Transcripts For CSPAN2 Health Human Services 2021 Budget Request 20240713

[inaudible]. [inaudible]. [background sounds]. [background sounds]. [background sounds]. Good morning everybody. I think before i give my statement, we have several visits and 30 and i think we worked it out with senator white biden, and other people that we will keep this meeting going. So i am going to believe that the 1030 and vote once and then come back and i think the first vote always takes a long time. And then when he gets back, then he will vote. In other words, i will vote for the second there but i will stay over there and do them together. You know how it works out. I may not explain it very good. I want to welcome our witness, our secretary of health and Human Services. Honorable alex i appreciate the secretary a czar, your pairing before the committee to discuss the budget. The new budget, he oversees very Strong Department with programs that are crucial to the health and wellbeing of Many Americans and maybe all americans. The budget represents the administrations recommended funding for those programs as well as key policy proposals. While congress decides funding levels of program changes, we have a duty of course to review the administrations Budget Proposal. And secretary a czar is here to help us do that. As with any budget submission i disagree with some of the proposals but i do want to speak to a few issues where it reflects priorities that i have a lot of these priorities are shared by a lot of democrats and particularly working with senator so i mentioned rep. In my working to lower for strict Prescription Drugs rice prices. Top priority. President trump focus on this issue has been a real game changer. Particulate because in the state of the union, and has brought attention to that. Sec. Azar has been a point person in this effort as well. The secretaries also helped greatly with our legislative efforts and again referring to Prescription Drugs. And it has provided guidance and Technical Assistance as we develop to refine the bipartisan bill that the committee reported out 19 nine last july. Last year. I am pleased that the budget calls and congress to quickly pass this bill and includes a placeholder for a hundred and 35 billion reduced taxpayer subsidy. Two Drug Companies. Unless the secretary to expand on this so when we have questions and for now i will say that i look forward to continuing to work with the secretary the Ranking Member, and other senators to provide relief Prescription Drugs to these consumers. The budget also contains a number of proposals to improve Rural Community healthcare. And healthcare in iowa and other areas. But also, for most of the members of this committee. Its not really been a controversial issue in most cases. Ranking member and i continued to discuss how to help rural and other underserved areas in the Administration Budget further bolsters those efforts. I would like to also take a moment to highlight efforts to help hhs be more effective in executing his mission. I understand that hhs office of National Security is forging new ground with Intelligence Community to Leverage Technology and innovative ways to better streamline intelligence operations procedures and to mitigate counterintelligence threats. I encourage the intelligence communities have an even broader access to the office of National Security as a relates to its products and database. To allow then hhs to access Vital Information that he needs to mitigate threats to the department. It is funded partners and its inner agency colleagues. As you are aware on my oversight efforts, work to make sure that the office of National Security receives access to certain intelligence communities related material and that you have gained access to some but not all that you want. However more work needs to be done then. Recently assent to classified letters to the Intelligence Community component to help bridge the gap between the office of National Security and the icy counterparts. As ive said before, the lefthanded the right hand Work Together for the taxpayers as we have found out 911 may not have happened if we had more cooperation between the oil until intelligence people and the fbi is one example. Now of course hopefully that is better for the but its not as good as it should be. I will conclude by noting that hhs has many important challenges. Some are longstanding like high cost of Prescription Drugs. Other appeal to little notice. Such as coronavirus. While there is assured to be disagreements on many items in the budget, the issues i have highlighted are reminders that we can Work Together in the bipartisan way to get things done for the American People. Senator whidden. I appreciate your scheduling this so quickly and appreciate your working with me on a host of issues. We appreciate your being here and theyre willing to come as the budget comes out while that is issued. President trump healthcare agenda in my view ripped scores of nubile in the safety net that vulnerable americans are sure to fall through. The textbook example, is medicaid. Right now the administration is trying to do on its own, what a failed to get through congress. Block grant medicaid its a policy thing we debated in this very room. Back in 2017. It didnt make it out of the committee and it didnt get a vote on the floor it didnt go anywhere because its really horrible policy. That would hurt our people. And that said, the Trump Administration doesnt seem to mind. As trying to pull and administration run around the congress. To push the dirty work of medicaid block routes onto the state. In her whole lot of washington link now read about the flexibility they even gave it a name that goes in to the george hall of infamy. Scott healthy opportunity for adults. Make no mistake. The Trump Administration proposal to block grant medicaid, led by cms administrators, in my view would be the beginning of the end for the healthcare safety net. Its not about flexibility and certainly not about an opportunity to help the adult. It is about harsh cuts. Pedicabs in addition to the other cuts the Trump Administration has proposed medicaid. I will take a minute and see my good friend bob casey he was so eloquent on the subject and talk about what many kate really means for the American People. Medicaid pays for two or three Nursing Homes. That is because growing older in america cost a lot of money. Before is elected to congress, organization act. I spent a lot of time visiting the seniors in the homes. The majority of them, were folks who had to stretch every last penny to get by. So this is an issue that i take very personally. And even when our people do everything right, when they scrimp and save over decades and when they give up vacations and they didnt buy a boat, the lived modestly. They do everything they can to prepare for retirement. People run out of money when they get older. Politics is one is one surprise illness or injury, the bills start stacking up. Our family emergency or damage to home. At your semi strip that is the way life is. And then on top of that. We dont have savings. Millions of couldnt save just because they had to walk an economic tightrope, and have our People Struggle to keep up with 100 if they had an emergency. It doesnt mean that they have no right to see a doctor. Forget longterm care. Protecting those people is what medicaid in the Nursing Homes guarantee. Thats what it is. As i guarantee and it is what medicaid is all about. Without it, when it seniors turn. When theres any strap and head out as a nursing im supposed to stay open without coveting the services down to frighteningly four levels. Our lowincome seniors who want to stay in their homes how can they afford their healthcare. So when you hear all of this talk colleagues about flexibility. Innovative solutions, holding the states accountable. In my view, it is code for big medicaid cuts. The consequences are dangerous and they are personal. A couple of other points. The Trump Administration has gone to court for the entire preexisting conditions are gone and tax credits for healthcare on. Rule standing the worst insurance coveting abuses on. Millions of people, kicked off of their healthcare. And it would just be devastating for young people like jasper. Picture it on this card infamy, he is the little guy. Hes done hard. He was born with serious medical issues. Esther, one of my constituents Cystic Fibrosis and pancreatic problems. Hearing loss. Lots of costly treatments. And for him and his family, Affordable Care act is a lifelong to peace of mind they absolutely consider vital. Donald trump has no backup plan plan for jasper and his family. That didnt stop the president from staying during the state of the Union Address that he had made an ironclad pledge to always protect seniors with preexisting conditions. Donald trump protects preexisting conditions like sea lions protect salmon on her mighty columbia river. It is the kind of protection that comes with an uptick. In the mortality rate. So going to close with some comments about the Prescription Drug prices. A lot of raising events on this pretty big format list price on tv. That also was locked. Hes talk about requiring rebate going back to patients. In a height drug prices in the u. S. The drug prices abroad, nothing there. He had a policy to speed approval of generics. No apparent effects. The reality is patients are still getting mugged at the pharmacy counter. Drug prices are up again in 2020. So the set of demands kemeny has worked long and hard in the Prescription Drug issue. As has the house of representatives. As ive said in a number of occasions, chairman presley, has been a good partner on this and i hope we can find a way to move all of this good work forward. Bottom line is the president has been aching promises about bringing down the drug prices for three years and has not gotten done. We appreciate your being here. Particularly coming quickly. There is lot for us to talk about. Before calling the secretary. Were going to keep things going. While the abodes and the secretary, but if you want to ask questions because the secretary has to leave at 12. Thirty. And mr. As are mr. Azar secretary of the department as i have said, he served as general counsel and hhs for four years a 12 oh five and deputy secretary from oh five to seven. Secretary as are azar. Welcome. Thank you for inviting me to discuss the president s budget for fiscal year 2021. I am honored to appear before this committee for budget testimony as a changes as secretary for now the third time. Especially after the remarkable year of results that the men and women had hhs has produced. With support from this committee in many respects, this past year we have seen the number of Drug Overdose deaths begin to decline for the first time in two decades. Another record year generic drug approvals from fda and is sort dropped in Medicare Advantage Medicare Part b, and Insurance Exchange premiums. The prisons budget aims to continue delivering these kinds of results and move towards a future where hhs is a programmed work better for the people we serve. Our Human Services programs and put people on the center and where markets Healthcare System is affordable personalized and was people in control and treat you like a human being and not like a number. That is the vision behind this budget. I want to know that hhs has the largest discretionary budget of any non defense department. That means that there are again this year, difficult decisions made in order to put the Discretionary Spending on a sustainable path. The president approach protects what works and makes a better and ill mention two ways we do that. First by facilitating patients that are markets in healthcare and second by tackling key impeccable health challenges. The healthcare reforms in the president s budget aims to budget patient at the center. It would for instance eliminate costsharing for colonoscopies after discovery of a polyp. A lifesaving preventative service. We would reduce patient coinsurance and promotes competition on paying the same for Certain Services and hospitals with outpatient settings. The budget endorses bipartisan and bicameral drug price legislation what the plans formulated by chairman presley and member wyden and maybe members of this committee as well as transparency efforts in many of euros have championed. These will extend the life of the hospitals Insurance Trust funds up or at least 25 years. We propose investing 116 million and hhs initiative to reduce maternal mortality. We propose reforms to tackle the World Health Crisis in america. Including extensions of telehealth and inflexibility for rural hospitals. The budget increases investments to combat the Opioid Epidemic including the state Opioid Response Program which we have focused on providing medication assisted treatment while working with congress to give states flexibility to address stimulus like methamphetamines. We request 716 million to extend implementation of the Presence Initiative to end the hiv the epidemic in america. Weve already begun during the Progress Health in four jurisdictions. Finally, the budget reflects how seriously we take the first of an Infectious Diseases such as the china coronavirus. Is been a top priority for me as i let the federal governments coordinated response as chairman of the president Coronavirus Task force. The budget prioritizes funding for cdc Infectious Disease programs and maintains Effective Investments and hospital preparedness. Us that we announce the 14th confirmed case of the china coronavirus in the u. S. And this morning, cdc will be announcing the 15th. Both of him came from wuhan and are in quarantine and as of today i can announce that the cdc has begun working with both departments in five cities to use it Surveillance Network to begin testing individuals with flulike symptoms for the china coronavirus. Many questions about the virus remain in this effort will help see whether there is broader spread than we have been able to detect so far. On the Human Services site the goals of the budget are similar. We [applause] on programs that luck in results while reforming programs like to drive statement business and sporting work on all the benefits and brings for wellbeing. This years budget is going to protect and enhance americans wellbeing. It works better than rather just spend more. I look forward to working with this committee as always to make that common sense goal a reality. Thank you. We will start out with what you probably would expect me to start out with. I referred to it in my opening statement. In that statement i commanded you for helping with your leadership and help lower Prescription Drug prices and particularly helping us with our legislation. Can you speak to the proposal in the budget to reduce Prescription Drug costs as location of our 35 million and reduce spending and also including in your answer, your general thoughts on how this could be helpful to me and senator widen all the people in this committee. Thus support our bill. Ive been delighted to work with you and Ranking Member wyden on this legislation. This package is reasonable on the bipartisan and he can really help in terms of helping to control list price increases to decrease outofpocket spending five patients especially by her singers. And the incentives in the Party Program to really give the plan the incentive to really negotiate hard against the big pharma. I dont understand why big pharma is a supporting. These are important reforms. Packages like this and other bipartisan efforts are important assuming seniors money. Something must price increases and Getting Better negotiations i think these are some of the best reforms we can work on together. Thank you. I am interested in Rural Health Care and this committee has been in the middle of that for at least three decades. It is difficult to keep high quality medical care in those environments. Over the past decades, i have championed landmark role healthcare legislation. Theyve had some successes. Things change rapidly while maybe not rapidly but they slowly change in rural america. So when we have problems still developing. Im very pleased to see the president s budget, it containing a new focus on the role healthcare while the page budget provides a broad outline of past accomplishments and future goals. They do not contain specific details about the policy. That is why today i wanted to give you secretary azar an opportunity to explain in some detail of how the ministration plans to build rural delivery models and create appropriate rural provider payments. Thank you mr. Chairman. And thank you for your decadelong advocacy supporting role healthcare. I am the product of role healthcare in america. It and suffering. We have developed a comprehensive agenda and im delighted to see how prominent it is. To be seeing a lot of activity this year. Some of the changes that we do proposing a budget, one of them is to help stop rural hospital closures. What we would do is ask congress to allow critical access hospitals in rural areas to voluntarily convert to Emergency Hospitals so that they dont have to comply with the regulatory requirements of also offering inpatient beds. They the same medicare payment rates as other Emergency Departments paid under the outpatient prospective payment subsystem plus an additional payment. Those are working to advance telehealth and telemedicine in our proposal expanding regulatory plus ability for providers who participate in medicare and advance payment models by lifting telehealth restrictions. We also want to modernize rural payments for rural health clinics. They are in rural america, more money and we want to increase flexibility for access hospitals to convert these outpatient only facilities and continue serving their communities. Ranking member wyden, we similar to the United Network for organ sharing. Oversight and i know youll appreciate this is a problem. There are more than 600 people in iowa waiting for organ transplant. The hundred and 13000 nationwide. About 29 date without getting the help. What is hhs doing to take a more active role in providing oversight over this system to hold its Government Contractor and procurement organizations accountable because we think except in a few, there is not really a very good effort made to harvest organs. In regard to the particular issue of liver allocation policy i just wanted to know as a said before, that i share your concerns and other members concerns and frustrations with the Decision Making process their credit ive been robust also in my efforts. The oversight there that we have is hhs is limited but statute to protect independence of the organ allocation policies. In terms of his vision when i look at the specifics it looks like a nightmare to me. First to touch on the Graham Cassidy bill with the punitive approach and to gut preexisting conditions and the 1332 waivers green light and to furthers paperwork requirements and what do we have to show for it cracks the uninsured rate has gone up each year from 2017 and the rate of uninsured kids is up for the first time in a decade. So for me this vision looks more like a nightmare because we have healthcare for fewer people i want to ask a specific question about Womens Health under trump care so to take a met Womens Health to make it harder and harder for women to access the health care that they need last Month Administration approved medicaid funding with Family Planning providers it has a clear agenda and the administration is now proposing a budget to gut even more Womens Health protections. Medicaid is a lifeline for so many women with central familyplanning services and it would be slashed to the bone for millions of womens and girls in jeopardy president trumps aca repeal nz ironclad protections for preexisting conditions to take america back to the day when American Woman could be charged just for being a woman. So my question is why should the dhs the in the business of telling women which doctors they can go and see . Senator wyden we dont have any women or men for which they should see in their programs we grant flexibility in running the Medicaid Program and we make Major Investments and we continue with a direct Healthcare Service that is a major priority to make sure access to health care for women and girls across the entire lifespan where 58 percent are female and then they are racial or ethnic minorities we will spend approximately 137. 5 billion on Womens Health i look forward to work with you to keep advancing Womens Healthcare. I have outlined the medicaid cuts i would respectfully disagree. You are telling that they could tell the doctors which i think is particularly unfortunate. It seems that women in this country particularly women of modest means with those healthcare choices and basically you are a green lighting that opportunity for the state. With medicaid and health care for tax cuts. Know in the president s budget is it right it reduces medicaid spending my 920 billion . It has changes to medicaid that would resolve every single year it increase right now five. 4 percent which is twice the average worker changing that to three. 1 percent every year. Did they say it would be 900 . It is less than the rate of growth but it would decrease by 450 million . Seven. 87. 3 percent per year a six. 3 percent by making common sense changes others recommended with medical education and uncompensated to finally bring some payments. I have two or three other examples for professionals and big pharma for what this budget adds up to. First of all secretary i appreciate the job you are doing. There is a lot in there. The first on triscuit but i notice that it is the equivalent to the cities that we have with Prescription Drug cost reductions thank you for that. And i urge you to continue working with us on a bipartisan basis that is important to the constituents and the Prescription Drug prices i also notice and then to increase funding and also for the recovery act that we have been victorious at this battle but the reality is but that crystal meth and cocaine which are psycho stimulative have come back with a vengeance i appreciate the flexibility you are providing to the states because that is what we allow i just finished another round of business in ohio talking about this. In the last couple of weeks with a mixture of fentanyl and cocaine and crystal meth thank you for the flexibility. This is a Great Program a Demonstration Program and to put in the budget it should be permanent and actually provides better care and also saves the government money. What is wrong with that quicks so i would help our seniors in ohio that your budget is successful to make it permanent to transition 90000 americans from hhs with the readmission rates that the average per person monthly cost decreases from 13000 to 9500 per month so it is providing better care and also less expensive one of our challenges is skeptical of the cost savings and also commit to the cost based on the data you have given us. But in terms of savings we have seen the results of this demonstration have been positive and thank you for your leadership is tough to convert this from being the Grant Program to a state option with a cab billed under the intransit fabric of the program. Covering the age of hospice back in the day but on 2017 for the First Time Ever the majority of Medicare Beneficiaries choose Hospice Services are endoflife care and with end of life challenges to have the dignity we have legislation we have introduced and something that i see in your budget you like to see similar pedestals on penalties for the bad actors. And to provide more input into the legislation and Technical Assistance and i know that hhs is busy but to make it a good bipartisan accomplishment for this committee to help so looking for that dignity at endoflife and also highquality care. Absolutely will be happy to help you with you we have propose greater ability to make transparent the accreditation surveys for facilities so they can make informed choices also make major investment the 442 million of certification work at the expanding number of providers and with regard and with the oig recommendation of how we can bring modified payments and to seek out beneficiaries and nursing facilities and that would give you statue authority to do that and i thank you mr. Chairman and secretary a czar i would first start with the concerns about medicare or medicaid cuts then to transition what we talked about a number of times to improve peoples quality of life and we have an opportunity to do that but first this is henry, nine years old he treats everybody with a big hug he loves performing and is in dance class and the challenges he is with a number of preexisting conditions and as you can imagine he has been in and out of the hospital with a lot of challenges because of you dont have access to Affordable Health coverage was well before henry was one years old so in addition to the cuts of medicare and medicaid we are very concerned there is nothing that stops the ata going to the court to take away coverage on preexisting conditions and Everything Else under the aca. I am very concerned when the court initially agrees with the fact the aca should be repealed the president tweeted great news for america not great news for henry. So i am concerned about that. And to make a difference of Health Services with those efforts around addiction and opioid treatments. Those that are apt to do that are people with addiction and. Know we have ten democrats and ten republicans with that eight state demonstration project that literally shows we save money and people are not in jail to do quality Outpatient Care and Addiction Services you save lives and you save money. So to be very supportive of the Ranking Member of the 19 states that meet the quality standards and are ready to take the next step and also grants but there has been a study that has shown in the last two years some of the results and the positive impact that happened as a result of what has been and under the influence of Mental Health. I wonder if you might share some of those results we have seen in two years. Absolutely thank you for your leadership on these issues. This program is served by the Behavioral Health program serving 24000 individuals as of august 2019. To provide comprehensive coordinated range of evidencebased Health Services and what we see is they make services more convenient, more frequent appointments and offered to diverse populations and expanding access to care in our communities. We propose to extend this program through fy 2024 the eighth current participant because we are believers and happy to continue working with you to other states so i thank you mr. Secretary for putting in the full extension across the country and then to do this right i will also say to talk to folks about this then talk to a sheriff in one of the communities they are now getting Community Outpatient treatment talk to those who are running Emergency Rooms but getting care through the 24 hour psychiatric Emergency Centers set up for echo and the final thing is actually a good news story that cbo has dropped more than the original estimate on what it would take to pass the active this year. So i hope you will be leaning heavily to make sure people are not left behind. Thank you. Thank you mr. Secretary we appreciate that. We dont always agree but we appreciate it nonetheless. Senator grassley has already raised the issue of him and senator wyden to reduce Prescription Drug prices is not every day we have that consensus we have that we are encouraged by that. And then to justify the prices for their products in the day and age with other healthcare costs and then to support the bipartisan bill to reduce drug prices. We have been very active working with the bipartisan leadership to pass the legislation and to get that package and the other approach to get this to the past we are open to that but we are deeply engaged with the democrats and republicans on this committee to grasp this legislation. Some of our republican colleagues that the bill would amount to price controls to jeopardize immigration and as a former ceo the drug company ceo and that Drug Companies can continue to innovate. With all respect i fundamentally disagree with the notion the penalty provisions in the Grassley Wyden bill is price cap or price control. These are reasonable restrictions on price increases with the financial disincentive to the year after year price increases one of those as long as they are in the system we can see the price increases but its important to remember that these Drug Companies already signed contracts with the middlemen with price predictability guarantees this is not an alien concept it is a commercial practice already to get the benefit. Since we pay taxpayers money and then to cap the subsidy that is the important innovation and then that changes the dynamic and those that have every incentive for the Drug Companies to jack up the list price because it raises the catastrophic phrase where the government pays most that would be fixed by Grassley Wyden. And the changes here still leave plenty of room for profit margin. And that r d to United States which we are all committed to. Bend and i desperately needed those pharmaceuticals but the intent is clear. It with respect to the president s budget the answer to these questions is not entirely but too often is no. As you know and the pharmaceutical. And then on the texas lawsuit then to replace to leave them stranded without Health Insurance with that Prescription Drug among us. How does the president protect americans if the aca is struck down in the courts crack. The present has been very clear he will never sign legislation if it does not have adequate protections for preexisting conditions. Its worth remembering that even under the aca there is a statement of protecting against preexisting conditions if your twoperson family making 70000 in missouri you can pay 30000 per year in a premium and 10000 outofpocket. So we have to not over glamorize the Current Situation of those with preexisting conditions because for those people that insurance card is a meaningless protect protection especially if they would really apply it to something. My understanding if the ac was struck down in the courts than that would be it. We need to keep our eyes on that. Mr. Secretary you are being defended in texas versus us. Yes. Is it true this administration has taken the position it will not defend the Affordable Care act. And as the other provisions are not severable it is the administrations view that the entire law of the Affordable Care act should be struck down quick. If it is struck down what is the immediate plan to replace it . Millions have Health Insurance who didnt have it before many under Medicaid Expansion that didnt have it before for call millions have protections against preexisting conditions that didnt have those protections before. With no lifetime cap with on those expenditures that they have with a serious illness. And it to have a very long way to proceed with the District Court. Why will we wait with the healthcare of millions of americans to see what the Court Decides we have been hearing about killing obama care since it was created. Why would we wait for a disaster to deal with those this young man is alive today because of the Affordable Care act. And like him, millions in my state and across the country are alive because of it. I dont know what youre waiting for. If you have a better idea show us but i have yet to see one plan the administration has put forward with the healthcare of millions of americans. What are you waiting for quick. Until there is a final judgment by the final court of authority that would be the Supreme Court there is a very long process whether the statute is struck down by the Supreme Court. These are hypotheticals at this point we are faithfully administering. These are hypotheticals we dont play with. This is not some abstract consequence if it happens. Let me ask you this. The president s 2021 budget calls for zeroing out funding for Gun Violence Research did the nra administration tell you to do this to zero out the funding for Gun Violence Research quick. I have no idea about their interaction. I can tell you why we didnt put that in the budget we have a tight budget 9 percent cut at hhs because of the discretionary caps go seven. 52 plus one increase in 2021 with the nondefense with a disproportionate share of that. We had to prioritize of Infectious Disease. We didnt have chilean and a half tax cut and then with the military beyond everything that has been done it seems to me that understanding the consequences of gun violence would save lives of the government. So the remain in mexico policy called migrant protection protocol has 60000 asylumseekers to weigh in dangerous conditions for the Us Immigration court hearing. Over 800 cases of murder rape, torture, kidnapping and other violent assaults have been reported. What mechanism is the office every settlement used to identify affected by the mpp. And if that child is identified. Hhs and have no role to determine eligibility if a child comes in unaccompanied and those that with the mexico is part of the mpp that is not subject to statute. But but ultimately it is returned to family in mexico are you doing any tracking quick. And they determined that childs parents are in custody that we can safely read reunify the child. Dhs determines if there is a criminal history to preclude hiding and that dhs informs the intake team the referral is with the family in the mpp to keep track if they come to us at the familys request to return to mexico and leave the child here we work with dhs to keep them in contact so we track that between them if we receive a referral like that spirit thank you mr. Chairman and mr. Secretary for your service. I want to follow up on Prescription Drugs first talk about the middle person the pharmaceutical benefit manager to protect the patients and in reality they are not doing that. We have a chance at passing a cost Prescription Drug bill and get a bill to the finishing one to the finish line we are the wealthiest nation in the world with 200 plus common drug drugs. They are relatively inexpensive and critically important for care. Newborn babies. Bladder Cancer Patients and therapy drugs that are not available for treatment. That is outrageous. Know is speaking out to these necessary drugs to be available to consumers in this country we need your help to make sure we include this so we do look after the people in this country and we recognize the pharmaceutical benefit managers are not protecting the patients in this country. Im happy to talk about shortages but i want to give you a little bit of good news i am very pleased to announce that is working through the interagency agreement. [laughter] thank you for your leadership. With that central importance. There are several legislative proposals to mitigate product shortages to assess critical manufacturing infrastructure to collect better about supply chain management. And with those key recommendations right now is to create a shared understanding for generics that may be contributing with procurements and low pricing that could be driving at. We also want to create a Rating System so that race to the top on these drug shortages and to promote Sustainable Practices in terms of genetic procurements with solesource generic providers. Into what you are doing in this legislation. Help us create the legislative mandates that are not being we do solely because it is not as profitable as other drugs. Nobody read argue the pharmaceutical community are not making enough money so why should we not have these drugs available . In addition and your budget is very good on telehealth we have bipartisan support to expand into medicare. We need Technical Assistance from your agency to gave you the legislative backup that is another area we can Work Together to provide a permanent legislative basis to make sure we dont have drug shortages and to expand telehealth. I want to cover one other issue. Yes i heard your explanation on the medicaid cut you call a reduction in growth i could tell you in maryland and every state in the nation in poor neighborhoods its difficult to get providers to provide the access of care that we need. The block grant type or proposal that you are making could very well lead to lower reimbursement rates for medicaid patient patients, fewer services being provided and less eligibility which means additional pressure for providers not locating in underserved communities. As you look at this to develop the accountability system that we are providing top care to all communities in this country because we are not meeting that goal and im afraid if you turn medicaid into a block Grant Program , you will find much more difficult circumstance for underserved communities to have healthcare spirit mr. Chairman tell us the plan in terms of questions. Were going to keep rolling. Thank you senator roberts and the chairman and the Ranking Member for having this hearing and also secretary a czar for being here today. As others have noted we have passed Bipartisan Legislation to address the high cost of Prescription Drugs and senator cassidy and i have been working with their colleagues working on the medical bills administrations focus should be on working with us to get the bills across the finish line and released to patients and families not cutting medicare and medicaid. Secretary a czar nearly four out of ten adults with opioid use disorder received care through medicaid state Medicaid Programs cut across medication and assisted treatment and outpatient therapy. Medicaid saves lives. According to your department the treatment to manage Substance Abuse disorders have cost savings this is a woman who lives in New Hampshire. This is a picture of her with her husband and children she start using opioids at age 14 with an equal treatment until getting coverage through medicaid i met her last year with meeting her in the moms for a Recovery Program for those grappling with Substance Abuse disorder without medicaid she would not be able to afford treatments or prescription medication. Mr. Secretary your own department recognizes the savings of federal spending achieved through a strong investment of medicaid funding for treatment and recovery. How does that square with the budget to cut almost 1 trillion from medicaid . Thank you for i hope we have your support for that would extend medicaid coverage from those that are suffering. But how does a 1 trilliondollar cut square with our understanding that medicaid saves dollars in the lives . According to the cbo your proposed cuts would cause states to start the process ending the program that would put 17 million americans at risk of losing coverage including 57000 people in New Hampshire it doesnt slow the medicaid growth rate from healthcare but by eliminating access to coverage. I may be incorrect but the cbo analysis to previous Budget Proposals opposed to this one which is a broader allowance to work with congress how we can fix those perverse incentives for instance have the ablebodied adults pregnant women and children. Let me say this i will follow up with you with those proposals essentially are cutting eligibility and keeping people away from healthcare as opposed to looking at the rate of growth in healthcare costs. Lets move on to a second question. As others have mentioned you support to repeal the Affordable Care act including the lawsuit to strike down the law in its entirety. The present claims he wants to protect patients with preexisting conditions but if repealed health plans will once again be able to deny coverage to individuals struggling with Substance Abuse disorder. Momentous balance to senator carper and menendez that those were meaningless i will tell you to the people in my state who can now have healthcare it is not meaningless or abstract can you point to specific policies in your budget to explicitly protect not just Substance Abuse disorder but also pregnant women or diabetes or Heart Disease based on what the plan could be preexisting condition . Other elements that provide those protections . There would be no change to the Affordable Care act with preexisting conditions so even on a remote date or possibility the Supreme Court judges around the Affordable Care act there will not be any statute we will veto if it doesnt have adequate protections for preexisting conditions. We would be a lot further in the process of this bill and Healthcare System if you are not in court trying to tear it up. You have had three years to come up with a proposal. I am out of time i will follow up about some of the recent settlements we have seen what we can do to prevent those perverse incentives such as Electronic Health records. Mr. Secretary. Senator brown is not here so you thank you mr. Secretary and mr. Chairman for doing an outstanding job please convey our appreciation to the good folks at hhs who do the work day in and day out which we very much appreciate. I will take the bait. Many of our colleagues have talked about the lawsuit involving the constitutionality of the individual mandate and Affordable Care act in you correctly pointed out it could be years before that litigation is concluded by the Supreme Court. In the meantime the leading candidate for the democratic nomination for president of the United States is proposing to do away with all private Health Insurance including the Affordable Care act to replace it with medicare for all. If you are the member of a labor union and have negotiated a Good Health Care coverage, you are prohibited from keeping the coverage with everybody forced into medicare. Without having paid the premiums over our lifetime to contribute to the cost. What is the consequence to the Public Health system if medicare for all became law of the land . That would be devastating to the American People and seniors. Right now americas seniors get a benefit through medicare as we call cross subsidy medicare under pays doctors and hospitals and as a result commercial insurance has to overpay providers to keep them in business if we moved to medicare for all or even Medicare Options that rely on medicare rate rates, that is up for americas seniors that benefit will be gone and it will cause what we see another socialist and european system a twotier system of healthcare the doctors will flee and go off the books so it will reduce access for americas seniors. And it would take away what people like 180 million americans have private insurance through their employer or labor union that would be stolen away from them. People want improvement healthcare they like their expectations thats why the president s philosophy is protect what works and make it better. Dont take away what works for people. Talking about Prescription Drug reform and bringing down the cost to consumers into the government, i supported the finance Committee Bill and look forward to continue to work on that with other proposals but we have a couple of bills making their way out of the Judiciary Committee to address the patent problem where Drug Companies for example who make the drug humira have 127 patents which block competitors and lower prices from American Consumers meanwhile in europe there are five different competitors favorable. This bill i have introduced with senator blumenthal voted unanimously out of the senate Judiciary Committee and we tried to bring it up on the floor several times but the democratic leader has objected and blocked it on multiple occasions even though he admits it is a good bill. It doesnt do as much as he wants, and willing to do more. But lets think what we have in hand right now. If the senate were to pass it and coming to the president s desk would you recommend the president signed that into law quick. I dont know if we have a formal statement of the administrations position on that piece of legislation i have to get back to you on that but your leadership on the patent is vital we need to address them so the particulars i will get back to you but you are absolutely correct just one drug alone with a bio similar is billions of dollars of savings they layer patent on top of patent as extending beyond anything for intellectual property when they are approved and what is stopping us from having a robust bio similar market in the United States but those have to get to market and they have to be reimbursed. The medicaid fiscal accountability is a concern to my governor. The stakeholders are worried about what could the two hospital closures and access to care to threaten the safety net. I would ask for your commitment to work with us with the stakeholders to make sure these concerns are addressed would you make that commitment quick. Absolutely we will work to recreate the practice and conformant with the statute. Thank you mr. Chairman mr. Secretary good to be with you again thank you for being here im holding a picture one of my colleagues have a folks that we represent Aaron Gabriel from Beaver County five counties the way to the west the three children is abby in the wheelchair, each child when have autism they receive the benefit of medicaid. Thank god for that. The children depicted in the picture represent why we have a Medicaid Program. Heres what Aaron Gabriel said to me my Childrens Health is so much better because of the Medicaid Services they receive they need to see their doctors and specialists much less because they receive these services earlier so their lives are much better but because they have services only through medicaid they can see the doctors and specialists much less when we debate the new regulation that was referred to that was of concern or debate the budget cuts to medicaid i and call my colleagues we were also thinking of part of my state you are familiar with i represent a state that has 67 counties but 48 are rural. If you look at most of the state the last count the largest rural population in the nation of any state was three and a half Million People living in rural pennsylvania. Some dont have as many people. So when i think of rural pennsylvania or America First we think about rural hospitals , you spoke to some of the concerns you have of rural communities. I think of the jobs of those hospitals between 25 and 30 counties. The second largest of lawyer is the hospital they are already operating under tight margins. They use medicaid and chip at a higher rate. 45 percent of rural and smalltown kids and it would be more likely than urban kids to live in poverty. So the Medicaid Program faces the greatest significance than it does for other children. In 2018 the uninsured rate for children went up for the first time in a decade. So those are concerns that we have and then we read the details of this years budget and medicaid card is 920 billion then you have the regulation not only senator cornyn but others that have real concerns the nga letter dated january 29 so we are concerned the proposed rules drafted significantly curtail the flexibility states have to fund and pay for services in the Medicaid Programs. So i ask you on behalf of Aaron Gabriel and other families in the worries that they have that the medicaid cuts will hurt their family and the changes to the Medicaid Expansion many with the opioid addiction problem how do you justify those cuts . And number two can you guarantee that her children will never lose their coverage under medicaid as long as you are secretary of hhs quick. Obviously any changes to medicaid have to be done on a bipartisan basis given the makeup of both houses of congress. These are proposals we think actually fix the poor incentives for children in our system. With Medicaid Expansion to create perverse financial incentives for states to focus on ablebodied adults over traditional children blind or disabled women so part of the budget is the focus on how do we store the focus to make sure medicaid is there for them. Just answer the question about the children will they lose coverage. There is nothing in our budget that proposes the change of the mandatory eligibility of traditional medicaid. I just hope you could guarantee they would never lose coverage. Thank you very much for coming back. Mr. Secretary thanks for coming. I think youre doing a good job. Now the adjectives and the adverbs on the other side of the aisle. May be here i think youre doing a good job. Eightytwo critical access hospitals we have in kansas and facing difficult situations. You are proposing a new model to allow these hospitals to convert to an emergency facility that does not have inpatient beds and we have seen this from other groups in the past. The budget proposes these hospitals are reimbursed to be assessed with capital cost last year alone the allegations with cms requesting the agency work with kansas hospitals to develop the program so i need to ask you on their behalf on when we can expect to see a new agency. Im afraid i do not know the details on the kansas model. But you are working on yours. Can you give me a time frame . Eightysix . I imagine there is between ten and 12 on the edge . There is certain unpredictability is what im asking for. The big change im very supportive of around critical access hospitals and allowing them to focus and not have to support the inpatient beds that are not reliable to them would require legislation but not models. I have the bill moving quickly if there is anything anything that they think that requires hospitals as well to have a physician to certify the patient would be discharged or transferred within 26 hours this is very burdensome regulation to focus hospitals to turn away patients and they could have provided with high quality care i know several situations have happened a person came in with a diagnosis not the fault of the folks there. But obviously he could not come back in for three days even though the situation was very dramatic. So if you explain that decision process the last years budget indicated the certification requirement would have zero impact for the budget impact of this policy. So what happened in the last year accounted for the change quick. I dont know the difference of modeling the thanks to leadership it does get rid of the 96 hour rule so we will keep pushing so providers spend more time with their patients not unduly burdensome regulations with apposition certification requirement because it causes people who have to predict before somebody can come in he went to work with you to get rid of that. Be for senator whitehouse asks his question then to go back 1230 anyway bit between now and then. Thank you very much mr. Secretary i want to raise a situation that continues to bedevil me. For a while rhode island has been a reimbursement whole. With lower reimbursement rates from connecticut and massachusetts. We are not a high cost reimbursement area and are already compensated one under compensated. Then 2018 came. Unilaterally called that made our payment discrepancy to neighboring connecticut and massachusetts worse by 25 basis points. To create the situation and then to have a hospital with the reimbursement rate one. 3525. Whats the difference it is a discrepancy. If you go over here and then from the rhode island border compared to one. Zero three. Do the math, a 25 percent discrepancy. We were told dont worry big reform will smooth it all out. I was lied to paraguay dont think theres any sign of this reform and then comes this budget. Not only is there no reform but it is a demonstration project from when you dont have a real plan. And what it had the nerve to say here is the language from your budget the demonstration aims to reduce sharp differences in the medicare payments from nearby hospitals. Does that not mean your organization knows that sharp differences in the wage index are a bad thing. That is what you want. If i can work with you if you could please get her to do what she did over a year ago. She unilaterally made these differences in nearby hospitals worse by a factor of 20 to 25 and we were already under reimbursed at the 25 milliondollar lost the last fiscal year because of the decision that she made. You can go to their hospitals around the country and they would be making money because of the way in which they are reimbursed. We had our old unilaterally dug deeper by 20 to 30 by your administrator. We were not told the truth about what was going on. We now have a bogus demonstration project coming out with no place that admits it is wrong to be doing just what she did. This is a consequence for our hospitals. They are in pain as a result of this and it is tiresome to no end that your bureaucracy sits around doing nothing about this, making it worse actually making a problem that you identified thyou identifiedthe salt of thed unilaterally worse. I do want to say neither of us, the administrator or myself have the control of the over the regulations and policies, but even within the administration of us have the unilateral control and the challenge in the wage index. I dont blame you, i blame her. I want you to fix it. Senator cassidy. The antibiotic market, you are very familiar with the challenges in the pharmaceutical industry. We have these very resistant organism and you want an antibiotic that covers them, but you are going to use them on very few people and most of the people you use it up on our own medicare or medicaid and in the va is going to be at least two thirds or maybe four fifths public payer. One idea has been to carve out these extraordinary importance rarely used antibiotics from the drg and put them into Medicare Part b. Sure you have the Accountability Associated in the stewardship program. If you have a shorter hospital stay and of course if you have a more effective antibiotic. Any thoughts about that . Maybe you cant be official but because your expertise . You put your finger on the Antimicrobial Resistance in what we are developing and its something i wrestling with our team right now. We have essentially a market failure as you described so rightfully. We want them to invent an antibiotic that wont get used. That is an economic problem. So im looking at different approaches. One approach could be about the payment policies as you mentioned the direct path to the repayment. The other is increasingly reason lindauer bioterrorism countermeasure programs where the government basically is the only purchaser for the value of certain products, almost a stockpiling issue. Ive commissioned work to look at this. We have tools to deal with market failures and need to look at how they can be used for amr. There is at least one antibiotic that the United States taxpayer invested hundreds of millions into the developed and sold 16 million to a company from india. You have to ensure there is either a commercial marketplace that is likable or a government market that will make them sustainable. You said something that you are actually working perhaps on a solution regarding this. With this solution what stage is this work . Some of the recent challenges of these products and then even not surviving necessarily its an economic problem. Another that im interested in. Even before they are agitated, they lose their medicaid. Now, if they have a stabilizer that works for them but its not on the formulary, they may get either not based on something or placed on something inadequate and may be compensated and the behavior worsen they are now kind of wandering on the streets as opposed to holding a child and paying taxes. I think the administrations budget allows them to continue coverage for six months while in jail but i would ask since the definition is that you stay there until you are adjudicated and that can be up to a year why not for an entire year ended the entirety of the coverage of care for the Mental Health issue . I think that would go a long way to address the revolving door going in and out of jail with the disruption of care. Any thoughts on that . We were able to get in the budget this year at the prohibition of states terminating coverage for the First Six Months of incarceration at the process and facilitate the release to avoid relapse into their Health Crisis so we got that far but raised an issue about whether one should go further and would be happy to share the issue on and lummis and incarceration and that transition and hand off in the incarceration as well as well as the community. There is some suggested either that the mentally ill are cycling through jails and agree we stabilize that. Not perhaps everybody comes with fully clean hands and this has been a challenge thats been going on for some time. In virginia when we finally expanded medicaid a year ago, weve got a 375,000 people but obtained access to health care, critically important. I agree with the letters myself and i want to make sure you work with the states all states are going through the budgeting process right now. The way that i read this regulation as it could potentially come out sometime later this year and dramatically Medicaid Eligibility and payment plans that are in place and that will wreak havoc in the budgets red state and blue states across the country to make sure we limit the impact because the regulation will not be finished by the time most states put forth in the budget which are a little bit better than we are in terms of meeting their deadlines they will be done by midto late spring. We understand the changes that would be implicated one to be fair and equitable not every state has these improper transfers. Some of it is transparency to even identify what is going on to make sure that the money is being spent in the program and it will work with states also to help them to find ones that are complying it in the future. We are going to try to be reasonable. These are partners in the program we are not trying to cut medicaid beyond the regulation to make sure that its the right kind of spend them. There is great concern that that is part of the role of the administration and i hear this from democratic and republican governors and i think its reflected a little bit in the president s budget. If there is a new systemic approach that allows everybody to bring cleaner hand, i get it. I have two minutes left. Your interoperability i think we talked about this at 1. 1 of the great mistakes that was large bipartisan agreement to one piece around obamacare we need to move to dhr and have better use of the data and one of the major mistakes w we did it becae they spent all that money without any interoperability. My background was in cell phone we would have never had a Wireless Industry in america if we required interoperability. In the security concerns and the ability approach weve really got to be popular about it and i frankly do not believe i have great exception to the administration but said the Technology Companies are doing a good job of protecting this information. I dont think they are. I also want to make sure that they have rights to have privacy protections. How do we make sure in the last 30 seconds that we get this right and i agree we are getting to the goal of interoperability that im concerned we are not seeking this fully into consideration. I should say weve also contacted almost all of the Healthcare Systems and they youd be amazed at how they will acknowledge and how unprepared they are. In that transfer consenting to that as we work on the final rules on interoperability information blocking that kind of protection in patient ownership my time is up i just want to say we want to work with you on that because there are mixed signals coming from the administration. Senator brown. Thank you mr. Chairman. Colorectal cancer is the secondleading cause of cancer of men and women combined in the u. S. And the Cancer Society estimates there will be 100,000 new cases of diagnosis just this year. The screenings are considered a Preventive Service and as a result they are available at no cost, no copayment, no deductible, and another thing og thats important in the Affordable Care act despite your bosss efforts to repeal it. Due to the glitch in the wall if you are a beneficiary and get the screenings i know that you know this well, it is to present and you wake up with a hefty copay. I say all this because im thankful ti thinkwhat the presio include a legislative proposal to eliminate the unexpected cost some beneficiaries experience thaexperiencewith the get the s. My daughter removing this ensures preventive Colorectal Cancer screenings are fully covered. To working with me at the chairman and Ranking Member in getting this done. Absolutely i want to thank you. You are the one that brought this anomaly and statute to my attention. Its really absurd that a senior goes in for a colonoscopy expecting to have no copayment and if they happen to find a polyp which is what we are are screening for they come out of anesthesia and get a bill because it is converted into a procedure i ask you to connect to a number of things involved in the efforts to curb the use when i asked if he would commit to reducing nicotine in cigarettes in a non addictive level you answered and i quote absolutely, that is the rule that we will be working on. He went on to say that youve been driving for the efforts to restrict and your words he wouldnt hesitate to take aggressive action if necessary to curb the misuse. They dropped the nicotine reduction proposal from the unified agenda. Hhs also backtracked on a promise to remove all tobacco flavored cigarettes from the market and the final guidance released last month accepted the bathing products and flavored liquids into thousands of them remained on the shelves. A huge progress made for 50 years is in jeopardy because of that. If you can tell me why is the department deciding to cave to the industry and political pressures have stepped back . On the flavors and cigarettes, it is requiring that those child friendly used flavors come off the market pending authorization so we advance to a more aggressive posture and even when we spoke before because of the time the commissioner had only been speaking about the site and fill restrictions. So i want to be aggressive on this on the enforcement date has had us but in terms of disposable flavored cigarettes, if we see the utilization here in disposable shift, we have seen these replaceable items driving this and we would certainly take aggressive action. Nothing has to be set in stone. We want to keep these away from kids even if we try to make the other products available for adults to move off of combustible. I appreciate the answer and your sincere agenda but i also believe in the white house on thursdays and fridays it looks like a retreat for tobacco executives but im still concerned about the disposable products that are out there on the shelves and you need to do better and we need to do better. Last point quickly the budget recommends more than 9 hhs and you can claim is pending on direct services but the primaryy patent Directive Services as medicaid. The budget cuts for the 900 billion for this essential program. It would cause hundreds of thousands maybe millions of people to lose healthcare and i remember working with the governor in support of the lawsuit combined with the healthcare vision in the Budget Proposal to slice medicaid. On the Colorectal Cancer issue i think that will be huge for patients if we can get this passed off congress. On the Medicaid Program we are reducing the rate of growth for 5. 3 to 3. 1 . We have the expansion population how we can control the rates of growth and also fix the progress incentive where we favor the ablebodied approach into the beneficiaries that we ar are now prejudice against in the systems so that this sort of the heart the next that youre in a Cabinet Meeting and see the president i dont know if he knows hes lying about this or is used to doing it but would you correct him when he says hes supporting the preexisting condition because hes trying to take that away and tried to take them away legislatively. I assume it wont change if you still go on the campaign trail and talked about the condition that if somebody of your stature. Fullstop hes lying maybe that would be helpful we are going to adjourn this meeting. Ive got to go to a vote. And so do i. Secretary, i thank you again for being here. One note, were already hearing from pediatricians in New Hampshire that one week after the ban on the flavored pawed theyve discovered they are cheaper in the bargain s bargais taken one week for teenage behavior to begin to change and they are still using these devices. To rely on Electronic Health records as a source of accurate clinical information. A into Electronic Medical record essentially it was an edit that coached towards a certain product. Its when a patient would need twouldnthave needed it so theye overprescribing it was paid for to the electronic record. To try to get them to put the non opioid at the top of the list in terms of pain medications if its not right there. This is about the integrity of the Electronic Health record we have to be able to depend on them and doctors do also. There was a second a settlement that goes to the same about making sure that we are policing the Drug Companies correctly. A nonprofit copay was found to have taken money from the drug company for the sole purpose of paying medicare copayments for the pain medication into particular concern this nonprofit knowingly facilitated access to this highly dangerous drug. Weve seen an increasing number of settlements in recent years as the Drug Companies become more sophisticated in their efforts to drive over utilization. One way to protect and save taxpayer dollars is to leverage transparency to identify these relationships before they can take hold in the medicare program. So, does your department collect data from the Drug Companies to the nonprofit copayment or payments to Electronic Health record vendors. I do not know for sure what level of disclosure is, let me check and get back to this that could medicare and medicaid on the press reporting it may be in that context. Thank you for your indulgence, mr. Chair. I hear from seniors across my home state of montana who are struggling with high outofpocket costs. Thats why im working across the aisle on the committee to do with the cost of Prescription Drugs and establishing outofpocket maximum. My question mr. Secretary can you explain how and outofpocket cap would affect the average senior in montana. Under the current Medicare Part d. Benefit, she would have to pay 6,350 before she would hits up the catastrophic cap in Medicare Part d. To pay 5 of drug costs up to that point. Shes been to pay more for the deductible and the period she would likely move quickly through the deductible period and get to the catastrophic but no 5 . And what you have supported the fall of two important benefits to her. First, because of the savings we get from the inflation penalty tap we create a new catastrophic cap at 3,100 at that point it is a complete cap she will never pay for drug expense in that year. In addition to the Critical Innovations to allow for the option of spreading the catastrophic cap over a 12 month period. She could elect to never pay more than 258 a month for her drugs, no matter what the drug expenses. Its an incredible outofpocket change for the americans in there if we can do this. Thank you. Its a great example and important policy to navigate certainly this committee did about here on the floor of the senate. I want to shift gears. Many states have been hit hard by the Opioid Epidemic but in montana we are facing a meth crisis. Its been one of my top priority for congress to ensure that the communities and families, any reservations, lawenforcement have the resources they need to combat use and i have the Vice President we got to see firsthand what is happening when we visited the building. The efforts include states like montana because we need to make sure we target available resources where they are needed to prevent Drug Overdoses. In fact im pleased the budget increases funding for state Opioid Response Programs to address the abuse in addition to the scourge of opioids. To address their needs when it comes to Substance Abuse and Drug Overdoses. Absolutely, senator. Each state is going to be different some are facing more than opioid problem and some are increasingly facing a meth problem in 15 of 3 the 36 states that reported overdose by drug type, meth is responsible for more than synthetic opioids between 2018 and 201 2017 we hae seen a 30 rise for methamphetamine so as you say ys a very big issue. They brought us so much of the crisis as we have pressured them down on the opioids they have expanded the commercial grade production and importation of methamphetamine. So i was delighted when congress and the 2,020th for creation of a lot of the money to be used by the states also for the stimulant methamphetamines. We continued the policy recommendation in the budget for this year. That flexibility for the states to address and keep it from the fourth wave of the addiction crisis. I want to thank you also for calling out for mexica the mexi. This is the shift we are seeing in montana. We are a northern border state owith the southern border crisis that is once upon a time it appeared he is in the 20 to 30 range into the next cartel as you know has purity is a 95 so far more potent, the distribution has increased and this is why. We have a site for calm as it relates to meth and thank you for your help in math. Math. Im out of time and i believe senator lankford, you are up next. Thank you for all the work youve done to be able to help folks have opportunities to get greater healthcare and options i appreciate very much. I want to bring us to something new that the state was first in line to be able to engage with and that is the Healthy Adult Opportunity Initiative to allow greater flexibility on medicaid. Oklahoma isnt the same as alaska now we are open to working with states that think its important to remember no individual would be deemed ineligible. For the expansion of the Affordable Care act would remain with the partial de expansion so they would provide an innovative approach for these ablebodied adults and the expansion population only if the state wishes to be doing this. Youve put out proposals on generic to allow a specialty to try to get the benefits out there. If theres any recommendation not just a benefit across the board but to those that are the consumers what is that at this point and what are your thoughts on that . As a part of the regulation to create the second plan to have the second tier for specialty drugs those would be the more expensive maybe around 660 of triggers that. Right now they somewhat disable the Insurance Companies from negotiating bigger discounts because it has just the one tear. To get even more discounts to secure access and lower cost share. Its one of the things several of us on the committee are working on and other options for that. Some of the companies that are preventing drugs from going on this tier and pushing it is something we are working on legislatively. Several of us mentioned the hospital relief. My state has seen several that have closed. Senator durbin and i are working on some legislation deal with critical access in getting flexibility. I know you are also trying to do deal with that as well to allow the Emergency Hospital access. Where does that stand at this point . Im very happy its in the president s budget this year to have congress authorized to allow that flexibility is a critical access could have emergency function that cannot be subject to the requirements. The budget proposes via payments for the critical access hospitals that would elect for emergency to be reimbursed at the regular emergency rate as well as a supplemental amount of payment for them. We look forward to getting the chance to go through that because that would be imported and they will continue on the legislation to be able to solve this longterm. The university of Vermont Medical Center made the decision to have a nurse during an elected abortion be forced during her conscience to be able to purchase a paid even though there were nurses that were available and willing to do it she was compelled to be able to participate against her conscience. Your team has reached out to the Medical Center has made requests to find out where they are and what their standards are. Its been months with no response back in the process. That process. As you know, with any of these cases we tried to work towards resolutions that bring in compliance with the university of Vermont Medical Center refused to work with us on that and we had to issue a notice of violation to try to get their attention. Where things stand now i couldnt go into detail about the back and forth, but the critical issue we try to work with providers so they can make a commitment to bring themselves into compliance. Waitll continue to watch for that. One last quick question deals with nicotine levels and vaping. Several of the devices choose to have very high levels. Its an area that we raised but is there a way to get a standard so these devices dont intentionally get loaded up to increase addiction or where does that stand . Theres not a regulation in the authorization process that we have for novel Tobacco Products and regulations but in the course now that the court has said to come in and apply for approval or authorization under the pmt a looking at appropriate levels will be one of the factors we can examine to determine the furtherance of the Public Health so that is one thing we can look at. Senator cortez. Thank you for being here. Appreciate it. Like my colleagues said many of us are concerned and similar to what ive heard earlie occurrede state of nevada they are what the state said thanks to the Affordable Care act we are able to expand medicaid and what this gentleman here whose 28yearsold, hes alive today because of medicaid. My concerns are similar to what youve heard from colleagues. Why are we making these cuts and most importantly why are we putting vulnerable groups against one another and how can we make those decisions to decide what is life to save and what wife not to save those are the concerns you are hearing from us but let me take this even further. I am also concerned about what ive seen happening and let me put this on your radar because i know theres good work that is being done but i dont think people appreciate the impact that has had. They designate as the pay of last resort helping stretch those dollars further. Medicaid expansion, premium tax credits have boosted coverage and enabled to collect reimbursements that have allowed them to hire more providers and specialists and ensure the facility met the standards including those for ongoing accreditation. The reality is we know right now in the court of law this administration is trying to repeal them to take away the Affordable Care act including coverage for the existing condition. That is reality. Its not conceptual, it is reality. If that happens i guess my question to you is what happens and how to be addressed immediately take away the Affordable Care act and coverage what are we going to do to help them move forward and have access . In terms of the litigation this is no sympathetic to the District Court for the analysis, this is going to take considerable time to go back to the fifth circuit and the Supreme Court so this is a rather remote item. Im an attorney general, i know what litigation is about. They think it is unconstitutional in the course of litigation you cant sit here and tell me today the Administration Position is to support the Affordable Care act and they want to keep the coverage into preexisting condition so dont try to walk around it somehow by saying this is going to be prolonged so we dont care it doesnt really matter right now. It does matter. That is what this administration values and it is set up into the American Public needs to know that so please dont start with that. If it is taken away. Lets speculate hypothetical if its taken away, what do we do, what is plan b. . There was funding for the health service, so weve increased by 10 since 2018. Weve got an additional 3 in 2021 making critical investments in that service. We put 85 million in the budget into the Quality Improvement programs and weve created the first ever policy offic hold the within ihs trying to bring their outcomes. What im trying to drive and i hope that we confirm the director, i want to bring a complete quality safety cultural transformation within the service. We owe them the finest Quality Service to the beneficiaries they are and its not just about getting the various facilities to meet the certification which of course that is the baseline but its ingrained in the culture of every aspect of what we do in the organization. Thats part of what we are doing in the budget and its also what is confirmed as the director. I agree and ive had conversations with the nominee. I think that hes the perfect person for the job and we have to Work Together to address the needs of im glad to hear you say that and i look forward to working with you on those issues. Another area i want to talk about his alzheimers research. The president signed into law the infrastructure for alzheimers act, a bill that i cosponsored and it takes a Public Health approach by tasking the cbc with overseeing preparedness and surveillance associated with the disease. In december, congress funded the grant and the cbc is getting ready to send the money out to the states and local centers of excellence. This budget proposes to discontinue the work on chronic disease management and using the new americas block grant. It doesnt appear to include alzheimers cookie so i guess my question to you is thus it. The grand home that would actually create the areas of highest concern. Right now cdc programs are very silo ansideloading micromanagedy these areas, this and that. The grant gets adopted by congress of course and with the flexibility for states to cover thetook overthey find the great. We have a vote so you can count on my being brief. If we cover two things very quickly as you know we have the strong oppose all to the taxpayerfunded base Foster Care Agency to refuse to work with otherwise qualified parents because they are jewish or catholic eight months later your department expanded the taxpayerfunded discrimination announcing that it would allow all of your funded grantees to deny service to people on the basis of sex or religion. So now not only the Early Childhood center could turn away a child from their program because the childs parents were jewish or only people that they refused to not take Vital Services you could go on and on. How can you claim this as protectinisprotecting the religy of america. We believe all individuals should be treated with the committee and respect and whether it is our hope or programs with an inservice programs, that should be the expectation of every aspect of the program. Those that are passed by congress and we want to vigorously enforce those that were promulgated singling out one particular Supreme Court case as an obligation and also with the flexibility act and implementation we could have a proposed regulation that would require guarantees to require all Supreme Court case into the complaints with the antidiscrimination law everybody should be treated with respect in the Human Service programs. As i read them all coming went from essentially a Pilot Project to saying that all funded guarantees could deny service to people on the basis of sex or religion. That is a horrendous precedent for the department that is so important and we are not going to get the parents we need for the foster care programs. Let me ask about one other thing and that is as you know, i have felt very strongly. We are in the middle of an enormous transportation in the medicare program. Now its about chronic disease, strokes and here in this committee we pass on a bipartisan basis to chronic care act which took a number of constructive steps for the technology and the tele Health Programs you could have those with Medicare Advantage be able to pay for those at risk of a fault. My question to you because time is so short what can you tell us is being done to make sure the program gets expanded to the traditional medicare because as you know thats an area where we say there is a lot more to do with the future of medicare is not what i was dealing with when i was the director. The future of medicare is cancer, diabetes, Heart Disease, stroke and people with two or more if th of the conditions, so whats being done to address traditional Medicare Services . With the chronic care act it important to think about the chronic care and also tele health. The traditional medicare this is where i would encourage you to do what we are doing at the center for medicare and medicaid around direct contracting for total cost of care. If we can get providers, whether integrated systems or care providers the applications that are due very soon, if we can get them to assume total cost of care, we can get out of micromanaging them on the procedures, the individual procedures instead of paying for the longerterm outcomes and then having the financial upside of the longterm management. I believe long term that is what caused the investments in the Chronic Care Management like what you are talking about. Or to lead to a better longterm chronic care outcome because they would have skin in the game. What you are talking about sounds constructive to me. If you could, for the record, gave a brief report about what the department has done since you all took office there and what are the projects that you plan to do in the next year, i think that would give us a Little Something in you to get michael to discuss this and i thank you. Thank you for your attendance today. Anyone that wishes to set it to the record please do so by the close of business thursday, for the great 27th. With thatif not, the hearing is adjourned. [inaudible conversations] [inaudible conversations]