effective and especially for 
patients themselves?
    Secretary BECERRA. We will be there side by side with you 
if you try to negotiate the terms of that because, again, most 
of this is baked in in statute, and so we are going to have to 
make changes through Congress.
    Mr. SMITH of Nebraska. Thank you. I appreciate that.
    Finally, earlier this year, CMMI released three new models 
targeting prescription drugs, and to date CMMI tested more than 
50 models, only six of which have delivered statistically 
significant savings and a less than 12 percent success rate, 
not acceptable in many eyes.
    I have been concerned for year that CMMI often overextends 
itself by attempting to do too many things at once, and this 
leads to overlapping and counterproductive results which can 
harm both patients and providers, while currently wasting 
Medicare's finite resources.
    CMMI Director Fowler even said, quote, ``We need to move 
away from this `spaghetti against wall, see what flowers bloom' 
approach,'' end quote.
    Can you perhaps explain how simultaneously launching three 
different models targeting the same problem is different than 
the failed scattershot approach of the past?
    Secretary BECERRA. And, Congressman, I answer this knowing 
that as a former member, I like you and many others would 
always ask CMMI to test certain things. CMMI is supposed to be 
our incubator, our place to test ideas made on a very small 
scale.
    So if they do not work, we have not spent a ton of money, 
but if they do work, the return will be phenomenal, and what we 
want is to promote innovation.
    So CMMI is the place where we can tell the private sector 
give us your best idea. We will help seed it, and if it can go, 
great. And if it does not, no one, including the taxpayer, 
loses a whole lot.
    So I would want to work with you to make sure that we get 
good ideas coming forward to CMMI, but I would hate to do 
anything that stifles the innovation and competitiveness that 
CMMI promotes.
    Mr. SMITH of Nebraska. Thank you.
    I yield back.
    Chairman SMITH. Mr. Thompson, from California is 
recognized.
    Mr. THOMPSON. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary, for being here.
    And I just appreciate your pointing out the benefits of the 
ACA, everything from access to preventive health care, doing 
away with the preexisting condition limitations.
    And remember before we passed the ACA, being a woman was a 
preexisting condition. Getting a handle on prescription drug 
costs. No more junk policies.
    There are countless examples of my district and everybody 
else's district of how people that we represent have benefitted 
from this, and thank you for your ongoing support.
    I would like to ask about two priorities of mine, mental 
health and telemedicine. I am grateful that you and President 
Biden have made mental health a high priority, but I am 
concerned that too much of our focus is on treating the 
symptoms of mental illness as opposed to understanding its 
underlying causes.
    There is not enough money in any President's budget to 
treat every mental health symptom. We need to get ahead of the 
curve, and that is why Mr. Kelly and I have legislation that 
will provide tax incentives for brain research.
    I have sent that bill to Treasury to get their comments, 
and I would appreciate it if we could send it to you and get 
your team's comments on that as well.
    Secretary BECERRA. Absolutely.
    Mr. THOMPSON. Thank you.
    And I would also like to ask about telemedicine.
    And thank you, Mr. Smith, Nebraska's Smith, for raising 
this issue. It has been a long-time priority of mine, and I 
think one of the few silver linings in the COVID cloud, as you 
know, we passed my legislation to allow Medicare beneficiaries 
to access health care services via telehealth, and that was a 
real help to them, and it really provided a better means by 
which providers could treat their patients.
    And last year, we passed a two-year extension of those 
telehealth flexibilities. Part of the reason we passed that 
extension was to give agencies, including HHS, the opportunity 
to study health utilization over the past several years, how it 
was used, where it can be approved, and how it has affected 
cost.
    I have legislation with Mr. Schweikert along with our 
colleagues on the Energy and Commerce Committee which would 
make telehealth a permanent part of Medicare.
    That bill, by the way, was sponsored last year by over half 
of the U.S. Senate.
    So as the two-year extension plays out, I would like to 
know how you envision the role of telehealth in the future, 
particularly in Medicare programs.
    And is there anything specific that your agency is looking 
at to make sure that we have the best handle on this?
    Secretary BECERRA. Congressman, I know we do not have much 
time, but what I will tell you is that we have seen the 
dramatic results in behavioral health. We were not sure what 
would happen with folks who needed mental health care services. 
We thought perhaps they needed to have that person-to-person 
contact with their physician and their health care provider.
    It turns out that one of the greatest gains was made in 
mental health where, because you could do this in the privacy 
of your home, you felt more comfortable coming forward and 
accessing mental health services.
    At the same time, we saw a dramatic drop in missed 
appointments because now you do not have to worry about 
traveling there if you did not have transportation.
    We hope that we can work with our States to figure out how 
we deal with the cross-State issues that are involved with 
licensing of medical practitioners.
    Mr. THOMPSON. Are you saying you are for making it 
permanent?
    Secretary BECERRA. We are absolutely. It depends on where 
we are going, but, yes, there is absolutely a need to continue 
some of these telehealth flexibilities.
    Mr. THOMPSON. Thank you.
    I yield back.
    Chairman SMITH. I recognize the gentleman from 
Pennsylvania, Mr. Kelly.
    Mr. KELLY. Thank you, Mr. Chairman.
    Mr. Becerra, it is good to see you again. It has been a 
little bit of time in between.
    I just wanted to ask you something because I have been in 
the private sector my whole life, and I am trying to figure out 
how you put all of these pieces together. You have 83,000 
employees; is that right?
    Secretary BECERRA. About there, yes.
    Mr. Kelly. That is a big payroll. That is a big payroll.
    Secretary BECERRA. Yes.
    Mr. KELLY. And approximately 4,000 of these employees are 
based at the CMS, at the Woodlawn, Maryland headquarters.
    So how many employees are working today in person, actually 
in person?
    Secretary BECERRA. Congressman, the HHS workforce went back 
to full-time work from the get-go. We were able to use 
telehealth during COVID, and now that we are beyond that, we 
are able to continue workforce at full time.
    And you have heard some of the dramatic results of a 
workforce that has continued forward. Some have never left 
coming into the office or coming into work. Others are taking 
advantage of some of the flexibilities that we provide. So they 
could come in some days and work from a different site other 
days.
    Mr. KELLY. Yes, well, I have a photo. This picture--well, I 
know you said these people are at work. This is last Monday, 
okay, March 20th. This is at 10:30 a.m. in the morning.
    So a beautiful parking lot. There is everything on there 
except cars. I guess I do not know how your people get to work, 
but this is your office building, and you are telling me they 
are working full time. They must be working full time from home 
or some other way of doing that.
    I just do not understand that.
    Secretary BECERRA. Congressman, that is not my----
    Mr. KELLY. This year--no, Mr. Secretary, this is the 
picture. You have seen it before, and you know what it is.
    Secretary BECERRA. Yes.
    Mr. KELLY. And then we request another $18 million in rent 
compared to last year. So when you look at the people that fund 
all this stuff, and these are hardworking American taxpayers. I 
like the talk that goes back and forth, but what we are going 
to do for six people, how we are going to shore this thing up, 
how we are going to do this, how we are going to cover all of 
this stuff, but at the end of the day, there is only one person 
signing that check, and that is the taxpayer.
    So why should the American people be expected to pay rent 
for an office building that is not even being used?
    There is so much waste in this government. There is so much 
fat in this government it is impossible. I am embarrassed to go 
back home and tell people this is the way it is supposed to 
work.
    This is not the way it is supposed to work. This is crazy 
stuff. Nobody would look at this as a business model and say, 
``You know, good idea. Let's pay a lot of rent. Nobody has to 
be there, but we will pay rent.''
    Now you have said you are going to get the whole workforce 
back to work. They are actually going to show up in person in 
their buildings and actually work.
    And I am not talking about being on these little things we 
have set up. All of the little pictures show up and people get 
a chance to talk.
    I do not know. I think that they are so inefficient right 
now.
    Are you telling me--and I want to know this seriously--do 
you ever expect to be back fully at work at their desk in their 
buildings doing the work for the American people?
    Secretary BECERRA. Congressman, we are fully at work full 
time.
    Mr. KELLY. Well, this was a national holiday then probably, 
right? This was March 20th.
    Secretary BECERRA. You know, Congressman, I do not even 
recognize that photo. That is not certainly a photo of my 
office building.
    Mr. KELLY. Oh, okay.
    Secretary BECERRA. Maybe a parking lot of a building that 
HHS has employees----
    Mr. KELLY. Yeah.
    Secretary BECERRA. I doubt that you could say that that 
speaks to the work that is being----
    Mr. KELLY. Well, I would tell you this, that this is 
Woodlawn. This is Woodlawn, Maryland, your headquarters. If 
this is your headquarters at 10:30 in the morning on a Monday 
morning on March 20th, there is something that does not match 
with what you are telling me.
    I do not want to keep grilling you on this because I will 
tell you what. Both you and I pay a portion of whatever it is 
that we earned to fund all of these things.
    I just am appalled at the way this government works. There 
is so much fat. The things that we have to do, yes, do them, 
but you had better learn how to work within a budget and make 
sense.
    I cannot take this home and tell my people that I 
represent, ``You know what? Listen. It may not make sense to 
you but it does not have to. This is the way we run our 
government.''
    This is your parking lot in Woodlawn, Maryland. That is 
where it took place. It did not take place someplace else.
    Secretary BECERRA. But you cannot say that the folks that 
work in that Maryland site, if there is a site there, are not 
working.
    Mr. KELLY. I do not know. You know what? I would love to go 
sometime. I would even like to go to the IRS and see those 
people working at their desk, and I would like to see your 
people working at their desk.
    Eighty-three thousand people getting a paycheck from the 
American taxpayer and we say if they will work part time, 30 
hours a week is part time. I would just say that this 
government has a lot of people that are part time.
    I thank you. I yield back.
    Listen. I do appreciate your service because I like you 
personally. You know that, but I do. More than you, I like our 
taxpayers, and you are the guy in charge.
    It is a heavy lift. My God, 83,000 people.
    Secretary BECERRA. And they are working, Congressman.
    Mr. KELLY. Yeah, well, I know. I hear what you say. I am 
just saying the pictures do not reveal that they are working, 
and I think the American people deserve an answer.
    Secretary BECERRA. I will bring you some pictures next 
time.
    Mr. KELLY. Okay. Very good. Thank you.
    I will go there with you.
    Chairman SMITH. The gentleman from Connecticut is 
recognized, Mr. Larson.
    Mr. LARSON. Thank you, Mr. Chairman.
    And thank you, Secretary Becerra, for being here. It is 
great to have you back with the committee, and thank you for 
your continued work and support, both while you were here and 
as Attorney General for the State of California and now in your 
capacity as Secretary of HHS.
    Mr. Secretary, last year we passed the Inflation Reduction 
Act, and as you hear Ranking Member Neal run through a number 
of the things that were accomplished, I want to associate 
myself with his remarks.
    But as someone like yourself, who has been a long-time 
advocate of lower drug prices through Medicare negotiation, we 
were pleased to see that the President's budget calls on 
Congress to build on what we did in the Inflation Reduction 
Act, which keeps money in seniors' pockets, while also making 
Medicare more solvent.
    My question and to give you a time to do this, can you walk 
us through your agency's progress in implementing the drug cost 
provisions in the Inflation Reduction Act and tell us how each 
provision will continue to deliver for the American public?
    Secretary BECERRA. Congressman Larson, thank you for your 
efforts over the years on these issues as well.
    Well, today those who are in need of insulin are getting it 
for $35 a month or less, and that is something that is saving 
most Americans several hundred dollars for this year alone.
    Those same Americans on Medicare now can access a vaccine, 
whether for the flu, for COVID, for shingles, and I always hear 
about shingles because apparently that is a pretty expensive 
vaccine, 100 to $200. Free now, no out-of-pocket cost for folks 
on Medicare to access that. That is saving people quite a bit 
of money.
    On top of that, we made the announcement that come 
September we will announce the first ten drugs that will be 
part of that drug price negotiation that will begin.
    The companies that manufacture those drugs will go through 
the process then of negotiating for the best price for folks on 
Medicare, and we hope to continue that process because at the 
end of the day this is about saving people money.
    Right now Americans, as you know, are paying two or three 
times more for the same drugs that are being sold in other 
countries, even if those drugs may have been manufactured HERE 
in the U.S.
    Mr. LARSON. And so this direct negotiation, seniors have 
long been anticipating this. So it will be in September that we 
will hear.
    And how many drugs?
    Secretary BECERRA. There will be ten drugs, and then next 
year there will be 15 more. Then the year after that we add 
more, and every year we get to add them.
    I think in your wisdom you said make sure you do it right 
for the first ten and then let's keep going from there.
    Mr. LARSON. Thank you, Mr. Secretary. I greatly appreciate 
it.
    And with that, I will yield back.
    Chairman SMITH. The gentleman from Arizona, Mr. Schweikert, 
is recognized.
    Mr. SCHWEIKERT. Thank you, Mr. Chairman.
    Mr. Secretary, this may sound odd, but I think you actually 
have one of the most interesting, if not one of the most 
difficult, jobs in the world.
    Secretary BECERRA. I concur.
    Mr. SCHWEIKERT. But I also am constantly frustrated that we 
do not take your agency dramatically more seriously.
    And look. In the President's budget, you have new taxes. 
The President's budget has new taxes in there for shoring up 
part of Medicare Part A. That equals out about what, 600, 660 
billion over a ten-year cycle?
    And I am not asking you to play budget with me. I am just 
sort of setting up a question.
    But the math from 2022 basically said Medicare shortfall 
over 30 years, with interest, so this is from two years ago, 
was over $80 trillion.
    So I am elated, hey, you are going to talk about shoring up 
the Medicare Part A Trust Fund, but remember the vast majority 
of Medicare spending is general fund.
    It turns out your agency, our obligation we made to 
seniors, is the primaries, three-quarters of all the borrowing 
over the next 30 years. You are the epicenter of what in many 
ways is the greatest threat to our republic, and that is our 
debt, you know, whether it be my kids or someone's secure 
retirement.
    So there are some things that are not meant to be got-you, 
but are there things we could do to help your folks on the 
innovation side be much more innovative, much more risk taking, 
much more forward viewing?
    We have a document that was working through your numbers 
saying 31 percent of all Medicare spending is diabetic related. 
Okay. Could we actually do an all-in approach to stabilize pre-
diabetic populations?
    Do you remember that there is a phase one that has just 
begun of a potential cure for diabetes?
    In a weird way, you, your agency, break us or the 
innovation in your folks save us from a future that is just 
brutal, step-wise.
    And I guess my rambling is more about what can I do, what 
can we as members do. Because I have gotten some really crappy 
responses sometimes from your innovation folks who say, ``We 
are looking at that,'' and then we never hear before.
    What can we do to make them almost techno-utopians, that we 
have to to push the solution?
    Secretary BECERRA. So, Congressman, let me see if I can 
give you two or three different points, and you can build on 
them if you like.
    First, I go back to what I said earlier because you hit it 
on the money. Why are we spending so much money on diabetes? 
Because so many of these cases of diabetes could have been 
prevented.
    And so rather than try to cure it, as my mom always used to 
say to me [speaking foreign language], ``Better to prevent than 
to remediate.'' Why not try to prevent it?
    And my whole opening statement was about how moving from an 
illness care system, which is what you are pointing out, to a 
wellness care system.
    Mr. SCHWEIKERT. But what I beg of you is in your opening 
statement you said wellness care, but you did not say we need 
to fix nutrition support. The way we do it, that is not 
working.
    There are actually things we can do to help people manage 
their blood glucose. You have seen even the discussion of 
something I can wear on my wrist that may tell me what my blood 
glucose is.
    We now have--and I am going to screw it up--GPL-1 
inhibitors and a variety of those that are off patent. The fact 
in medicine there may be a stem cell therapy coming.
    If it is the single biggest driver of debt in our country, 
where is your all-in approach? Where is the maniacal fixation 
that we are going to take this on?
    Because it is not partisan. It is not Republican/Democrat. 
It is moral.
    And with that I yield back.
    Chairman SMITH. Mr. Blumenauer from Oregon is recognized.
    Mr. BLUMENAUER. Thank you, Mr. Chairman.
    Mr. Secretary, welcome back. I must say you look 
increasingly distinguished.
    Secretary BECERRA. More like you, huh?
    Mr. BLUMENAUER. Well, not that distinguished. [Laughter.)
    Mr. BLUMENAUER. Thank you for joining us. I want to thank 
you for the work that the department has done working with the 
State of Oregon and, I think, Massachusetts dealing with 
innovative efforts in terms of the waiver, being able to focus 
on social determinants of health that actually help people with 
things like nutrition and housing that will lower costs.
    I appreciate the creativity and look forward to working 
with you and the department to realize the benefit of those.
    I would, as you know, be remiss if I did not mention one of 
the topics that we have discussed.
    Secretary BECERRA. I see the chart.
    Mr. BLUMENAUER. In the last 30 years we have gone from a 
country where there was no legal State either medical or adult 
use, and in that period of time we now have 37 States where at 
least some form of cannabis is legal. In 21 States, it is fully 
legal.
    The American public overwhelmingly supports it, and yet the 
Federal Government is hopelessly out of step.
    I welcome the President's call to do a reappraisal of how 
we characterize this so we can have the Federal Government 
catch up with where the American people are as it deals with 
the reality of cannabis, and I look forward to working with 
you.
    I appreciate your notion of the prescription drug reform. 
The American senior primarily does not have to pay two, three, 
four, five times the world price for prescription drugs in 
order to underwrite medical research for the rest of the world.
    I am not certain that the pharmaceutical companies would 
hold us hostage, but I think it is too steep a price. American 
consumers, especially seniors, should not be held hostage, and 
I appreciate the work you are doing implementing this bidding 
effort.
    Let me just touch on one other area. We have talked about 
some of the concerns we have, for example, in terms of for-
profit Hospice, where we found shadow companies that have 
buildings, get money, but have nobody that they are serving.
    I notice that you have $5.2 billion for program integrity. 
Can you talk about what that is going to enable us to do to 
make sure the taxpayer is getting full value?
    Secretary BECERRA. Congressman, we know that during COVID 
we had more people die in nursing homes than was acceptable. We 
know that in too many cases people are profiting off of saying 
they are caring for some of our most precious loved ones who 
need help.
    And we want to make sure we get to go in and do some 
oversight. We want to make sure sunshine will be a good 
disinfectant when it comes to caring for our loved ones.
    And so we--hope you will consider, truly consider our 
request for more money so we can do the oversight.
    I speak as a former Attorney General who worked hard to go 
after some of this abuse against elderly Americans, and we are 
going to do as much as we can.
    Mr. BLUMENAUER. I think you will find bipartisan support on 
this committee to deal with the integrity of the Hospice 
Program so we are not cheating patients or the government.
    Secretary BECERRA. Amen.
    Mr. BLUMENAUER. I yield back.
    Chairman SMITH. The gentleman from Illinois, Mr. LaHood, is 
recognized.
    Mr. LaHOOD. Thank you, Mr. Chairman.
    Mr. Secretary, welcome. Mr. Secretary, last year you and I 
spoke about my concerns with the response times from HHS in 
responding to congressional letters, and unfortunately, I 
cannot say that that has improved today.
    Just this afternoon I received a letter that I sent asking 
for a response five months ago. I do not find it a coincidence 
that I received a response today when you are appearing before 
this committee.
    As we all know, Mr. Secretary, workforce challenges are a 
major concern across industries, but particularly within the 
healthcare community. This is why last Congress I introduced a 
bipartisan bill called the TRAIN Act, along with 
Representatives Blunt Rochester of Delaware, which became law 
at the end of last year.
    This bill addressed a nursing workforce issue caused by CMS 
in which they began to recoup funds given to hospital-based 
nursing schools based on a CMS error.
    Taking funds away from nursing schools during the pandemic 
and workforce crisis certainly seemed misguided to me, and so 
we worked in a bipartisan way to address this issue to prevent 
the recoupment.
    However, we passed that law. It now appears that CMS is 
going against congressional intent in their recent transmittal 
notice for implementation of the bill. CMS has created a 
complicated formula to describe how these impacted schools 
would get their money back.
    The formula would not fully stop recoupment and returning 
the funds, but instead only provide between 29 and 76 percent 
of the funds owed back to these schools.
    In our bill, CMS was directed to return the funds that were 
taken from each school. It is beyond frustrating, Mr. 
Secretary, that something so clear in the statute could be 
implemented in this way.
    These hospital-based nursing schools, of which I have 
several in my district, provide hands-on education allowing 
more nurses to enter the workforce and serve rural and 
underserved communities.
    Before our bill could become law, many of these schools 
closed and now CMS continues, Mr. Secretary, to impact the 
remaining schools by only returning a portion of the funds they 
are owed. This is simply unacceptable.
    And I would like your commitment, Mr. Secretary, to look 
into the creation of this formula and respond to me in writing 
on why CMS chose to go against our directive and the clear 
congressional intent on this issue.
    Secretary BECERRA. Congressman, let me do this. I will 
call. After this hearing, I will try to reach out to you and 
have a specific conversation. You let me know who from CMS you 
want to have on that conversation and let's follow up so we can 
make sure that we are following the intent the way it should 
be.
    Mr. LaHOOD. Thank you.
    Mr. Secretary, in my remaining time here I would also like 
to comment briefly on my concerns with CMS determination on 
coverage with evidence development CED requirements for 
Alzheimer's treatments.
    In February, I along with 74 of my colleagues wrote to you 
with our concerns on how CMS continues to address the CED 
process, particularly as it impacts constituents and their 
families and caregivers in my district who are unable to 
participate in academic clinical trials.
    I have serious concerns about how CMS is making decisions 
on this issue, and I await your timely response to our letters 
sent to you on February 6, and I would just say that does not 
mean waiting five months from now.
    You mentioned earlier in Mr. Buchanan's comments that you 
told the advocates to keep pushing. There is immense 
frustration that my constituents and many people across the 
country cannot participate in these academic clinical trials.
    If you could, respond to that.
    Secretary BECERRA. Yes, and we are trying to make sure that 
we do provide for a diversity of participation in these trials. 
Oftentimes we find that folks in rural American do not get to 
participate in trials. Folks in some urban poor areas of 
America do not get asked to participate.
    So we are trying to make sure that those who will 
participate include those from all parts of our country. We 
could do everything we can within the clinical trials, but at 
the end of the day, it is the investigators who have to make 
sure that they are pursuing folks to participate.
    But I am absolutely prepared to work with you and others 
who are interested in this subject to make sure what where 
there is a clinical trial that everyone has an opportunity to 
participate.
    Mr. LaHOOD. Thank you.
    Chairman SMITH. The gentleman from New Jersey is 
recognized.
    Mr. PASCRELL. Welcome back, Mr. Secretary. Thanks for the 
work on the Biden team. You have done an outstanding job.
    Americans emerged from the pandemic with the best economy 
in decades. The pandemic opened their eyes to the titanic need 
of skilled nursing.
    So I welcome the President's bold goal to remake our 
Nation's 15,000 nursing homes, and I am damned angry when I 
look at the results.
    This is a $130 billion industry. Wall Street's control over 
nursing homes grows with risks and abuses. Problems in our 
nursing homes have been ignored for too long.
    We need transparency for tax dollars going into big 
companies, and we must hold bad actors accountable when they 
provide substandard care for our seniors.
    A lot of statistics came out of these last two and a half 
years, three years. I am not going to go into too many 
statistics because I have done that before.
    Private equity firms, they are having a song and a dance. 
You wonder why so many nursing homes are closing. You cannot 
provide service unless you pay the help. You cannot provide 
service if the help is not up for the job. You have got to pay 
for that. You get what you pay for.
    And private equity gets what they pay for. So we need 
transparency.
    One year into the White House initiative, what has this 
Administration done to increase transparency of ownership so 
that we could figure out who owns the darn place and management 
of our skilled nursing facilities?
    What has happened in one year?
    Secretary BECERRA. Congressman----
    Mr. PASCRELL. Tell me that in two sentences.
    Secretary BECERRA. First, thank you for your advocacy in 
this area.
    We have for the first time in as far as I can remember 
required the disclosure of ownership interest in these 
facilities because we know that a shell game is often played 
with regard to who actually handles them.
    And probably something which you did not quite say it 
explicitly is that oftentimes when ownership goes into the 
hands of a Wall Street firm, they are in there for the money, 
and so what they do is they extract assets and they oftentimes 
leave a shell.
    And the folks who are needing care are the ones who suffer 
as a result of having less than ideal services.
    We are also moving forward on the idea of having minimum 
staffing levels so that regardless of who purchases that 
facility, you cannot move below a certain level.
    Mr. PASCRELL. Excuse me, Mr. Secretary. You have been 
looking at that for years. Your Administration, the previous 
administration, the administration before that, the 
administration before that.
    What have you done?
    Secretary BECERRA. Congressman----
    Mr. PASCRELL. Do you want me to give you a list in New 
Jersey?
    Secretary BECERRA. I cannot speak for the previous 
administration, but I can tell you we are in the process of 
coming out with a rule that will require minimum staffing 
levels. That is more than I have seen any administration do.
    Mr. PASCRELL. And you are going to work this out with the 
equity firms?
    Secretary BECERRA. We do not need to work that out with any 
equity firm. We get to do that based on a rule that is based on 
the authorities you gave us.
    Mr. PASCRELL. To your health.
    Secretary BECERRA. Thank you.
    Mr. PASCRELL. I yield. [Laughter.]
    Chairman SMITH. The gentleman from Ohio is recognized.
    Mr. WENSTRUP. Thank you, Mr. Chairman.
    You go, Bill.
    I am deeply concerned, Mr. Secretary, with the state of 
health services and human services in our country. I continue 
to hear from providers across the country, which I was one for 
three decades, they are closing the doors, walking away from 
providing care to patients every day because of the challenges 
that have come from this administration and because of some of 
your decisions, sir.
    Physicians are the ones that continue to show up to the 
front lines and make sure that patients receive the care that 
they need. Doctors are the ones who provide the health and 
human services to patients across this country.
    And if this pattern continues, there will not be enough 
doctors left to take care of patients across America.
    Your budget grows. You treat no one. You are a lawyer, and 
you ask providers to do more with less until they close their 
doors.
    Congress spent years negotiating a solution to solve 
surprise billing and do it in a balanced fashion, and, yes, we 
took patients out of it. That we did.
    Congress passed a No Surprises Act to protect patients, 
create a balanced process. The President signed it into law. 
You ignored that.
    And we created a bill that created incentive for doctors 
who want to be in network and for insurance companies to want 
doctors in network. But you decided to implement the law in a 
manner that unfairly tips the scale in favor of insurers by 
placing undue weight on the qualified payment amount, which was 
just one component of arbitration and did not have weight over 
any others.
    You directly defied the law as written, and it is 
interesting considering you are a lawyer that you would violate 
the law.
    And your illegal actions have led to a backlog of claims, 
and you called the claims recently to be frivolous. Well, you 
ask the patients that got the care if it is frivolous, and you 
ask the doctors that have to pay their staff and their salaries 
and to stay open and to be in the black.
    You ask them if it is frivolous. You said patients are not 
affected. They are affected. Doctors retire or they quit taking 
calls.
    You come in in that ambulance and guess what. There is no 
doctor on call because of the way you have implemented the No 
Surprises Act. You.
    So you are directly harming patients actually. Doctors and 
hospitals need to be in the black to keep their doors open, to 
continue to provide a service. And they cannot pay their help 
if they do not.
    What this says to me is you clearly do not value the work 
of physicians and surgeons and what they do for those in need, 
and without them we have no health system at all.
    Mr. Secretary, will you implement the No Surprise Act as 
written in statute and not stray from the letter of the law, as 
you have continued to do, as you have been informed that you 
have done by the courts, and maybe get out of the courtroom and 
into the emergency room and the operating room where HHS 
belongs?
    Secretary BECERRA. Congressman, I respect especially the 
passion with which you speak to the subject, and so what I will 
tell you is where we have gotten guidance from the courts, we 
have followed it.
    We will try to do the best we can. If you are one of those 
who helped pass the law, I thank you. You probably remember 
when that was being discussed, I think at that point people 
thought ten, maybe 20,000 disputes would be sent for this 
independent dispute resolution process.
    In the first eight months, 164,000 claims were filed.
    Mr. WENSTRUP. But you are responsible for that, sir. The 
way you have implemented the law has driven this. You took away 
the fair process.
    Secretary BECERRA. Congressman, if you look at what we 
did----
    Mr. WENSTRUP. Well, of course they want to go to 
arbitration.
    Secretary BECERRA. Congressman, there is nothing that we 
did----
    Mr. WENSTRUP. You called it frivolous, which is an insult 
to every provider out there.
    Secretary BECERRA. I am not calling it. It is the 
arbitrators.
    Mr. WENSTRUP. I yield back.
    Secretary BECERRA. The arbitrators are the ones that are 
saying that those were frivolous claims.
    Chairman SMITH. The gentleman from Illinois, Mr. Davis, is 
recognized.
    Mr. DAVIS. Thank you, Mr. Chairman.
    Mr. Chairman, I ask unanimous consent to submit for the 
record a statement describing the accessibility of imported e-
cigarettes and vaping material to young people in our country.
    Chairman SMITH. Without objection, so ordered.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. DAVIS. Thank you, Mr. Secretary, for your work and the 
outstanding work of members of your staff.
    Medicare physicians' pay and its impact on patient access 
to care remains a major issue for many of my constituents. In 
fact, adjusted for inflation, in-practice costs Medicare 
physicians' pay actually declined 26 percent from 2001 to 2023, 
or by 1.8 percent per year, on average.
    Nonpartisan government stakeholders are recognizing the 
damage and impact these payments cuts are having on patients' 
access to care.
    The 2021 Medicare Trustees' report states that after the 
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, physicians are 
pushing for 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.
    Mr. Secretary, could you share with us some of the 
Administration's thinking relative to Medicare payments to 
physicians?
    Secretary BECERRA. Absolutely, Congressman, and as you 
know, the President declared emphatically during the State of 
the Union that not only was he going to protect Medicare for 
today's seniors and Americans with disabilities who receive 
Medicare, but he was going to protect it for the next 
generation as well.
    And so his budget makes sure that Medicare not only remains 
strong, but it continues to offer benefits that, under 
traditional Medicare fee for service or under managed care 
Medicare, either way Americans receive their services.
    And that is why the proposal that we have put forward when 
it comes to reimbursement to providers continues to increase 
the amount that they will receive.
    The amount that we are proposing in this year's proposal is 
greater than the amount that we had proposed last year, and of 
course, we protect all Medicare benefits. We do not cut any 
benefits. We continue to preserve access to those same benefits 
that all Americans have become accustomed to having under 
Medicare.
    Mr. DAVIS. Thank you very much, and I am sure that the 
thousands of Medicare physicians, as well as their millions of 
patients, will be delighted to hear this answer. Thank you so 
much.
    Thank you, Mr. Chairman, and I yield back.
    Chairman SMITH. The gentleman from Georgia, Mr. Ferguson, 
is recognized.
    Mr. FERGUSON. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary, for being here.
    A couple of items here. First of all, one of the things I 
am very concerned about is antimicrobial resistance. We have 
not been doing a great job in this country of developing the 
next generation of antibiotics to fight these resistant 
infections.
    It has cost the system almost $5 billion a year, and really 
probably somewhere around 35, 36,000 people a year die because 
of this.
    We have a system failure here. It is a failure of the 
marketplace, and there are some very specific reasons.
    Do you think congressional action is needed to correct 
this, to prepare ourselves for the next pandemic and to address 
the immediate cost to the system?
    Secretary BECERRA. Congressman, first I have to say 
halleluiah for asking that question because nobody asks about 
antimicrobial resistance.
    It is absolutely essential, and absolutely Congress needs 
to act because we have to figure out a way to get the market to 
want to invent some of these new lifesaving treatments.
    Mr. FERGUSON. Good. I look forward to working with you on 
that.
    You know, I----
    Secretary BECERRA. Can I just add real quickly?
    Internationally, we are trying to take this on as well, and 
so there is a lot of interest internationally to deal with 
antimicrobial resistance.
    Mr. FERGUSON. We just want to make sure that we lead.
    Secretary BECERRA. Absolutely.
    Mr. FERGUSON. So with that, listen. You touched on Medicare 
Advantage issues. Again, I just do not share your position on 
that.
    I want to say this. You made a comment to my colleague here 
from Ohio, Dr. Wenstrup, that you were trying to implement the 
surprise billing law the way we intended it, and I will simply 
say that trying is nothing more than failing slowly. Either you 
are going to do it or you are not.
    And I would encourage you to do it. So do not fail slowly. 
Just get it done the way Congress intended for that and the way 
that this committee intended for you to implement that and to 
make the changes.
    Next, a couple of series of questions here. Over the past 
decade and a half or so, really, yeah, about the past decade 
and a half has there been any sector of the health care 
environment that has grown at a slower rate than inflation?
    Secretary BECERRA. Any sector of----
    Mr. FERGUSON. Yes, any sector in our health care economy 
that has grown slower than inflation.
    Secretary BECERRA. We would probably have to crack our 
heads together to see if we could find one.
    Mr. FERGUSON. You will get a split in your skull you will 
have to crack your head so hard so many times on that.
    Has there been an increase or decrease in premiums in the 
past decade and a half?
    Secretary BECERRA. Well, here actually there is some good 
news. If I take you on the Affordable Care Website, you can 
find a premium today for----
    Mr. FERGUSON. No, no, no, not the cost of individual but 
the overall cost of the premium including the subsidies that 
have to be paid to drive that cost lower.
    Secretary BECERRA. Okay. Well, we still have to take a look 
because I am going to----
    Mr. FERGUSON. The answer is I do not think you are going to 
find many folks that are saying that their health care premiums 
are going down.
    Secretary BECERRA. For most the costs have gone down.
    Mr. FERGUSON. Really?
    Secretary BECERRA. Yes.
    Mr. FERGUSON. In what State?
    Secretary BECERRA. Pretty much every State that has access 
to the Affordable Care Act.
    Mr. FERGUSON. You are going to tell us that the health care 
premiums in the State of Georgia are lower now than they were a 
decade and a half ago?
    Secretary BECERRA. Absolutely, absolutely. When you can 
find a premium at $10 a month or less----
    Mr. FERGUSON. No, no, no, no, no, not to the individual. I 
am talking about the overall cost to the system.
    Secretary BECERRA. I get where you are going, but what I am 
saying to you American----
    Mr. FERGUSON. Well, I am getting where I am going because 
we are spending entirely too much money. We have got an 
inefficient system.
    Reclaiming my time, a couple of other quick questions.
    Are there more rural hospitals in America today or fewer? 
Just more or less.
    Fewer. I will answer it for you, at least in my district.
    Are Americans healthier today than they were in 2010?
    And do we have more solo practitioners or more vertically 
integrated health care systems where an insurance company owns 
a PBM that owns a pharmacy that owns the health care system?
    Ms. SANCHEZ. Mr. Chairman.
    Mr. FERGUSON. My point here is that how you judge success--
--
    Ms. SANCHEZ. Mr. Chairman.
    Mr. FERGUSON [continuing]. Of government-run health care 
and how we do are maybe two different things.
    With that, Mr. Chairman, I would yield back.
    Chairman SMITH. Thank you.
    The representative from California is recognized. Ms. 
Sanchez.
    Ms. SANCHEZ. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary, for your testimony today.
    My colleagues and I worked tirelessly to pass the Inflation 
Reduction Act and to lower drug costs under Medicare, and these 
critical policies are saving beneficiaries an average of $800 
per person per year. I call that progress.
    I am also pleased to see that the Administration is 
building on the work in the last Congress to extend ACA premium 
tax credits as well as put more money in Medicare 
beneficiaries' pockets by capping out-of-pocket drug costs.
    I also think it is important to highlight your plan to 
close the Medicaid coverage gap, particularly as we see 
millions of Californians currently go through the 
redetermination process as the PHE comes to an end.
    These are the types of investments that we must continue to 
make in order to meaningfully reduce the cost weighing heaviest 
on working families and to help close those health care 
disparities.
    The HHS budget also includes expanded funding for long-term 
care through Medicaid home and community-based services. I want 
to bring your attention to that because studies have predicted 
that the number of seniors over the age of 85 who will need 
personal care due to fragility of aging and other disabilities 
will quadruple between now and 2040.
    Now, these are folks that do not need 24-hour medical care, 
but they do need assistance with everyday living tasks like 
eating, bathing, cleaning. Seniors with dementia, in 
particular, need these, and these tasks often fall on the 
shoulders of working families, and these tasks are often 
uncompensated.
    I have experience in this. I have been extremely fortunate 
to share caregiving responsibilities with my siblings for both 
of my parents, but I know firsthand how difficult it is to 
balance being a working mom and a caregiver, even when you have 
the means to do so.
    An average year of long-term care costs over $70,000, and 
most seniors' entire life savings are a little more than double 
than that, and Latino and African American households have 
significantly less in retirement savings than the average 
household.
    For example, half of elderly Latinos rely on Social 
Security as their sole source of retirement income.
    In Medicare, Medicare Advantage, Medigap, none of those 
insurers cover long-term supportive care. The only option for 
those who can afford assisted living facilities, costly private 
long-term insurance plans or if they qualify for Medicaid.
    So, Mr. Secretary, I want to know what the department doing 
to address the predicted rise in long-term care needs.
    And how would you suggest financing such a system that does 
not solely rely on Medicaid?
    Secretary BECERRA. Congresswoman, first, thank you for your 
commitment to this particular subject.
    Secondly, I mentioned the work that we are doing to try to 
improve the services at existing facilities, whether it is a 
nursing home facility or providing Hospice care.
    We are in this budget providing for $150 billion in 
Medicaid home and community-based services because we know 
there is the need to increase access to that long-term care.
    We are doing everything we can to do more inspection of 
facilities because we know that there have been a number of 
complaints, and the need to make sure that there is 
transparency in the services that are provided, and we are 
doing as much as we can to try to increase the ability of 
States to do some of those inspections themselves and to the 
complaint surveys' response themselves as well.
    So we have an investment of about $500 million, a little 
bit more than $500 million dollars in discretionary monies to 
help those States do those survey and certification programs.
    Ms. SANCHEZ. I thank you for your work on that and for your 
presence today.
    And I yield back.
    Chairman SMITH. The gentleman from Kansas, Mr. Estes, is 
recognized.
    Mr. ESTES. Well, thank you, Mr. Chairman.
    And thank you, Mr. Secretary, for being here today.
    You know, when I combed through the President's budget that 
adds $17 trillion to the deficit over the next ten years, I see 
much of the failed policies that have caused record inflation 
over the last two years, and it is hurting Kansas families.
    In fact, a surgery center in Wichita told me that this year 
more patients are delaying surgery because they simply have to 
make a choice between having a procedure or putting food on the 
table.
    Secretary Becerra, over the last two years I have heard 
from numerous doctors in my district and the State that have 
indicated participation in Medicare is becoming untenable due 
to the instability of reimbursement year after year. This means 
patient access is in jeopardy across the country, including my 
home State of Kansas and particularly in rural areas.
    I have got a couple questions that are really yes or no.
    I mean do you recognize the instability of the physician 
fee schedule the past two years that has disproportionately 
appropriated patients, particularly rural ones, and 
particularly in specialty care?
    Secretary BECERRA. Congressman, I think we all, and I 
remember being a member of Congress as well. The challenge that 
we have in trying to make sure that we are adequately 
reimbursing providers has always been there. It is something 
that we always have to address and you have to address.
    Mr. ESTES. And will you help work with us and commit to 
helping evaluate the impact on rural access before you make 
future reimbursement changes?
    Secretary BECERRA. Absolutely.
    Mr. ESTES. I also am concerned a little bit particularly 
about changes made under the REMs for mifepristone. Under your 
direction REMs have been changed so that a woman no longer 
needs to see her physician in person in order to receive this 
harmful drug, but one in five women who take this drug need 
medical intervention following its use. That is one in five.
    Your own FDA said that women should not take it if they 
have an ectopic pregnancy, and FDA explains that if an ectopic 
pregnancy is not identified and removed, it can rupture and 
cause abdominal bleeding that can kill the pregnant woman.
    Ectopic pregnancies can only be ruled out by a health care 
provider using blood tests and an ultrasound.
    And FDA has further warnings for women if they have 
problems with their adrenal glands or if they are taking 
certain medications. This critical information is given by 
health care providers with access to their medical history.
    Do you think the new REMs for this drug put women in 
danger?
    Secretary BECERRA. Congressman, FDA puts out those REMs 
after reviewing all the science and the evidence that is out 
there. Mifepristone has been available for more than 20 years. 
It has been proven to be, as FDA has to show it, to be a safe 
and effective drug.
    And now they are moving forward, based on several years of 
evidence and especially during COVID where they found that it 
could be prescribed safely and effectively without having to 
have the in-person visit by the patient in order to get access 
to the drug.
    Mr. ESTES. I am just concerned that one in five need 
additional care afterwards. That has no bearing on that, but it 
is caused by that, as well as the ectopic pregnancies.
    How do you plan to help make sure that they are checked for 
an ectopic pregnancy before this drug is dispensed to them?
    Secretary BECERRA. Yes, and I would need to check those 
numbers. I have not heard those numbers that you have recited. 
And I know I hear from my wife, who is a high-risk OB-GYN, all 
the time about this.
    This is a drug that has proven itself over the course of 
time. You do not just get access to it because you want it. You 
still have to get it prescribed, and so your physician, your 
medical provider, would still have to prescribe it.
    And so those kinds of areas where you need to have 
safeguards are still in place. It is just that the in-person 
requirement that a woman go to a particular spot to get that 
prescription drug would be removed.
    Mr. ESTES. Mr. Chairman, I yield back.
    Chairman SMITH. The gentleman from Pennsylvania, Mr. 
Smucker, is recognized.
    Mr. SMUCKER. Thank you, Mr. Chairman.
    Good afternoon, Secretary.
    The Work and Welfare Subcommittee is having a hearing 
tomorrow looking at strengthening TANF work requirements, and I 
am sure you know that only six States have a 50 percent TANF 
work participation rate requirement, and 34 States have a zero 
percent requirement.
    How is HHS making sure that States are being held 
accountable in implementing TANF work requirements?
    Secretary BECERRA. Congressman, that is a great question, 
and I hope we can actually work on some of this because we are 
trying to work with the States to get more information.
    We all heard about the situation in Mississippi where a lot 
of TANF dollars were misused, and that was as a result of State 
officials not keeping watch of the money.
    We would love to work with you to make sure that our work 
to do oversight continues forward, the program integrity work 
that we do, but we really need your help.
    Mr. SMUCKER. So you agree that it is a problem we need to 
address and we can work together on that?
    Secretary BECERRA. Well, when State officials divert 
dollars that are meant for needy families, that is absolutely a 
problem.
    Mr. SMUCKER. I am talking specifically about the work 
requirements.
    Secretary BECERRA. We can absolutely talk to you about any 
number of issues including work requirements, but what we want 
to do is make sure that we are getting dollars to the families 
that are needy that qualify for those funds.
    Mr. SMUCKER. Thank you. I look forward to talking with you 
about it.
    As you know, as a hospital insurance fund trustee, the 
trustees currently estimate that Medicare Part A will go 
insolvent in 2028, at which point the program will only be able 
to pay 90 percent of benefits, meaning seniors will face a ten 
percent cut in benefits; is that right?
    Secretary BECERRA. What I can tell you is that the 
President's budget addresses that to make sure that no senior, 
no person with disability will face any change in their 
benefits.
    Mr. SMUCKER. Let's talk about that because I do appreciate 
that there are some proposals in the budget to extend the 
solvency. I mean that certainly is a goal shared by Republicans 
and Democrats.
    So I do hope that we can work together in a bipartisan 
fashion. However, I do have trouble seeing how the math adds up 
in the some of the President's proposal.
    And a basic question. I think we will agree on this. If the 
government raises taxes by $100 and then spends that $100, it 
is a zero impact on the deficit, correct?
    Secretary BECERRA. Are you speaking about the Medicare 
Program?
    Mr. SMUCKER. If the government raises taxes by 100 and then 
spends 100, what is the net impact on the deficit?
    Secretary BECERRA. But if you are going to relate that to 
Medicare, then I want to make sure we are----
    Mr. SMUCKER. No, it is a basic question.
    Secretary BECERRA. Well, if you are speaking about Medicare 
and the President's budget, then I could answer that question 
because I do not want you to then say that I have said that the 
President will not strengthen Medicare.
    Mr. SMUCKER. That was a basic question, but is it true that 
the President's budget counts savings from potential drug 
pricing reforms towards both deficit reduction and then also 
injecting funds into the Hospital Insurance Trust Fund?
    Secretary BECERRA. The President's budget, because it 
reduces deficits over the course of the next ten years will be 
good for America and our economy. At the same time, the 
President's budget will strengthen the Medicare Program without 
cutting any benefits.
    Mr. SMUCKER. But it really sounds like a budget gimmick 
when you are counting both the same cuts as deficit reduction 
and also injecting funds into the trust fund.
    Secretary BECERRA. Well, the Congressional Budget Office, 
which is your scorekeeper, also shows that the President's 
budget will save us money.
    Mr. SMUCKER. Is it true that the President's budget 
increases taxes on small businesses by $650 billion?
    Secretary BECERRA. So the President said that no one who 
earns less than $400,000, and if you are a small business 
person at the end of the day----
    Mr. SMUCKER. The budget does increase taxes by $650 
billion. Will those new taxes be used to pay for Medicare 
solvency?
    Secretary BECERRA. And those are taxes on corporations and 
the wealthiest individuals, but again, anyone earning less than 
$400,000, whether it is through your small business or through 
your employment, will not pay any increased taxes.
    Mr. SMUCKER. It is the double counting of the same funds 
that makes no sense.
    And, Mr. Chairman, I would like to enter into the record a 
budget model from Penn Wharton, that their analysis points this 
out, the double counting and the budget gimmicks that the plan 
employs.
    So I would like to submit that into the record if I could.
    Chairman SMITH. Without objection, so ordered.
    [The information follows:]

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    Mr. SMUCKER. Thank you.
    Chairman SMITH. The gentleman from New York is recognized.
    Mr. HIGGINS. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for being here.
    In New York, every single hospital is reporting significant 
nursing shortages that they cannot fill. Over the last three 
years, contract labor has increased nationally over 250 percent 
and significantly in New York State as well.
    So many nurses across the country have left hospital-based 
positions and have gone to these traveling staffing agencies. 
It is understandable because the work is better, the scheduling 
is more flexible, but these agencies charge hospitals a 
significant markup to employ their nurses, leading some 
hospitals to accuse them of price gouging.
    The Federal Government pays a lot for health care, probably 
$1.6 trillion every year for Medicare, Medicaid, tax treatment, 
VA. It is a lot of money, but it is a lot of leverage.
    Is your agency aware of this problem?
    And are there other efforts to address the shortage in a 
legitimate way without profiting significantly, these agencies 
that employ traveling nurses?
    Secretary BECERRA. Congressman, thank you for the question.
    And just as the State of New York is suffering through a 
workforce shortage, so are, I know, my State of California and 
I suspect every member at this dias would say the same thing.
    We are making investments and this budget does make 
investments to help expand the workforce. It also helps provide 
States with the opportunity to train more people, whether 
nurses, doctors, or childcare workers.
    We want to increase the size of the workforce. One of the 
things that would help us increase the size of the workforce is 
if we get more women back into the workforce. We know that it 
has been very difficult.
    If you cannot find childcare, sometimes it keeps people 
from being able to go to work, whether you are the father or 
the mother, but principally we know mothers have that prime 
responsibility more often than fathers do.
    And so we are working where we can. We did a grant 
proposal. That was, I think, last year, $103 million, where we 
put it out, and the recipients of the grant, we did not put a 
lot of restrictions on it. What we said is we want you to use 
it to try to retain some of your workforce, increase your 
workforce, or up-train your workforce.
    And what we are trying to do is help keep folks in the 
health care profession.
    Mr. HIGGINS. Thank you.
    I yield back.
    Mrs. MILLER [presiding]. The chair recognizes the gentleman 
from Oklahoma.
    Mr. HERN. Thank you, Madam Chair.
    Mr. Secretary, thank you for being here today.
    My time is short. So let me be real quick here.
    Two years ago during your first budget hearing, you 
responded to one of my questions by saying that as Secretary of 
HHS, you are ``in the business of creating more jobs and 
getting people the health care they need,'' end quote.
    As you know, our current system is complex, unaffordable 
for small businesses to offer health care.
    Do you support the previous administration's policy to 
allow small businesses to cover the premiums of their employees 
through individual coverage health reimbursement accounts, also 
known as ICHRAs?
    Secretary BECERRA. Congressman, I want to make sure. If you 
are talking about plans that would violate the Affordable Care 
Act and provide less benefits, if they are what we call these 
junk plans or skinny plans, we do not support those.
    Mr. HERN. So you are saying based on your Website on 
October 17th, 2019, you said you are willing to support plans 
that are not junk plans.
    Secretary BECERRA. Correct. Plans that offer real benefits, 
they may have a low payment, but the reason they have a low 
payment is because when you really need to use them, they offer 
you very little coverage for the services you will use, and you 
are stuck with the bill for the high coverage of those 
particular benefits.
    Mr. HERN. So just so I am clear, you and I are clear, you 
are willing to work with us on ICHRAs as long as they are not 
so-called junk plans?
    Secretary BECERRA. Willing to work with you on any plan, 
whatever the idea is, because you are entitled to that work 
effort from our folks at the agency.
    Mr. HERN. I think that is a yes.
    Mr. Secretary----
    Secretary BECERRA. That is a yes. That is a yes.
    Mr. HERN. Mr. Secretary, since the bipartisan Orphan Drug 
Act was enacted into law 40 years ago, rare disease and cancer 
patients have benefitted from the development of over 600 new 
treatments. This is tremendous achievement though there is more 
work to be done.
    More than 30 million Americans across this country are 
living with a rare disease or disorder, and too many patients 
living with rare diseases and cancer still have no treatments 
available to them.
    Some of you may have family members with a rare disease. So 
you know the pain they face every day and the hope they have in 
spite of everything. I have a sister who passed away from spina 
bifida and another sister and her daughter living with spina 
bifida.
    Unfortunately, the 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. It is sad this budget proposes to expand those 
harmful policies further.
    Mr. Secretary, will you commit to doing what you can, be a 
guidance in rulemaking to ensure that the pipeline of life-
altering therapies continue for patients living with rare 
diseases and cancers?
    Secretary BECERRA. Congressman, we will absolutely do what 
we can to make sure that some of those orphan drugs are still 
available because otherwise many of those folks would have no 
hope.
    Mr. HERN. Mr. Chairman, I think that is a yes, and I 
appreciate it again that you are working with us on these 
issues because there are problems that we need to work together 
on that have been falling through loopholes and have been 
subject to concern based on what is coming out of the recent 
policies from the Administration.
    So I appreciate you working with us.
    And I yield back.
    Mrs. MILLER. Thank you.
    I now yield to myself.
    Thank you, Ranking Member Neal, and thank you, Secretary 
Becerra, for being here today.
    One of my biggest concerns about the United States health 
care is the current workforce shortage that we are all facing 
around the country. This shortage is particularly concerning in 
rural communities where hospitals are closing at higher rates 
than anywhere else in the country.
    While inflation caused by the Biden Administration's out-
of-control spending is partly to blame for hospitals 
struggling, a dwindling workforce is often also cited as one of 
the biggest problems for rural hospitals.
    One policy which contributed to the shrinking health care 
workforce was a vaccine mandate for the health care workers, 
which was put in place by the Biden Administration. The Centers 
for Medicare and Medicaid services gave hospitals an ultimatum: 
force your entire staff to get vaccinated or no Medicaid 
services, or they will no longer participate in Medicare or 
Medicaid Program.
    In rural America where a disproportionate share of patients 
are enrolled in Medicare and Medicaid, this gave hospitals an 
impossible choice. Your agency forced health care workers that 
did not want to get a vaccine out of the workforce.
    Secretary Becerra, on September 18th of last year, 
President Biden declared that the pandemic was over. The 
Administration has also announced they plan to end the public 
health emergency on May 11th of this year.
    Can you please explain to me why this Administration 
intends to keep the CMS vaccine mandate in effect until 
November of 2024, especially when we know this policy is 
contributing to the workforce shortage?
    Secretary BECERRA. Congresswoman, let me see if I can 
address your question straight on. COVID is still with us. It 
is not what it was three years ago, but today two to 300 
Americans will likely die from COVID. It is still something we 
have to take into account and protect against.
    It is worse, and you will remember those days, when you 
could not even walk into a hospital to visit your relative who 
was sick with COVID because you could become infected as well.
    We have to make sure we are protecting each other. And 
certainly health care workers have to be protected against 
COVID, and we have to make sure we are protected against health 
care workers who are treating COVID-infected patients.
    And it would be irreconcilable to say that a health care 
worker who is around COVID should not be vaccinated to make 
sure that he or she is not inadvertently passing COVID on to 
people who are not yet infected.
    Mrs. MILLER. You just repeated that basically.
    I would like to now turn to something that will help 
bolster our health care workforce. In 2020, Congress took the 
historic step of adding 1,000 new graduate medical education 
slots to train additional physicians for the first time ever.
    Multiple hospitals in my district utilized the GME Program, 
and I was so encouraged when Congress put guardrails in to 
ensure that the slots were distributed to rural areas that face 
acute provider shortage.
    Can you imagine my dismay when I saw recently that nearly 
20 percent of the GME slots distributed around went to New York 
State alone?
    Can you commit to the committee that the next round of 
distribution will better prioritize rural areas?
    Secretary BECERRA. Absolutely, Congresswoman. We will work 
with you because I have also fretted over this. When I was a 
member of Congress, I raised this issue of GME.
    And one of the issues and perhaps for those of you who are 
in rural parts of the country, it is nearly impossible to get 
any of these GME slots because rarely do you find any of the 
medical schools located in rural America. So we have to figure 
out how to get some of these training slots because oftentimes 
where you train is where you end up living and practicing.
    And so we need to make sure we are directing some of these 
future doctors to communities like rural America where there is 
a shortage of them.
    Mrs. MILLER. We have three wonderful medical schools in 
West Virginia.
    Thank you.
    I yield back my time.
    Now, Ms. DelBene.
    Ms. DelBENE. Thank you, Madam Chair.
    Thank you, Mr. Secretary, for being with us today. It is 
great to see you.
    I first want to commend you for working to improve prior 
authorization for seniors on Medicare Advantage. I partnered 
with Congressman Kelly for years to make this archaic process 
fully electronic and streamlined so seniors can get the care 
that they deserve faster and so providers are not buried in 
paperwork.
    The last Congress we passed our legislation through the 
House with unanimous bipartisan support, a rare thing.
    In line with our legislation, I appreciate HHS' proposed 
rules to improve prior authorization, and I would like to 
highlight your agency's detailed economic analysis, which found 
that these policies would save physician practices and 
hospitals over 200 million hours in administrative time over a 
ten-year period.
    That means a total cost savings of $15 billion. So as you 
work to finalize these rules, I encourage you to require real 
time prior authorization decisions for routinely approved 
services, and faster time frames when there is an emergency. So 
please keep that in mind.
    Secretary BECERRA. Absolutely will.
    Ms. DelBENE. Now I want to turn to another important issue. 
More than 37 million Americans live with kidney disease, 
including more than 800,000 with kidney failure for which there 
is no cure.
    Although some are lucky enough to receive a transplant, 
most Americans starting dialysis will die within five years. 
That includes over 13,000 people who have kidney failure in my 
home State of Washington.
    Medicare spent $150 billion last year just on kidney 
diseases. That is over 18 percent of Medicare's overall budget. 
Yet the core technologies to treat and care for people living 
with kidney failure have not advanced much over the past 50 
years.
    So I am a strong supporter of the KidneyX Program, which is 
speeding up the development of new treatments, particularly for 
the world's first artificial kidney. In January, along with my 
colleagues in the bipartisan and bicameral colleagues in the 
Kidney Caucus, I wrote the Administration a letter requesting 
an increase in funding to $25 million, up from $5 million, for 
KidneyX, a very humble request.
    I have sent similar letters in previous years.
    Unfortunately, the President's budget continues to keep 
funding flat for this critical program. This funding increase 
is important, a small and yet very, very important investment 
that would be relatively or especially compared to the current 
cost of treating kidney failure.
    Unlocking new treatment options would be life changing for 
people with this condition and would significantly improve the 
physical health of Medicare over the long term.
    So when KidneyX was created, there was an expectation of 
$125 million from the private sector and $125 million from the 
Federal Government, and we are not meeting our end of the 
bargain.
    So given the success of KidneyX in its first three years 
and the President's commitment to preserve Medicare for the 
next generation, why is the Administration not doing more to 
prioritize this program, which could provide a revolutionary 
return on investment?
    Secretary BECERRA. Congresswoman, first thank you for 
championing KidneyX and for being such a proponent.
    I think you would find so many people at HHS who would 
support what you have just said. We do have to do what we can 
with the monies that we have. We are limited.
    And whether it is kidney, I was answering questions in a 
previous hearing on asthma and how we should do more on asthma. 
We are not going to say we cannot do more or should not do 
more. We just need more resources.
    And so I will put it back to you and say we look forward to 
working with you so you all can get us more money so we can do 
more with KidneyX.
    Ms. DelBENE. This is a huge cost to Medicare right now so I 
hope we can make an increase in its investment.
    Thank you so much.
    I yield back, Mr. Chairman.
    Chairman SMITH [presiding]. The gentleman from North 
Carolina is recognized.
    Mr. MURPHY. Thank you, Mr. Chairman.
    And thank you, Secretary, for coming.
    I want to just follow up on one of my colleagues' comments 
earlier, Dr. Wenstrup. I personally also as a physician, we 
sent you all a bipartisan, bicameral bill signed by a President 
for the No Surprises Act, and you absolutely took it to the 
left and have hurt, I believe, Americans.
    And you talk about all of the disputes that occurred. 
Absolutely, because it was not interpreted as it was sent over. 
I will just leave that as a comment.
    The one thing that you and I definitely will agree on is 
the antimicrobial resistance. I have lost patients. I have seen 
I think the record is now about 35,000 a year that die because 
we do not have drugs to treat them.
    I know you probably know some of this, but just for the 
edification of some of the other members, from the time it 
starts, when a drug starts from the beginning to a patented 
molecule sometimes takes ten, 15 even longer, that many years, 
and it costs billions of dollars of investment.
    And for every one molecule that passes through, there are 
probably about 100 to 150 that do not make it.
    From the time they patent a molecule, it gets a 14-year 
clock. However, now that 14-year clock has changed to nine 
years, and as a direct result of that, so many pharmaceutical 
companies because they cannot--and I am not advocating for 
pharmaceutical companies. I am advocating for patients.
    So many pharmaceutical companies have because of that 
restriction of their ability to earn and recoup their losses 
are stopping production, and for the record, Mr. Chairman, I 
would like to submit an article, as well as source, of a list 
of 42 companies that have mentioned the IRA this year and 
delayed launches of their medications, impacts to long-term 
planning for new cures, and impacts to oncology R&D.
    May I just submit these for the record, sir?
    Chairman SMITH. Without objection, so ordered.
    [The information follows:]

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    Mr. MURPHY. And so we go back to the antimicrobial 
resistance. We really have not had a new generation come along. 
We have had it in the quinolones and there are some fifth 
generation cephalosporins that are helping.
    How can the IRA and then with the fact that Biden wants to 
have the moonshot program and develop these new cancer cures, 
how can that fit with the fact now that we are killing American 
R&D and trying to develop new cures because we are cutting 
their ability to actually fund for them?
    Secretary BECERRA. Congressman, here is my difficulty in 
following the logic of your question. If a company----
    Mr. MURPHY. I think I was pretty clear. It calls for 
somebody to develop drugs who are cutting them out from earning 
that money so they will not develop the drugs.
    Secretary BECERRA. And if they are putting that drug out 
there on a competitive price, what would be the problem?
    It is when you put a drug out there for an uncompetitive 
price, where you essentially charge Americans two to three 
times more than what you charge others around the world, that 
is what the Inflation Reduction Act attacks. It lets us 
negotiate to get the best price.
    Mr. MURPHY. Well, tell that to the 42 companies now.
    Secretary BECERRA. I would say that to the 42 companies.
    Mr. MURPHY. That have stopped production of cures and 
treatments, which include antibiotics.
    Secretary BECERRA. Competition should not stop anyone from 
trying to develop a drug.
    Mr. MURPHY. I am not pleading for pharmaceutical profits. 
Please do not take me that way.
    But I am saying it costs billions of dollars to do this, 
and now we have 42 companies that say they are not going to do 
it because if the IRA.
    Secretary BECERRA. And how those 42 companies can make a 
decision on a law that just took effect and that will not be 
negotiating prices for several years to come is beyond me.
    But what I can tell you is----
    Mr. MURPHY. That is planning in corporate America. That is 
planning. You have to plan 20 years for these drugs. That is 
how long it takes for these drugs to come out.
    Secretary BECERRA. And you are entitled to plan to make a 
profit. You are just not entitled to gouge Americans for the--
--
    Mr. MURPHY. I agree 100 percent. I agree 100 percent.
    Secretary BECERRA. So why would the companies not want to 
create a drug in America, the richest country in the world, so 
they could sell it and make a profit, not gouge, but make a 
profit?
    Mr. MURPHY. Because their timeline to make that profit has 
been cut by 30 percent.
    Thank you, Mr. Chairman. I am going to yield back.
    Chairman SMITH. The gentleman from Tennessee is recognized.
    Mr. KUSTOFF. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for appearing today.
    I want to ask you about a New York Times article dated 
February 25, 2023, the headline, ``Alone and Exploited Migrant 
Children Work Brutal Jobs Across the U.S. Arriving in record 
numbers, they are ending up in dangerous jobs that violate 
child labor laws, including in factories that make products for 
well known brands like Cheetos and Fruit of the Loom.''
    The article talks about migrant children have been coming 
into the United States without their parents in record numbers, 
are ending up in some of the most punishing jobs in the 
country.
    A New York Times investigation found, it says, 12-year-old 
groupers in Florida and in Tennessee. The article goes on to 
say that the number of unaccompanied minors entering the United 
States climbed to a record 130,000 last year, three times what 
it was five years earlier, and this summer is expected to bring 
another wave.
    The Federal Government knows they are in the United States, 
and the Department of Health and Human Services is responsible 
for ensuring sponsors will support them and protect them from 
trafficking or exploitation.
    But as more and more children have arrived, the Biden White 
House has ramped up demand on staffers to move the children 
quickly out of shelters and releasee them to adults. Case 
workers say they rushed them through vetting sponsors.
    While HHS checks on all minors by calling them a month 
after they begin living with their sponsors, data obtained by 
the Times showed that over the last two years the agency could 
not reach more than 85,000 children.
    Overall the agency lost contact with a third of migrant 
children.
    Mr. Secretary, is the New York Times correct that HHS 
cannot account for 85,000 migrant children in the U.S.?
    Secretary BECERRA. Congressman, no, they are not.
    Mr. KUSTOFF. Okay. What is the number then, Mr. Secretary?
    Secretary BECERRA. You have to understand the 
responsibility that HHS has. We do a follow-up check on these 
migrant children by contacting the children and their sponsors, 
but our authority that Congress gave us goes toward caring for 
the child while they are in our custody.
    Once they are in the custody of those sponsors, we do not 
have jurisdiction over the children.
    And so for the New York Times to say that we lost contact 
with them, it is not that we lost contact. We try to make an 
effort to follow up with them, but they are under no obligation 
to respond to us, neither the child nor the sponsor.
    And so the New York Time could have done a little bit more 
homework to figure out what HHS' responsibilities truly are.
    Mr. KUSTOFF. All right. Let me ask this because the article 
specifically says the agency cannot reach more than 85,000 
children. You are saying that is an incorrect statement.
    Secretary BECERRA. That is an incorrect statement.
    Mr. KUSTOFF. And you do or do not know what that actual 
number is?
    Secretary BECERRA. I can tell you the number of children 
that we have placed in the care of sponsors, and every one of 
those children we follow up with.
    Mr. KUSTOFF. What is the number of children that you do not 
have contact with?
    Secretary BECERRA. Congressman, as I just explained, we no 
longer have jurisdiction over the children once they are placed 
in the care. You did not give us the authority to keep in 
contact with those kids.
    Mr. KUSTOFF. You do not know what the number of children is 
that you do not have contact with, correct?
    Secretary BECERRA. We make contact. We try to make contact 
with every child that has been in our care that we place in the 
hands of a sponsor.
    Mr. KUSTOFF. Thank you.
    My time has expired. I yield back.
    Chairman SMITH. The representative from California, Ms. 
Chu, is recognized.
    Ms. CHU. Secretary Becerra, I wanted to thank you so much 
for your visit to my district in Monterey Park, California, 
last month. The visit meant so much to the people of Monterey 
Park who are still reeling from the mass shooting that took 11 
lives in January.
    The shooter was a person who was deteriorating mentally, 
who should not have had a gun but did, and did terrible harm.
    The wide availability of guns in the wrong hands has 
yielded a drastic increase in gun violence deaths, as AEPI 
youth, in fact, have the fastest growing firearm suicide rate 
of any racial or ethnic group, which is a 71 percent increase 
in the last decade.
    Because of this I will soon be releasing legislation to 
ensure that all communities, including limited English 
proficient and immigrant communities, have access to gun safety 
and prevention strategies, such as safe gun storage 
recommendations and mental health services for suicide 
prevention that are recommended by CDC.
    One part of the President's budget that is so important is 
an increase of $50 million for the suicide prevention program 
to expand CDC's work to reduce suicide.
    How will you ensure that this important research and safety 
guidance will be accessible to these LEP and immigrant 
communities?
    Secretary BECERRA. Congresswoman, first, that was a special 
visit. As you know, I used to live in Monterey Park. I still 
have a home there, and you could see it in so many of the 
people's expressions, how not just painful, but how 
appreciative they were when anyone would give them a chance to 
just speak their mind.
    And speak their mind is important for your point because 
oftentimes they are not able to communicate with authorities 
because they do not converse easily in English.
    We are doing everything we can to make sure that we provide 
culturally and linguistically appropriate services. The 
materials, we try to translate them into appropriate languages. 
The people we hire, we want them to not only know different 
languages, but also have lived experiences that relate to the 
people that we are trying to help, and in so many ways we will 
try to support the work that you are doing to make sure that we 
are approaching people with services that accommodate their 
needs.
    Ms. CHU. Thank you so much.
    I would like to have your comments on Title 10 and 
Medicaid. You know, Title 10 family planning has been flatlined 
for the last ten years, and yet the need is greater than ever 
now.
    So I commend you and the Biden Administration for proposing 
$512 million for the Title 10 Family Planning Program, the 
first increase since 2014.
    And then there is the Medicaid unwinding, the continuous 
coverage requirements, you know, started during COVID, but 
unwinding this Friday, and millions could lose coverage.
    So can you speak to the importance of Title 10 and also how 
does the department plan to protect those most vulnerable to 
losing coverage once Medicaid unwinding begins?
    Secretary BECERRA. Congresswoman, we have been in 
conversations with governors throughout the country to make 
sure that they are aware of what is coming once the public 
health emergency comes down. We want to make sure that no 
American loses health coverage because the public health 
emergency has ceased.
    And we continue to work with States. Some are better 
positioned than others. Some are doing more than others, but 
every State is aware that there are a number of individuals--so 
it could be close to 14, 15, up to 16 million Americans--who 
could lose their coverage even though they qualify for other 
coverage, whether it is through the Affordable Care Act or 
whether it is through existing Medicaid programs where if they 
reapply, they will still qualify.
    And we want to make sure everyone is aware that that is 
available to them, including employer insurance, which maybe 
they did not have when COVID hit and they got onto Medicaid but 
now they are employed and they have access to coverage. They 
need to know those things so we do not lose coverage for those 
Americans.
    Ms. CHU. Thank you.
    I yield back.
    Chairman SMITH. Ms. Van Duyne from Texas is recognized.
    Ms. VAN DUYNE. Thank you very much, Mr. Chairman.
    And thank you, Secretary for being here today.
    Mr. Secretary, as you know, the Hospice Care Program is a 
vital part of the health care system, with over 50 percent of 
Medicare patients utilizing the program.
    But it is also one of the hardest realities that a family 
can endure. We know how personal this issue is for you as you 
and your family provided for your father excellent end-of-life 
care.
    But not everyone is as lucky. The system had been overrun 
with rampant fraud and abuse, and your agency's responses to 
the crisis has been extremely alarming. We have been told just 
last week to, quote, ``be patient'' while CMS investigates.
    But families only have one chance to provide excellent end-
of-life care for loved ones, and while CMS asks for patience, 
more and more fraudulent Hospice providers are gaming the 
system. They are stealing Medicare dollars, assessing opioid 
medication, and depriving patients of access to the care that 
they need.
    Mr. Chairman, I ask for unanimous consent to enter into the 
record the ProPublica article entitled ``End Game, How the 
Visionary Hospice Movement Became a Nonprofit Hustle.''
    Chairman SMITH. Without objection, so ordered.
    [The information follows:]

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    Ms. VAN DUYNE. So, Mr. Secretary, we are well beyond the 
time to be patient and the time for action is now. Families 
deserve more from this Administration.
    We have a bipartisan group of lawmakers, including my 
colleague from Oregon, Mr. Blumenauer, ready to address this 
issue.
    And, Mr. Secretary, you served as a member of Congress 
representing Los Angeles County and on this committee at a time 
when your district was seeing an increase in fraudulent Hospice 
activity.
    You also served as the Attorney General of California as 
this crisis continued to build. Now you are HHS Secretary. How 
can we trust that you are finally going to take this issue 
seriously?
    Will you review how penalties actually prevent fraud?
    And when can we honest to God expect an answer from CMS on 
what is going on?
    Secretary BECERRA. So, Congresswoman, I am surprised you 
did not get the answer that you wanted from CMS, and we can 
actually follow up if you would like with CMS.
    Ms. VAN DUYNE. That would be great.
    Secretary BECERRA. But they are not sitting around. We are 
acting aggressively. In fact, in this budget we are asking for 
money to do exactly that, to go after the fraud and the abuse 
that is going on.
    Ms. VAN DUYNE. And I appreciate that you are doing this, 
and I know. Look. We have three and a half minutes because you 
limited your time in front of this committee. I will be 
following up with requesting a legitimate answer in writing 
from your office.
    Now, I know that you actually do have a history of not 
responding to our requests for information from this committee. 
So I am going to ask you will you commit to answering my 
questions which will be submitted for the record regarding 
Hospice care?
    Secretary BECERRA. Having been a former member of Congress 
and made requests for answers in writing,----
    Ms. VAN DUYNE. Is that a yes?
    Secretary BECERRA [continuing]. We make every effort to 
make sure we respond----
    Ms. VAN DUYNE. Thank you very much.
    I want to turn to a completely different topic, Mr. 
Secretary. Approximately 100 facilities nationwide, also known 
as pediatric transgender clinics, are performing gender-
affirming treatment in the form of hormone therapy and surgery 
on children at age 11 or younger.
    There are even allegations that some of these clinics 
perform these treatments without conducting thorough mental 
health assessments beforehand or even bypassing certain 
parental consent.
    Ten States have now restricted these treatments for 
children including eight States that ban this treatment for 
children outright.
    Are you aware of any medical facilities conducting 
pediatric gender-affirming treatment that either receive HHS 
grants or Medicare or Medicaid reimbursement?
    Secretary BECERRA. Congresswoman, there are a number of 
facilities that could receive funding from HHS so long as it is 
a federally prescribed service, and so therefore, we would make 
sure that they are using the monies appropriately.
    Ms. VAN DUYNE. So, Mr. Secretary, can you confirm that 
these facilities, none of them are using a dime of Federal 
taxpayer dollars to provide pediatric gender-affirming 
treatments to children?
    Secretary BECERRA. Congresswoman, those facilities are 
under law required to make sure they are using any federally 
provided money in the appropriate----
    Ms. VAN DUYNE. They are or they are not providing that 
service?
    Secretary BECERRA. Now you are asking me about every 
facility in the country. I can tell you that CMS has an 
obligation to make sure that we are doing oversight. If you 
help us with our budget----
    Ms. VAN DUYNE. Okay. Thank you very much.
    Secretary BECERRA [continuing]. We will do as much as we 
can.
    Ms. VAN DUYNE. I yield back.
    Chairman SMITH. The gentleman from Pennsylvania, Mr. 
Fitzpatrick, is recognized.
    Mr. FITZPATRICK. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for being with us today.
    Mr. Secretary, my constituent Phil Guttes was diagnosed 
with early onset Alzheimer's seven years ago. He received this 
diagnosis as part of a clinical trial for Aducanumab, a drug, 
and has been on this drug for almost I would say probably the 
last seven years or so.
    He will receive two more infusions as part of this trial, 
and then because of the discriminatory and unprecedented 
decision by CMS not to cover this drug and FDA-approved drugs 
like it, he will be faced with either wiping out his retirement 
savings to pay for the drug on his own, outside of Medicare, or 
go without treatment altogether.
    Mr. Secretary, never before, to my knowledge, has CMS 
refused to provide coverage for an FDA-approved drug. So my 
question: what does the Administration have to say to the 
millions of patients, caregivers and families who will be 
denied access to these breakthrough treatments, like my 
constituent Phil, many other people like him across America?
    And what is the Administration doing to ensure that access 
to these FDA-approved drugs will be provided to our seniors?
    Secretary BECERRA. Congressman, I would say to those 
individuals what my wife and I said to our own family members 
who, when we were experiencing these same issues of dementia, 
Alzheimer's, and that is we are going to work together. We will 
do everything now, and as the Secretary, I will do everything 
we can to make sure that lifesaving treatments are made 
available whether it is first through FDA, which has to ensure 
that a drug can be put out onto the market safely and 
effectively, or whether it is through CMS, which has to make 
sure that for purposes of Medicare, that it is a drug that will 
get coverage under the Medicare Program.
    But I will say it, as Secretary as I would say it as the 
father or the son-in-law or as the son of those who might be 
affected by these types of illnesses, that we will do 
everything we can to make sure that we are providing the care 
that they need.
    Mr. FITZPATRICK. Well, see, everything you can, and it is 
your decision, your purview of your department----
    Secretary BECERRA. Yes.
    Mr. FITZPATRICK [continuing]. Regarding the decision of CMS 
to refuse to provide coverage for this medication.
    Secretary BECERRA. Congressman, we apply the laws that you 
pass, and the laws require Medicare services to go through a 
certain type of check. We have to abide by that law.
    The law that governs CMS is different from the law that 
governs FDA. If you wish to wish to have the law that governs 
CMS be the same as the law that governs FDA, then it is up to 
you to make that change.
    Mr. FITZPATRICK. Lastly, Mr. Secretary, I have a question 
which is going to extend beyond my time. So, Mr. Chairman, I 
ask unanimous consent to enter this question into the record 
regarding the effect of GPOs and PBMs on drug shortages and 
drug prices.
    Chairman SMITH. Without objection.
    Mr. FITZPATRICK. And, Mr. Secretary, if I could get your 
commitment to a timely response to this question that we enter.
    Secretary BECERRA. We will make every effort to respond as 
quickly as we can, Congressman.
    Mr. FITZPATRICK. I yield back, Mr. Chairman.
    Chairman SMITH. Thank you, Representative.
    I recognize the lady, the gentlelady from Wisconsin, Ms. 
Moore.
    Ms. MOORE of Wisconsin. Thank you so much, Mr. Chairman.
    And I, too, want to thank you, Secretary Becerra for coming 
to my district and really doing an amazing job to educate my 
community about the importance of the various investments that 
have been made in our community.
    Just very quickly, I am looking at your written testimony, 
and on page 5, you said, ``The budget also proposes to further 
expand the health care workforce by allowing community health 
workers to be able to bill for select services under 
Medicare.''
    Can you share with me what those might be? That is very 
exciting.
    Secretary BECERRA. I am sorry. Can you pose the question--
--
    Ms. MOORE of Wisconsin. Your written testimony says that 
you are going to allow community health workers to be able to 
bill for select services under Medicare.
    Secretary BECERRA. We are trying to move both the Medicare 
Program and the Medicaid Program to a space where we make 
access to services more readily available because one of the 
things we found, Congresswoman, is too often people are 
deprived of services even though they are eligible for them 
because they do not know how to access them.
    And so whether it is in Medicare or Medicaid, we are going 
to do everything we can to make sure access is being most 
available.
    Ms. MOORE of Wisconsin. Thank you, Mr. Secretary.
    I am so pleased to see this. This is like a dream come true 
to look at a budget that is really centered around children and 
women, and I do not have enough time to address everything, but 
I was curious about the foster care provision that just came 
onboard in January 2023 that would enable foster youth to have 
Medicaid through age 26.
    And I am concerned about the implementation of that 
program, whether or not there is a sort of plan to contact 
foster youth who may or may not know that if aged out of foster 
care, that they are still eligible for Medicaid.
    Secretary BECERRA. Yes, that is one of the biggest issues, 
is when you leave the foster care program, sometimes there is 
no safety net to catch you.
    We are going to try to do what we can to follow up. Simply 
because you turn a particular age, 19, 21, depending on what it 
is, it should not mean that all of a sudden you fall over a 
cliff when it comes to the services that you need.
    Foster kids, as you know, are the most in need of service. 
They are the ones that are calling the 988 suicide prevention 
hotline----
    Ms. MOORE of Wisconsin. Exactly.
    Secretary BECERRA [continuing]. More often than not.
    Ms. MOORE of Wisconsin. Exactly.
    Secretary BECERRA. So we are going to do everything we can 
to make sure no foster care child believes that they are second 
class.
    Ms. MOORE of Wisconsin. I am really happy to see that you 
are very intentional about moving into mental health.
    And you know, we talk about mental health parity all the 
time, at least as long as I have been a member of Congress, and 
so I am wondering what in particular that we wrap our arms 
around are you doing to make sure that mental health parity is 
more than just a conversation?
    Secretary BECERRA. Congresswoman, we are doing as much as 
we can to get insurance companies to follow the law, and so 
that if you are an insurance company, you provide reimbursement 
for physical health care, benefits and services that a patient 
receives, that you are also providing reimbursement for mental 
health services in an----
    Ms. MOORE of Wisconsin. This is a really big problem. I 
mean, women postpartum have severe depression, and it has a 
real impact on the wellbeing of the entire family.
    You know, when Mama ain't okay, nobody is okay.
    I yield back.
    Chairman SMITH. The gentleman from Florida, Mr. Steube, is 
recognized.
    Mr. STEUBE. Thank you, Mr. Chairman.
    On January 30th of this year, a Corcoran Report was 
released, and it found that for, and I quote, ``medical and 
surgical masks,'' and a separate analysis for N95 P2 
respirators, and I quote again, ``Compared with wearing no mask 
in the community studies, only wearing a mask may have little 
to no difference in how many people caught a flu-like illness 
or COVID-like illness.''
    Are you aware of the analysis that I am referencing?
    Secretary BECERRA. Congressman, I have heard of a lot of 
analyses. I know that at the end of the day wearing a mask has 
helped keep Americans alive.
    Mr. STEUBE. Well, not according to the Corcoran.
    The medical and surgical mask analysis reviewed nine 
studies in over 276,000 people. The N95 P2 analysis reviewed 
five studies in over 8,400 people.
    But then on March 10th, Corcoran put out a statement noting 
that their analysis was actually inconclusive and that the 
exact quote from their analysis that I just read was, quote, 
``misleading'' after they had just found all of that based on 
all of those studies.
    So it is clear that somebody in the Administration or 
somebody somewhere influence Corcoran's attempt to back-tread 
from their previous findings three months prior.
    So my first question is is it true that you had 
conversations with Corcoran regarding their January findings 
after their report was released?
    Secretary BECERRA. If your ``you'' refers to me, that is 
not true.
    Mr. STEUBE. Okay. Did anyone acting on behalf of HHS 
contact Corcoran about their January 30 findings after their 
report?
    Secretary BECERRA. Best I know, no, but I can try to find 
out if you would like.
    Mr. STEUBE. So would you be willing to give any documents 
or correspondence that anybody in your agency had with Corcoran 
between January and March 10th of this year?
    Secretary BECERRA. We will provide to you whatever 
documents are disclosable by law.
    Mr. STEUBE. Okay. I will put that into a letter.
    Is it true that someone from HHS or the Biden 
Administration pressured Corcoran to change or back away from 
their January 30 findings?
    Secretary BECERRA. I know nothing of that ever happening.
    Mr. STEUBE. So you are not aware, but you are saying that 
you are not aware that somebody in the agency may have had 
conversations with them?
    Secretary BECERRA. As far as I know, I know of no one in 
the agency who engaged in that kind of a conversation.
    Mr. STEUBE. And your testimony here today is that you would 
be willing to provide correspondence between anybody in HHS 
with Corcoran after January of this year, after the findings?
    Secretary BECERRA. We are prepared to provide you with 
whatever documents legally you are eligible to request.
    Mr. STEUBE. Okay. Has HHS ever contacted social media 
platforms, such as Twitter or Facebook, to pressure them to 
remove statements about COVID-19 that the Administration did 
not want circulated?
    Secretary BECERRA. I believe now you are making reference 
to some lawsuits that sort of make those kinds of allegations, 
but I can say to you that I am not aware of anything like that, 
at least not from me.
    Mr. STEUBE. So you have not had any conversations with any 
social medica platforms about anything related to COVID and the 
information that they are putting out to the American public?
    Secretary BECERRA. Other than perhaps using some of these 
platforms to put out information.
    Mr. STEUBE. So you have had conversations with social media 
platforms as it relates to putting out information?
    Secretary BECERRA. I have put out information on some of 
these social media platforms. I have not had conversations with 
the representatives or the leaderships of these platforms 
trying to influence them to do one thing or the other.
    Mr. STEUBE. So your testimony is that you put things on 
platforms, but you have not had conversations with executives 
or anybody at Twitter or Facebook or otherwise.
    Secretary BECERRA. Now you are stretching it. Have I ever 
had conversations----
    Mr. STEUBE. Well, I am following up on your testimony.
    Secretary BECERRA. So the answer is there may have been 
occasions for me to have conversations with executives from any 
of those media platforms on any number of subjects.
    Mr. STEUBE. Did Surgeon General Vivek Murthy participate in 
meetings with White House officials and social media company 
officials discussing what information should be hidden from the 
public?
    Secretary BECERRA. I suggest you ask Surgeon General----
    Mr. STEUBE. Are you aware of any conversations that they 
had?
    Secretary BECERRA. I know that he has conversations with 
lots of entities and individuals, but I could not specify if in 
this particular case----
    Mr. STEUBE. I'm asking if you are aware that he had 
conversations with those social media platforms.
    Secretary BECERRA. I am not aware.
    Mr. STEUBE. Mr. Chairman, I ask unanimous consent to add to 
the record the Corcoran Library analysis, Physical 
Interventions to Interrupt or Reduce the Spread of Respiratory 
Viruses, and the Corcoran three months' later statement on 
physical interventions to interrupt or reduce the spread of 
respiratory viruses.
    Chairman SMITH. Without objection, so ordered.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman SMITH. Representative from New York, Ms. Tenney, 
is recognized.
    Ms. TENNEY. Thank you, Chairman Smith and Ranking Member 
Neal, for holding this important meeting.
    And thank you, Mr. Secretary, for testifying before the 
committee.
    Over the past couple of years, many of us have shared 
numerous concerns about the Department of Health and Human 
Services prioritizing politics over its duty to promote and 
protect the health and welfare of the American people. This has 
included HHS' insistence to keep the unscientific CMS health 
care workforce COVID-19 vaccine mandate, referenced by my 
colleague from New York, Mr. Higgins, which has exacerbated 
health care staffing shortages, especially in rural districts 
like my own in Upstate New York.
    The department has also spent time altering Medicare 
payments to re-incentivize doctors to develop anti-racism 
plans, for example, instead of boosting health quality care or 
health care quality for all patients.
    At the same time, HHS has failed to properly implement 
bipartisan surprise medical billing provisions passed by 
Congress or reform its guidance to allow seniors to access new, 
innovative treatment for Alzheimer's disease, as my colleagues 
have referenced.
    But I want to jump right into this issue about vaccine 
mandates if I could, Mr. Secretary. Over the past few years, 
multiple scientific studies have found that the COVID-19 
vaccines do not reduce transmission of the virus. In fact, our 
own CDC Director, Dr. Rochelle Walensky, she is a Doctor of 
Medicine, unlike you and I who are doctor of laws.
    She said in referencing the COVID-19 vaccine, what they 
cannot do anymore is prevent transmission.
    So you just stated in your testimony today that the reason 
we are extending this vaccine mandate, especially on health 
care workers, until November of 2024 is because of the 
transmission of the disease.
    This is causing huge problems in Upstate New York in terms 
of staffing, as I indicated. In the Finger Lakes Region and 
Buffalo Region, which I share with Mr. Higgins, hospitals have 
had a 375 percent increase in contract labor costs due partly 
because of the vaccine mandate, having to hire visiting nurses, 
which are much more costly.
    There have been protests, and a lot of objections to this 
vaccine mandate, particularly among nurses and those heroes who 
served when we did not have a vaccine, who now have been laid 
off and lost their jobs.
    And we think this is unsustainable. What are your plans 
under CMS--and I know you have indicated to my colleague, Mrs. 
Miller from West Virginia; what are your plans in dealing with 
this vaccine mandate now that we know that this is not 
transmissionable by Dr. Rochelle Walensky, our CDC Director?
    Would you be willing to overturn this vaccine mandate 
earlier so that we could get people back to work in New York 
and really provide the health care we owe to our patients?
    Secretary BECERRA. Congressman, thank you for the question.
    And as has always been the case, and you can----
    Ms. TENNEY. Can you just answer would you be willing to do 
that? Because I want to also add a New York judge actually just 
struck down the vaccine mandate in January.
    So is this something you are willing to do to override this 
based on the law and also based on science?
    Secretary BECERRA. The actions are taken based on science 
and the evidence, and that will continue to be the case.
    Ms. TENNEY. So Dr. Walensky is not accurate as a doctor in 
determining that these vaccines do not transmit the disease?
    Secretary BECERRA. So I am not sure about the quote that 
you attribute to her, but what I could tell you is that Dr. 
Walensky, like all of those who are working on COVID within the 
Department of Health and Human Services, base their actions on 
science and the evidence.
    Ms. TENNEY. Would you be willing to waive Novak Djokovic's 
entry into the United States to play in the U.S. Open, tennis.
    Secretary BECERRA. So you give me more power than I have, 
authority than I have. Those are not----
    Ms. TENNEY. You oversee the CDC?
    Secretary BECERRA. CDC does not make the decision about who 
can come in and cannot come in. Those are issues that----
    Ms. TENNEY. They could issue the waiver.
    Secretary BECERRA. I'm sorry?
    Ms. TENNEY. The waiver could be issued.
    Secretary BECERRA. A waiver for one individual?
    Ms. TENNEY. For anyone, anyone that is coming in. I mean, 
we have illegal immigrants crossing our border every single day 
who do not actually take the vaccine.
    Secretary BECERRA. We provide the vaccine to those 
unaccompanied migrant children who do come into the country, 
yes.
    Ms. TENNEY. And what about American citizens who choose to 
play in these sports that do not take the vaccine? They are 
waived from coming in.
    Are they dangerous to the----
    Secretary BECERRA. American citizens are able----
    Ms. TENNEY. Is that science?
    I mean, I am just saying, I mean, we allow American 
citizens unvaccinated to play in the U.S. Open. So is that 
scientific? Should we mandate that they are vaccinated in order 
to play in sporting events, for example?
    Secretary BECERRA. The actions that our Administration has 
taken with regard to American citizens is to protect them as 
best possible against COVID. The actions we take with regard to 
those trying to enter the country are somewhat similar, but 
there are some differences because these are folks who are 
asking for permission to come into the U.S.
    Ms. TENNEY. Would you not say that the decisions are 
political at this point?
    Secretary BECERRA. The decision is based on science and the 
evidence.
    Chairman SMITH. We need to move on.
    Ms. TENNEY. My time is up. My time has expired.
    Thank you very much.
    Chairman SMITH. Thank you.
    The gentleman from Michigan, Mr. Kildee, is recognized.
    Mr. KILDEE. Thank you, Chairman Smith and Ranking Member 
Neal, for holding this hearing.
    And thank you, Secretary Becerra, for being here this 
morning and, in particular, for discussing the proposed 2024 
budget. You and I served together here in this body. I consider 
you a friend, and I am glad to have you here with us, and I 
appreciate you addressing some of these issues.
    I am pleased with the priorities that I--have seen come 
forth in the aspect of the budget that you have responsibility 
for. I am particularly pleased that the budget includes $5 
million for the Flint lead registry, which as you know is a 
powerful tool to help improve the lives of kids and families 
that I represent in my hometown of Flint that have been exposed 
to lead contaminated water, and I do appreciate this being a 
priority for the department.
    Because Mr. Kustoff raised it, I want to give you an 
opportunity to address some of the work that you are doing on 
this issue of child labor violations.
    I know that you most recently have stood up a task force to 
address this issue. It is a serious issue. It is one that we 
have to take seriously, and you know, Mr. Kustoff raised this 
issue as I have with you privately in the past.
    We do know that this is really a question of your 
authority, but even to the extent that you do have some 
authority, it is also an issue of resources. And that is why I 
am happy to see $39.4 billion for the Department of Health and 
Human Services, Administration for Children and Families in the 
President's budget.
    It is ATF that works to protect the wellbeing of 
unaccompanied children by assessing the placements that they 
will be placed in connection with the other resources that they 
will be provided.
    And because a budget decision affects what you are able to 
do, I wonder if you might just tell us how cuts, which I do 
believe some would advocate for, cuts to the Department of 
Health and Human Services Department's Administration for 
Children and Families would impact your ability, even given the 
authority that you have to protect children from exploitation.
    Secretary BECERRA. Well, Congressman, that is a broad 
question, but what I can tell you is if we lose some of the 
funding we have within the Administration for Children and 
Families, we would have less opportunity to provide the child 
care services support, the Head Start services support, to be 
able to with regard specifically to the refugee program and 
within that the Unaccompanied Migrant Kids Program, be able to 
provide the level of custody care that we provide.
    And so you impact kids in so many different ways, and as I 
say, children are children, and whether they are your children, 
my children, in this country we should let children be treated 
as children.
    Mr. KILDEE. Thank you, and I ask finally do you know, and I 
hope you do, that the Administration would support my efforts 
to increase the civil and criminal penalties for employers?
    Because look. We need to hold people responsible for this. 
You know, you have some regulatory authority, but employers 
have a responsibility. Those employers who are illegally hiring 
children in dangerous jobs need to face stiffer criminal and 
civil penalties.
    And I ask if the Administration would support our effort to 
do just that.
    Secretary BECERRA. You hit it right on the money, 
Congressman. If an employer, if a company was not willing to 
hire against the law these children, we would not see the type 
of exploitation, and that is the heart of this. We should not 
be allowing this to happen right in front of us.
    Mr. KILDEE. Thank you, Mr. Secretary.
    And thank you, Mr. Chairman. I yield back.
    Chairman SMITH. Thank you.
    The gentleman from Utah is recognized.
    Mr. MOORE of Utah. Thank you, Mr. Chairman and the Ranking 
Member.
    Secretary Becerra, thank you for being here today and 
putting in the time to dialogue with us on these issues.
    This is it. This is the most crucial, most important 
matters of our Nation, is getting things related to health care 
figured out. This is something in every single district across 
the board. So incredibly important.
    According to a recent estimate, 250,000 Americans die each 
year due to medical error. This is an issue Congress and CMS 
have tried to address for decades through quality measure 
activities.
    However, a 2019 GAO report noted that CMS failed to 
properly track its spending on quality measurement activities 
and how its spending is or is not helping it achieve its 
strategic objectives, such as lowering administrative burdens.
    We talk a lot about administrative burdens, but sincerely, 
this is an area that we could truly lower administrative 
burdens. My team and I think that this could be a significant 
win and a bipartisan win in the 118th Congress.
    I sent you a letter yesterday asking five detailed 
questions on this topic.
    Will you commit to answering these questions in my letter 
by the end of April? Will that be enough time for you to 
consider this?
    Secretary BECERRA. So----
    Mr. MOORE of Utah. You have not seen the questions, but----
    Secretary BECERRA. Yes, I have not seen the questions, but 
I commit we will respond and we will try to do it as best we 
can as quickly as we can.
    Mr. MOORE of Utah. And we will follow up, and once you have 
had a chance to look at them, I have got a copy of it here 
today. We would love a sense for just when you will have time 
to get to them.
    We are going to drive this this Congress, and you know, 
time is running out. We want to get this going.
    Secretary BECERRA. Having sat where you sit today, I know 
how important it is to get the answers.
    Mr. MOORE of Utah. Some more context on that, if you will 
commit to working with us to make these quality measures 
outcome oriented and transparent, would you be willing to, you 
know, without seeing the exact questions, making this outcome 
oriented and transparent we think is a significant bipartisan 
win here so that they are indicative of the quality of care 
patients actually receive and that patients are not in some 
cases forced to shop around for their health care in the dark?
    Secretary BECERRA. Congressman, looking forward to working 
with you and reading this letter.
    Mr. MOORE of Utah. Thank you.
    Finally, the last piece here on the budget, your budget 
claims to extend Medicare solvency by 25 years. I looked at 
this. My team looked at this, and your plan, the way we view it 
does this primarily by funneling existing general tax revenues 
to the Medicare Hospital Insurance Trust Fund.
    The trust fund, general, it is just funneling them over 
into the trust fund to extend that solvency.
    According to CBO data, if Medicare is allowed to run its 
course and we merely finance it by borrowing against our 
children's future, Medicare will add over $17 trillion to the 
national debt over the next 25 years just in additional 
interest payments.
    When you and the President formulated your budget, did you 
consider the cost, the specific cost, of additional interest 
payments caused by borrowing?
    Secretary BECERRA. And, Congressman, again, I do not 
understand that math because the President's budget, as opposed 
to what you have described, the President's budget actually 
reduces deficits. It not only extends the life of Medicare and 
strengthens it, but it reduces deficits moving forward into the 
future.
    It makes some painful decisions that some folks may not 
like, but it does protect Medicare, those benefits, and it does 
continue to make it available not just for today's seniors but 
the next generation.
    Mr. MOORE of Utah. We had an opportunity to dig into this 
in the Budgetary Committee, and there is argument over whether 
that truly does reduce deficits here.
    Secretary BECERRA. I would love to go through those 
numbers.
    Mr. MOORE of Utah. You are taking from one pot and just 
pushing it into the other. We are not truly going after the 
solvency here.
    Secretary BECERRA. Again, I disagree with that, and I am 
more than willing to sit down and go number to number, mano to 
mano on that one because the President made a commitment. It is 
real.
    Secretary BECERRA. We will gladly sit down and go mano to 
mano at any time on this, on these details.
    Thank you.
    Secretary BECERRA. Thank you.
    Chairman SMITH. Mrs. Steel from California is recognized.
    Mrs. STEEL. Thank you, Chairman Smith.
    And thank you, Secretary Becerra, your coming out and you 
know how many hours you have been here for testifying. So I 
really appreciate that.
    You know, I am concerned about Center for Medicare and 
Medicaid Services' oversight of new Hospices and home health 
agencies. This is particularly an issue in California, which 
instituted a moratorium on State licensures January 1st, 2022.
    Despite this moratorium, Hospices in California that 
previously received State licenses are still being certified by 
Medicare. In fact, 443 California-based Hospices received 
Medicare certification in 2022. Three hundred seventy-five out 
of 443 were issued in L.A. County only.
    Considering the moratorium in California and the State 
Auditor's Report highlighting these bad actors, why is Medicare 
still certifying Hospices that are likely engaged in fraud?
    Secretary BECERRA. Congressman, that is a great question. I 
am not totally abreast of what the State of California, my 
State, is doing, but as you will recognize, the laws that guide 
us on Medicare and Hospice care are different from what guides 
the State of California.
    What the State can do is not necessarily what we can do and 
vice versa. If someone applies to provide Hospice care, we have 
to make sure that what they are doing is fulfilling the 
criteria that by Federal law they must achieve. If they do, we 
do not have the luxury of saying, ``No, we will not because 
your State is saying you may not be a good actor.''
    We have to base it on the information they provide to us, 
and if they meet the criteria to qualify for funding under 
Medicare.
    Mrs. STEEL. So who does the audit?
    Secretary BECERRA. Who does what audit?
    Mrs. STEEL. These Hospice cares, especially caretakers.
    Secretary BECERRA. If you are talking about the work that 
the State has done to suspend further licensing, then it is the 
State who would do some of those audits.
    If you are talking about the Medicare Program, that is a 
Federal program. The State does not operate Medicare.
    Mrs. STEEL. So Medicare certifications they were just still 
giving out to these fraud cases.
    Secretary BECERRA. Medicare would not give out a 
certificate for operation of a Hospice Care Program if it was 
doing it fraudulently. Those programs would have to be able to 
show that they meet the criteria.
    If they subsequently commit fraud----
    Mrs. STEEL. So who finds out that they are fraudulent, such 
is the case or not? Who find out? Because it is the Medicare 
certificate that we are talking about here.
    Secretary BECERRA. That is where you rely on the surveyors, 
the investigators who periodically go in to see how those 
programs are operating.
    The State might have some folks who are doing it. When I 
was Attorney General of California, we had the authority to go 
in and look at all of these different facilities for how they 
were caring for folks. That is why we expanded the program that 
actually looks into nursing homes.
    That is different from what the Federal Government does.
    Mrs. STEEL. So you know what? Let me just change the issue. 
I am going to go a little more deeply, and I am going to work 
with you about this.
    Secretary BECERRA. Of course.
    Mrs. STEEL. Fraudulent certificates.
    But lastly, constituents of mine from Fullerton and 
Placentia rallied on Capitol Hill about CMS decisions to deny 
senior access to vital Alzheimer's treatments.
    What do you expect me to tell my constituents about not 
having access to care? Because USC, Stanford, UCLA, UC-Irvine, 
UC-Berkeley, UC-San Diego, these are just really good 
universities. They all say it is a breakthrough medication.
    So why not?
    Secretary BECERRA. Congresswoman, I would tell you to tell 
them that you will advocate as hard as you can to make sure 
that where possible, we will make access to those medicines and 
service that help them with their particular condition or 
disease.
    And if they probe even further, you might want to make sure 
you can tell them the distinction, the difference between the 
work that the FDA does to make a drug available and the work 
that CMS does within the Medicare system to make those drugs 
available for reimbursement within the Medicare Program.
    Mrs. STEEL. So how are we going to do that though because 
they are not reimbursing it? They have been denying those 
coverages.
    Secretary BECERRA. That is what I am saying. People have to 
understand how CMS and Medicare operate so they can understand 
the decisions, the determinations that are made by CMS.
    CMS did provide some coverage for some of those Alzheimer's 
drugs, but under limited conditions.
    Mrs. STEEL. You know what? My time is up. I am going to do 
it in writing and I will ask all of these questions. Actually I 
have more than ten questions here that I want to ask you, but I 
just do not have time.
    So I yield back.
    Secretary BECERRA. Thank you, Representative.
    Chairman SMITH. The Representative from Virginia, Mr. 
Beyer.
    Mr. BEYER. Mr. Chairman, thank you to you and Ranking 
Member Neal for having this hearing.
    Mr. Secretary, welcome back to Ways and Means. It is great 
to have you back.
    I want to praise the work that you have done and CDC and 
SAMHSA on suicide prevention. There is always a lot more work 
to be done, but I am really proud of this Administration's 
budget, your intent to take suicide seriously.
    The $80 million directed just for the Suicide Prevention 
Program for CDC for fiscal year 2024 is just wonderful.
    You know one of the biggest pieces has been the transition 
to the lifeline, to the 988 number, and you mentioned it in 
your opening statement.
    Thanks, by the way, to Mr. Moulton, a Democrat, and Mr. 
Stewart, a Republican, and their leadership on this issue.
    And we successfully secured funding to help that transition 
last year, but it only went into effect in July. There was a 
huge surge in August in that number, and right now I think 
SAMHSA expects calls to double in this next year as word is 
getting out about the 988.
    And one of the pieces of this conversation is trying to get 
an awareness of the campaign going for the new number and for 
suicide resources broadly because how we treat it today is much 
different than when we were kids.
    And this, by the way, was something that Governor Gianforte 
and Mr. Kinzinger have both partnered with me on, and I was 
encouraged to see this year's President's budget called for an 
awareness campaign similar to the bill we had last year, the 
Campaign to Prevent Suicide Act.
    Can you just speak to us as the leading health care 
official in this country about why this is so important?
    Secretary BECERRA. Congressman, I do not know if there is 
anyone in America who has not lost a loved one at some point 
because of suicide or drug overdose, and it is amazing to see 
the age of some of the people who are calling in to 988, 
children, pre-teens.
    You hear the stories from parents about how they are not 
sure what to do, that their kids are suffering. You hear the 
stories directly from the children. America is hurting.
    COVID did not create it. It just really exposed some of 
what is going on, and the President is very committed to 988 
because it is a way to say to people who are hurting we are 
here, we are listening, and we are here to catch you.
    And thank God working with all the States we were able to 
stand up a program that actually works, and now the President 
wants to continue to double down, do even more, and I hope you 
will help us with that because we want to do six million 
additional contacts.
    Mr. BEYER. Great. Thank you.
    One more question. I am intensely interested in looking at 
how we can decrease costs within the health care system, and 
AHRQ, a foundational agency that helps tackle much of this 
work, and I have been particularly interested in the role of 
all payer claims databases.
    You know, State after State have picked this up, and it is 
wonderful how all of the data is pulled together State by 
State, but what we really need is a Federal all payer claims 
database to bring this all together.
    And I know your budget looks at supporting this work within 
AHRQ. Can you speak to what you might see as the benefits of an 
all-payer claims database on a national level?
    Secretary BECERRA. Well, we will get to see what every 
country is doing better, and we will get to pass along the best 
practices to every part of the country because by collecting 
data and having it from all parts of the country, we can let 
folks see what is working and what is not.
    But if you are never seeing the data, you will never know 
the success stories or the failures and will continue to make 
the same mistakes.
    And so we are hoping that we can do a far better job of 
collecting that data nationally because there is so much data 
out there now. It is just that we do not have in some cases the 
authority or in some cases the capacity to collect it, but, 
boy, if we were able to collect it, Congressman, the stories we 
could tell and the improvements we could make in the health 
care system.
    Mr. BEYER. Thank you, Mr. Secretary, very much.
    And I yield back.
    Chairman SMITH. Thank you.
    Mrs. Fischbach from Minnesota is recognized.
    Mrs. FISCHBACH. Thank you, Mr. Chair. I appreciate the 
opportunity.
    You know, I am going to just power through these because I 
have got a few questions.
    Secretary, throughout my district and across the Nation 
nursing homes are already struggling to maintain current 
staffing levels and have an even more difficult time finding 
new staff members to fill vacancies.
    And I know there was some discussion about nursing homes, 
but President Biden's additional staff ratios requirements on 
top of the ongoing workforce shortages would greatly reduce the 
number of patients served in facilities.
    Secretary, do you agree that long-term care facilities are 
facing labor shortages?
    Secretary BECERRA. Congressman, without a doubt the whole 
health care system is facing shortages.
    Mrs. FISCHBACH. And I agree with that, Mr. Secretary.
    Could the President's new staffing ratios force nursing 
homes to reduce the number of patients they can serve or, 
worse, even close their doors entirely?
    Secretary BECERRA. Ah, here is where we probably diverge 
because I would say the most important thing about any nursing 
home facility is that they offer quality care, and if you 
cannot offer quality care, maybe you should not have your doors 
open.
    And that is why we want to make sure that if you are open, 
first and foremost, you care about the people that you are 
serving, which means you have to have the level of services 
required for the people that are needed.
    Mrs. FISCHBACH. Well, Mr. Secretary, are staffing ratios 
the only measurement of care?
    Secretary BECERRA. Oh, no, no, no.
    Mrs. FISCHBACH. Quality care?
    Secretary BECERRA. No. There are many measures.
    Mrs. FISCHBACH. Okay.
    Secretary BECERRA. But staffing levels make a difference.
    Mrs. FISCHBACH. But potentially you could close nursing 
homes, I think, is what you said.
    Secretary BECERRA. By themselves, they should not be the 
reason you close. If you have the correct number of staff----
    Mrs. FISCHBACH. Well, if they cannot get enough, Mr. 
Secretary, if they cannot get enough nurses or nursing staff--
--
    Secretary BECERRA. What if they do not provide enough 
nurses? Is that good?
    Mrs. FISCHBACH. That is not the issue here because it is 
ratios and you are going to increase those and make it already 
more difficult. It is difficult to get nurses, and I think you 
agreed with that.
    Secretary BECERRA. Obtaining nurses, and they will tell you 
they cannot have them doing everything for everyone. You need 
to have enough nurses in a facility. You are right.
    Mrs. FISCHBACH. Nurse and CNAs and LPNs, nursing staff.
    Secretary BECERRA. Absolutely.
    Mrs. FISCHBACH. And you know, Mr. Secretary, I do not know 
who you are talking to, but I do think maybe you should talk to 
some of the rural folks that are struggling to keep nursing 
homes open under the already tight ratios and provide people 
care close to their families and close to their homes.
    But I have got to move on.
    Secretary BECERRA. I just want to assure you we have been 
talking to folks in rural America about this.
    Mrs. FISCHBACH. Reclaiming my time, Secretary, the Hyde 
Amendment protects taxpayers by prohibiting taxpayer funding of 
abortion, and as you well know, this language, this vital 
language, has been included in appropriations bills every time 
since 1977, with strong bipartisan support.
    Does the President's budget request include the Hyde 
Amendment language?
    Secretary BECERRA. The President's budget does everything 
possible to make sure that women are entitled or afforded----
    Mrs. FISCHBACH. I am asking you a direct question, Mr. 
Secretary. I think it is a yes or no.
    Does the President's budget request include the Hyde 
Amendment?
    Secretary BECERRA. The Hyde Amendment is something that 
Congress has added, and it is up to Congress to determine 
whether it will add the Hyde Amendment.
    Mrs. FISCHBACH. Well, does the President want the Hyde 
Amendment included in that budget request?
    Secretary BECERRA. The President's budget does everything 
possible to protect the reproductive health care rights of 
all----
    Mrs. FISCHBACH. Mr. Secretary, with all due respect, I am 
going to take that as a no.
    And the Dornan Amendment, I am assuming that is also a no, 
that that is not included in the language in the legislation 
either.
    And I do not know. I should at some point find out for 
sure. I know we have been looking for language on the budget, 
if we have gotten that, but I am going to assume that neither 
of those are included because you did not answer with a yes or 
no.
    But this is something since 1977 that has been included 
with bipartisan support, and it really does leave Americans 
vulnerable to being forced to pay for elective abortions, even 
though the majority of Americans are opposed to tax dollars 
going towards abortion funding.
    But I understand that under this budget the Democrats would 
rather appease their extremist base that want Federal funding 
for abortion on demand, and I just say it will be very, very 
sad that the left is forcing this onto Americans.
    With that I yield back.
    Chairman SMITH. The gentleman from Pennsylvania is 
recognized.
    Mr. EVANS. Mr. Secretary, it is a pleasure to have you come 
back before this committee. I have enjoyed listening to you.
    This year, no one on Medicaid will pay more than $35 a 
month for insulin. The question I would ask you, Mr. Secretary, 
can you please explain and discuss how the change helps 
constituents in Philadelphia and across the country?
    Secretary BECERRA. Congressman, the benefits are immediate. 
I cannot tell you how many folks have come up to me and said, 
``I cannot believe it. In December, I was paying''--I think 
this one woman was paying $117 for her insulin for a month, and 
she said, ``I got charged $35 in January. I went back to the 
provider and said I think you underbilled me, and they said, 
no, that is the new price.'' She was ecstatic.
    And that is something that is being repeated over and over 
because the savings are not just real, but they are current, 
and I will tell you that in your State of Pennsylvania, the 
savings on average this year for Americans who are on Medicare 
and need insulin will be somewhere around close to $550. That 
is $550 in their pocket that they would have had to otherwise 
spend to buy their insulin.
    That is the average. That means some people are saving a 
little less, but it means there are a whole bunch of folks who 
are saving a lot more.
    Mr. EVANS. I want to thank you.
    I yield back. I thank you very much.
    Chairman SMITH. The gentlemen from Iowa, Mr. Feenstra, is 
recognized.
    Mr. FEENSTRA. Thank you, Chairman Smith and Ranking Member 
Neal.
    And thank you, Secretary Becerra, for being in front of us 
today.
    I have just got a quick question. Do you support a single 
payer system?
    Secretary BECERRA. Congressman, I have worked for many, 
many years to make universal health care available to all 
Americans, and now as the Secretary I put into place the 
President's proposals which include lowering cost----
    Mr. FEENSTRA. So you are simply saying you are not going to 
answer the question and you are going to dodge the question.
    Secretary BECERRA. I have always been for universal health 
care, to make sure everybody----
    Mr. FEENSTRA. Well, here is why I asked that. I listen to 
all of my colleagues, and the responses I have got it seems 
like we are going down that path very quickly.
    When you start capping obviously pharmaceuticals, that 
crushes the research and development. When you do not update, 
you know, your reimbursements, that obviously dramatically 
hurts rural hospitals, rural clinics, doctors, and so forth.
    And then the elimination of 2,200 codes is an actual 
crusher. So my question to you is this. If you dramatically 
increase taxes on a business, do you think that business will 
pass those increased costs onto the consumer?
    Secretary BECERRA. You are asking me a question which is 
speculation.
    Mr. FEENSTRA. All right. You are not going to answer that.
    Let me say this. Cutting payment to health plans in the 
end, it will be the patient that bears the cost. We have seen 
this time and time again. It happens.
    And a recent analysis suggests that this will be about $540 
per month per member per year. So the Biden Administration 
highlights its desire to lower cost on health coverage and 
provide better benefit. Yet the 30 million seniors and people 
with disabilities who choose to enroll in Medicare Advantage, 
which is close to 50 percent of them, will see either the 
benefits reduced or the costs go up.
    So how is the Administration and yourself, how do you 
explain that to the customers?
    Secretary BECERRA. Because, Congressman, there is nothing 
in our proposals that would cut Medicare benefits. I defy you 
to find me something in our proposal.
    That is what the commercials say that are paid for by the--
--
    Mr. FEENSTRA. Okay. So this is you singularly saying this, 
but do you want to know something? A hundred and fifty groups 
that represent patient, providers, and plans--I yield back--150 
groups representing patients, providers, and plans are saying 
that this will happen, and including the American Medical 
Association.
    So who is right, yourself or 150 other groups that are 
saying that this is what is going to happen?
    Secretary BECERRA. Take a look at the proposal. It makes--
--
    Mr. FEENSTRA. Your proposal is arbitrary, and if I had to 
guess, if I look at the real nuts and bolts of it, it is wrong.
    Now we are arguing.
    Secretary BECERRA. We are not arguing, Congressman. It is 
just a fact. We are not getting paid money to do those 
commercials. They----
    Mr. FEENSTRA. I have not just fallen off a turnip truck. I 
have my Ph.D. in health care administration. I see what is 
going on here. All right? I see what is going on.
    And if we were here next year at this time when all the 
Med. Advantage plans go up or their benefits are lost, I would 
love to hear what you have to say.
    Secretary BECERRA. Congressman----
    Mr. FEENSTRA. And I yield back.
    Secretary BECERRA. They cannot cut those benefits.
    Mr. FEENSTRA. I yield back.
    Secretary BECERRA. That is the deception that is going on. 
They cannot cut Medicare benefits. They can tell people that, 
but they cannot cut those benefits.
    Chairman SMITH. The gentleman from Illinois, Mr. Schneider, 
is recognized.
    Mr. SCHNEIDER. Thank you, Mr. Chairman.
    It is always good to see you and thank you for making the 
time to be here, and your patience.
    You know, it is critically important that we continue to 
make the progress we have made on expanding affordable access 
to health care. As you talked to, it has been a lifetime 
devotion for you, and I appreciate your work and will continue 
to do so.
    I take great pride in the fact that in the decade since ACA 
became law, the number of Americans without health insurance 
has dropped by almost half. Preexisting conditions are no 
longer a barrier to getting health insurance. Kids are able to 
stay on their parents' program until age 26, and lifetime caps 
are history, and those are just a few of the highlights of ACA.
    I want to focus on telemedicine. According to the CDC, just 
in 2021, more than one-third of Americans made use of 
telemedicine in the previous year. Prior to the pandemic, I do 
not want to speak for everyone, but I would suggest that this 
panel ran the spectrum from curious to skeptical on telehealth.
    Post-pandemic, I can promise you that this is a roomful of 
evangelists singing the benefits of telehealth.
    Telemedicine has improved access for virtually every 
American, including those who live far from medical facilities, 
those who do not have ready access to transportation, folks in 
need of mental health who cannot find a provider with an open 
appointment near them, or maybe they are just too shy to go in 
public because of the perceived stigma.
    So with the emergency coming to an end in May and the 
pandemic winding down, we have to consider how we are going to 
take the lessons learned from telehealth and make sure that 
they stay strong.
    I will soon introduce my bill, the Primary and Virtual Care 
Affordability Act. This bill would extend the temporary 
provision that allowed HSA eligible, high deductible plans to 
waive the deductible for telehealth services.
    I am also joining with my colleague, Mrs. Steel, as co-lead 
on her bill, Telehealth Expansion Act, that is being introduced 
today, may have already been introduced, to make telehealth 
flexibility permanent.
    My question for you in the last minute is can you speak to 
the Administration's other actions to expand telehealth 
services, and how do we build on this progress to make sure 
telehealth is something that is part of our future?
    Secretary BECERRA. I will mention one thing that actually 
is not within HHS' jurisdiction which is crucial if you are 
going to get your bill passed and deployed, and that is that 
broadband has to be made accessible to all communities because 
you can do telehealth if you have got good broadband, but if 
you do not have good broadband, you cannot do the connection.
    And so we want to make sure all communities have decent 
broadband so they can take full advantage of telehealth.
    The other thing we want to make sure we do is get people 
trained up. So especially places like rural America, we get 
providers, physicians who are ready to use telehealth because 
in some of those communities, that is where it is going to have 
the greatest advantage. And so we want to make sure folks are 
ready for this time.
    And then finally, we are going to need to work with you 
because the end of 2024 will come soon. Those extensions for 
telehealth will be upon us before you know it, and what we do 
not want is for a whole bunch of providers to be wondering can 
we or can we not continue to do this. The clock is ticking.
    Better we take care of it early to give predictability to 
those providers of how we will do telehealth.
    Mr. SCHNEIDER. My hope is we can extend telehealth long 
before we get to the deadline in 2024.
    Thank you. I yield back.
    Chairman SMITH. The gentlelady from New York, Ms. 
Malliotakis.
    Ms. MALLIOTAKIS. Thank you, Mr. Chairman.
    Thank you, Secretary, for being here today.
    You know, this Administration talks a lot about setting 
what I would call innovation killing price controls, but one of 
the things that I do want to talk to you about where I think we 
could really work together on access and affordability of 
prescription drugs would be PBMs. Okay?
    Obviously, our pharmacy benefit managers, which it is 
troubling to me that the three largest PBMs actually control 80 
percent of the market. There is no transparency. They are 
making a lot of money by keeping rebates instead of passing 
them on to consumers.
    They exclude drugs from their formulary, and they are 
dictating what their competitors are making, right? And they 
are crushing my small Mom and Pop pharmacies.
    Here you have PBMs that are also the insurer and then they 
are the pharmacy, and they are controlling everything in terms 
of pricing. Okay?
    For example, CVS Caremark, they also own the insurance 
company Aetna, and then they own the pharmacy, CVSes all over 
the country.
    Now, do you think that is a problem?
    Secretary BECERRA. Congresswoman, PBMs, you know, no one 
knows everything they do. We are surprised sometimes when we 
see what comes out, and there absolutely has to be more 
transparency in the way they do business.
    Ms. MALLIOTAKIS. Well, the FTC recently announced their 
plans to probe the largest six PBMs in the U.S., and with the 
role that PBMs play in Medicare drug pricing, can you explain 
why HHS has not launched its own investigations, is not pushing 
for more transparency in order to shed some light into this 
very opaque process?
    Secretary BECERRA. Well, Congresswoman, let me assure you 
we are working in this space. You may not have seen a 
particular rule come forward, but we are absolutely working in 
this space.
    And if you are interested, we would love to work with you 
because this is an area where reform is needed.
    Ms. MALLIOTAKIS. Well, you say you are working in the 
space. How so?
    Secretary BECERRA. Some of the work that we are doing is in 
the process of we are trying to get some rules ready that would 
deal with some of this. At the same time we are trying to avoid 
some of the lawsuits that are being filed.
    And what we are trying to do is continuing to give 
consumers access to some of these prescription drugs at the 
best cost we can get for them.
    It is difficult, but we are trying to do what we can 
working within the constraints we have within the laws because 
we can only go as far as the authorities have given us.
    Ms. MALLIOTAKIS. Well, I think actually the Administration 
is, I think, in a unique position to be going after the PBMs 
actually.
    And you mentioned rules. You said that, ``I see a rule,'' 
and then you said, ``Well, we have some rules coming out.''
    You know, I think that needs to be clarified there that 
maybe you have not done anything just yet, but I am just trying 
to understand why HHS seems to be sitting on the sidelines and 
giving PBMs, you know, free rein considering the role that they 
are playing, particularly in Medicare prices, but also just 
pharmaceutical drugs for all our constituents who are paying 
just way too much right now, and it is because of the games 
that they are playing and the lack of transparency.
    Secretary BECERRA. Yes. I can guarantee you we are not 
sitting on the sidelines. As we have talked about insulin, it 
is $35 a month.
    Ms. MALLIOTAKIS. Well, once again, that is a price control. 
That is not going after the PBMs.
    Secretary BECERRA. But we are affecting the price of drugs. 
We are making them more affordable and that is what counts. And 
ultimately the work whether PBMs or making sure we negotiate 
prices for drugs, it is to make sure consumers, Americans, get 
better prices for their medication.
    Ms. MALLIOTAKIS. I have run out of time.
    Thank you.
    Chairman SMITH. The gentleman from Ohio is recognized.
    Mr. CAREY. Mr. Secretary, good to see you again.
    In 2020, the Centers for Disease Control and Prevention 
reported that Ohio had the fifth largest overdose death rate in 
the country. In the same year, Ohio, fentanyl was involved in 
81 percent of all of the overdose deaths, often with a 
combination of drugs.
    Last year Drug Enforcement Agency seized enough fentanyl to 
kill every American, capturing more than 50 million fentanyl-
laced pills and over 10,000 pounds of fentanyl powder.
    I have been to the border. I have seen how the cartels are 
able to smuggle drugs into the communities, and we need HHS to 
protect Americans from fentanyl flooding our border.
    We need to hold Mexico accountable and continue to warn 
Americans about the potential for fentanyl-laced drugs.
    In the President's budget, there is roughly $40 million to 
combat fentanyl trafficking and disrupt international criminal 
organizations.
    What steps, Mr. Secretary, is your agency taking to prevent 
fentanyl from entering the United States and killing more 
Americans, including constituents of mine back in Ohio?
    Your answer, sir?
    Secretary BECERRA. Congressman, and I want to be respectful 
here in the answer because you are asking me what I at HHS can 
do, and much of what you are asking is about the border, and 
that is not within the purview of Department of Health and 
Human Services.
    I can tell you if you wish--I know you have limited time--
what we are doing with regard to fentanyl, but it will not be 
so much at the border. That is really the Department of 
Homeland Security and other agencies.
    Mr. CAREY. So is HHS working to combat the large amounts of 
fentanyl-laced drugs currently circulating in the U.S.?
    Secretary BECERRA. Absolutely. We are dedicating some $11 
billion in our budget for drug overdose prevention and to try 
to address it as best we can working with the States.
    Mr. CAREY. Just one thing I found that was interesting in 
the President's budget. Climate is mentioned 74 times more than 
the word ``fentanyl.'' So just an interesting point.
    Real quick, I do want to just touch upon something that we 
have seen particularly during the COVID time with our EMS 
personnel and with the treatment in place that we have actually 
seen, and it has been really saving people a lot of money 
because, as you are well aware, EMS personnel in the past, and 
currently most of our EMS personnel, are actually only paid if 
they take somebody to a hospital.
    But under this waiver program with this treatment in place, 
we are finding that these folks are able to actually save money 
by being able to diagnose it on site.
    So it is a good program. It is something that I know works 
with your agency. I just wondered if you had any thoughts on 
that.
    You know, I have 45 seconds.
    Secretary BECERRA. And I will be brief. It moves us more 
toward prevention and rather than waiting till you send someone 
to the ER room and see if you can catch them before they die. 
It is trying to make use of the evidence that shows that 
certain preventive approaches can actually save lives early.
    And so we want to move in that direction where we can.
    Mr. CAREY. Okay. Thank you, Mr. Secretary.
    Mr. Chair, I yield back.
    Chairman SMITH. The gentleman from California is 
recognized.
    Mr. PANETTA. Thank you, Mr. Chairman. Thank you, Ranking 
Member Neal.
    Mr. Secretary, it is good to see you again. Thank you for 
coming back and being here and being willing to answer these 
questions.
    In recent months, more so kind of in recent weeks, we have 
heard a lot of reports about the spread of illicit xylazine 
being cut with fentanyl. Fentanyl has been using xylazine to be 
cut and creating this drug that we are hearing that is called 
``Tranq'' or ``Zombie drug'' that does some miserable things to 
the human body, including eating flesh and potentially leading 
to amputation and making the use of fentanyl cheaper, more 
addictive, and even deadlier.
    Xylazine itself is used by people for sedatives in animals. 
So those are illicit uses. However, there is no licit purpose 
for it to be used in humans.
    That is why I have introduced my bipartisan, bicameral bill 
today called Combatting Illicit Xylazine Act, which will help 
basically allow enforcement of the illicit use of Xylazine 
under Section 21 USC, as well as using the CSA under Schedule 3 
of the CSA, of the scheduled drugs.
    I just wanted to make you aware of that, but also wanted to 
see if your department is responding to the Xylazine threat in 
any way.
    Secretary BECERRA. I can get back to you because I cannot 
tell you specifically what we might be doing, but we are 
generally speaking, whether it is opioids, whether it is 
fentanyl, we have a drug prevention strategy that tries to help 
localities address the scourge of drugs.
    Mr. PANETTA. Great. Thank you.
    Moving on to Medicare economic index, MEI, according to 
data from the Medicare Trustees, Medicare physician pay 
nationwide has increased just ten percent over the last two 
decades, as you know--well.
    Meanwhile the cost of care increased 42 percent from 2001 
to 2022. This type of inflation measured by the Medicare 
economic index is even worse in our home State of California.
    This month MedPAC recommended that Congress increase 
physician fee rates above the current law and make an 
inflation-based payment tied to the MEI.
    A couple of questions here for you. Can you talk more about 
why the physician fee schedule has failed to keep up with the 
cost of care?
    Do you agree that indexing these fees for inflation is the 
right solution?
    Is there anything that we can do legislatively to correct 
this?
    Secretary BECERRA. Actually, your last statement is the 
most operative, Congressman, because having been where you are 
for 24 years, I remember going through this all the time.
    By law we have to make sure we level set when it comes to 
the payments that we make to physicians. It has to be neutral. 
So if you raise it here, you have got to lower it here. You 
have to be budget neutral.
    And so that is one of the issues that is at hand here. We 
cannot change that. You have to change that.
    And so when you ask is there something that we, meaning 
Congress, can do, you have to take a look at how you want to do 
the reimbursement for physicians. If you are going to leave it 
to us and if we have to be budget neutral, we are always going 
to be making adjustments that hurt some and help others.
    Mr. PANETTA. In the same note, obviously Medicare 
geographic adjustments, they really have not kept up with the 
cost of care and created access challenges for many 
constituents of mine receiving traditional Medicare.
    Is the HHS doing anything about the geographic adjustments 
having not kept up with the cost of care?
    Secretary BECERRA. Congressman, you are talking to a 
Californian.
    Mr. PANETTA. Yes.
    Secretary BECERRA. So fully aware. Again, where we can do, 
how we can do it, to some degree we are constrained by 
statutory prescriptions.
    What we try to do is make sure we make the adjustments 
based on the best evidence we have in front of us.
    Mr. PANETTA. Okay. Thank you, Mr. Secretary.
    Mr. Chairman, I yield back.
    Chairman SMITH. Thank you.
    I want to thank you, Mr. Secretary, for staying throughout.
    Oh, well, you are not done yet. We do have one more member.
    Before we proceed there, I would like to just say how it is 
great to see so many of the Alzheimer's advocates in the 
audience today. You can see the passion that several of our 
members on both sides have in regard to making sure that you 
have the right medicines and the cures. But it is good to see 
you throughout the entire hearing.
    Mr. Arrington from Texas.
    Mr. ARRINGTON. Thank you, Chairman. My apologies for coming 
in late. I was balancing the budget. So I was delayed.
    Secretary BECERRA. Congressman, you can go back to 
balancing the budget. That is okay with me.
    Mr. ARRINGTON. I know. Well, listen. My constituents would 
say the same thing. Quit talking. Go save this country from a 
debt crisis.
    In all seriousness, both parties have made their 
contributions to this runaway deficit and unsustainable debt 
trajectory, and I say that, Mr. Secretary, because I am not 
giving any party a pass on it.
    But before we put out our budget and our long-term vision 
and the values reflected in that budget framework, we are 
unpacking President Biden's budget, and there is a lot to 
unpack because it is the highest levels of sustained spending, 
taxes, and deficits in the history of the United States.
    And this after a lot of spending, a lot of inflation, 
soaring interest rates, and an economy that is spiraling 
downward.
    So I am looking for a change in direction. I am looking for 
a course correction, and I see nothing but doubling down on the 
policies that are driving the deficit spending and the debt and 
very little consideration, in my opinion, for our children and 
grandchildren because we are really borrowing on their backs 
and their future to pay for this stuff.
    When it comes to health care, which is a big driver and one 
that we all have to roll up our sleeves and figure out how do 
we lower cost of health care across the board, I was very 
concerned about the expansion of Obamacare subsidies in the 
IRA, about $65 billion worth, and now in the President's budget 
proposal, I am sure you are aware, $185 billion in more 
expansion.
    Here is the first rub for me. We are expanding to people 
who already have insurance, as I know you are aware. In the 
IRA, we only covered 1.7 million people who were uninsured. The 
rest of the folks that were covered who were making, by the 
way, upwards of 200, $300,000 already had employer-based 
insurance.
    So we are spending taxpayer monies to subsidize people that 
are making hundreds of thousands of dollars a year.
    In the second round I have read--I have not confirmed 
this--that people making upwards of $600,000 are getting ACA 
subsidies. Now, that does not make sense in any world to me 
unless the intention is to move our country to a universal care 
system, to a single payer system.
    Is that the real--it is okay. It is a position. It is a 
view of the world and government's role. It is not my view, but 
is that--and I am not being cute about it. Is that the 
intention of these expansions of Obamacare to people making 
hundreds of thousands of dollars who already have insurance?
    Are you trying to move the country to a single payer 
system?
    And I yield for the answer, and I appreciate your time.
    Secretary BECERRA. Congressman, thank you for the question.
    I have to start by saying that your depiction of the 
President's budget I cannot agree with. Your numbers that you 
mentioned, I do not know where you got them. I know nowhere 
where anyone has ever mentioned that someone making $600,000 
would qualify for Affordable Care Act coverage with subsidies.
    But what I can tell you is this. The President in his two 
years in office has reduced the deficits each year. The 
President's budget proposal that he put forward to Congress 
also reduces the budget deficits moving forward over ten years.
    And so I am not sure where you are getting those numbers, 
but the President's numbers are out there, whether it is Office 
of Management and Budget in the Executive Branch or whether it 
is the Congressional Budget Office, CBO, which does the scoring 
for Congress. I remember that from 24 years.
    Both have said that the President's budget would reduce 
deficits.
    Mr. ARRINGTON. I know my time has expired. So I am not 
going to abuse that.
    I am just going to say we have a wildly different opinion 
about it, but I respect your answer and I appreciate your time.
    So I yield back and thank you.
    Chairman SMITH. Mr. Secretary, in my opening statement I 
highlighted the point that you all had an interaction with, 
$183 billion in increased funding for Obamacare subsidies, and 
you can make up to $600,000 a year under the President's 
budget, and that was in my leading statement.
    I do want to thank you for being here. We appreciate the 
opportunity that you can be before the Ways and Means members.
    Please be advised that members have two weeks to submit 
written questions to be answered later in writing. Those 
questions and your answers will be made part of the formal 
hearing record.
    With that, the committee stands adjourned.
    [Whereupon, at 5:19 p.m., the committee was adjourned.]
      

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