Transcripts For CSPAN HHS 20240705

Well, lcome to the session. The Congress Session will now commence. Please welcome to the stage. The 24th and 25th u. S. Secretaries of health and human services, alex azar and Javier Becerra in conversation with Institute Chairman Michael Milken to discuss the road ahead, reflect tions and insights to improve health for all. Mr. Secretary, thank yofor joining us today. And i just want to strs to everyone watching this hour and with us today how important your jobsre. Taking care of the health of not only people in the United States, but in many ways the world. And i ought i might start by going back to a 1754 Benjamin Franklins slide, which told the colonies that they needed to combine in order to survive live. So he took this snake and divide it into parts as a message to try to convince the heads of the 13 colonies they neede to be one and the same thing exists today. When we tnk of a system of health ce, whether its the hundred heads of philanthropists and the medical field that have joed us, the Academics Centers not only from the unitedtates but around the world, have joined us today at the vernment agencies for profit biotech, Bio Science Companies today. And just want to set the stage for the enormous responsibility these two Public Servants have taken on over the yearhere to remind everyone that the number one ct here on Economic Growth in the United States and t world in the last 200 ars is blic health and medical research eac and if we think about whats ocrred, most of the Economic Growth of and size of our population has grown over the last 200 years at the start of the0th century, average Life Expectancy othe planet was 31 years of age. Today it is over seven. And so were going to touch on the issues of Life Expectancy, inclusion, equitable access to health and my other iues. But one of the things with the very Diverse Group of more tn a thousand people there with today, i thought id start, mr. Cretary, with the first question how does hhs collaborate and engage internally with other agencies as well as externally with the states, local government and community is to accomplish the mission of the agency and i think manyeople who are viewing are aware thathis is the largest sector of the United States govnment. More than one third of the governmentudget, maybe twice as large as our Defense Budget is fused on Public Health and medil research. So lets start with the 24th secretary of hhs. How did you seek coordinating betweethese diverse efforts here . Well, mike, thank you. And i think youroint about the e brok snakelide tt ben franklin used, i guess he didnt have powerpoint. Was probably not a sde. But that well, that that was his picture. Exactly. That. I think its an apt description of our Health Care System because in a way, calling it a system is an ovetatement. Its a disaggregated collection of different pieces working sometimes harmony, sometimes at odds. And i do think that our roles as Health Secretary allow you to serve as a convener. Ill give one example of that type of collaboration for operation warp speed. Really, i thought of it as three key collaborate for partnerships. One was a Partnership Within the u. S. Government because warp speed could not have happened without the intense partnership of the Defense Department. D then, of course, many other agencies, the department of energy, with its you know, with its quantum computing powers and many other agencies involved, then therecollaboration and cooperation with the private sector. Its not a govement solution. Putting a man on the moon was not a government solution. Building the atomic weapon of the manhattan manhattaproject was not a government solution. Each of these were great public, private, but collaborations with mutual respect, understanding each others needs and incentive structures. And then the final was collaboration and partnership with states. Because we dont have a national level, federal level system, we act with and through states and even some certain cities have their own independent Public Health departments that as secretary, we interact with. So pulling all of those together ani could probably go through 20 other types of collaboration, but it really is almost the center of a bicycle hub and spoke kind of model. So secretary rivera, you come from california, you represented california. Now youre representing in many ways notust the United States, but the world. How have you seen this issue of collaboration, not only in the u. S. , but maybe internationally today . My first thanks to you to diana dunn and the team that made it possible for both secreties or nice to be here. I appreciate it. In many ways that that diagram that y see, the cut up snake still appli. Think secretaries are was right. You know, spot onight on the money when he mentioned h were still a system i call it a nationwide system of Public Health, not a national system, because wereependent on the 50 states to want to buy in, because the constitution gave them control over health car anso we have to prod the states to do certain things. So thats why you think medicare, medicaid, all of them happenedecause we put money on the table for the states to buy in. They didnt have to provide health care to seniors or to l income, but they do it becau they get a big portion of money from the feds to do so. And so we have to we see that continuing so today, partnersp work, we just commercialize. Now onaccines for covid before under secretary or leadership the first and thenith our coinuation, the federal government provided access to vaccines to all americans for covid. Nearly 700 million shotsn the arms of americans to date. Now, thats transitio now the manufacturers of those vaccines are going to take over and its now back to the commercial market. Same time were relyi on the states to continue to feed us infoation,ata that lets us know where the hotspots are with covid. Theyre not required to do that duringovid and the crisis, a nationalmergency. They did have to because we had powe in National Emergency powers to require them to give it to us. Once the Public Health emergency came down, we lost that emergency power to demand that th give us data. Now whave to get them to voluntarily provide us the data of whats going on in their states. And i suld just mention quickly, mike, internationally, were in the midst of trying to reach a Global Pandemic deal that would let us be collectively prepared and collectively resnd to any future pandemic or other form of attack tt might come our way. You know, its ing to be as tough to get a global deal as you can imagine. It is to get a National Deal on what to do on health care. And like, you know, i should mention you nted at this, that secretary becerra, which is the global aspect, thats another partnership that is very important. 2020 just coincidentally happened to be america being the presidency of the g7. And so every almost every thursday morning at 8 a. M. , i would convene the Health Ministers across the g7 and we would share Lessons Learned. Wed share best practices. What we were seeing on covid, on a weekly or bi weekly basis, and really helped that type of collaboration and coordination. Yeah. So you just secretary of a very you just camfor sarah. You just came back from meeting to talk about that internationalization cooperation. So as secretaries or mentioned, weet together whether through g7 or g20 or the World Health Assembly and for the last more than a year, theres been a concerted effort to try to not just comup with an accord, but also to update our International Regulations that deal with health. And its not an easy deal because everyone has their particular angle to this. And what were trying to do is have an approach that ultimately has everyone taking certain responsibilities. You can imagine trying to get the u. S. To sign on to some form of treaty where were committed to do something in particular. When was the last time you heard the senate pass a treaty . And so were ting to convince our International Partners that if if they try to go down there, the road of, saying, binding agreements that are essentially a treaty, we may never get to the point of getting 67 votes to pass that out of the senate. And we want in we want to do stuff. In fact, we did more than any other country did during covid, but we have to make it so realistic. And so were trying to get there. We hope were hoping that may of next year we actually strike this deal. So its interesting. I think everyone here and aroun the world would like to know what is the path to take to become the secretary of hhs. Yes. Okay. What what how wh prepas you to be a diplomat . Deal with science, etc. And im not sure everyones aware that that path include Yale Law School or stanford law school. So youre probably not aware that one of the necessary requirementso leadhe Health Efforts for the world is go to law school. Now, alex, lets start with you whenid you start thinking about Public Health, medical research, etc. , for the first time . So oddly, my first ever job was as an intern in the reagan administration. When i was in college, i just ended up being an intern in the hill under the secretary. But several understand what a dirty word this is. I was an intern in the health and income Maintenance Division of the office of management and budget, which is the group that supervises the money at hhs, of all things. I then one that actually i did a lot of legal work there, ended up going to law school from that, but then forgot about health care until just really by accident in the bush cheney transition in 2001, i got a call from secretary Tommy Thompson Office Asking me if i had any interest in being the general counsel of hhs and, you know, ill just let you in a ltle secret. We conservative lawyers, we dont dream of being involved in thwelfare state. Normally, you know, separation of powers, war powers. Thats what youre here sort of raised on. Its idiotic. Once i got there, i was one seventh of the american economy, one third of the u. S. Government. My goodness. And it became my lifes work. But that really was what started me on that journey was in many respects, fates left serendipity. So i remember after 911 visiting hhs and secretary thompson had created his own war room. Yeah, there at hhs. And to focus on the health of people throughout the world, savior, what wasour path . So i married into health my sweetheart icolleg who then went on to medical school, became a high risk ob gyn, a perinatal allergist. And so i was surrounded by that all the time. T when came to congress, i had the privilege of representing a district in los angeles that at the time was prably the third or fourth. Fourth most uninsured Congressional District in the nation. But yet to juxtapose that, because while we had one of the highest rates of uninsurance for health care, we had i think my Congressional District had the highest rate of work partipation, which is a term that department of labor uses to show how often or how much you work. So on average, people in my district work longer hours, more days than any other place in the nation, yet they didnt ear enough and therefore couldnt affo to get hlth insurance. So it became a big issue for me. My service in congress included a lot of work on hlth care issues, including on the ways and means coittee. And over time, i just did ways did a lot of work in hlth care. But youre right, we dont have cessarily the right three last three letters behind our name. And i got that was onof the biggest critisms by god dung my confirmation press ishat i didnt have the m. D. , i d the jedi behind my back. You know, that comes ua lot. And in many countries, being heal secretary, health minister, are ctors. T when you think about the largest part of the hhs budget, youre actually running the Worlds Largest insurance companies. The Affordable Care act, medicaid paid medicare. That and thats business leadership. The law can be very good training for that in terms of rigorous, logical thinking. And a lot of the department is not actually m. D. Focused. Yeah. Youre managing. Yep. So one of the other challenges is that youre both very aware as balancing the public need for health care and the cost of health care. And so the inflationary reduction act, the medicare drug price negotiation program, is in full implementation. What milestones have been achieved . Xavier and the positive effect and how do you balance the need of pharmaceutical companies and industries being able to innovate and patients being able to afford life . Seven saving and le giving medications. So by the way, mike, my parents had the wisdom of naming mahavir berra wi an x and i know in life ive had a go throughout most of my life. Explain the x is pronounced li an. Javier. But wh you got to Xavier University andavier cugat, yre going to have a tough time. But anyway, to the qstion, as i said, i learned a long time ago to try to do what we could to reduce costs, nor not only because in my family we didnt have a lotf money. So we had to always make ends meet. But my mom would alway always tell folks, yes, my mom would always just really pound in, does not prevent k kerimian you are better to prevent than to remediate. And in health care, its absolutely the case that it is better to prevent than try to remediate. Unfortunately, have a system of health care thats focused on curing, on treating disease, and on getting y to get well again, rather than trying to promote your wellness from the very beginning. And sohat wererying to do is geto the point of wellness before treating illness. Part of that, of course, means maki sure you have access to the right medicines. But if it becomes too expensive, it becomes very difficult. So t inflation reduction act, as a principal component, the reduction of costs for americans on the prescription medication. Everyone knows about the insulin today. Months of insulin. Now, those on dicare wont p more than 35 bucks. Less than a year ago, they we paying 150 200. Today, those same seniors on medicare can get a shingles vaccine. And i suect i see some folks here of the age to get a shingl vaccine. If you havent, go get it. You do not want shingles that uldost you three or 400 bucks today. Zero cost. And so president was very committed when he ran for office for president , he said on health care, im ing to lower costs with better care for more people. And so far, ats what we are doing. Were gng to continue. And on negotiating drug prices, you know, its hard to beeve that you have to explain to folks why its a good idea to be able to negotiate to get the best price, which were accustomed to doing that, whher its buying your car or gointo the flea market. And ive never heard that trying to inspire competition is bad for america. Our system is based on competition. You know, competition, negotiating prices that as american as apple pie. And so thats what were trying to do for the 65 Million People on medare who need medicine more than other folks. Why shouldnt we get to negotiate the best price for em instead of have a fixed price fixed by the industry . And thatwhy were negotiating. And re going to make sure that we continue to innovate in america by making sure we have competion drive with the price of pscription drugs will be. Alex, as you know, the uted stat and covid and sasha in many ways protects e world wi innovatn. Ourharmaceutical companies, oubiotech companies today a i ow you have had think throh how to balae the issu of fordab healtare today and and still providing incentives tthe private place industry. How do you view that . So my approach in health care, and maybe it comes from having been an industry and being a micro economist and thinking is how do we get in Health Care Market forces to work as best possible . Because youre going to get the right allocation of capital, the right incentives structures on innovation. The more youve got basically free market approaches towards pricing mechanisms, there are ways in which, of course, that doesnt work well, in part b, thats the physician administered drugs in the United States. We historically simply pay a sticker price, price plus a markup, 106 of average sales price. So what i did was actually mandate that if the Drug Companies were willing to negotiate deals with socialist countries abroad that are high income, thered be most favored nation status. And we would get the benefit of that deal in part b. Now, in fact, th wouldnt pull us down to their level. What it would do would be to create a market regulating mechanism where they wouldnt be willing to give away the store to the european ends because theyd have to pay the penalty here in the u. S. Of that tradeoff, d it would lead to basically a trade measure and equalization. Whats happening in part d really concerns me. I mean, with all respect, i im a so you mentioned im a lawyer, but im a scalia clerk. And justice scalia, we used the websts second edition, which is the normative definition of words, how they should be used. Websters third is a heresy. Its a positive of how words are actually used. I looked up this morning the second edition to negotiate a means to treat with another respecting purchase and sale, to confer with another in bargaining or trade. To hold conference and discussion with a view to reaching agreement on a contract. The inflation reduction act. The negotiation provisions are not that i price, its just price fixing. Its saying if you wish to be a company, not just a product, a Company Selling in medicare and medicaid, which is the bulk of the market in the United States, you must accept a price set by secretary becerra or his successors. According to certain factors, including a statutory regime. Thats just pce fixing. And the sanction is a 19 penalty. If you dont comply or being kicked completely, your entire company out of the program, even the socialist countries of europe, its just product by product. You can decide whether you will take the price theyre willing to give you. Theres a lot that actually in the ira that i worked with, senators widen and grassley on. So the inflation penalties, the restructuring of the pt d benefit that the catastrophic coverage is there. So there are things that are very targeted towards reducing costs for people. But im quite nervous, mike, with the ira that were going to see a dramatic reduction in the incentives in innovation. You wont see investment in line extensions. You wont have enough time to add new indications you might see delayed launches in the u. S. While you launch in other countries. I mean, americans ent going to be happy when france gets drugs before we do. Youre going to have the perverse incentive where lets say enbrel, which lets lets say its paying a 60 rebate. Right now to the pbms. It gets put on the ira as a price fixed drug. That rebate now no longer goes to the part d plan. And so the part d plan has to cover the drug, but it can put it as tier six. So it could make it a bottom tier drug with 80 cost sharing and cover a more expensive novel. Il 23 mechanism in tier two, lowerrice. And so you could perversely end up having more out of pocket costs to the patient from the system because its not built with an understanding of how pa d plans work. So i wt to stress and im going go back to secretary sarah, how impornt thiissue is. And uve raisea rlly important issue. And many years ago i california, Governor Brown created this commiion and i s on cled the commiion for personalized medicine. And after nine months, we changed our name to the commission for Precision Medicine because of sequencing, we now could give you precisely what you needed. And before we submitted the report, in line with your comments, secretary beshear, we anged our nameo presion health while we spending 80, 90 of the cost of Health Care Care and n focusedn rmission. But i think you have a little dierent view of this challenge and i justant totress to everyone here in the room, this is an portant balancing act. It is these vaccine lines, etc. , and cures of disease th really have driven th world not only the extension of life, but the increaseduality of life. And so its aiffere whole balae of wt is besfor the population and the access to care at affdable rates. And cawe create incentive for people to invest billions of dollars . Secretary fisher yeah, so i wouldnt be surprised that i have a slightly different interpretation. We would be st so pointed. So i think you have to go back to some fundamentals first. You. No one is captive in this negotiation. No one is forced to negotiate. If any of those drugmakers dont wish to negotiate, theyre not required to. They are asked to participate in in the negotiation on a particular drug they want to access to the 65 million america kids who have medicare. Wereaying, well, we want to be able to negotte a price. Its like its like, you know, car dealership requires you to buy the car from them. So its unfair to so of claim that these companies are going to be compelled to accept a price that the secretary says, no, you dont have to participate in that process. Secondly, in that process, were going to essentially disclose to them all the information were getting, that were asking them for information so we know exacy how theyre coming about the pricing of their particular product. Wed like to have some transparency so we can see what theyre doing. Well show them as well. There are companies in these as alex, but s sort of socialized European Health systems. There are companies that are based in those countries that are producing these very pharmaceutical drugs. So it aint so bad that they are wiing to actually base themselves there and still be profitable. But more to the point, why is it that those manufacturers and actually, to give you a little bit of hint to this, why is it that those same drugs that were paying one amount for those countries are able to secure those drugs at a third of the price that we are seeing . Drugs, same drugs. Why are we, the folks who get taken on a ride to pay for those drugs . All we want to do is negotiate sort of to alecs point prevusly, which want to negotiate to make sure were not were not the saps here and being taken advantage of so they can make money elsewhere or keep the price lower elsewhere. We want to have fairness for the 65 million americans who are on medicare. Id love to have it for everyone. But right now the law only gives us authority for the folks o medicare. But at the end of the day, these are market forces. We cant negotiate a deal without being able to show folks whats behind the curtain. And remember, none of the drugs that were going to target for negotiation, the first ten that are dgs that have tremendous competition, these are all drugs that have to have the market. And all the data show dt have real competition on their price. Otherwise, if there were competitn, wcan inude that for negotiation. And so, you ow, all the mpanies that are part of the negotiation sued uto not go forward with ts new lawnd so far, they lost ery one of ose lauits. And ess what . All all of tho Drug Companies ve signed up to negotiate with us as well. So were not going to answer this question because the two secretaries could debate this for the next two weeks. But i want we want to stress how important this is. And i just want to underli saying that bioscience and Public Health is driven the world for more than 200 years and the vcines that have been approved over this period of time, we just dont even remember. Now, lets go to one of the great successes of medical research in a short period of time. And that was our efforts in covid 19. I personally was flying back from our conferencen johannesburgnd felt a dark cloud at e end of february, circling the world as this covid. And we at the Milken Institute at faster cures and all of our centers, we pulled the leaders together and said that we would all be judged by what we did during this period of time. And one day of accelerating a solution might be worth. 10000 to 25000 lives. Alex, you were there. You were involved. I was calling you constantly. So. And the teamwork required what barda did, etc. , take us back for just a couple moments to those days and the strategy. Yeah. So we were already early on investing in funding throug barda project bioshield, nih in therapeutics and vaccines from from really the first days we were funding them. We were funding through the traditional grant like mechanisms, which means youre putting money out there and the Drug Companies were working according to their own schedule and what i realized by the end of march was that wasnt going to get us there in any relevant timeframe. That would save the lives that we needed to save. And so thats when i came up with working with pot with with peter marks and bob kadlec and paul mango on our team with the framework for what became operation warp speed, we actually initially called it a Manhattan Project to it was its codename originally s mvp to certain people then suggested maybe that wasnt the best name for a project designed to save miions of lives. And so the idea and this is where having been involved in and run part of a drug company and understand the incentives made a difference. What i said to the team was take money off the table. I will get any amount of money that you need, whether we have it or i need to go to congress get it, take money ofthe table, be constrained only by the laws of science and physics, by what can actually be done. So we derisked everything we prefunded and derisked all development. We prefunded and derisked all manufacturing. We were in large scale commercial manufacturi of vaccines in june of 2020 when we were still beginning phase two studies of molecules. Thats unprecedented. Derisked the commercial market. Most of these companies had gotten out of making these drugs because zika murres monkey pox, they had done that work. But they got out because the market collapsed before they could actually get their products to market. So guarantee a market so take all of that funded all derisk it because Drug Companies, its the riskiest business on earth that draws the most risk averse people on earth to work in it. You how do you derisk their investments by usinghe full power of the Us Government. And thats how we were able to drive rwc to be so fast. We had massive trials, 30,000 people in each arm of these Clinical Trials for vaccines that led to faster results. We were pre manufac looking at commercial scale so we figured out how to optize manufacturing. We had the full power of the Defense Department working there on manufacturing on distribute ocean logistics, procurement, all of that and thats what drove it. So we estimated that it was sting just the united. States 1 trillion a month and youre decision that ten, 20, 30 billion was a drop ithe bucket. And the idea that the Us Government and hhs leadership would manufacture before we knew if it worked so we didnt have to wait six months that a Pharmaceutical Company would shut down its production to produce another pharmaceutical companies product. On a six month that you would build production facilities before you even knew if the product worked was an azing change. And we led by aster crowe on faster cures. We focused as ground zero and on every single more than 500 antiviral oils and vaccines, so anyone in the world could see what was going o but just because you have a solution or prove johannas soluon, if we go back to the polio vaccine more than a year after it was approved, less than 1 of all teenagers in america had been vaccinated. It and it took a young man on the edge sullivan show to vaccinated name elvis press story to convince people it was okay for elvis. It was okay for us and within six months, 80 of all teenagers inmerica happening. Thanks. In 80 sends, roy besse you came in recognizing all these challenges. And 1 million monday morning quarterbacks telling us at we should have done, what we did do was dropped on your doorsp. What are the Lessons Learned and are we prepared for another pandemic . So we learned that we dont have enough elvises and we dont have the type of directed, concerted in investmt that you need except when it becomes a crises. And so what secretary azar described is how essentially uniquelyhe federal govnment was able to bring all of these talents anthe Scientific Capabilities together to give us something that otherwise would ve taken a long time and probably would not have been distributed as equitably as it ultimately was when we came in. And by the way, today. You see all of the covert operations based at hhs while they were dod. They have now operation rp speed is now each corps. It is based at hhs and has bee you probably didnt recognize it. It has been since 2021. And we manage it very, very well. As i mentioned earlier, some 700 million shots have gone into the arms of americans with the covid vaccine. The way, if you havent gotten vaccinated with the up to date vaccine, i urge you to do so. It is proven the most effective keeping you safe in. Quite honestly, if youre goi to go for the holidays, yo stt kissg your grandmand everybody asks, this is a good time to make sure that you dont infect that your 89 year old grandparents. It took everyone coming together. It took what we usually have. The authities, we dontave, becausas we scribed earlier, were a nationwide system of Public Health, not a national system. And we ultimately end up waiting tille have a crisis before we hit, you know, light bulb goes off and we realize weve got to do this together. But again, only the federal government would have made thi happen. And thank god that secretary azar and his team decided to make sure that nothing was an obstacle of getting a share because otherwise millions more would have died. So you talked about an emergency and one of the side effects of covid has been a Mental Health emergency. And our country. How does it look from hhs . In fact as we all know, weve actually had a reduction of Life Expectancy in the United States over the past few years. So, secretary sarah, how do you attempt from hhs to coordinate the efforts there . What changes do you see in the Mental Health area today . So we been facing a Mental Health crisis for quite some time. You poll americans, nine in ten will tell you americas facing a Mental Health crisis. Covid just exposed it, made it more obvious, made it so you could not ignore it. President biden has made sure weve invested more than any previous president on Mental Health, but were so far behind. We have a law that says you have to treat Mental Health on par with all other types of health, physical health. We still dont see providers, insurers doing that. And so were trying to move in that direction. One of the things that weve done is at least try to make sure people can reach someone because too often what happens is and the reason youve seen so many suicides in the last few years is because people give up hope. And so were trying to at least make sure they get connected. So i hope youve heard by now about 98 it is 911 for those who are going through a Mental Health crisis. And so you can dial today nine, eight, eight, actually text you can chat today or call and youll youll get connected with someone who can start giving you some good advice on what to do. Were also expanding what are called Critical Health care Access Points for those with Mental Health services. 24 seven critical access care that wasnt available before. But what we need to do is change this framework where too many insurers, too many providers dont treat Mental Health at par with what we consider regular health. You can go in and get your your childs arm mended. If they if he or she breaks it, you can go in for your cold. You can do all those things that were so accustomed to, but go to your primary care physician and ask or him what to do about Mental Health. And theyll probably say, im going to have to refer you to a specialist, because i didnt i didnt get trained in that. And thats one of the problems is we dont train to be able to preventatively start dealing with Mental Health and were trying to change that. I mean, i think Mental Health is going to be the next wave of health reform. Were the last country that pays for Substance Use disorder and Mental Health care by basically grant and cash pay, as secretary bizzaro noted. I mean, mentahealth parity really is not a reality. We pay primary care doctors who really only treat the most mild instance as a Mental Health disorder. We pay them more than we pay psychiatrists for the same for for the same amount of time delivering care. We have had some really positive movements. Congress passed the expsion of the Certified Behavioral Health community. Behavioral health centers, which could be a new way of delivering holistic behavioral and Substance Use disorder care to individuals. But we have a long, long way to go here. So let me deal with o other issues. Thfirst one is thenormous demographic changes that have occurred in our country. And secretary, im sure you full well knothat anyone under 25 in california today that more than 50 of everyone under 25 in california is now of latin american ancestry than our country has changed from a country where 85 of the people that werent born here were born in europe or to today, where 85 or so of the people noborn here have come from africa, asia or latin america. And so this has been a very important issue for, our faster cures. But its really the theme of this future of Health Summit here in 2023 is essentially Equitable Health care from the standpoint that. Lets start with you secretariat as sarah how do you see the opportunity for Equitable Health care . And we know it works. One of our medical foundations, the Prostate Cancer foundation with the d. O. D. Put up 50 million for a program here that if you serve the country, you were in the va system and serve the country in the dod. Now in the va system, that if you enter the va system, you would also enter the leading Cancer Center in over a period of 4 to 6 years, weve been able to reduce the death rate of africanamericans, which was 100 higher than the general population in Prostate Cancer, by offering equal care. I know this is the theme of this conference and our focus, and i know both you, secretary, this has been a key area that you both been focused on. Secretary becerra, why dont you start on this issue . So we start by incorporate rang equity. We call it equity by design. And so when we are going to propose a program or amend a regulation or a proposed new regs, we insist that our teams consider equity in the design of whever were going to shoot out. That helps ensure that youre not leaving people behind. Quick example. When i came in in 2021, march or so, by april or so became pretty obvious. Getting the daily briefings. As alex mentioned, he got his well on that. What we were seeing, what we always see the disparity grow by april may of 2021, about two thirdsf white adult had received aleast their fit shot of the covid vaccine, less than 50 of black d latinos had at that point received tir shot. And you could sethe disparity growing. So we said, were not going to wait for folks to realize that the federal government is making the vaccine available to everyone for free. Too many people didnt know it. Too many people couldnt get off of work to go get it. So were going to go where they are. So thats whate did. We told our teams that work with the states and lets go where people are that are being missed by january 2022, more than 90 of adult white americans had received at let one shot of the covid vaccine. 90 , at least 90 of black American Adults had received at least one shot. 90 of latino American Adults had received at least first asianamerican native. Every everyone, at least we reached 90 with everyone on that first shot. And thats because we didnt wait for them to come to us. Equity by design. We went to them and thats what we continue to do. Thats why we have a Record Number of americans today who are insured. We have more than 300 million americans who today have their own Insurance Coverage for health care. Never happened before in the country. Private or public insurance. They now have it and under president biden, we have seen obamacare go from about 11 Million People who receive their insurance, health insurance, through the Obamacare Program to over 16 and a half Million People and thats because we didnt wait for folkso come last. The greatest increases in obamacare coverage, black and latino americans. Its nothat they didnt want it. Its that they didnt know enough about it. But now that they know about it, theyre signing up. So, alex, you were there and many communities i know weent out to the africanamerican churches particularly to talk about health, but many of them are skeptical or skeptical at the time you were there in the middle of this pandemic. People were scared, different opinions. How do you see the closing of this health gap . Eres no reason why your zip code should determine your life span or the quality of your life. Mike, u stole my le. I was going to s the number one focus has to be how do we make sure your zip co doest determine the quaty of alth care that you t in ts country . And i think l of that inlves docrating accs to the highest quality care we e entirelyoo slow. Weve got to dramat ange the cycle times of high quaty clinical practice, aption throughout the medical profession. Everybod regardless of zip co, ought to be le to get the highest oology in cance care. We need to we need to able to fix rural health care, materl mortality,aternal health care. Weve g to get the practice of medicine thrghout the couny democrated. Havequal access to people to be able to get into that care. It shouldnt matter where you live or what strings you pull, whether you live or die from cancer in this country and that that we have these pockets and we just dt share th learning. We dont update educatio we dont we donthare the best practices. We dont are the accs to Clinical Trial we need to democraze access to Clinical Trials which ich we remarkably well, i think historically well on the covid vaccines, the but that s intentional. I mean, that was jeme ada, r surgeon general, francis collins, ty fauci and many others sitting there every saturday morning, moncef slai sittg there every turday morng with the dru comnies sayingour results on clinical trl enroment arent acceptable. Anthe dsmb ll notpen up the results. With the type of data that you are presentg far,ouve got to go outsidof your usual imary investigators. Youve got to go outside of your usual clinicalrial subjects. Youve got tgo outside of ur usual enrollment sites, and youve got to get people i and with that intentionality a force that actually worked well, one sector in this era, secretaryzar, we thank you. We thank you for your commitment to service. And many of us in the world of philanthropy, i learned 50 years ago that no good deed ever goes unpunished from that standpoint. And youve taken on both of you such enormous challenges that we had to face and we just want to thank you for your commitment and fear continued work in this area. And thank you for joining us today. Thank you very much. Regretful your knowledge, the participation of the following organizations whose generous support in hosting this conference positive you. I want. To be a part of their participation in this event. We we thank the Milken Institute, a Strategic Review of