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 ChairmanMichael 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 ThompsonOffice 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 her