    [House Hearing, 115 Congress]
    [From the U.S. Government Publishing Office]

            OVERSIGHT OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                               FEBRUARY 15, 2018

                                   __________

                               Serial No. 115-101

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                    _________

                         U.S. GOVERNMENT PUBLISHING OFFICE

     30-188 PDF                   WASHINGTON : 2018

                        COMMITTEE ON ENERGY AND COMMERCE

                              GREG WALDEN, Oregon
                                     Chairman

    JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
      Vice Chairman                        Ranking Member
    FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
    JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
    MICHAEL C. BURGESS, Texas            ELIOT L. ENGEL, New York
    MARSHA BLACKBURN, Tennessee          GENE GREEN, Texas
    STEVE SCALISE, Louisiana             DIANA DeGETTE, Colorado
    ROBERT E. LATTA, Ohio                MICHAEL F. DOYLE, Pennsylvania
    CATHY McMORRIS RODGERS, Washington   JANICE D. SCHAKOWSKY, Illinois
    GREGG HARPER, Mississippi            G.K. BUTTERFIELD, North Carolina
    LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
    BRETT GUTHRIE, Kentucky              KATHY CASTOR, Florida
    PETE OLSON, Texas                    JOHN P. SARBANES, Maryland
    DAVID B. McKINLEY, West Virginia     JERRY McNERNEY, California
    ADAM KINZINGER, Illinois             PETER WELCH, Vermont
    H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
    GUS M. BILIRAKIS, Florida            PAUL TONKO, New York
    BILL JOHNSON, Ohio                   YVETTE D. CLARKE, New York
    BILLY LONG, Missouri                 DAVID LOEBSACK, Iowa
    LARRY BUCSHON, Indiana               KURT SCHRADER, Oregon
    BILL FLORES, Texas                   JOSEPH P. KENNEDY, III,
    SUSAN W. BROOKS, Indiana             Massachusetts
    MARKWAYNE MULLIN, Oklahoma           TONY CARDENAS, California
    RICHARD HUDSON, North Carolina       RAUL RUIZ, California
    CHRIS COLLINS, New York              SCOTT H. PETERS, California
    KEVIN CRAMER, North Dakota           DEBBIE DINGELL, Michigan
    TIM WALBERG, Michigan
    MIMI WALTERS, California
    RYAN A. COSTELLO, Pennsylvania
    EARL L. ``BUDDY'' CARTER, Georgia
    JEFF DUNCAN, South Carolina

                             Subcommittee on Health

                           MICHAEL C. BURGESS, Texas
                                     Chairman
    BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
      Vice Chairman                        Ranking Member
    JOE BARTON, Texas                    ELIOT L. ENGEL, New York
    FRED UPTON, Michigan                 JANICE D. SCHAKOWSKY, Illinois
    JOHN SHIMKUS, Illinois               G.K. BUTTERFIELD, North Carolina
    MARSHA BLACKBURN, Tennessee          DORIS O. MATSUI, California
    ROBERT E. LATTA, Ohio                KATHY CASTOR, Florida
    CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
    LEONARD LANCE, New Jersey            BEN RAY LUJAN, New Mexico
    H. MORGAN GRIFFITH, Virginia         KURT SCHRADER, Oregon
    GUS M. BILIRAKIS, Florida            JOSEPH P. KENNEDY, III,
    BILLY LONG, Missouri                     Massachusetts
    LARRY BUCSHON, Indiana               TONY CARDENAS, California
    SUSAN W. BROOKS, Indiana             ANNA G. ESHOO, California
    MARKWAYNE MULLIN, Oklahoma           DIANA DeGETTE, Colorado
    RICHARD HUDSON, North Carolina       FRANK PALLONE, Jr., New Jersey (ex
    CHRIS COLLINS, New York                  officio)
    EARL L. ``BUDDY'' CARTER, Georgia
    GREG WALDEN, Oregon (ex officio)

                                      (ii)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Michael C. Burgess, a Representative in Congress from the
      State of Texas, opening statement..............................     2
        Prepared statement...........................................     3
    Hon. Gene Green, a Representative in Congress from the State of
      Texas, opening statement.......................................     5
        Prepared statement...........................................     5
    Hon. Doris O. Matsui, a Representative in Congress from the State
      of California, prepared statement..............................     7
    Hon. Greg Walden, a Representative in Congress from the State of
      Oregon, opening statement......................................     8
        Prepared statement...........................................     9
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................    10
        Prepared statement...........................................    11
    Hon. Ben Ray Lujan, a Representative in Congress from the State
      of New Mexico, prepared statement..............................    13

                                    Witness

    Alex M. Azar II, Secretary, Department of Health and Human
      Services.......................................................    14
        Prepared statement...........................................    16
        Answers to submitted questions...............................    94

                               Submitted Material

    Letter of February 9, 2018, from Seema Verma, Administrator,
      Centers for Medicare & Medicaid Services, Department of Health
      and Human Services, to Mr. Pallone, with letter of January 31,
      2018, from Mr. Pallone, et al., to Administrator Verma,
      submitted by Mr. Pallone.......................................    75
    Letter of February 8, 2018, from Ms. Schakowsky, et al., to Alex
      Azar, Secretary, Department of Health and Human Services,
      submitted by Ms. Schakowsky....................................    79
    Article of February 14, 2018, ``Bevin's Medicaid changes actually
      mean Kentucky will pay more to provide health care,'' by
      Deborah Yetter, Louisville Courier Journal, submitted by Mr.
      Kennedy........................................................    81
    Letter of December 1, 2017, from Ms. DeGette, et al., to Eric
      Hargan, Acting Secretary, Department of Health and Human
      Services, submitted by Ms. DeGette.............................    85
    Article of February, 2018, ``Immigrant rights group in email says
      it was warned not to mention abortion to teens,'' by Ann E.
      Marimow and Maria Sacchetti, The Washington Post, submitted by
      Mr. Cardenas...................................................    90

            OVERSIGHT OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES

                                  ----------

                          THURSDAY, FEBRUARY 15, 2018

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 12:33 p.m., in
    room 2123, Rayburn House Office Building, Hon. Michael C.
    Burgess (chairman of the subcommittee) presiding.
        Members present: Representatives Burgess, Guthrie, Upton,
    Shimkus, Latta, Lance, Griffith, Bilirakis, Bucshon, Brooks,
    Mullin, Hudson, Collins, Carter, Walden (ex officio), Green,
    Engel, Schakowsky, Butterfield, Matsui, Castor, Sarbanes,
    Lujan, Schrader, Kennedy, Cardenas, Eshoo, DeGette, and Pallone
    (ex officio).
        Also present: Representatives Welch and Tonko.
        Staff present: Jennifer Barblan, Chief Counsel, Oversight
    and Investigations; Mike Bloomquist, Deputy Staff Director;
    Adam Buckalew, Professional Staff Member, Health; Kelly
    Collins, Staff Assistant; Zack Dareshori, Legislative Clerk,
    Health; Paul Eddatel, Chief Counsel, Health; Adam Fromm,
    Director of Outreach and Coalitions; Caleb Graff, Professional
    Staff Member, Health; Jay Gulshen, Legislative Clerk, Health;
    Ed Kim, Policy Coordinator, Health; James Paluskiewicz,
    Professional Staff Member, Health; Mark Ratner, Policy
    Coordinator; Kristen Shatynski, Professional Staff Member,
    Health; Jennifer Sherman, Press Secretary; Danielle Steele,
    Counsel, Health; Austin Stonebraker, Press Assistant; Josh
    Trent, Deputy Chief Health Counsel, Health; Hamlin Wade,
    Special Advisor, External Affairs; Jacquelyn Bolen, Minority
    Professional Staff Member; Jeff Carroll, Minority Staff
    Director; Waverly Gordon, Minority Counsel, Health; Tiffany
    Guarascio, Minority Deputy Staff Director and Chief Health
    Advisor; Una Lee, Minority Senior Health Counsel; Miles
    Lichtman, Minority Policy Analyst; Rachel Pryor, Minority
    Senior Health Policy Advisor; Samantha Satchell, Minority
    Policy Analyst; Andrew Souvall, Minority Director of
    Communications, Outreach, and Member Services; Kimberlee
    Trzeciak, Minority Senior Health Policy Advisor; C.J. Young,
    Minority Press Secretary.
        Mr. Burgess. The Subcommittee on Health will now come to
    order. I ask everyone to please take their seats.
        And before we get started, I do want to take a moment to
    recognize yesterday's devastating events in Florida. We will
    continue to learn more about how things occurred, and I know my
    colleagues and I will keep the victims, the injured, and their
    loved ones foremost in our minds.
        Representative Bilirakis and Representative Castor, we will
    also be thinking of you, the entire Florida delegation, and the
    people of Florida during this difficult time.
        I would like to recognize myself 5 minutes for the purpose
    of an opening statement.

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

        This afternoon, we are honored to have Secretary Alex Azar
    before the Health Subcommittee to discuss the Department of
    Health and Human Services' budget for the fiscal year 2019.
        First, Secretary Azar, congratulations on your recent
    confirmation, and we appreciate your willingness to participate
    today, and I believe this is your third congressional hearing
    in 24 hours. So we also appreciate your endurance.
        Earlier this week, President Trump and his administration
    released their budget, which provides a blueprint on where
    Federal investments could be made as well as areas of
    additional funding and resources and areas of efficiency.
        We appreciate the administration sharing its vision for the
    upcoming fiscal year as all of us on the committee work to
    solve many of the healthcare issues impacting our respective
    communities across the country.
        Mr. Secretary, you see before you on this dais men and
    women with a multitude of backgrounds and experience and
    different political approaches to solving these problems--
    different political philosophies.
        But I can tell you for a fact everyone seated on this dais
    on either side is committed to seeking solutions and doing the
    work necessary, and I pledge that we will work with you as we
    accomplish these goals for the American people.
        The Energy and Commerce Committee, specifically this
    subcommittee, has the broadest jurisdiction in Congress over
    our Nation's healthcare matters, major policy operations under
    the Department of Health and Human Services.
        These include both private and public health insurance
    markets, Medicare, Medicaid, Children's Health Insurance, and
    the Affordable Care Act; biomedical research and developments,
    particularly those emanating out of the National Institutes of
    Health; the regulation of food, drugs, and medical devices, as
    well as cosmetics through the Food and Drug Administration.
        We also oversee Federal policies affecting substance abuse
    and mental health, which demand interagency collaboration,
    especially with the Substance Abuse and Mental Health
    Administration; and oversight of not only the Nation's public
    health but also global health, including the Centers for
    Disease Control and Prevention.
        Again, Members on both sides of this dais on this
    committee, we do have our differences but I believe we have the
    mutual goal of delivering for the American people and working
    together on issues that demand our full attention.
        We have got an opiate crisis that demands our attention. We
    have got to improve the quality and access to healthcare
    products and services. We have to harness the scientific and
    medical technologies of today to advance the healthcare
    policies of tomorrow.
        What this committee has already accomplished under the
    previous administration and the current administration is
    indicative of what is certainly possible: passage of the
    Medicare and CHIP Reauthorization Act to repeal the sustainable
    growth rate formula; the enactment of the 21st Century Cures
    Act; the reauthorization of several key user fees at the Food
    and Drug Administration last year; the reauthorization of
    Children's Health Insurance and community health centers and
    other important public health and Medicare extenders just last
    week.
        On this committee, we were able to include 19 Member-led
    healthcare initiatives in the recent Bipartisan Budget Act that
    included both Republican and Democrat priorities. The Health
    Subcommittee still has an extensive list of items to finish
    before the end of this year. These include holding hearings on
    legislative policies and developing the proposals to blunt the
    opioid epidemic, to reauthorize the Pandemic and All-Hazards
    Preparedness Act and the Animal Drug User Fee, and examining
    the cost drivers of the Nation's healthcare infrastructure and
    offering solutions and improvements to programs like 340B drug
    discount under the Health Resources and Services
    Administration.
        We are also interested in Consumer eHealth in the Office of
    the National Coordinator for Health Information Technology.
        I would like to build upon the work that our subcommittee
    initiated last year and continue assessing the ways that our
    current healthcare infrastructure can more positively impact
    Americans in urban and rural areas where illnesses like
    Alzheimer's disease and mental health disorders pose challenges
    for our loved ones and their families.
        As a physician who understands the demands and challenges
    of treating patients while maneuvering through the reporting
    and other compliance requirements, which can often be barriers
    to providing better patient care, I want you to know I am
    committed to relieving the burdens that have been placed on
    doctors through commonsense market-driven solutions.
        Many of the actions the current administration has taken
    thus far are very encouraging, and it is my hope we can
    continue to work together on this effort.
        Mr. Secretary, I want you to regard this subcommittee as a
    resource and a partner to you and your agency to fulfill your
    mission and deliver for America.
        Again, I want to welcome you, Secretary Azar, and I want to
    thank you for being here. I look forward to hearing your vision
    for the Department of Health and Human Services and exploring
    opportunities to work together on the many critical health
    issues on behalf of the American people.
        [The prepared statement of Mr. Burgess follows:]

                 Prepared statement of Hon. Michael C. Burgess

        Today, we are honored to have Secretary Alex Azar before
    the Health Subcommittee to discuss the Department of Health and
    Human Services' budget for the fiscal year 2019. First,
    Secretary Azar congratulations on your recent confirmation, and
    we appreciate your participation today, which I believe will be
    your third congressional testimony within the last 24 hours.
        Earlier this week, President Trump and his administration
    released their budget which provides a blueprint on where
    Federal investments could be made as well as areas of
    additional funding resources and efficiencies. We appreciate
    the administration sharing its vision for the upcoming fiscal
    year as all of us on the committee work to solve many of the
    healthcare issues impacting our respective communities across
    the country.
        You see before you on the dais, men and women with a
    multitude of backgrounds and experience and different political
    philosophic approaches to solving these problems. But I can
    tell you everyone seated on this committee is committed to
    seeking solutions--and doing the work necessary.
        The Energy and Commerce Committee, specifically this
    subcommittee, has the broadest jurisdiction in Congress over
    our Nation's healthcare matters, encompassing the major
    policies and operations under the Department of Health and
    Human Services. These issues include both private and public
    health insurance markets under Medicare, Medicaid, CHIP, and
    the Affordable Care Act; biomedical research and developments,
    particularly those emanating out of the National Institutes of
    Health; the regulation of food, drugs, medical devices, and
    cosmetics through the Food and Drug Administration; Federal
    policies affecting substance abuse and mental health, which
    demand interagency collaboration, especially the Substance
    Abuse and Mental Health Administration; and oversight of not
    only the Nation's public health but also global health
    pandemics, including the Centers for Disease Control and
    Prevention.
        Again, Members on both sides of the dais on this committee
    do have our differences, I believe that we have the mutual goal
    of delivering for the American people and working together on
    issues that demand our full attention, such as combatting the
    opioid crisis, improving the quality and access to healthcare
    products and services, and harnessing the scientific and
    medical technologies of today to advance healthcare policies of
    tomorrow. What this committee has already accomplished under
    the previous and current administration is indicative of what
    is certainly possible--the passage of the Medicare and CHIP
    Reauthorization Act to repeal the SGR; the enactment of the
    21st Century Cures Act; the reauthorization of several key user
    fees at the FDA last year; and the reauthorization of CHIP,
    community health centers, and other important public health and
    Medicare extenders last week. Just on this committee, we were
    able to include 19 Member-led healthcare bills in the recent
    Bipartisan Budget Act that included both Republican and
    Democrat priorities.
        The Health Subcommittee still has an extensive list of
    items to finish before the end of this year. These include
    holding hearings on legislative policies and developing a
    package of proposals to blunt the opioid epidemic,
    reauthorizing the Pandemic and All Hazards Preparedness Act and
    Animal Drug User Fee, and examining the cost drivers of the
    Nation's healthcare infrastructure and offering solutions, and/
    or improvements, to programs like 340B drug discount under the
    Health Resources and Services Administration and Consumer
    eHealth at the Office of National Coordinator for Health IT.
        I would also like to build upon the work our subcommittee
    initiated last year and continue assessing the ways our current
    healthcare infrastructure can more positively impact Americans
    in urban and rural areas, where illnesses like Alzheimer's
    disease and mental health disorders pose challenges for our
    loved ones and their families. As a physician who understands
    the demands and challenges of treating patients while
    maneuvering through reporting and other compliance
    requirements--which can often be barriers to providing better
    patient care--I am committed to relieving the burdens that have
    been placed on doctors through commonsense, market-driven
    solutions. Many of the actions the current administration has
    taken thus far are encouraging and it is my hope we can
    continue to work together on this effort.
        I want you to regard this subcommittee as a resource to you
    and your agency, and a partner to fulfill your mission and
    deliver for America. I again want to welcome Secretary Azar and
    thank him for being here. I look forward to hearing your vision
    for the Health and Human Services Department and exploring
    opportunities to work together on the many critical healthcare
    issues on behalf of the American people.

        Mr. Burgess. At this time, I would like to recognize the
    ranking member of the Health Subcommittee, Mr. Gene Green of
    Texas, for 5 minutes, please.

       OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
                    CONGRESS FROM THE STATE OF TEXAS

        Mr. Green. Thank you, Mr. Secretary and Mr. Chairman. Thank
    you, Mr. Secretary, for being here today, and it is unusual to
    have two Texans who are ranking and chair of the Health
    Subcommittee. We wondered about that for most of this session.
    But somehow it works out.
        This week, President Trump released his 2019 budget
    request. Budgets are more than just numbers on a page. They are
    statements of priorities.
        Unfortunately, I believe the priorities of the
    administration are out of whack. This budget doubles down
    policies that would hurt working Americans and jeopardize their
    health.
        It proposes devastating cuts to Medicaid, Medicare, public
    health programs, and yet again calls for repeal-and-replace of
    the Affordable Care Act.
        This dangerous budget imperils access to care for millions
    of Americans and puts our Nation's healthcare system at risk.
        Three million Americans lost their health insurance this
    year because of the administration. This budget proposes to
    take away from millions more.
        Proposing to cut Medicaid by $1.4 trillion is an assault on
    the working families and would be even crueler than the
    permanent caps on funds that Trumpcare passed by the House
    would have imposed.
        It would implement harsh barriers to coverage for low-
    income families altogether. The budget would gut the single
    largest insurer of children, enact an unprecedented cut on the
    largest payer for behavioral health, and threaten care for
    seniors in nursing homes, individuals with disabilities, and
    working families.
        Repealing the ACA and cutting 675 billion in healthcare
    dollars over a decade would take healthcare away from millions
    of Americans, raise costs, and destroy Obamacare's protections
    for people with preexisting conditions.
        This budget cut of almost $500 billion from Medicare shifts
    costs to seniors and cutting our healthcare safety net. It cuts
    $1 billion from the Centers for Disease Control and Prevention
    at a time when a robust public health infrastructure couldn't
    be more important.
        It is clear they have very different aspirations for this
    country and what our healthcare system should look like.
        The picture of the administration's budget paints a harsh
    one where more and more Americans join the ranks of the
    uninsured every day, where seniors face declining quality of
    care and Medicare due to deep and irrational cuts to pay for
    the tax cuts for the wealthy, and where working families and
    people with disabilities can no longer rely on the safety net
    that is Medicaid.
        [The prepared statement of Mr. Green follows:]

                     Prepared statement of Hon. Gene Green

        Thank you, Mr. Chairman, and thank you to Secretary Azar
    for being here this morning.
        This week, President Trump released his 2019 Budget
    Request.
        Budgets are more than a numbers on a page--they are a
    statement of priorities.
        Unfortunately, I believe the priorities of this
    administration are wildly out of whack.
        This budget doubles down policies that will hurt working-
    class Americans and jeopardize their health.
        It proposes devastating cuts to Medicaid, Medicare, and
    public health programs, and yet again, calls for ``repeal and
    replace'' of the Affordable Care Act.
        This dangerous budget imperils access to care for millions
    of Americans and puts our Nation's healthcare system at risk.
        Three million Americans lost their health insurance this
    year because of this administration, and this budget proposes
    to take coverage away from millions more.
        Proposing to cut Medicaid by $1.4 trillion is an assault on
    working families and would be even crueler than the permanent
    cap on funds than the TrumpCare bill passed by the House would
    have imposed.
        It would implement harsh barriers to coverage for lower-
    income families and all together, the budget would gut the
    single largest insurer of children, enact an unprecedented cut
    on the largest payer for behavioral health, and threaten care
    for seniors in nursing homes, individuals with disabilities,
    and working families.
        Repealing the ACA and cutting $675 billion in healthcare
    dollars over a decade will take healthcare away from millions
    of Americans, raise costs and destroy Obamacare's protections
    for people with pre-existing conditions.
        This budget would cut almost $500 billion from Medicare,
    shifting costs to seniors and cutting our healthcare safety
    net.
        It cuts more than $1 billion from the Centers for Disease
    Control and Prevention, at a time when a robust public health
    infrastructure couldn't be more important.
        It is clear we have very different aspirations for this
    country, and what our healthcare system should look like.
        The picture the administration's budget paints is a harsh
    one- where more and more Americans join the ranks of the
    uninsured each day; where seniors face a declining quality of
    care in Medicare due to deep and irrational cuts to pay for tax
    cuts for the wealthy; and where working families, and people
    with disabilities can no longer rely on the safety net that is
    Medicaid.
        I appreciate the opportunity to hear from our witness and
    look forward to answers to our questions.
        I yield 1 minute to Congressman Ben Ray Lujan.
        I yield 1 minute to Congressman Peter Welch.

        Mr. Green. I appreciate the opportunity to hear from our
    witness. I am looking forward to asking questions, and I'd like
    to yield 1 minute to my California colleague Ms. Matsui.
        Ms. Matsui. Thank you very much, Mr. Green.
        I am extremely concerned by the priorities reflected in
    this President's budget. This proposal directly and negatively
    impacts hard-working families who depend on crucial services.
        It guts Medicaid by $1.4 trillion. These cuts mean working
    single mothers in between jobs, families with a family member
    who suffers from addiction, and grandparents in long-term care
    facilities will have less access to care.
        And the HHS budget once again declares war on the
    Affordable Care Act, restricting access to coverage. These are
    cruel inflictions from an administration who claims to be
    addressing the opioid crisis.
        I am disappointed that HHS, which has a mission to enhance
    and protect the health and well-being of all Americans, has
    presented a budget that targets the most vulnerable in our
    communities--women, children, people with disabilities and
    mental illness, and the LGBT community.
        I sincerely hope that in our conversation today we can
    address the failings in HHS' budget vision and how the agency
    should in fact be working to protect all Americans.
        Thank you. I yield back to the ranking member.
        [The prepared statement of Ms. Matsui follows:]

                   Prepared statement of Hon. Doris O. Matsui

        Thank you for yielding. I am extremely concerned by the
    priorities reflected in this President's budget.
        This proposal directly and negatively impacts hard-working
    families who depend on crucial services.
        It guts Medicaid by $1.4 trillion. These cuts mean working
    single mothers in-between jobs .. families with a family member
    who suffers from addiction. and grandparents in long term care
    facilities. will have less access to care. And, the HHS budget
    once again declares war on the Affordable Care Act. restricting
    access to coverage. These are cruel inflictions from an
    administration who claims to be addressing the opioid crisis.
        I am disappointed that HHS, which has a mission to enhance
    and protect the health and well-being of ALL Americans. has
    presented a budget that targets the most vulnerable in our
    communities: women, children, people with disabilities and
    mental illness, and the LGBT community. I sincerely hope that
    in our conversation today we can address the failings in HHS'
    budget vision and how the agency should, in fact, be working to
    protect all Americans. Thank you, I yield back.

        Mr. Green. Mr. Chairman, I yield 1 minute to my colleague
    from Vermont, Congressman Welch.
        Mr. Welch. Thank you very much.
        Mr. Secretary, in March of 2017, President Trump invited
    Congressman Cummings and me to the White House to discuss drug
    prices.
        This committee has got a big concern about that. Mr.
    Burgess has been very active. And his concern was that the
    prices are beyond affordability for individuals, for the
    businesses that are trying to cover their employees, and for
    taxpayers. He believes they are too high. He's explicit that
    it's inexcusable and unsustainable. The causes are many. You've
    got incredible experience in the industry, so you understand
    it.
        And the hope, I think, that the entire committee has is
    that, when you come back in a year, let's say, we are going to
    show that the price has stabilized or started to go down.
        The status quo is just killing us. And if you have these
    medications that have great promise but people can't afford
    them, they are not going to be sustainable.
        Mr. Green. Mr. Chairman----
        Mr. Welch. And I yield back.
        Mr. Green. OK. In my last six seconds, I want to also take
    personal privilege. My staff member Kristen O'Neill, this is
    her last day with us. She's going to bigger and better things.
        She's been in our office doing healthcare for 6 years and,
    as you know, that's been pretty traumatic for both sides of the
    aisle. But I'll miss Kristen because she's been a great staff
    member and made sure I didn't make too much of a fool of
    myself.
        [Applause.]
        And I yield back my time.
        Mr. Burgess. Gentleman yields back. The Chair thanks the
    gentleman.
        Chair recognizes the gentleman from Oregon, Mr. Walden,
    chairman of the full committee, 5 minutes for an opening
    statement.

      OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
                   CONGRESS FROM THE STATE OF OREGON

        Mr. Walden. Well, thank you, Mr. Chairman, and I would also
    join in I guess congratulating Kristen on her departure. I
    don't know if that's a good thing or a bad thing.
        But you've certainly played a key role on healthcare issues
    here and done a great job for Gene, and our team has enjoyed
    working with you as well. So we wish you every success in going
    forward.
        Mr. Secretary, we are delighted to have you here as well.
    Welcome to the Energy and Commerce Committee.
        On behalf of all of us, I'd like to again congratulate you
    on your confirmation as the Secretary of the Department of
    Health and Human Services.
        Your previous leadership experience at the Department and
    in the private sector I think gives you a tremendous
    springboard to do great work for the American people, and we
    like to work as much as we can around here in a bipartisan way
    and we know we share a lot of common objectives. We appreciate
    your appearing before the subcommittee so shortly after your
    confirmation.
        Energy and Commerce has always led the way in delivering
    meaningful healthcare reforms and policies for the American
    people, and last year we completed our work to spur new
    innovation and competition in the life sciences sector through
    the FDA Reauthorization Act.
        Ensuring and strengthening America's leadership role in
    biotechnology to help consumers will continue to be a priority
    for our committee.
        We also just enacted the longest extension of the
    Children's Health Insurance Program--as you know, CHIP. We did
    critical extensions of Medicare extenders that seniors rely
    upon.
        We strengthened public health by providing funding for
    community health centers--really, really important, especially
    I know in my part of the world, 240,000 Oregonians get their
    care through our very important network of community health
    centers--and we have done a lot of other public health
    priorities.
        We also rolled back the Affordable Care Act's Independent
    Payment Advisory Board, which threatened to undermine care for
    our Nation's seniors who rely upon the Medicare program.
        We did this all in a fiscally responsible way by doing the
    hard work of ensuring that new spending was fully paid for with
    targeted and smart reductions in other spending.
        These priorities and others were part of the 19 Energy and
    Commerce Committee bills that were signed into law by President
    Trump as part of the Bipartisan Budget Act of 2018. So we got a
    lot of work teed up through here, and then we are able to put
    it in that package and the President signed it.
        So, Mr. Secretary, we had a chance to talk earlier this
    week about our shared priorities, and we look forward to
    partnering with you and the entire Department of Health and
    Human Services.
        This committee has a rich tradition of bipartisan oversight
    and legislative work, and I see a lot of opportunity for us to
    continue down that path in the coming weeks and months.
        Particularly, I'd like to focus on the issue of opioids and
    the crisis that is afflicting our country and our citizens.
    It's a top priority for me. It's a top priority for Members on
    every side in this committee. We need to build upon our
    previous legislative efforts, known as the Comprehensive
    Addiction Recovery Act, or CARA, and the funding provided in
    the 21st Century Cures Act.
        I would point out that's the most funding the United States
    Government has ever put directly toward the opioid epidemic,
    and we intend to do more and we are set up in the budget
    agreement to do even more, going forward. But we want to make
    sure it goes to the right places for effective purposes and
    helps in this effort.
        While these laws resulted in record amounts of money being
    devoted to this fight, more is needed to address this growing
    crisis, and in last week's budget bill we were able to deliver
    headroom to provide new resources for both 2018 and 2019. So we
    look forward to working with our friends in the Appropriations
    Committee as we work on how that money should be spent.
        Last year, we held a Member Day. We solicited solutions to
    combat the opioid epidemic. We had, I think, something like 50
    Members of Congress come before this committee--an
    unprecedented show of support--with their ideas and their
    suggestions about what we could do.
        We also have had tremendous work being done by our
    Oversight and Investigations Subcommittee, now led by Chairman
    Harper, looking at how these drugs got into our communities and
    the tripwires that didn't trip, or if they did we want to know
    why somebody didn't take notice.
        Given that addressing the opioid epidemic has bipartisan
    support and President Trump's leadership and commitment to this
    issue, it is my hope and belief this committee will deliver
    additional legislation this spring and that we can get into law
    soon.
        The Health Subcommittee also plans to build upon the work
    of our Oversight and Investigations Subcommittee's report on
    340B. This program is important, as it serves our low-income
    individuals. But it's essentially not been modernized in two
    decades. So it's our belief that reforms are necessary to both
    strengthen and secure the program so it can best serve low-
    income populations and make sure they have access to affordable
    medications. So we look forward to working with you on that.
        Along with finding opportunities to lower costs for
    consumers across the board and addressing reauthorizations
    later this year, 2018 will be busy for this subcommittee and,
    Secretary Azar, we look forward to partnering with you on these
    initiatives and many more going forward.
        And with that, Mr. Chairman, I yield back.
        [The prepared statement of Mr. Walden follows:]

                     Prepared statement of Hon. Greg Walden

        Secretary Azar, welcome to Energy and Commerce. On behalf
    of all of us, I'd like to congratulate you again on your
    confirmation as the Secretary of the Department of Health and
    Human Services. Your previous leadership experience at the
    Department and in the private sector will give you a tremendous
    springboard to do great work for the American people.
        We appreciate you appearing before the subcommittee today
    so shortly after your confirmation.
        Energy and Commerce has led the way in delivering
    meaningful healthcare reforms and policies for the American
    people. Last year, we completed our work to spur new innovation
    and competition in the life sciences sector through the FDA
    Reauthorization Act. Ensuring and strengthening American's
    leadership role in biotechnology to help consumers will
    continue to be a priority for this committee.
        We also just enacted the longest extension of the
    Children's Health Insurance Program, critical extensions of
    Medicare extenders that seniors rely upon, and strengthened
    public health by providing funding for community health centers
    and other important public health priorities. We also rolled
    back the Affordable Care Act's Independent Payment Advisory
    Board--which threatened to undermine care for our Nation's
    seniors who rely upon the Medicare program. We did this all in
    a fiscally responsible way by doing the hard work of ensuring
    new spending was fully paid for with targeted and smart
    reductions in health spending.
        These priorities and others were part of 19 Energy and
    Commerce Committee bills that were signed into law by President
    Trump as part of the Bipartisan Budget Act of 2018.
        Secretary Azar, we had a chance to talk earlier this week
    about our shared priorities and we look forward to partnering
    with you and the entire Department of Health and Human
    Services. This committee has a rich tradition of bipartisan
    oversight and legislative work--and I see a lot of opportunity
    for us to continue down that path in the coming weeks and
    months.
        Particularly, I see a great opportunity to for us to work
    together to combat the opioid crisis, a top priority for me and
    for this committee. We need to build upon E&C's previous
    legislative efforts, namely the Comprehensive Addiction
    Recovery Act (CARA) and the funding provided in the 21st
    Century Cures Act. While these laws resulted in record amounts
    of Federal resources being devoted to this fight, more is
    needed to address this growing crisis. In last week's budget
    bill, we were able to deliver headroom to provide new resources
    to combat the opioid crisis for the rest of FY 2018 and FY
    2019. We look forward to working with our friends at the
    Appropriations Committee on this point.
        Last year, we held a Member Day to solicit solutions to
    help combat the opioid crisis--hearing directly from Members
    both on and off this committee, Republican and Democrat. Later
    this month, this subcommittee will launch its review of
    targeted solutions to help combat the opioid crisis. This work
    will be done in tandem with our Oversight and Investigations
    Subcommittee work led by Chairman Harper.
        Given that addressing the opioid epidemic has bipartisan
    interest and with President Trump's leadership and commitment
    to this issue, it is my hope and belief that this committee
    will deliver additional legislative solutions that we can move
    to the full House later this year.
        The Health Subcommittee also plans to build upon the work
    of our Oversight and Investigations work regarding the 340B
    program. This important program designed to serve low-income
    individuals has essentially not been modernized in more than
    two decades. It is my belief that reforms are necessary to
    strengthen and secure the program so it can best serve low-
    income populations access affordable medications. We look
    forward to working with HHS and stakeholders to make sure we
    get the job done right.
        Along with finding opportunities to lower costs for
    consumers across the board and the addressing reauthorizations
    later this year, 2018 will be a busy year for this
    subcommittee.
        Secretary Azar, we look forward to partnering with you on
    these initiatives and working on many of our shared priorities
    together.

        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair recognizes the gentleman from New Jersey, Mr.
    Pallone, ranking member of the full committee, 5 minutes,
    please.

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

        Mr. Pallone. Thank you, Mr. Chairman.
        To my dismay but not my surprise, President Trump's 2019
    budget proposal continues the cruel and complacent perspective
    of ripping healthcare away from millions of Americans to help
    pay for the Republicans' tax scam that overwhelmingly benefits
    the wealthy and corporations.
        This budget is an attack on working families, seniors, and
    lifesaving programs. I want to just highlight some of the more
    egregious issues with the budget.
        It doubles down on gutting and capping the Medicaid
    program, the Nation's largest health insurer, and cuts our
    Nation's safety net by $1.4 trillion.
        Meanwhile, it builds on the administration's ongoing
    illegal efforts to kick vulnerable Americans off Medicaid
    through work requirements, lockouts, and proposed lifetime
    limits.
        Simply put, the Trump administration's vision for our
    country through this budget is to take coverage away from
    families living on the brink that depend on Medicaid to make
    ends meet.
        The Trump budget also includes over $500 billion in cuts to
    Medicare, jeopardizing healthcare for seniors. Deep cuts to
    safety net providers, nursing homes, home health agencies, and
    other providers appear to be based not on any real policy
    rationale but cutting for the sake of cutting. Essentially, cut
    healthcare for seniors to pay for that Republican tax cut.
        Sadly, the Trump budget continues the same Republican
    efforts to repeal the Affordable Care Act. As proposed, ACA
    repeal would leave millions more uninsured, gut protections for
    preexisting conditions, and result in a $675 billion cut to our
    healthcare system.
        In addition, ongoing efforts to sabotage the ACA such as
    cutting off cost-sharing reductions and rolling back consumer
    protections have already resulted in skyrocketing costs for
    middle-class families and 3 million more Americans uninsured in
    2017.
        And now, HHS is sitting by the sidelines while Idaho
    clearly circumvents the law, and this is simply unacceptable.
        Today, we will hear from our newly confirmed Secretary
    Azar, and Mr. Azar moves into the top leadership position at a
    very trying time.
        The Department has been embroiled in scandal since day one.
    From former Secretary Tom Price's exorbitant travel expenses,
    to the use of official resources to lobby in favor of ACA
    repeal-and-replace, to Brenda Fitzgerald's purchases of tobacco
    stock while she was the head of CDC, these issues deserve
    immediate attention.
        This morning I sent a letter to you, Mr. Secretary, asking
    you to conduct a top-down review of the Department and all of
    its operating divisions to assess the extent to which HHS
    personnel are abiding by all applicable Federal ethical
    regulations and policies and whether appropriate safeguards are
    in place to protect against abuse and conflicts of interest.
        I hope we hear today about your plans to faithfully uphold
    the laws set by Congress, improve transparency, and eliminate
    conflicts of interest and protect the health of working
    families.
        The American people deserve a commitment to restore the
    integrity of the Department.
        [The prepared statement of Mr. Pallone follows:]

                 Prepared statement of Hon. Frank Pallone, Jr.

        To my dismay but not my surprise, President Trump's 2019
    budget proposal continues the cruel and complacent perspective
    of ripping healthcare away from millions of Americans to help
    pay for the Republicans tax scam that overwhelmingly benefits
    the wealthy and corporations. This budget is an attack on
    working families, seniors and life-saving programs.
        I want to just highlight some of the more egregious issues
    with this budget. It doubles down on gutting and capping the
    Medicaid program, the Nation's largest health insurer, and cuts
    our Nation's safety net by $1.4 trillion. Meanwhile, it builds
    on the administration's ongoing, illegal efforts to kick
    vulnerable Americans off Medicaid through work requirements,
    lock outs, and proposed lifetime limits. Simply put--the Trump
    administration's vision for our country through this budget is
    to take coverage away from families living on the brink that
    depend on Medicaid to make ends meet.
        The Trump budget also includes over $500 billion in cuts to
    Medicare, jeopardizing healthcare for seniors. Deep cuts to
    safety net providers, nursing homes, home health agencies, and
    other providers appear to be based not on any real policy
    rationale, but cutting for the sake of cutting. Essentially cut
    healthcare for seniors to pay for that Republican tax cut.
        Sadly, the Trump budget continues the same Republican
    efforts to repeal the Affordable Care Act. As proposed, ACA
    repeal would leave millions more uninsured, gut protections for
    preexisting conditions, and result in a $675 billion cut to our
    healthcare system. In addition, ongoing efforts to sabotage the
    ACA, such as cutting off cost-sharing reductions and rolling
    back consumer protections, have already resulted in
    skyrocketing costs for middle-class families and 3 million more
    Americans uninsured in 2017. And now--HHS is sitting by the
    sidelines while Idaho clearly circumvents the law. This is
    simply unacceptable.
        Today, we will hear from newly confirmed HHS Secretary
    Azar. Mr. Azar moves into the top leadership position at a
    trying time--the Department has been embroiled in scandals
    since Day 1. From former Secretary Tom Price's exorbitant
    travel expenses, to the use of official resources to lobby in
    favor of repeal-and-replace, to Brenda Fitzgerald's purchase of
    tobacco stock while she was the head of CDC, these issues
    deserve immediate attention. This morning, I sent a letter to
    Secretary Azar asking him to conduct a top-down review of the
    Department and all of its operating divisions, to assess the
    extent to which HHS personnel are abiding by all applicable
    Federal ethical regulations and policies, and whether
    appropriate safeguards are in place to protect against abuse
    and conflicts of interest. I hope we hear today about his plans
    to faithfully uphold the laws set by Congress, improve
    transparency and eliminate conflicts of interest, and protect
    the health of working families. The American people deserve a
    commitment to restoring the integrity of the Department.
        Thank you.

        Mr. Pallone. I'd like to yield--I don't have exactly 2
    minutes, but half my time initially to Mr. Lujan and then to
    Mr. Kennedy. I yield to Mr. Lujan at this time.
        Mr. Lujan. Thank you, Mr. Pallone, and Mr. Secretary, thank
    you for being here today.
        In previous hearings, you told some of my Democratic
    colleagues that we all shared values on healthcare. I am
    interested to hear more about how the Trump administration's
    budget reflects these shared values, or perhaps explore where
    in fact we are not aligned.
        I believe healthcare is a right, not a luxury. I believe
    healthcare should be affordable no matter your income,
    accessible no matter where you live, high quality no matter how
    you're insured.
        The President's budget proposal continues the Republican
    obsession with repealing the Affordable Care Act, which would
    strip healthcare away from tens of millions of Americans.
        Let me be clear. Those are not my values. I believe it's a
    tragedy that seniors all across this country have to choose
    between rent and prescription drugs.
        I believe it's a tragedy that, before the Affordable Care
    Act, more Americans filed bankruptcy for medical debt than
    anything else. I believe it's a tragedy that, before Medicaid
    expansion, paying for inpatient opioid treatment was out of
    reach for so many middle-class Americans.
        This Trump budget dismantles Medicaid and the Affordable
    Care Act. It represents an attack on working families and
    lifesaving programs. The Trump budget cuts care for children,
    families, women, and people with disabilities while once again
    favoring the wealthy over corporations. Those are certainly not
    my values.
        I yield back.
        [The prepared statement of Mr. Lujan follows:]

                    Prepared statement of Hon. Ben Ray Lujan

        Thank you, Secretary Azar, for joining us today.
        In previous hearings, you told some of my Democratic
    colleagues that we all have shared values on healthcare. I'm
    interested to hear more about how the Trump administration's
    budget reflects these shared values, or perhaps explore where
    we in fact are not aligned.
        I believe healthcare is a right, not a luxury.
        I believe healthcare should be affordable--no matter your
    income.
        Accessible--no matter where you live.
        And high quality--no matter how you are insured.
        The President's budget proposal continues the Republican
    obsession with repealing the Affordable Care Act, which would
    strip healthcare away from tens of millions of Americans.
        Let me be clear. Those are not my values.
        I believe it's a tragedy that seniors all across this
    country have to choose between rent and their prescription
    drugs.
        I believe it's a tragedy that before the Affordable Care
    Act, more American's filed bankruptcy for medical debt than
    anything else.
        I believe it's a tragedy that before Medicaid expansion,
    paying for in-patient opioid treatment was out of reach for so
    many middle-class families.
        The Affordable Care Act and Medicaid expansion provided a
    historic step forward in addressing the health disparities have
    plagued our communities.
        A healthcare system that addresses these issues reflect my
    values.
        This Trump budget dismantles Medicaid and the Affordable
    Care Act. It represents an attack on working families and
    lifesaving programs.
        The Trump budget cuts care for children, families, women,
    and people with disabilities while once again favoring the
    wealthy and corporations.
        Those are certainly not my values.

        Mr. Pallone. Mr. Kennedy, you got, like, 10 minutes left.
        Mr. Burgess. Ten minutes?
        Mr. Pallone. Ten seconds.
        Mr. Kennedy. I got 6, 7 seconds. So I'll yield back.
        Mr. Pallone. I am sorry. Thank you, Mr. Chairman.
        Mr. Burgess. Gentleman yields back. Chair thanks the
    gentleman.
        This concludes Member opening statements. The Chair would
    remind Members that, pursuant to committee rules, all Members'
    opening statements will be made part of the record.
        Testifying before our subcommittee today is the Honorable
    Alex Azar, Secretary of the United States Department of Health
    and Human Services.
        Secretary Azar, you will have an opportunity to give an
    opening statement followed by questions from Members. We do
    want to thank you for being here today.
        You are now recognized for 5 minutes to summarize your
    opening statement, please.

     STATEMENT OF ALEX M. AZAR II, SECRETARY, DEPARTMENT OF HEALTH
                           AND HUMAN SERVICES

        Mr. Azar. Chairman Burgess, Ranking Member Green, Chairman
    Walden, and Ranking Member Pallone and members of the
    committee, thank you for inviting me here today to discuss the
    President's budget for the Department of Health and Human
    Services for fiscal year 2019.
        I would like to begin by expressing, of course, my
    sympathies and prayers for the victims and families of the
    tragedy in Florida. I want to echo the President's comments
    this morning that this administration is committed to working
    with States and localities to tackle the issues of serious
    mental illness.
        It's a great honor to be here. It's an honor to serve as
    Secretary of the Department of Health and Human Services. Our
    mission is to enhance and protect the health and well-being of
    all Americans.
        It is a vital mission, and the President's budget clearly
    recognizes that. The budget makes significant strategic
    investments in HHS' work, boosting discretionary spending at
    the Department by 11 percent in 2019 to $95.4 billion.
        Among other targeted investments, that is an increase of
    $747 million for the National Institutes of Health, a $473
    million increase for the Food and Drug Administration, and a
    $157 million increase over 2018 funding for emergency
    preparedness across the Department.
        The President's budget especially supports four particular
    priorities that we have laid out for the Department, issues
    that the men and women of HHS are already working hard on:
    fighting the opioid crisis, increasing the affordability and
    accessibility of health insurance, tackling the high price of
    prescription drugs, and using Medicare to move our healthcare
    system in a value-based direction.
        First, the President's budget brings a new level of
    commitment to fighting the crisis of opioid addiction and
    overdose that is stealing more than a hundred American lives
    every single day.
        Under President Trump, HHS has already disbursed
    unprecedented resources to support access to addiction
    treatment. This committee in particular took a major step in
    addressing the crisis through creating the 21st Century Cures
    Act's State-targeted response to the opioid crisis grants.
        The budget would take total investment to $10 billion in a
    joint allocation to address the opioid epidemic and related
    mental health challenges.
        Second, we are committed to bringing down the skyrocketing
    cost of health insurance, especially in the individual and
    small group markets so more Americans can access quality
    affordable healthcare.
        This budget recognizes that this will not be accomplished
    by one-size-fits-all solutions from Washington. It will require
    giving States room to experiment with models that work for them
    and allowing customers to purchase individualized plans that
    meet their needs.
        That's why the budget proposes a historic transfer of
    resources and authority from the Federal Government back to the
    States, empowering those who are closest to the people and can
    best determine their needs.
        The budget would also restore balance to the Medicaid
    program, fixing a structure that has driven runaway costs
    without a commensurate increase in quality.
        Third, prescription drugs cost too much in our country.
    President Trump recognizes this, I recognize this, and we are
    doing something about it.
        This budget has a raft of proposals to bring down drug
    prices, especially for America's seniors. We propose a five-
    part reform plan to further improve the already successful
    Medicare Part D prescription drug program.
        These major changes will straighten out incentives that too
    often serve program middlemen more than they do our seniors.
    These changes will save tens of billions of dollars for seniors
    over the next 10 years, adding to savings we are already
    generating with reforms the Medicare Part B payments under the
    340B drug discount program.
        The budget also proposes further reforms in Medicaid and
    Medicare Part B to save patients money on drugs and provide
    strong support for FDA's efforts to spur innovation and
    competition in generic drug markets.
        We want programs like Medicare and Medicaid to work for the
    people they serve. That means empowering patients and providers
    with the right incentives to pay for health and outcomes rather
    than procedures and sickness.
        Our fourth departmental priority is to use the tremendous
    powers we have through Medicare as the largest purchaser of
    medical services in the U.S. to move our whole healthcare
    system in this direction.
        This budget takes steps toward that by, for instance,
    eliminating price variation based on where post-acute care is
    delivered, rationalizing payments to physicians and hospital-
    owned outpatient facilities, supporting investments in
    telehealth, and advancing the work of accountable care
    organizations.
        The future of Medicare must be driven by value, quality,
    and outcomes, not the current thicket of opaque, unproductive
    incentives.
        Making our programs work for today's Americans, sustaining
    them for future generations, and keeping our country safe is a
    sound vision for the Department of Health and Human Services,
    and I am proud to support it.
        Thank you, Mr. Chairman.
        [The prepared statement of Mr. Azar follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. Mr. Secretary, thank you for your testimony.
    Thank you for being here today. We will move on to the Member
    questions portion.
        I would like to first recognize the vice chairman of the
    subcommittee, Mr. Guthrie of Kentucky, 5 minutes, please.
        Mr. Guthrie. Thank you, Mr. Chairman. I appreciate it.
        Mr. Secretary, thank you for being here. I had a meeting
    earlier today with Workforce on Opioids, and that's something
    that we are all concerned about, particularly my home State.
        And one tool that could be improved to combat the opioid
    crisis is prescription drug monitoring programs. As you know,
    PDMPs can help spot potential drug misuse or diversion.
        I've heard from stakeholders that integrating PDMP data
    into the clinical workflow in a timely manner is needed to
    improve provider and dispenser resources.
        Can you please describe how HHS is thinking about
    leveraging its authorities to encourage best practices within
    PDMPs?
        Mr. Azar. So thank you, Congressman, for that question.
        I look forward to any ideas that you and others may have
    about ways that we can support States in this critical effort.
        One of the proposals in our budget is to require States to
    monitor high-risk billing activity to identify and remediate
    abnormal prescribing and utilization patterns that may indicate
    abuse in the Medicaid system. That may include States with
    prescription drug monitoring programs as a vehicle to do that.
        We also are asking for authority to make sure that,
    whenever we exclude a provider, it will automatically lead to
    transmission of that information to DEA to pull the physician's
    ability to write controlled substances through the DEA.
        Mr. Guthrie. Thank you.
        Second question, on Medicaid rebates. Strengthening and
    improving the oversight of the Medicaid drug rebate program is
    something this committee has been working on for several years.
        In fact, recently the HHS Office of Inspector General just
    issued a report on CMS' oversight of the program. In their
    report, the OIG found that, from 2012 to 2016, Medicaid may
    have lost $1.3 billion in base and inflation-adjusted rebates
    for 10 potentially misclassified drugs, with the highest total
    reimbursement in 2016. This budget includes a proposal to
    clarify Medicaid definition of brand and over-the-counter drugs
    under the Medicaid drug rebate program to prevent
    inappropriately lower manufacturer rebates.
        We are interested in your legislative proposal in this
    budget, and could you describe it and then have your office
    provide us with details?
        Mr. Azar. Yes, thank you.
        So this is an issue that came up in the last year or last
    year and a half regarding making sure that manufacturers are
    clearly understanding and that the rules of the road are very
    clear--what's a branded drug, what's a generic drug, what's an
    over-the-counter drug--so that we are getting our proper rebate
    payments in the Medicaid program, and as you mentioned, that
    can be an error to the tune of $1.3 billion of misreporting. So
    we are asking for language that would clarify that.
        In addition, you know, we have got in our budget proposal a
    plan that we would like authority to grant up to five States
    the ability to negotiate their own formulary for drugs with
    drug companies to see if they can do an even better job than we
    do through our statutory Medicaid drug rebate program to bring
    down drug costs.
        Mr. Guthrie. Thank you. I look forward to looking at the
    details of that.
        And one more. I'll go back to my first question on the
    prescription drug monitoring programs. It's my understanding
    that prescription drug monitoring programs are not allowed to
    have data on patients receiving methadone.
        On the other hand, buprenorphine prescribed in an office-
    based setting is typically filled at the pharmacy, and
    pharmacies can submit dispensing information to the PDMPs.
        So methadone dispensing and buprenorphine dispensing are
    treated unequally when it comes to this prescription drug
    monitoring. What can the Department and Congress do to improve
    safety and health outcomes for patients while still protecting
    patient privacy?
        Mr. Azar. I am glad you mentioned that.
        I had not been aware of that issue with methadone reporting
    into the prescription drug monitoring databases. I'll be happy
    to look into that. I don't understand why that would be the
    case. These can be very important vehicles to prevent physician
    shopping as people try to abuse legal opioids. So I am happy to
    look into that.
        Mr. Guthrie. Well, thank you. I look forward to sharing
    that with you and looking forward to getting the answers.
        And I appreciate you being here. I know you've had a couple
    of long days. And I have about 50 seconds left, so I just want
    to say I actually drove to Greenbrier, and when I got there
    everything that had happened, and they were interviewing Dr.
    Burgess, and the person interviewing Dr. Burgess on the radio
    kept trying to, well, ``Wasn't there fuel--wasn't there
    whatever--essentially, did you run into a dangerous
    situation?'' Dr. Burgess kept saying--like all the others
    there, he kept saying, ``Well, I didn't think about that. I was
    just trying to help people.''
        So I've always known you to be a man of principle, and it's
    great to verify also you're a man of character. So I appreciate
    that very much, and I yield back.
        Mr. Burgess. And Dr. Bucshon as well, of course, that day.
        Mr. Guthrie. Yes--I have 14 seconds--yes, everybody. But I
    heard you specifically say that. So I appreciate it.
        Mr. Burgess. All right. If you're through praising me, I
    was going to yield you another 15 minutes.
        [Laughter.]
        Chair recognizes the gentleman from Texas, 5 minutes for
    questions.
        Mr. Green. Mr. Chairman, I'll reserve my time.
        Mr. Burgess. Gentleman reserves--the Chair recognizes the
    gentleman from New Jersey, 5 minutes for questions, please.
        Mr. Pallone. Thank you, Mr. Chairman.
        Secretary, the State of Idaho recently released guidelines
    that would eviscerate critical protections that are enshrined
    in Federal law and would potentially destabilize the health
    insurance market.
        Idaho would allow insurers to deny people with preexisting
    conditions, not cover pediatric dental or vision care, charge
    older Americans more, and exclude maternity and newborn
    coverage.
        I sent you and Administrator Verma a letter on this issue a
    few weeks ago, and I asked questions about whether these
    guidelines are in compliance with Federal law and, if not, what
    the agency planned to do to enforce the law, and I received
    what I consider an unacceptable response.
        And I quote, it says, ``At this time, the Centers for
    Medicare and Medicaid Services does not have any additional
    information to share regarding this bulletin. We are committed
    to fulfilling our obligations under the law while continuing to
    work with States to provide flexibility where possible and we
    are happy to keep you informed of any developments.''
        So Mr. Chairman, I'd like to ask unanimous consent to enter
    my letter and the response into the record, and I'll give them
    to you now.
        Mr. Burgess. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Pallone. And, again, this response is inadequate and
    nonresponsive, so I'd like to use my time today to follow up on
    some of the questions set forth in my letter, and where
    possible I'd ask you to respond yes or no because we have only
    got 3\1/2\ minutes.
        Secretary, are you aware that the Affordable Care Act
    imposes certain requirements on health insurance coverage
    offered in the individual market, including, for example,
    community ratings, coverage of preexisting conditions, and the
    inclusion of essential health benefits? That, I think, can be a
    yes or no.
        Mr. Azar. That would be a yes, I am aware.
        Mr. Pallone. All right. Thank you.
        Is it your impression that these requirements are optional
    for States or able to be waived?
        Mr. Azar. I would need to check under 1332 our waiver
    authority against each of those. I still haven't sat with the
    attorneys and learned all the parameters of what can be waived
    or what can't be waived through our waiver----
        Mr. Pallone. All right. Well, I'd ask you, if you could, to
    get back to me in writing within, like, a week or so about that
    because I don't think it would be that difficult to respond.
        Secretary, are you aware that, under Section 2761 of the
    Public Health Service Act, as Secretary of the Department you
    have a legal obligation to enforce the law and take action
    against any insurers offering noncompliant plans in the State
    of Idaho?
        Mr. Azar. So we have only--at this point, I've seen what's
    in the press reports, and I've seen what Idaho has purported to
    pass, and then just the recent news about the Blues' plan
    coming in with a plan.
        If that gets to the point where it's actually both
    finalized as well as certified by the State or not certified,
    where there is final action, we would certainly review that
    and--a searching review for compliance with the legal
    obligations that we have in our statutes.
        Mr. Pallone. I mean, I appreciate that. But, you know, in
    my opinion--and I know you don't agree with me--I think that,
    you know, these news reports are pretty clear what they are
    proposing, and I would think that, you know, if you felt--and I
    do--that they were in violation of the law, you could initiate
    and start some kind of investigation now. You wouldn't have to
    wait until, you know, you see whether they are finalized or
    not, because what my concern would be, that if we wait until
    then, you know, they might already have a negative impact on
    the public.
        But explain to the committee--I know you haven't taken any
    action against the State, you said, or any action against
    insurers who are clearly in violation. But how long would this
    take? You said, I have to wait until it's final. I mean, I am
    concerned that this--you know, that this happens and people are
    negatively impacted. You want to give me some kind of time
    line, if you could?
        Mr. Azar. Well, we are certainly not going to let anyone be
    negatively impacted by noncompliance with the law. What we are
    going to do, though, is not reach out--I just--I can't reach
    out to every press report and----
        Mr. Pallone. No, I know. But----
        Mr. Azar [continuing]. Take enforcement action based on
    information in press reports.
        Mr. Pallone. You see, my concern though----
        Mr. Azar. We are tracking it very closely, though.
        Mr. Pallone. All right. But I just would like to make sure
    that you complete an evaluation before the plans are approved
    by Idaho and sold to consumers, which I am told by the news
    report could happen as soon as April.
        So can you at least assure me that your evaluation and
    decision whether to go after them or not allow it would be made
    before they approve it and sell it to consumers?
        Mr. Azar. I cannot imagine a circumstance where we would
    not evaluate it for compliance against the law before offered
    to consumers.
        I do think it's appropriate to wait to see even if the
    State finds it in compliance with whatever their State laws
    are. I don't see why we would be reaching in and picking up
    matters out of press reports.
        Mr. Pallone. All right.
        Mr. Azar. We don't make it a habit of reviewing
    applications of States.
        Mr. Pallone. Would you at least assure me that you--would
    you at least assure me that you wouldn't allow them to go ahead
    and sell these things without doing that evaluation and
    determining?
        Mr. Azar. I fully expect that we would do so.
        Mr. Pallone. All right.
        Mr. Azar. I fully expect that would be--I can't imagine why
    we would not.
        Mr. Pallone. All right. I appreciate that.
        Thank you, Mr. Chairman.
        Mr. Burgess. Gentleman yields back. The Chair thanks the
    gentleman.
        The Chair recognizes the gentleman from Michigan, former
    chairman of the full committee and the author of the Cures for
    the 21st Century, Mr. Upton. You're recognized for 5 minutes.
        Mr. Upton. Thank you, Mr. Chairman, and welcome, Mr.
    Secretary, to our great committee.
        I do have a couple questions. The opioid crisis--and I know
    that this committee looks forward to a bipartisan series of
    bills in the next number of weeks, moving forward--for me, I
    have a district that's sort of a blend between rural and urban,
    and I just want to know what some of your thoughts are
    providing particularly technical assistance to some of those
    communities that may not have the resources even though we know
    that our more populated centers are stressed to the Nth degree
    as well.
        Mr. Azar. Thank you for asking about that.
        I am just really very--I am just gratified, excited that on
    a bipartisan basis we are able to tackle this opioid crisis and
    the $10 billion of funding appears to be in the budget
    agreement, and we have requested $3 billion of that for 2019 on
    top of $3 billion in 2018 that we are hoping will come through
    the omnibus.
        So significant funding on top of the historically high
    level of funding through 21st Century Cures that we put out in
    2017.
        We have one program in particular I wanted to call your
    attention to for more rural areas. So through HRSA in 2019 we
    would propose $150 million for rural substance abuse to
    actually help those providers in more rural areas and ensure
    there is adequate capacity there for treatment for addiction
    and dependence.
        We also would be putting $400 million into quality
    improvement payments for our community health centers--just, by
    way of example, some of the steps at the community level.
        Mr. Upton. Yes. I visited a couple of our community health
    centers, one in particular this week, and they do a really
    amazing job and, again, one of the things that's certainly been
    bipartisan as this committee has moved forward.
        I don't know if you're familiar with this fire retardant
    PFAS, which has been in the ground water and particularly in a
    lot of our military installations from years past.
        Our delegation--Michigan delegation--met formally earlier
    this week, and I know that we on a bipartisan basis are looking
    to do a letter to the appropriators asking that there may be
    funding in this omnibus appropriation bill next month for the
    Centers for Disease--a CDC study looking at how extensive that
    is. Are you very familiar with this issue?
        Mr. Azar. I am slightly familiar. Obviously, not as much as
    you are.
        I know that CDC is already working on gearing up and
    preparing for that study work in the event of appropriation.
        Mr. Upton. So, if you could help us on that, that would be
    appropriate.
        As the newly sworn-in Secretary of HHS, you are certainly
    taking a very important role--oversight role on major Federal
    and State programs.
        There have been a couple of pretty high-profile State
    budget battles not only--in particular, Illinois, which has had
    a significant disruption in payments to vendors, which led to
    hardships for some Medicaid recipients in that State.
        I am working on a proposal that, again, I think will be
    bipartisan to ensure that Medicaid beneficiaries are not
    impacted by those budget battles by ensuring that managed care
    plans can, with late payments from the State to third parties
    in order to maintain a cash flow and continue paying their
    front line providers who are, in turn, treating those Medicaid
    beneficiaries.
        I don't know if you're aware of that situation or not.
        Mr. Azar. I am not, but I'd be happy to get back to you on
    that if you could give more detail, because that's not a
    situation--I know the Illinois issues on payment in the past,
    certainly, but I hadn't heard of this particular third-party
    issue.
        Mr. Upton. Yes, they continue to--we are looking to try and
    resolve that, particularly for the companies that are in
    essence eating the--not getting paid for now years because of
    those Illinois battles.
        The last question I have is, in '05 Congress changed the
    Medicaid--excluding the prompt-pay discounts from the AMP
    calculation.
        I've introduced legislation to fix the prompt-pay loophole
    in order to treat prompt pay in Medicare the same as in
    Medicaid, and as most businesses use it as a tool to make
    markets work more efficiently. It will raise reimbursement for
    community-based physicians to help improve access in less
    expensive settings.
        Does the administration support applying that same prompt-
    pay policy in Medicare as well as in Medicaid?
        Mr. Azar. This would be in the ASP+6 methodology----
        Mr. Upton. Correct.
        Mr. Azar [continuing]. And excluding it from ASP. I don't
    know. That's a new issue to me. I have not heard about the
    question of prompt pay within ASP submissions. Again, happy to
    look at that and get back to you on that.
        Mr. Upton. Yes. I may submit a formal question and let you
    respond in the days ahead.
        With that, yield back. Thank you. Thank you, Mr. Secretary.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair recognizes the gentlelady from Illinois, Ms.
    Schakowsky, 5 minutes for questions, please.
        Ms. Schakowsky. Thank you, Mr. Chairman, and thank you,
    Secretary.
        I am very concerned about the skyrocketing costs of and the
    crushing burden of prescription drug prices. Families around
    the country are struggling to be able to pay for them, and some
    people are dying.
        Tragically, Shane Patrick Boyle and Alec Raeshawn Smith
    both died because they could not afford the jacked-up price of
    insulin during the time that Eli Lilly was under your watch and
    this occurred.
        I think it's completely unacceptable. So you acknowledged
    in your Senate Health Committee testimony and in your comments
    today to Senator Sherrod Brown that the list price is part of
    the problem.
        So what I want to know is, what is HHS going to do
    specifically to deal with the list price? I really don't want
    to hear about the other ways that you may be under control of
    the Medicaid negotiation or more generics. If there is nothing,
    you can just tell me that there's nothing. But I really want to
    know about the list price set by pharmaceutical companies.
        Mr. Azar. So the list price is a problem, and so we have in
    the budget proposal, one of the items is in Part B, the
    physician-administered drugs, to actually have an inflation
    penalty in there as we do in Medicaid, so that, if a pharma
    company increases the price above inflation, there would be a
    reduction in the reimbursement that would be offered by
    Medicare and that then flows through also to the patient, who
    pays a share of that at the point of sale or at the doctor's
    office.
        We also are looking at--we proposed five major reforms to
    the Part D program, several of which we think actually reverse
    the incentives for high list prices.
        Ms. Schakowsky. OK. Let me interrupt--let me interrupt for
    just a second.
        Again, there are sectoral ways that you might be dealing.
    So we are dealing with Medicare, dealing with Medicaid.
        But in terms of doing something for all consumers of drugs,
    is there not something that can be done about these list prices
    that--it's like, in dealing with an avalanche, we are dealing
    with the middle of the avalanche rather than the top of the
    avalanche, which is really the issue of the list price.
        Mr. Azar. Well, if--there is only one list price. So if we
    can use our influence through these Government programs and
    create incentives towards lower or flatter list prices, it
    benefits everybody.
        So that actually is what we are trying to do,
    Congresswoman.
        Ms. Schakowsky. So you're saying if, in Medicare Part D,
    that you would do that--that that would affect the list price
    for everyone, including people not in Medicare Part D?
        Mr. Azar. It creates a disincentive towards higher list
    price, and that list price is the same across the entire
    sector. There is one list price. It's called the wholesale
    acquisition cost. And so that would impact everybody and
    benefit everyone if we can do that. What we are trying to do is
    look for, and I am open to ideas you would have--how do we--
    every incentive in the system right now is towards higher list
    prices.
        Ms. Schakowsky. Exactly.
        Mr. Azar. And we create incentive towards lower or flatter
    list prices that respect--that way it respects innovation, it
    respects marketplaces, but actually make the finances in the
    market work to push down list prices.
        Ms. Schakowsky. I would hope so, because otherwise the
    least insured person is going to be the one that's going to pay
    that jacked-up price so that the pharmaceutical companies can
    continue to make their profits if we don't do it across the
    board.
        Mr. Azar. I agree with you.
        Ms. Schakowsky. So OK. I wanted to, in the time remaining--
    so last week, as the ranking member of the now-defunct select
    panel that was dealing with the issue of fetal tissue, I wrote
    to you with the other Democratic members of that panel raising
    questions about HHS Office of Civil Rights chief, Chief of
    Staff March Bell, who I--well, worked with is not quite the
    right word--who was the chief counsel to Chairman Blackburn on
    the panel.
        Mr. Bell has acknowledged working with David Delaiden, who
    was indicted for his action in creating the highly edited video
    that prompted the panel's beginning even in the first place.
        And by the way, I ask unanimous consent, Mr. Chairman, to
    submit that letter that I wrote into the record.
        Mr. Burgess. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Ms. Schakowsky. So these connections pose a serious risk
    with March Bell's new position at HHS. So I would like to know,
    yes or no, given the ethical questions surrounding Mr. Bell's
    conduct during the select panel's investigation, can you commit
    that March Bell will be recused from any case pending before
    OCR on fetal tissue or abortion services?
        Mr. Azar. We just received the letter that you sent, and I
    appreciate your raising these concerns. We will look at them
    seriously, and we will work with the career-designated agency
    ethics official and ensure that he and we follow any applicable
    Government ethics rules on recusal.
        Ms. Schakowsky. And I am happy, and I think other members
    of the panel--that were members of the panel--would be happy to
    work with you, as well. We were mistreated, and the connections
    that he had were really unacceptable.
        So I thank you, and I yield back.
        Mr. Burgess. The Chair thanks the gentlelady. The
    gentlelady yields back.
        The Chair recognizes the gentleman from Ohio, Mr. Latta, 5
    minutes for questions, please.
        Mr. Latta. Thank you, Mr. Chairman, and thank you very
    much, Mr. Secretary, for being with us today. And before I
    begin my questions, I'd like to thank your staff at FDA for all
    their hard work and collaboration on the OTC monograph reform
    work that we are doing, and I look forward to working together
    to get this important legislation across the finish line.
        As you mentioned in your testimony, one of the HHS' top
    priorities is and should be tackling the opioid epidemic, and
    you've heard from the former full committee chairman about the
    issues that opioids are having across this country.
        The misuse of opioids is taking lives of individuals far
    too soon, and the crisis is particularly horrific in Ohio. A
    recent report indicates Ohio's drug overdose deaths rose 39
    percent between mid-2016 to 2017.
        That's the third-largest increase among States. More
    importantly, that's 5,232 lives lost in a 12-month span.
        This crisis is devastating families and our communities. In
    December 2017, HHS held a symposium and code-athon to identify
    and develop data-driven solutions to the opioid epidemic.
        It is my understanding the event went well and helped to
    develop ideas that could become foundational solutions to the
    problem. It seems the event also highlighted the continued
    challenge the Federal Government has in leveraging data across
    departments and agencies, particularly within HHS, given the
    sensitivity of health data.
        Mr. Secretary, what do you need from Congress to enable
    data sharing within HHS across your own agencies and with other
    departments in a safe and secure manner that both protects
    patient privacy and facilitates innovative solutions?
        Mr. Azar. Congressman, I have not had raised to me the
    issues of any data security or data transfer issues within HHS
    among our agencies.
        So I'd love to check back with our folks and see what they
    came up with, and if there are authorities that we would need
    to enable effective transfer of information and collaboration,
    I certainly agree that we need to be doing that.
        Mr. Latta. OK. Let me go on because, again, especially in
    Ohio, as I said, this is truly an epidemic.
        Continuing with the data discussion, I have a bill, the
    Indexing Narcotics, Fentanyl, and Opioids Info Act, that seeks
    to improve how communities respond to the epidemic by putting
    information on Federal funding, efforts on prevention and
    treatment data on effective programs, and data on areas hit
    hardest by opioid abuse all in one place.
        In what ways is HHS currently working to make the data
    surrounding the epidemic more easily accessible to the public,
    and if I could just be more specific: In my district and when
    I've been across the State of Ohio, I've heard from
    departments, agencies. They have a very hard time. They don't
    have grant writers, and they are trying to get help and they
    can't find the help really out there, and they also are trying
    to find where the money is to help facilitate this.
        So it's really--does HHS have something out there right now
    that the communities and law enforcement could be looking at to
    get some help?
        Mr. Azar. So, if the concern is around sharing best
    practices, that's actually something that I've spoken with our
    SAMHSA administrator about--how we can create better vehicles
    to ensure that what we learn from one State can be taken by
    others without reinventing the wheel.
        In fact, just this week, the President and I separately
    have spoken with Governor Kasich about the work going on in
    Ohio and what best practices from there we might be able to
    take and translate out to others States as having been sitting
    in the epicenter of the opioid crisis.
        Mr. Latta. OK, because also just--you know, again, to
    follow up, though--if someone's out there looking for something
    right now that HHS might have to help them, could they out
    online and find it right now?
        Mr. Azar. I believe at the SAMHSA.gov Web site but also
    certainly just letting--calling in into SAMHSA, we would be
    very happy to point them to available resources that we have.
        Mr. Latta. OK. And because, again, I think maybe just
    follow up again because, if you could provide the specific
    steps. So if someone--you say they'd have to go to the SAMHSA
    website? And again, I want to thank HHS, because they have been
    in my district at one of our events that we had to get
    information out to the public from HHS and SAMHSA.
        But, again, what I am hearing from the people in my
    district is that they can't find the information. So, again,
    that's why I've introduced the legislation, to try to make it
    more accessible.
        You have a one-stop shop, you might say, that you can find
    this information. So I'd like to work with you all on this as
    we go forward because, again, this is what we hear from back
    home, from our departments or agencies or ADAMHS boards. But
    it's critical for them to get the help, get the information.
        Mr. Azar. Happy to work with you on that.
        Mr. Latta. Thank you.
        Mr. Chairman, I yield back.
        Mr. Burgess. Gentleman yields back. Chair thanks the
    gentleman.
        The Chair recognizes the gentlelady from California, Ms.
    Matsui, 5 minutes for questions, please.
        Ms. Matsui. Thank you, Mr. Chairman, and thank you,
    Secretary Azar, for being here today with us.
        Mr. Azar, you previously stated that one of your top goals
    as Secretary is to address the opioid epidemic. The President's
    proposed budget acknowledges the fight that States and local
    communities are waging against the crisis and proposes
    increasing some funding for prevention efforts.
        I share this goal and appreciate the additional funding,
    particularly for things like community behavioral health
    clinics.
        However, the massive cuts this budget makes to Medicaid and
    the repeal of the Affordable Care Act would undo any progress
    made and, indeed, take a step backwards in our efforts to
    provide treatment to those suffering from a substance abuse
    disorder.
        To take it a step further, the proposed budget preserves
    the CMS OPPS rule that is an attack on the 340B drug discount
    program. The purpose of this program is to allow hospitals and
    clinics to stretch scarce Federal resources to serve the
    underserved.
        So taking a piece of that away takes away critical
    resources that these providers are using for things like
    fighting the opioid epidemic on the ground in our communities.
        Giving some of those savings back to the hospitals that
    have high levels of charity care not only does not make sense
    administratively, it wrongly indicates that 340B providers are
    not already serving the vulnerable.
        That is the point. In fact, the flexibility allowed by the
    savings in the program allows hospitals to do things like open
    new clinics in rural or underserved areas. Why would we want to
    take that away?
        It seems evident that this budget is taking money from the
    very communities the Trump administration claims to want to
    help. The 340B program, a crucial player in our fight against
    opioids, does not cost a dime of taxpayers' money. It should be
    a program with strong bipartisan support. I cannot comprehend
    why it is under attack.
        As I said, this budget proposes to cut Medicaid by over
    $1.4 trillion through block grants and per capita caps. And
    yet, shoring up Medicaid and strengthening that program is
    perhaps the single best thing we can do to battle the opioid
    crisis.
        Medicaid covers 4 in 10 nonelderly adults with an opioid
    addiction and a full 80 percent of treatment for infants with
    neonatal abstinence syndrome. It is the largest insurer for
    children and a lifeline for their parents. Often, Medicaid is
    the only way those with an opioid addiction come into the
    healthcare system for treatment.
        Your rhetoric on the opioid epidemic is not matched by your
    actions. Cutting the very insurance coverage that treats these
    people for ideological reasons--the coverage that provides
    opioid abuse treatment--will not help us address the opioid
    epidemic.
        The President's budget has made it abundantly clear that
    he's not serious about this epidemic. Secretary Azar, do you
    agree that Medicaid is a critical tool in the fight against the
    opioid crisis?
        Mr. Azar. Our Medicaid program is an important tool in
    providing healthcare to many Americans, but we also have to put
    it on a stable long-term sustainable footing for it to be there
    for this and future generations.
        That's the challenge that we have, and we want to empower
    the States so that they have the right incentives to actually
    deliver quality service, and for the States the opioid crisis
    is front and center, and so they will design their programs in
    the best way possible for them to be able----
        Ms. Matsui. We understand that. However, Medicaid has been
    a success and I really truly feel that eliminating the
    Medicaid--this is really truly eliminating the Medicaid
    entitlement, for all intents and purposes, by cutting by $1.4
    trillion.
        Now, the Affordable Care Act then only expanded Medicaid to
    cover those who often had no access to employer-sponsored
    coverage. It ensured that plans offered actually cover services
    that people need, from preventive care to inpatient hospital
    care.
        Secretary Azar, do you believe in the value of preventive
    health services?
        Mr. Azar. I think we all share the goal of preventive
    health services.
        Ms. Matsui. OK. Do you believe that people are more likely
    to seek and receive preventive health services when they are
    free of charge?
        Mr. Azar. People are going to seek--if they are insured and
    they have the ability to seek out preventive services, they are
    going to more likely utilize services.
        Ms. Matsui. Right.
        Mr. Azar. Sometimes they may overutilize from free of
    charge, as opposed to having cost sharing----
        Ms. Matsui. Well, preventive care, though, is really
    important.
        Do you believe people are more likely to seek and receive
    preventive health and chronic condition management services
    when they are available locally in the community, whether in
    person or remotely?
        Mr. Azar. Well, we want to make sure that services are
    available and are accessible to people through community health
    centers, through telehealth, through alternative service
    providers. That's part of our agenda, is to make sure that
    healthcare is affordable and accessible to people.
        Ms. Matsui. So do you also believe that a person is more
    likely to seek medical treatment if they have health insurance
    than if they were uninsured?
        Mr. Azar. We all share the goal of helping to make
    insurance be affordable and accessible to individuals. The
    challenge is our current individual system under the Affordable
    Care Act is not delivering on that promise for 28 million
    Americans for whom it's unaffordable.
        Ms. Matsui. Many of the provision in this budget claim to
    provide choice to patients when really they are just allowing
    patients to once again be offered less substantial coverage and
    services.
        With that, I yield back. Thank you.
        Mr. Burgess. The Chair thanks the gentlelady. The
    gentlelady yields back.
        The Chair recognizes the gentleman from New Jersey, Mr.
    Lance, 5 minutes for questions, please.
        Mr. Lance. Thank you, Mr. Chairman, and good afternoon to
    you, Mr. Secretary. Congratulations to you on your appointment
    and your confirmation, and I look forward to working with you.
        As you are aware, the administration received additional
    resources for the FDA--I believe it was $486 million--as a
    result of the 2-year budget agreement the President has signed
    into law.
        With these new funds we understand that the FDA will
    continue to do everything possible to bring safe new therapies
    to consumers as quickly as possible such as by investing in
    continuous manufacturing research, and that is research that is
    being done in part at universities in New Jersey.
        The administration worked with this committee on the 21st
    Century Cures Act 2 years ago and took a major step toward
    facilitating the further development of this technology.
        Mr. Secretary, could you please explain to the committee
    how this new funding could advance efforts such as these?
        Mr. Azar. Absolutely. Thank you, Congressman.
        We appreciate the work of this committee through 21st
    Century Cures to reinvigorate and strengthen the FDA for the
    21st century and the funding that we got through the budget
    deal.
        This enables us actually to increase year-on-year FDA
    discretionary funding by $663 million, which allows us to put a
    huge investment to speed approval of new drugs and devices as
    well as to invest in our core quality and safety programs.
        So we are quite excited about this at FDA and think this
    will really help us with speeding access to safe, quality
    medicines for patients.
        Mr. Lance. Thank you, Mr. Secretary.
        I am pleased to see that the administration's budget
    request includes changes to Part D that will help lower costs
    to senior citizens by passing on negotiated discounts and
    rebates to beneficiaries.
        Would you please update the committee on this proposal, Mr.
    Secretary?
        Mr. Azar. Thank you so much, Congressman, for asking about
    that.
        We have a five-part proposal with the Part D drug program,
    with the idea of how do we lower out-of-pocket costs for our
    senior citizens.
        The first thing that we are requesting Congress do is
    require that the insurers pass at least one-third of the
    rebates they receive from the drug companies on to the senior
    citizen when they walk into the pharmacy at the point of sale.
        The second is to create, for the first time ever, a genuine
    out-of-pocket maximum for seniors so that, when they hit
    catastrophic coverage, they will pay nothing for their drugs.
        We would also fix an incentive in the system, where right
    now these high list prices keep pushing people to catastrophic
    coverage, where we, the Feds, are on the hook for 80 percent of
    that. We want to flip that so that the insurance companies are
    on the hook for 80 percent and we are on the hook for 20, so
    that they will push back to keep those list prices down.
        We also want to give free generics to our low-income
    seniors who are in the drug program. So free generics
    throughout for them.
        And we want to give the plans more flexibility to negotiate
    against drug companies, loosening up some of the rules that
    they have against them.
        Mr. Lance. And, Mr. Secretary, I hope that these plans
    might be put in place as quickly as possible.
        Mr. Azar. We will need to work with Congress on that. But
    this collection of efforts, including others I didn't have a
    chance to mention, could save seniors tens of billions of
    dollars in out-of-pocket savings on top of the $3.2 billion of
    savings President Trump already delivered through the Part B
    regulation that's been discussed here already, from saving out-
    of-pocket expense for seniors.
        Mr. Lance. Thank you, Mr. Secretary. I look forward to
    working with you on that issue as well as others. I have
    confidence in you based upon your distinguished career in the
    private sector and in the public sector working with President
    Bush and also your distinguished tenure with two of the best
    jurists in the history of the Nation, and I congratulate you on
    your becoming the Secretary of HHS.
        Thank you, and Mr. Chairman, I yield back the balance of my
    time.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair recognizes the gentlelady from Florida, 5 minutes
    for questions, please.
        Ms. Castor. Thank you, Chairman Burgess, and welcome, Mr.
    Secretary. I appreciate your comments at the outset of the
    hearing regarding the school shooting in Parkland, Florida.
        That's now the eighteenth school shooting in America so far
    this year, and we are here in mid-February. In America, about
    96 Americans die every day at the hands of a firearm. That
    includes domestic violence, incident suicides. More Americans
    have died from gun violence in America since 1970 than all who
    lost their lives in every war in the history of our country,
    and another completely saddening statistic is that more
    preschoolers die every year because of gun violence than police
    officers.
        So I appreciate your sentiments that we have to do more
    when it comes to mental health resources. Would you also commit
    here today that you will act in a proactive fashion to support
    new efforts for gun violence safety research at the agencies
    under your purview, including the Centers for Disease Control?
        Mr. Azar. Thank you, Congresswoman. Again, our sympathies
    to those of you from Florida.
        We believe we have got a very important mission with our
    work with serious mental illness as well as our ability to do
    research on the causes of violence and causes behind tragedies
    like this.
        So that is a priority for us, at especially at the Centers
    for Disease Control.
        Ms. Castor. So specifically on my question--you know, there
    was a rider that has been added to various appropriations bills
    over time that has had a chilling effect and, in essence, has
    acted as a ban on the Centers for Disease Control conducting
    gun violence safety prevention research just like we do with
    automobile accidents that has really ended up saving a lot of
    lives over time.
        Would you commit to that specifically, on gun violence
    prevention safety research?
        Mr. Azar. So my understanding is that the rider does not in
    any way impede our ability to conduct our research mission. It
    is simply about advocacy.
        Ms. Castor. So will you proactively speak out now, knowing
    we have had our eighteenth school shooting here? We are mid-
    February, and 96 Americans on average die a day. Will you be
    proactive on the research initiative?
        Mr. Azar. We certainly will. Our Centers for Disease
    Control and Prevention--we are in the science business and the
    evidence-generating business and----
        Ms. Castor. Thank you.
        Mr. Azar [continuing]. So I will have our agency certainly
    be working in this field as they do across the broad spectrum
    of disease control intervention.
        Ms. Castor. And we are going to hold you to it.
        And Chairman Burgess, this is an important topic for our
    committee. I wonder, would you commit to holding a hearing on
    specifically just the topic of gun violence prevention
    research? That's the purview of this committee.
        Would you commit today to holding a hearing? The Democrats
    had a hearing on our own, but we've got to work on a bipartisan
    way on this. Would you commit to holding a hearing here in the
    next few months?
        Mr. Burgess. The committee is open to all suggestions, and
    I think we've shown that track record over the past year and 2
    months.
        Ms. Castor. We haven't had a hearing on this. But thank
    you, Mr. Chairman. We will hold you to that.
        Speaking of the CDC, we are now living through a worse-
    than-expected flu season. Over the past years, we have had
    Zika, Ebola, and I am very troubled by the Trump
    administration's proposal for a $1 billion cut at the Centers
    for Disease Control. I mean, this is weakening our public
    health research, and I heard what you said--that you support
    science.
        Then why is a $1 billion cut to the CDC a good idea?
        Mr. Azar. Well, that's actually not what's happening. The
    $1 billion--most of that is the transfer of the leadership and
    supervision and budget for the strategic national stockpile--
    simply a transfer of that function to the Assistant Secretary
    for Preparedness and Response.
        And then the rest is the transfer, again, of the National
    Institute of Occupational Safety and Health to be within the
    NIH, where we believe it more accurately fits the research
    function. So----
        Ms. Castor. But then you also--you're cutting $140 million
    from chronic disease prevention and health promotion programs
    that will limit our ability to control these very chronic
    health conditions--cutting $60 million from emerging infectious
    disease programs.
        I just don't think that's wise in the days of--when we have
    had Ebola and Zika, and the CDC has such an important mission
    and prevention is so important.
        Mr. Azar. Actually, what we have done is invest the $500
    million in chronic disease and prevention through the America's
    Health block grant, $263 million through our immunization
    program, and $137 million in the emerging infectious disease
    and zoonotic disease----
        Ms. Castor. Fortunately----
        Mr. Azar [continuing]. And we regularize that now to not be
    in the prevention fund but actually move it to the
    discretionary side so it's part of our organic ongoing
    operations of the CDC that put us on a sounder footing for the
    future. I think----
        Ms. Castor. Well, I hope that's the case. We are going to
    exercise our oversight role aggressively, and fortunately, in a
    bipartisan way, we beat back significant cuts to the CDC
    proposed by the Trump administration last year, and I hope we
    will do so again.
        Thank you very much.
        Mr. Burgess. Gentlelady yields back.
        The Chair recognizes the gentleman from Indiana, Dr.
    Bucshon, 5 minutes for questions, please.
        Mr. Bucshon. Thank you, Mr. Chairman. Welcome, Mr.
    Secretary. Thank you for all the work that you will be doing
    and have done on behalf of the American people.
        In June 2015, a GAO report found that, and I quote, ``There
    is a financial incentive at hospitals participating in the 340B
    program to prescribe more drugs, prescribe more expensive drugs
    to Medicare beneficiaries.'' Again, that's a quote. That's not
    my comment--GAO report, 2015.
        A hospital is able to purchase these drugs at a significant
    discount with no requirement to pass along savings to the
    patient or Medicare.
        Do you believe that additional program requirements,
    including targeted guardrails and reporting on the use of 340B
    program savings, would help us reverse this unintended
    consequence?
        Mr. Azar. Congressman, I think that the Energy and Commerce
    Committee has done some exceptional work in looking at the 340B
    program and finding where it's not maybe meeting all of its
    purposes and where better oversight is needed.
        One of the things that we have proposed through the budget
    is actually enhanced regulatory authority and oversight
    authority for HRSA and for this important program.
        Mr. Bucshon. OK. Thank you.
        And I am also concerned about the increase in cost of
    healthcare for consumers, and I am interested in ways to
    address the problem.
        Experts and researchers, including some providing testimony
    in our oversight subcommittee hearing--just yesterday,
    actually--have expressed concern that the 340B program
    incentivizes hospital consolidation, and this consolidation can
    increase costs for patients.
        A recent New England Journal of Medicine study funded by
    HRSA and the Robert Wood Johnson Foundation found that the
    final hospital outpatient rule from CMS that would--and I am
    quoting again, ``Lower drug reimbursements to hospitals
    participating in the 340B program could slow hospital-physician
    consolidation while not adversely affecting care for low-income
    patients served by general acute hospitals.''
        How does this finding from a leading medical journal
    influence your thinking about potential new policies in 340B?
        Mr. Azar. I think it's undeniable that 340B has actually
    led to consolidations, especially hospital acquisition of
    independent physicians to be able to take advantage of the
    acquisition of drug cost or physician-administered drugs to be
    at a lower cost and have that arbitrage.
        We have seen that in the practice of oncology. So I think
    it's undeniable that that is going on. And so as we look at
    reforms in 340B to ensure that it serves its purpose of getting
    medicine as affordable as possible to low-income and uninsured
    individuals and to support those who do, we need to--we
    certainly want to examine those guardrails.
        Mr. Bucshon. Yes. I mean, I just want to say for the record
    I support the 340B program. I think it's a very important
    program.
        I have a lot of rural hospitals and other hospitals across
    the State that really need the 340B program. But I also support
    more oversight within the program, based on the Energy and
    Commerce Committee's final report that came out from our O&I
    Subcommittee oversight hearings on the program.
        I am going to make a quick comment, I mean, based on one of
    my colleagues' comments--and this is not a question to you, Mr.
    Secretary--but I want to point out that I was on the Select
    Committee for Infant Lives, and it has been discussed here
    about trying to deflect from the findings of that subcommittee.
        And I just want to say that what our Select Committee found
    and sent criminal referrals to the Department of Justice
    against, organizations that were selling human body parts for
    profit--the good news is they are not doing it anymore because
    they are completely shut down. So I just wanted to clarify that
    deflecting from the subcommittee's work and our final report,
    it doesn't change the fact that some will go to pretty long--
    well, extensive lengths to protect Planned Parenthood in
    addition to other organizations that are performing abortions
    in the United States.
        And then, so the FDA Commissioner Gottlieb has also stated
    publicly that the Congress should take action to clarify the
    regulation on LDTs--laboratory-developed tests--and
    Congresswoman Diana DeGette and I have draft legislation, and
    right now we have submitted to the FDA and CMS for technical
    assistance and we are waiting for those results.
        So I hope we can count on the full cooperation of HHS as we
    work through this process, because it's really a critical piece
    of legislation and some critical reforms.
        Mr. Azar. We will certainly be happy to continue that
    technical assistance in that very complex area of lab-developed
    tests.
        Mr. Bucshon. It is very, very complex. Again, thank you for
    your service.
        Mr. Chairman, I yield back.
        Mr. Burgess. Was the gentleman thanking the chairman for
    his service?
        Mr. Bucshon. Thanking the Secretary and the chairman, of
    course, for his service.
        Mr. Burgess. The Chair thanks the gentleman. The gentleman
    yields back. The Chair recognizes the gentleman from Maryland,
    Mr. Sarbanes, for 5 minutes.
        Mr. Sarbanes. Thank you, Mr. Chairman. I thank the
    Secretary for being here.
        I want to pick up on the first part of my time where
    Representative Castor left off in terms of research being
    conducted by your agency and by the CDC into gun violence.
        Yesterday, obviously, another community was forced to make
    sense of what is really a uniquely American tragedy, which are
    these school shootings we have seen.
        This it at least the 273rd school shooting nationwide since
    Sandy Hook occurred back in 2012. In those shootings, 439
    people have been injured, 121 people have died, and we keep
    sending our thoughts and prayers to the victimized families.
    But we really should be sending them laws that put in place
    commonsense gun safety measures.
        Members of Congress, that's our job. I mean, we provide
    thoughts and prayers. There are others who are in a better
    position to do that. Our job is to actually change the law to
    try to address these tragedies.
        I just assume--I mean, I know you had testimony yesterday,
    I think, on the Hill and earlier this morning. So you've not
    been back in the office since then.
        But I got to believe that this would--another tragedy like
    what we saw yesterday would just be an all-hands-on-deck moment
    for you and those around you, your team, to look in the agency,
    figure out how you can assemble some resources and put them
    behind some serious research into gun violence. Is that
    something that your team is undertaking now?
        Mr. Azar. Well, as you know, I am with you, so I am not
    back at the Department at the moment, so I'll have to check and
    see what's going on in terms of that.
        But with any kind of public health emergency or response
    we, of course, will update the Secretary's emergency operation
    center to ensure, for instance, with the response situation
    here, what's the hospital capacity--are we able to care for
    those who are injured--what is the census of local----
        Mr. Sarbanes. So I am going to interrupt you, because I am
    talking about a different kind of response. I get that
    response. I understand that you want to support the first
    responders that are on the ground, the hospitals that are
    taking the victims.
        I am talking about a response that says this is a public
    health crisis and our agency, which is charged with dealing
    with public health and is the Department of Health and Human
    Services, is going to have to really ramp up the kind of
    research--public health research--we do into this crisis of gun
    violence--an epidemic of gun violence across the country.
        So is that a commitment--as Representative Castor asked
    you, I am asking you again--is that a commitment that the
    agency and that you, new to the job, are prepared to commit to?
        Mr. Azar. So we will continue to look at it across our
    range. We have many public health issues and priorities that we
    have to investigate and conduct research on and what programs
    there are and studies that are available that are being worked
    on at the CDC.
        So I am happy to look into what is currently going on and
    get back to you on that. I am just not aware of--I am 14 days
    there, so I am not aware of every single research program that
    we have and every study that's being conducted at the moment.
        Mr. Sarbanes. Well, I hope you'll do that and, Mr.
    Chairman, I want to echo the request that we have some kind of
    hearing that addresses this issue of gun violence as a public
    health crisis.
        Real quickly, let me shift gears. I understand that the
    administration is looking at expanding what are called these
    short-term limited duration plans, coverage plans which, in a
    sense, are these kind of skinny junk plans where you don't have
    the same kind of protections, you can exclude coverage for
    pregnancy and childbirth if you're an insurer that offers these
    kinds of things, you can exclude coverage for mental illness or
    nervous disorders, for alcohol or drug dependence, et cetera--
    all the kinds of things we were trying to address in the
    individual market previously.
        But now there is this move on the part of the
    administration, and I assume it's going to be going through
    your office, to make these skinny plans that don't have the
    kind of coverage protections in place more widely available.
        You cannot believe that that is moving in a positive
    direction. I wanted to ask you to address that.
        Mr. Azar. Well, as you know, the short-term limited
    duration plans were supported and available during the entirety
    of the Obama administration as a vehicle available to
    individuals in transition and for whom the Affordable Care
    Act----
        Mr. Sarbanes. Right, for a short transition period.
        Mr. Azar [continuing]. The individual market for 365 days a
    year up until October of 2016.
        Mr. Sarbanes. Right. But going forward, there is a move on
    the part of the President to expand both the time frame and
    allow more of these junk coverage provisions to be in place.
        I hope that we are not going to start moving in that
    direction, because it undermines the very principles that were
    fundamental to the Affordable Care Act and providing a higher
    level of coverage.
        So I hope you'll be vigilant and make sure that those plans
    don't begin to swallow up the kind of decent coverage that
    Americans can expect across the country.
        Thank you, and I yield back.
        Mr. Burgess. Chair thanks the gentleman. The gentleman
    yields back.
        The Chair recognizes the chairman of the full committee,
    Mr. Walden of Oregon, 5 minutes for questions, please.
        Mr. Walden. I thank the chairman, and again, Mr. Secretary,
    thank you for being here.
        Our committee is spending a lot of time on the opioids
    investigation and trying to deal with this killer in our
    communities.
        I know in my State more people die from opioids overdoses
    than in traffic accidents, and I think that's pretty close to
    the case across the country. Every day, every hour, people are
    losing their lives. And so our focus has been and will be
    continue to be on the opioid epidemic.
        Prescription drug monitoring programs, or PDMPs, can be
    effective in improving the prescribing of controlled substances
    in addressing the opioid crisis. More and more PDMPs are being
    used as public health tools. However, current Federal efforts
    to support PDMPs are not well coordinated.
        However, the following programs could support PDMPs: the
    Harold Rogers PDMP program run out of the Bureau of Justice
    Assistance; National All-Schedules Prescription Electronic
    Reporting Act administered by SAMHSA but hasn't been funded
    since 2010; State demonstration grants for compressive opioid
    abuse response, which also has not been funded; CDC's Opioid
    Prevention in States grants, which provide the most supports to
    the States; are not even authorized in statute; and finally,
    the Office of the National Coordinator for Health Information
    Technology supported PDMP integration with health IT, but this
    effort only lasted from 2011 to 2013.
        So what is HHS doing to better coordinate all of these
    efforts? How can we better assist to address the needs of
    States to get timely, complete, and accurate information into
    the hands of providers and dispensers so they are able to make
    the best clinical decisions for their patients?
        What should we do in this space? What can you do in this
    space?
        Mr. Azar. So these can be--these prescription drug
    monitoring programs, these registries, can be very important
    vehicles to assist prescribers and pharmacists with knowing if
    they are dealing with a patient who is basically prescription
    shopping, physician shopping, pharmacy shopping, they've been
    shut down one place, they go somewhere else to get around the
    system.
        In our budget proposal, we actually are asking Congress to
    require that States have effective programs for this type of
    risk identification and risk mitigation for prescribers,
    pharmacists, and patients that are overutilizing,
    overprescribing, overdispensing.
        We don't specifically ask Congress to dictate the vehicle
    of it through the prescription drug monitoring programs. I am
    interested in looking more into the issue of interoperability.
        States have developed these programs already independently,
    and so there is a resource and burden question about forcing
    that interoperability to try to be nationwide. But, say, in
    Ohio, West Virginia, or Kentucky, where they are bordering and
    you could ease the abuse, I'd like to look at ways we can
    certainly encourage them to work towards connecting their
    systems up for ready interstate checking.
        Mr. Walden. I border Washington, Idaho, Nevada, and
    California with my district, and I know this is an issue I've
    heard about out there, and there is some collaboration and
    coordination. But it seems to me that part of what happens with
    people who are addicted, the desire is so high they are going
    to find every avenue that they can to satisfy it. And so it's
    something I think is really important.
        And, you know, we get a lot of questions about this
    potential allocation of money available under the CAPs to do
    work on opioids--you know, Where should it go?
        Have you have a chance to give any thought to where you
    think the money could best be spent and have the most impact?
        Mr. Azar. So, for the initial allocation that we have
    requested, which is the $3 billion in 2019, $1.24 billion of
    that would go to SAMHSA. One billion of that would go out to
    States in the State-targeted response grants, and so that's
    doubling what the 21st Century Cures funding was over the last
    2 years.
        We have got a very interesting $150 million new program for
    rural substance abuse----
        Mr. Walden. Good.
        Mr. Azar [continuing]. To really support providers in rural
    areas, a program for $150 million on infectious disease
    transmission to help with HIV/AIDS transmission, Hep C, $74
    million to help communities buy naloxone for first responders--
    --
        Mr. Walden. Good.
        Mr. Azar [continuing]. For overdose, drug court support,
    pregnant mother support, medically assisted treatment support,
    investing in all of those.
        Seven hundred and fifty million of it, we would be sending
    to NIH to support next-generation nonopioid pain treatment
    development and devices as well as the best cutting-edge
    research on other forms of pain management. CDC, FDA also would
    receive funding.
        So we have got a game plan that we already are articulating
    there.
        Mr. Walden. Excellent. Excellent.
        All right. We will look forward to working with you on
    that. Mr. Chairman, my time has expired.
        Mr. Burgess. Gentleman yields back. The Chair thanks the
    gentleman.
        The Chair recognizes the gentleman from Massachusetts, Mr.
    Kennedy, 5 minutes for questions, please.
        Mr. Kennedy. Thank you, Mr. Chairman. Mr. Secretary, thank
    you for your service. Thank you for appearing before us today.
        I've got a couple of minutes. I want to try to get through
    this quickly. My colleagues have, obviously, already touched on
    the fact that under your responsibilities resides the--or under
    your umbrella resides the Centers for Disease Control. They
    touched on the fact that 17 students went to school yesterday
    and did not come back. They've touched upon the fact that
    nearly 100 Americans die every day because of gun violence.
        No one needs reminding in this committee or otherwise that
    this is an epidemic that has infected our schools, our
    concerts--60 dead, 800 wounded just a few months ago--our
    churches.
        I received an email last night, or early this morning, from
    a 17-year-old high school student in my district, Mr.
    Secretary, that said, ``I don't think proper words can address
    my concerns. These school shootings scare me. I am scared that
    my school will be next, that my friends will be next, or that I
    will be next.
        ``I don't think it's selfish to want to be safe in school,
    is it? Not just for the victims. I imagine losing the people I
    love in an awful way like that and simply decide not to imagine
    it. There are kids who lose their best friends every day to
    this increasingly normal tragedy.''
        Something needs to happen here. Mr. Secretary, please, I
    ask you--and echoes of my colleagues here--to do everything
    that you can to make sure that a major public health crisis is
    going to be addressed under your tenure at HHS. Will you
    reiterate that pledge?
        Mr. Azar. So I will be happy to look, as I mentioned
    earlier, to look at what we have invested and if we have the
    right programs and the right level of research in this field
    and get back to you on that.
        Mr. Kennedy. Thank you, sir.
        Shifting gears a bit here onto Medicaid. There has been
    much written and said over the course of the past couple of
    months about Medicaid work requirements.
        Mr. Secretary, I am under the impression that the mission
    of your organization is to, quote, ``enhance and protect the
    health and well-being of all Americans.'' That's correct,
    right?
        Mr. Azar. Absolutely.
        Mr. Kennedy. And am I to then understand that the policy of
    this administration is that there is a direct link, a causal
    link, between working and healthier outcomes for Americans?
        Mr. Azar. We actually do believe that there is a causal
    link between those who are trained, educated, and able to
    work--for those who are able--and better health outcomes. And
    so we do believe in supporting that.
        Mr. Kennedy. Mr. Secretary, that's not the same question,
    respectfully. That somebody that is better trained, educated,
    and able to work is healthier is different than a work
    requirement makes people healthier.
        In fact, I believe a recent study put out--might have been
    today--indicates that the cost per patient in delivery of
    Medicaid in Kentucky is actually going to go up, not down, with
    the imposition of the work requirement. Have you seen that
    study?
        Mr. Azar. I have not seen that study.
        Mr. Kennedy. Oh. Well, we can submit it for the record for
    you.
        [The information appears at the conclusion of the hearing.]
        Mr. Kennedy. Shifting gears, as well, not only are there
    pieces put in place around Medicaid work requirements, there
    are disturbing reports coming out that at least five States and
    that CMS is entertaining the possibility of putting on lifetime
    caps on Medicaid.
        I want to try to understand this. Would it be the policy of
    this administration that it would be recommending that lifetime
    caps would somehow make a population healthier?
        Mr. Azar. There are requests that are coming in along those
    lines. We do not have a position on this, and I do not want to
    speculate on the ruling on a waiver. But that is not something
    that we have invited in terms of waiver requests, and so we do
    not have a position on that at this point.
        Mr. Kennedy. And I understand that the administration might
    not, and I understand that that's going through the process at
    the moment. But could you, perhaps given--I know you've only
    been there for a couple weeks, but you've got a lifetime of
    service in healthcare. You are truly--you're an expert, you
    were confirmed by the Senate, in a closely divided Senate, to
    this role. I assume you have some idea as to whether putting a
    lifetime cap on Medicaid would make a Medicaid population
    healthier.
        Mr. Azar. I understand the importance of this issue. I do
    not want to speculate without actually looking at it in the
    context of the request that we received. But we do not have a
    view that is supportive of it or against it. We need to look at
    it. I need to talk to our team as we evaluate any requests that
    come in on this--on this one.
        Mr. Kennedy. OK. Perhaps then, if I am to understand what a
    lifetime cap would actually mean, my understanding of the tax
    code is that there is in fact a taxpayer subsidy that goes to
    employer-sponsored healthcare. Is that right?
        Mr. Azar. There is, yes.
        Mr. Kennedy. And so what we are basically saying is healthy
    people can enjoy that taxpayer subsidy for their healthcare,
    but when it comes to being poor, if you get really sick, we
    could cut you off. Is that right?
        Mr. Azar. No. Again, I don't--I have not reviewed any of
    these waivers or requests that some States appear to be making,
    so I couldn't even speak to what they are asking for at this
    point. This is quite fresh.
        Mr. Kennedy. Well, there is public reports from The Hill
    and from the Washington Post indicating that five States are
    putting that forward. It might be going through your process,
    but I am trying to get some guidance as to whether the position
    of this administration is going to be that if you are healthy,
    you can get taxpayer subsidies, but if you are poor and sick,
    you don't.
        Mr. Azar. I don't make it a practice to rule on very
    serious matters based on what's in The Hill.
        Mr. Kennedy. Fair enough. Yield back.
        Mr. Burgess. Chair thanks the gentleman. The gentleman
    yields back.
        The Chair recognizes the gentleman from Oklahoma, Mr.
    Mullin, 5 minutes for questions, please.
        Mr. Mullin. I appreciate, Mr. Secretary, you not making
    decisions based on The Hill information, although some of it is
    quite entertaining.
        Mr. Secretary, thank you so much for being here. Mr.
    Chairman, thank you for allowing me to ask some questions. I am
    going to get right into it.
        Mr. Secretary, I was happy to see that HHS is setting aside
    $10 billion for the opioid and serious mental health issues.
    But I was surprised to see there was no mention about amending
    the CFR 42 Part 2.
        The President's opioid commissioner and former CDC
    administrator both believe that we need to amend Part 2. I was
    kind of getting your position. Have you looked at Part 2 to see
    what your thoughts are on----
        Mr. Azar. I apologize. Could you help educate me what Part
    2 is? That's not a provision I am familiar with.
        Mr. Mullin. Well, so----
        Mr. Azar. The substance of it--I don't know the substance.
        Mr. Mullin. Well, we have a bill right now, H.R. 3545, that
    I'll be happy to work with you on this if you want to. We'd
    love to educate your office on it. We have literally 4 minutes
    here, and I don't think I could go through Part 2 enough to get
    to it.
        But this is something that I have taken on that has been
    extremely important to me so I appreciate your honest answer on
    that. If you would like to have your office contact us. You
    guys are shaking your head. Right on. I appreciate that.
        Because we have--we feel like we have a fix for this in our
    office. So if you'll just meet with us. The bill is H.R. 3545.
        Mr. Azar. OK.
        Mr. Mullin. And we have had a hearing on it before in here.
    But I understand you've only been there two or three weeks,
    so--and by the way, I really do appreciate the time. You get
    confirmed and then all of a sudden it goes, ``Wow, what did I
    get myself into,'' right?
        One more thing I want to get into, I also chair the Indian
    Health Service Task Force, which is very important to me, being
    Cherokee. The opioid epidemic has unproportionately hit Native
    Americans.
        I have the privilege of representing District 2 of
    Oklahoma, which has the highest Native American population in
    the country, and opioid is wrecking our State and many people's
    States. And we are working extremely hard to try to figure out
    how we can put, as I say, the genie back in the bottle.
        You know, why we keep sending controlled substance that are
    highly addictive home is beyond me. That's beside the point.
    But I really do want to work with you on it.
        But yesterday, I think my colleague and a member of the
    task force, Kristi Noem, asked you about your plan to deal with
    the agencies and with IHS.
        You said that you had prioritized it and provided more
    money than the President's budget, and this was good to hear.
    But I wanted to know if you had any specifics that you could
    lead me down the road on that.
        Mr. Azar. So as I mentioned yesterday, in the President's
    budget with regard to--there are certain facilities that are
    having trouble with quality and certification from CMS and
    being able to perform.
        Most are Great Plains. We have got one Navajo. I don't know
    if there is one--I don't remember if there is one in Oklahoma
    that's been decertified also. I don't think so.
        Mr. Mullin. No.
        Mr. Azar. And so we have got $58 million that we are
    proposing to invest in assisting these facilities and achieving
    their certification, retaining it, and maintaining quality
    service for the people that we serve.
        Like I say, we put $413 million additional dollars in
    increase for IHS in the budget as well as another $100 million
    for IHS around the opioid crisis as part of that $10 billion
    funding in 2019.
        Mr. Mullin. Our task force is a very bipartisan task force,
    and we have left politics completely out of it. One thing we
    have noticed is there is very little standing operating
    procedures and there is very little communication between one
    clinic to the next.
        There is a drastic difference between the Great Plains and,
    say, in Oklahoma where we have maybe a little bit more funding
    to be able to put into our Indian clinics. I personally am a
    product of that. I grew up in Hastings Hospital and went there
    many, many, many, many times, and I found their service being
    very adequate--very adequate. My kids still use it.
        But we do understand there is a difference, and what I
    would like to do is work with your team. We would love to be
    able to maybe set something, where we meet you in South Dakota
    and see what's happening there and the lack of service that is
    given, and then also show you what's happening in Oklahoma when
    the Tribes invest in their own back yards and be able to work
    with you on coming up with standard operating procedures where
    we can draw the line and have the same quality of care no
    matter where you go inside the IHS system and where they can
    access records and quality doctors and quality healthcare.
        This is something our task force has taken on as very
    important to us, and if you would have your office reach out to
    us, we want to work with you on this. We want to get this
    solved.
        Mr. Azar. As do we. So we are open for any suggestions how
    we can improve the performance of IHS in delivering quality,
    safe services for our beneficiaries.
        Mr. Mullin. We'd love to meet you up there, too, and show
    you firsthand what's happening.
        Mr. Chairman, I am sorry. I went over. I'll yield back.
    Thank you.
        Mr. Burgess. The Chair forgives the gentleman. The
    gentleman yields back.
        The Chair recognizes the gentlelady from Colorado, 5
    minutes for questions, please.
        Ms. DeGette. Thank you so much, Mr. Chairman. Welcome, Mr.
    Secretary.
        The Washington Post is reporting today that HHS employees
    threatened to cut Federal funding from the Vera Institute of
    Justice if the organization's lawyers communicated with their
    clients about their abortion rights.
        Now, as a lawyer myself, this seems like an unacceptable
    intrusion into the attorney-client relationship to me. I am
    wondering, Mr. Secretary, did your staff instruct lawyers at
    the Vera Institute or any other organization not to discuss
    abortion rights with their clients?
        Mr. Azar. Congresswoman, I actually--I did not see that
    story. It's the first I am hearing it.
        Ms. DeGette. Well, OK. I am not asking you about the story.
    I am asking you, did your staff instruct the lawyers----
        Mr. Azar. It's the first I am even hearing of the issue. I
    have not heard anything about this.
        Ms. DeGette. So you don't even--you don't know. Would you
    think that would be appropriate, if they did instruct lawyers
    not to advise their clients of those rights?
        Mr. Azar. So I would like to go back and look into this and
    see. That's a serious claim----
        Ms. DeGette. So you're not going to answer my--you don't
    know if it would be appropriate or not?
        Mr. Azar. Again, I don't want to answer hypothetical
    questions without looking into the facts of the situation.
        Ms. DeGette. OK. Well, let me ask you this.
        There is something that's been around quite a while at HHS,
    and that is that there has been a pattern of conduct about the
    Office of Refugee Resettlement under Director Scott Lloyd's
    leadership, in particular, to disregard the rules in Federal
    law when it comes to women's reproductive rights and health.
        Let me talk to you about a couple things. As well as this
    report today, we also found out that Mr. Lloyd has attempted to
    deny access to abortion to at least four immigrant teens in
    detention, including one who was a victim of rape.
        Now, in each of these four cases, the Federal courts
    declared Director Lloyd's actions unlawful and allowed the
    girls to access their reproductive healthcare.
        Are you aware of those four cases, sir? Yes or no will
    work.
        Mr. Azar. I am aware of media reports about them.
        Ms. DeGette. Well, you're----
        Mr. Azar. I've just been at HHS for 14 days, so I haven't--
    --
        Ms. DeGette. Yes. Yes, you have. So you're not aware within
    the agency?
        OK. Well, I sent a letter to the agency--and you were not
    there then, in fairness to you--it was dated December 1st--with
    some other folks asking that Mr. Lloyd end these unlawful ORR
    policies denying reproductive healthcare to immigrant women and
    girls in detention.
        We have not yet received a response to this letter. Can you
    commit to me that we will get a response to this letter?
        Mr. Azar. Yes, we will certainly respond to your letter.
        Ms. DeGette. OK. And Mr. Chairman, I'd ask unanimous
    consent to put the letter into the record.
        Mr. Burgess. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Ms. DeGette. Now, Mr. Lloyd, as Secretary of HHS, you have
    the authority to stop Mr. Lloyd and his staff from advising
    people they can't tell people about their constitutional
    rights.
        Will you commit to me today that you will ask him to please
    stop doing that?
        Mr. Azar. So we have with regard to these children who come
    into our custody a very important statutory obligation, which
    is to look out for the health and welfare of them as well as
    their unborn children, and it is a solemn obligation. It is a
    difficult obligation----
        Ms. DeGette. Well, excuse me.
        Mr. Azar [continuing]. And it is now a matter of pending
    litigation, and I really can't--I do not know the facts of the
    situation nor could I comment, because these are pending
    matters in litigation.
        Ms. DeGette. OK. Well, good news. Four courts have already
    said that your Department can't stop them from getting
    abortions. Are you contesting those court decisions?
        Mr. Azar. I am not aware of the status on the litigation.
    I've been at the Department for 14 days.
        Ms. DeGette. OK. Is it the--let me----
        Mr. Azar. I will not comment on potentially pending
    litigation.
        Ms. DeGette. OK.
        Mr. Azar. It would be irresponsible for me as Secretary. I
    am the named party in the litigation.
        Ms. DeGette. Well, let me--then--excuse me, sir. Perhaps
    you can comment on HHS policy for me, then. Is it the policy of
    HHS to tell your contractors that they are not allowed to
    discuss abortion rights with their clients? Yes or no.
        Mr. Azar. As I told you, I am not aware of any policy
    either way----
        Ms. DeGette. No, no. OK.
        Mr. Azar [continuing]. Or the facts of that situation.
        Ms. DeGette. Well, you're the head guy. Would you support
    that kind of a policy?
        Mr. Azar. I am not aware of the facts of that situation,
    nor can I sit here and off of the cuff state a policy position
    for the Department.
        Ms. DeGette. If an employee of HHS told the Vera Institute
    that their Federal grant would be withdrawn if they advised
    their clients of their rights, would you support withdrawing
    it?
        Mr. Azar. I am going to repeat that I--it was irresponsible
    of me to sit here and on the basis of a supposition of facts
    articulate a policy position----
        Ms. DeGette. OK. But----
        Mr. Azar [continuing]. Without investigating and looking
    into it.
        Ms. DeGette. OK. Great.
        Mr. Azar. You would not expect me to do otherwise.
        Ms. DeGette. OK. Great. So will you commit----
        Mr. Azar. I need to be a responsible officer.
        Ms. DeGette. Excuse me. Will you commit to me that you will
    investigate and look into it?
        Mr. Azar. I will. I already mentioned----
        Ms. DeGette. And will you also commit to me that you will
    get me an answer back in writing within 30 days of this
    hearing?
        Mr. Azar. I will not be able to commit on the time line
    there because I do not know the nature of the investigation,
    the facts, or whether it connects to matters of litigation.
        Ms. DeGette. When do you think it would be appropriate to
    get back to me?
        Mr. Azar. I will not be able to commit on a date until I
    know the circumstances here and know whether it connects to a
    matter of litigation, because this may be a matter that the
    Justice Department would decide. I don't want to make a false
    commitment to you on getting back to you by a date certain on
    something that might be----
        Ms. DeGette. Will you get back to me?
        Mr. Azar. We certainly will, yes.
        Ms. DeGette. Great. Thank you.
        Mr. Burgess. Gentlelady's time has expired. The Chair
    thanks the gentlelady.
        The Chair recognizes the gentleman from Virginia, Mr.
    Griffith, 5 minutes for questions.
        Mr. Griffith. Thank you very much, Mr. Chair, and I
    appreciate your responses to the previous questions,
    particularly that you'll get back with some information but not
    a specific answer based on the legalities of everything.
        That being said, I also appreciate your answers previously
    in relationship to the opioid crisis, which is important to so
    many of us, and I think that my colleagues have covered that
    extensively, so I am going to move on to some other things. But
    appreciate working with you on that in the future.
        I've got a number of things that I am passionate about and
    that affect my district. One is I have a very rural district in
    the southwest corner of Virginia, and I want to ask you about
    telehealth because it seems me that we have some issues there
    with reimbursement.
        And if the doctor is willing to conduct a telehealth
    consult, I believe they should not be prevented or discouraged
    from providing the service because of outdated reimbursement
    policies, and I would like to work with you and HHS to help
    find ways to alleviate reimbursement challenges that are in the
    way of telehealth exploding and bringing medicine to the nooks
    and crannies of every part of America.
        So what policies are you all working on to facilitate the
    delivery of telehealth, and what policies do we need to
    change--and I know you may not have an answer after only 2
    weeks--but please let us know what do we need to change to help
    you all allow reimbursement for telehealth services so the
    people can get services all over the country and all--
    predominantly rural areas, but I can see applications in other
    areas, as well.
        Mr. Azar. Thank you for raising that issue. I am a big
    supporter of telehealth and how we can harness that, especially
    for underserved areas like our rural communities.
        I do suspect there are significant statutory barriers
    around reimbursement there, given that most of our constructs
    were set up in the 1960s for our payment regimes.
        So we'd love to work with you on that as I go back and we
    plow through and identify those barriers to see where we might
    be able to make changes.
        I believe in the budget we have one provision that we are
    recommending regarding Medicare Advantage plans, I think, and
    supporting greater payment flexibility around telehealth. But I
    am sure there are many, many more. But I am a big believer in
    the opportunities that we have there.
        Mr. Griffith. I don't think it's a partisan issue. I think
    you'd find support on both sides of the aisle to change the
    laws that are keeping you all from doing things that we all
    want you to do--so I appreciate that--in relationship to
    telehealth.
        Let's talk about neonatal abstinence syndrome. I am
    encouraged to see that CMS used State plan authority as it did
    in the case of West Virginia this week with respect to the
    State's request to allow its Medicaid program to reimburse
    certain treatment centers that take care of infants with
    neonatal abstinence syndrome.
        This move suggests that CMS and the States can work
    together to address the distinct needs of each State. If my
    home State of Virginia or my neighboring State of Tennessee or
    other States should choose to follow suit and request coverage
    of similar services through a State plan amendment or waiver,
    may I get your commitment that your staff at HHS and CMS will
    work swiftly to allow such a waiver so that we can ensure
    infants with NAS in Medicaid get the care that they need?
        Mr. Azar. I don't know the particulars on that approval,
    but we certainly will work with any State that is going to be
    delivering care in that area within the confines of our waiver
    and demonstration authority, and we will do that as swiftly as
    we possibly can. That seems quite noble.
        Mr. Griffith. All right. Now here's one more I am going to
    push you on: durable medical equipment. I know that there have
    been some issues. But for rural areas the competitive bid
    reimbursement adjustment has been deadly for durable medical
    equipment suppliers.
        Folks are having--I've got one fellow in particular. He's
    driving through, you know, up and down mountains to deliver
    oxygen, et cetera, to people that he considers friends and
    clients.
        He keeps having to lay people off just to make ends meet.
    So I ask you, there is an interim final rule that's pending at
    OMB. I've spoken with OMB and Mr. Mulvaney about that. Will you
    commit to working with Director Mulvaney to ensure this IFR is
    released expeditiously? It's currently sitting in your hands.
        Mr. Azar. So I can't speak to that particular IFR or that
    issue because I do believe that's a matter pending in
    litigation, but I will tell you our budget--I am very concerned
    about the issue of DME--the competitive DME and rural access,
    and our budget proposal actually has some I think very
    important reforms and suggestions for rural access there.
        Mr. Griffith. And I appreciate that, because I will tell
    you that it won't be a whole lot of months before he just has
    to completely shut down his operation and then I will have
    constituents who are no longer being served because, you know,
    when you're a long way from the nearest town, it's hard to
    drive down there and get your own equipment and drive it back
    up the mountain.
        Mr. Walden. Would the gentleman yield a second?
        Mr. Griffith. I yield.
        Mr. Walden. Yes, I just want to double down on that,
    because I am finding the same thing in rural parts of my
    district, where all of a sudden in Burns, Oregon, a long way
    away, getting access to DME, durable medical equipment, is a
    real problem.
        Oxygen is becoming a real problem, and this is something
    that I hope the administration will act on expeditiously, as
    well. So I am glad you raised that.
        Mr. Griffith. Thank you very much, Mr. Chairman.
        Mr. Chairman, I yield back.
        Mr. Burgess. Chair thanks the gentleman. Gentleman yields
    back.
        The Chair recognizes the gentleman from Oregon, Dr.
    Schrader, 5 minutes for questions, please.
        Mr. Schrader. Thank you very much, Mr. Chairman, and thank
    you, Mr. Secretary, for being here.
        You talked in your testimony about the need to improve the
    individual and small group markets, and I think, frankly, I am
    one of the folks, along with many others, both sides of the
    aisle that believes that's true.
        But very concerned that in the President's budget, it
    proposes actually repealing more of the Affordable Care Act,
    which would cause millions to lose coverage, and this is
    despite the fact that we had this big debate last year and
    Congress, who is the lawmaking body, decided not to move
    forward along those lines.
        I don't think Americans want to see their health coverage
    go away. I think they want to see us come together and
    strengthen and improve that individual marketplace, which is
    bleeding over to the small group.
        I am with a group of bipartisan Members, several of which
    serve on this committee, called the Problem Solvers, that has a
    bipartisan proposal--about 25 of us--that have supported this.
        We have legislation that's introduced. It includes the CSRs
    that were included in both the Republican and Democratic
    budgets. Talks about a stability fund that was in Republican as
    well as Democratic proposals. It gives the flexibility you
    alluded to to States, both in the 1332 and 1333 waivers. Rolls
    back some of the employer mandate and gets rid of the medical
    device tax.
        Would your administration and you personally be interested
    in promoting that type of proposal to solve the problem?
        Mr. Azar. So, obviously, we have our budget proposal, which
    is the broader Graham-Cassidy package, but I am also very happy
    to work with you and learn more about these ideas that you've
    got.
        Our commitment is, we want to make insurance affordable for
    people in the individual markets.
        Mr. Schrader. Thank you. Thank you. Well, I appreciate
    that, because we would like to work with you or the
    administration, come up with just a commonsense proposal to fix
    what needs to be fixed at this point in time so Americans have
    healthcare.
        Under the current budget there are huge cuts to Medicaid
    and the marketplace. Could you give us some idea of the numbers
    of folks that are going to lose coverage as a result of the
    proposals you've put forward?
        Mr. Azar. So I don't have a score that does any estimating
    on that. What we would do is----
        Mr. Schrader. If I may interrupt. I am sorry. I have only
    limited time. I apologize.
        The CBO does have a score, and they've indicated repeatedly
    that 23 million Americans would lose coverage if the Affordable
    Care Act is repealed in its entirety.
        Unfortunately, we have already gone through a measure of
    that with the current tax cut bill that came out. Very, very
    concerned that if we double down on that, that would be not
    good for Americans, and hope that as Health Secretary the goal
    would be to get people more healthcare, not less healthcare.
        Last piece, if I may--getting back to the proposals coming
    out of the great State of Idaho. I respect everyone's
    sovereignty, but I think the goal of the Affordable Care Act
    isn't just to treat conditions and people as they walk in the
    door but to make a better healthcare system, to make people
    healthier so that they don't have to walk through that hospital
    door quite as often.
        And I guess my question to you is, Would you and this
    administration enforce all the essential health benefits that
    are currently a requirement of the Affordable Care Act, given
    that that is the law of the land at this point in time,
    including prescription health benefits, mental health benefits,
    maternity, emergency care, ambulatory care, laboratory
    services, prevention and wellness, pediatric care,
    hospitalization, and rehabilitation?
        Mr. Azar. So we certainly have a duty to enforce the laws
    Congress has written and passed and within any flexibilities,
    of course, that we have under waiver and other authorities.
    But, obviously, we have to be committed to enforcing the laws
    that Congress have given us.
        Mr. Schrader. All right. I appreciate that very much, Mr.
    Secretary, and look forward to working with you.
        Mr. Azar. Thank you. Same here.
        Mr. Schrader. Thank you, and I yield back, Mr. Chairman.
        Mr. Burgess. Chair thanks the gentleman. The gentleman
    yields back.
        The Chair recognizes the gentleman from Florida, Mr.
    Carter.
        Mr. Carter. Well, thank you, Mr. Secretary. Congratulations
    and thank you for being here today. We appreciate your
    presence.
        I want to start by asking you about DIR fees. Are you
    familiar with DIR fees?
        Mr. Azar. You know, I am somewhat. Are we talking in the
    context of the specialty pharmacy issues?
        Mr. Carter. No, not necessarily in a specialty pharmacy.
    This would be in any pharmacy. These are--these are generally
    just the fees that are price concessions, or maybe even just
    fees that are imposed by the pharmacy, by the PBMs, and that
    are recouped sometimes years later, years after the
    prescription has been dispensed.
        And, obviously, the patients are not getting the benefit of
    this, and therefore it is costing taxpayers more money because
    in Plan D, as you well know, the higher the drug and the higher
    the cost to the patient, it's going to push them into the donut
    hole and then ultimately into the catastrophic part where the
    taxpayers will be taking up more of those costs.
        I've led several letters to your Department, to CMS,
    regarding this. I hope that you will look at this closely. One
    of my colleagues, Congressman Griffith, on this committee has a
    bill right now making it to where DIR fees would have to be
    recouped at the point of sale and could not be recouped years
    later.
        So I hope you'll look at that very closely. I want to ask
    you next about abuse deterrent formulations. Are you familiar
    with that and how it could be used in the way of opioids?
        Mr. Azar. I am somewhat. I am sure not as deeply as you are
    with your clinical background.
        Mr. Carter. OK. OK.
        Well, I hope that you will look at that. I think that is
    something that could benefit us and certainly, in our fight
    against the opioid, something I know you're committed to and
    certainly that we are committed to.
        If I may, if you could just hang with me for a second. You
    were the CEO of Lilly Manufacturing and Lilly Pharmaceuticals.
        Mr. Azar. I was just the president of the----
        Mr. Carter. Just the president.
        Mr. Azar [continuing]. Commercial business in the United
    States.
        Mr. Carter. But you understand how PBMs work, and you
    understand that whole scenario. As a practicing pharmacist for
    over 30 years, I too understand that. And I am just curious.
        Let's just take a product that Lilly may have had. Let's
    take Prozac or Zyprexa, and both of those are available now in
    generic formulations. But if you wanted to--let's take Prozac,
    for instance--if you wanted to get Prozac onto a formulary, as
    the pharmaceutical manufacturer did you have to offer the
    company, the pharmacy benefit manager who was compiling that--
    compiling that formulary--did you have to offer them a rebate
    in order to get it back?
        Mr. Azar. So if I could address this generally.
        Mr. Carter. Please do.
        Mr. Azar. I would not want to speak in the context of my
    former employer.
        Mr. Carter. I understand.
        Mr. Azar. But yes, generally, almost all brand of products
    will have to offer rebates to pharmacy benefit managers in
    order to secure equal or preferred status on a formulary.
    Otherwise, they will be disadvantaged or ever not covered by
    that PBM in terms of the benefit package. So that's quite
    standard.
        Mr. Carter. Yes, and I just want to----
        Mr. Azar. It would be the more unusual case where there
    isn't a rebate that's being paid.
        Mr. Carter. I've always wondered: Where does that rebate
    go? Do you know?
        Mr. Azar. Where does the rebate go?
        Mr. Carter. Yes, sir.
        Mr. Azar. So I am certain----
        Mr. Carter. I do know one place it does not go. It does not
    go to the pharmacist. I can assure you of that.
        Mr. Azar. I believe some of it, obviously, goes into the
    premium and buying that down. Depending on the PBM's business
    model, some may be retained by the pharmacy benefit manager as
    their profit or to cover their expenses. Some may be passed on
    in lower premiums. I think it would depend on each individual
    PBM how that works.
        Mr. Carter. But you would agree that that rebate is
    significant?
        Mr. Azar. It can be quite significant. Average commercial
    rebates approximate about 35 percent.
        Mr. Carter. Just out of curiosity, you know, if that
    rebate--it's not going to the patient, and it's not going to
    the pharmacy. The pharmaceutical manufacturer is paying it to
    the PBM.
        You know, I am not opposed to anybody making money. But the
    mission of a PBM is to control drug prices. If they are
    controlling drug prices, why is one of the President's
    initiatives to bring drug prices down?
        Mr. Azar. Why is it? The President wants----
        Mr. Carter. If the PBMs are doing their job, if they are
    indeed controlling drug prices, why did the President identify
    a drug price? Why have all these people on this committee here
    today asked you about prescription drug prices? Why is that one
    of the primary issues that we discuss up here?
        Mr. Azar. It's actually--so, first, there are pockets of
    our programs where we don't get as good of a deal as we ought
    to and can do, and that's what we are working on.
        Mr. Carter. But I am speaking specifically to the--I don't
    mean to interrupt.
        Mr. Azar. No, no. And I think it really has to do with list
    prices. Every incentive in our system is towards higher list
    prices.
        Mr. Carter. If I may, I just remind you that there are
    three PBMs that control 80 percent of the market and that one
    of the PBMs, Caremark, had gross revenues in 2016 that exceeded
    that of Pfizer Pharmaceuticals, of Ford Motor Company, and of
    McDonald's combined.
        Mr. Secretary, we got to do something about this. We need
    transparency. Sunlight is the best disinfectant out there. We
    have to have transparency.
        I can't see this in the Plan B. You won't let me see it. We
    need transparency.
        Thank you, Mr. Secretary.
        Mr. Azar. And we do support efforts towards greater
    transparency.
        Mr. Carter. I know you do, and I look forward to working
    with you. Thank you very much.
        Mr. Burgess. Gentleman's time has expired.
        The Chair recognizes the gentleman from New Mexico, Mr.
    Lujan, 5 minutes for questions.
        Mr. Lujan. Mr. Chairman, thank you very much.
        Mr. Secretary, thank you for being here today, as well.
        Mr. Secretary, I am going to ask you a yes-or-no question
    off the top here. There is $1.4 trillion less in the budget for
    the Medicaid program, yes or no?
        Mr. Azar. There is a $1.2 trillion new fund that would
    replace the Medicaid expansion and the individual subsidy
    program under the Affordable Care Act.
        Mr. Lujan. You're talking about Graham-Cassidy?
        Mr. Azar. Yes. Exactly.
        Mr. Lujan. So would you agree with the CBO's score--that
    the CBO said at the very least that Graham-Cassidy reduces
    Medicaid by $1 trillion? Are you unaware of that?
        Mr. Azar. I don't know the net score on this. You've got
    the $1.4 trillion that would come down, but the 1.2 that would
    actually replace it through the grant program there. So I don't
    know the ups and downs on the complete CBO scoring with regard
    to which part is expansion and where the subsidy--the
    advanceable, refundable tax credits fit into there.
        Mr. Lujan. So, Mr. Secretary, I mean, there can be a lot of
    spin around this, in the same way that during the repeal-and-
    replace effort my Republican colleagues said that they were not
    cutting Medicaid--that they were giving more flexibility to the
    States. Is that how you would describe the $1.2 trillion that
    you're describing here?
        Mr. Azar. Well, no. The core Medicaid program--the old--the
    traditional Medicaid will grow under our budget from about $400
    billion over 10 years to $453 billion.
        The Medicaid expansion does get rescinded as part of the
    Graham-Cassidy plan and is replaced along with the individual
    subsidy program with that $1.2 trillion grant program.
        Mr. Lujan. Let me ask the question a different way.
    President Trump, on several occasions, said that he would not
    cut Social Security, not cut Medicare, not cut Medicaid.
        May 7th, 2015, 10:40 a.m., he tweets, ``I was the first and
    only potential GOP candidate to state there will be no cuts to
    Social Security, Medicare, and Medicaid.''
        July 11th, 2015, 3:23 a.m., ``Republicans who want to cut
    Social Security and Medicaid are wrong.''
        A quote to Daily Signal: ``I am not going to cut Social
    Security like every other Republican. I am not going to cut
    Medicare or Medicaid.''
        Did the President keep his word in his budget?
        Mr. Azar. You know, with regard to----
        Mr. Lujan. Yes or no, Mr. Secretary. Did he keep his word?
        Mr. Azar. Well, with regard--with regard to Medicare----
        Mr. Lujan. Mr. Secretary----
        Mr. Azar [continuing]. What we are proposing there is to
    actually reduce by $250 billion over 10. The rate of growth
    goes from 9.1 percent annual increases to 8.5 percent. It
    doesn't take from beneficiaries. It actually continues to grow.
        Mr. Lujan. Mr. Secretary, did the President keep his word
    that he would not cut Medicare, Medicaid, and Social Security
    in his budget?
        Mr. Azar. I can't speak to Social Security, and then as to
    the core fundamental----
        Mr. Lujan. Mr. Secretary, let me ask you the question
    differently then. Did the President keep his word that he would
    not cut Medicaid and Medicare?
        Mr. Azar. The President kept his word that we are not
    taking from beneficiaries in Medicare, and for Medicaid the
    President----
        Mr. Lujan. Will the President--Mr.----
        Mr. Azar [continuing]. Has repeatedly been supportive of
    repealing and replacing Obamacare, and Medicaid expansion is
    part of that. He was clear from day one in his campaign about
    that.
        Mr. Lujan. Mr. Secretary, he didn't mention beneficiaries
    here. He said he would not cut Medicare and Medicaid and Social
    Security. He would not ``cut Social Security and Medicare and
    Medicaid like every other Republican.''
        Did the President keep his word that he did not cut
    Medicare and Medicaid?
        Mr. Azar. The President is keeping his word that we are
    supporting Medicare. We are making Medicaid sustainable for the
    long term for beneficiaries, and we are proposing the repeal-
    and-replace of Obamacare, which is not delivering for our
    people.
        Mr. Lujan. Mr. Secretary, did you have a hand in developing
    this budget?
        Mr. Azar. I arrived 14 days ago. So no, I did not.
        Mr. Lujan. You didn't approve what was submitted?
        Mr. Azar. The budget was already at the printer. If the
    Senate would have confirmed me sooner, I would have been able
    to be involved but----
        Mr. Lujan. Let me ask a question.
        Mr. Azar [continuing]. I arrived 14 days ago after----
        Mr. Lujan. Let me ask you a different----
        Mr. Azar. I can only do what I can do.
        Mr. Lujan. Let me ask you a different question: Do you
    support the President's budget?
        Mr. Azar. I do support the President's budget. That's why I
    am here today.
        Mr. Lujan. Did you keep your word that you would enforce
    not cutting Medicaid and Medicare as you answered to Senator
    Ben Nelson on the January 24th, 2018, Senate Finance
    Committee----
        Mr. Azar. I never said that I would enforce not cutting. I
    said the President----
        Mr. Lujan. Oh.
        Mr. Azar [continuing]. The President does not support----
        Mr. Lujan. Mr. Secretary----
        Mr. Azar [continuing]. Cutting Medicare and Medicaid.
        Mr. Lujan [continuing]. Let me read you a quote.
        Mr. Azar. And I support the President's position. I will go
    along with where the President is on these programs.
        Mr. Lujan. Mr. Secretary, if I may, there is a great video
    that's posted. I think C-SPAN has it, CNN has it. And here's
    what you said when Senator Nelson asked if cutting Medicaid,
    Medicare, and Social Security should be used to fill this huge
    budget deficit hole. You believe the President kept his word,
    and your job as Secretary would be to enforce, not to cut those
    programs. So I'll stand by that.
        Mr. Azar. As long as that is the President's----
        Mr. Lujan. Mr. Secretary----
        Mr. Azar [continuing]. I am here to implement Medicare and
    Medicaid----
        Mr. Lujan. Last question, if I may, because I am out of
    time here. Have you collected a check from Dr. Price for his
    travel on private planes?
        Mr. Azar. I do not know.
        Mr. Lujan. Have you investigated abuses at HHS with travel?
        Mr. Azar. I've just arrived 14 days ago, so I've been busy
    getting ready to come here to meet with you today.
        Mr. Lujan. Mr. Chairman, as my time is expired here, I know
    that we have talked about oversight hearings in this
    subcommittee on this issue. They still have not been scheduled.
        I look forward to seeing those scheduled so we could get to
    the bottom of this, and I'll be submitting more questions to
    the record to find out what's been investigated. This is a
    serious issue. Millions of dollars have been squandered, and
    the American taxpayers deserve----
        Mr. Burgess. The gentleman's time has expired.
        Mr. Lujan. Thank you, Mr. Chairman.
        Mr. Burgess. I am certain that Mr. Guthrie will--I mean,
    Mr. Harper from Mississippi will await your letter.
        The Chair now recognizes the gentleman from Florida, Mr.
    Bilirakis.
        Mr. Bilirakis. Thank you. Thank you, Mr. Chairman. I
    appreciate it, and thank you, Mr. Secretary, for being here. I
    appreciate it very much. Thanks for your service.
        I am on also--in addition to being on this great committee
    and this subcommittee, I am also vice chairman of the Veterans
    Affairs Committee.
        This gives me a unique opportunity to serve the health
    needs of various populations. Community health centers--and I
    was the author of the reauthorization of the community health
    centers. They do great work.
        As a matter of fact, the Administrator of HRSA, Dr.
    Sigounas, was down in my district recently. We discussed
    expanding substance abuse services but also mental health
    services and dental services, as well, and treating even more
    veterans.
        Community health centers already provide quality care to
    more than 300,000 veterans--as a matter of fact, he told me
    exactly 330,000 veterans across the country--and are an
    important source of care for veterans in rural areas, who may
    not be able to easily access VA facilities.
        Can you share with the committee some of the ways in which
    health centers are working with the VA to address the
    healthcare needs of our Nation's veterans? What more can we do
    to improve veterans' access to community health centers, and
    are you a proponent of community health centers?
        Mr. Azar. So I and we are absolutely proponents of our
    community health centers, and one of the things that I am very
    happy about through the budget deal that was reached is that we
    put the community health centers on secure footing financially
    and that we also, through our opioid program, we are going to
    be making significant investments into HRSA and the community
    health centers. I think $400 million will go through quality
    incentive programs to community health centers to assist them
    on the opioid crisis.
        I am not as familiar about veterans issues in connection
    with HRSA and community health centers and would be very happy
    to learn more about ways in which we can be supportive and
    helpful to our veterans through our community health centers.
        Mr. Bilirakis. Yes, I'd like to work with you on that. So,
    in other words, the VA people that are in the VA system, we
    want to make sure that they have an option, a choice, to go to
    a local community health center, particularly in some of the
    rural areas where the clinic or the hospital is far away. And I
    discussed that with Dr. Sigounas, and I have a bill that I'd
    like to talk to you about.
        Again, Mr. Secretary, in the budget submission, you
    mentioned changing--and again, this is probably--you said that
    you've only been on the job for two weeks, so it's really not
    your budget even though you approved the budget--you mentioned
    changing the Part D pharmacy lock-in program.
        Is your budget proposal trying to reform and centralize the
    lock-in program inside CMS rather than the Part D plans? Or are
    you trying to require all plans to initiate a pharmacy lock-in
    program?
        Mr. Azar. I believe it's just to require the Part D plans
    to initiate a lock-in program rather than a centralized one. I
    believe that's the case.
        Mr. Bilirakis. OK. Very good. Let me get into another
    issue, because we don't have a lot of time.
        Currently, ASPR's disaster medical assistance team is
    experiencing a staffing shortage. I am sure you're aware of
    that. As hurricane season is less than four months away, what
    is being done at HHS to address this serious public health and
    safety issue?
        Mr. Azar. So we are working--I've actually met with our
    Assistant Secretary for Preparedness and Response, and we are
    prioritizing the hiring to ensure that we get our full
    complement of national disaster medical services individuals
    for those disaster teams.
        You know, one of the important lessons coming out of this
    unprecedented hurricane season was our need to continue our
    learning processes for how we can deal with multiple either
    manmade or naturally occurring disasters and public health
    threats at one time. That was a really unprecedented episode,
    and it's a good learning for us.
        Mr. Bilirakis. Very good. I've got time for one more
    question, I believe, Mr. Chairman, and thank you for your
    service, by the way, Mr. Chairman.
        Currently, there isn't a clear standard for medication-
    assisted treatment prescribing, and we have heard reports of an
    increasing number of rogue actors offering MAT.
        In many cases, these pop-up clinics actively recruit
    vulnerable client population and provide standardized--
    substandard, in my opinion--services with minimal oversight.
        While we support consumer choice, of course, and market
    competition, we also want to balance this with the consumer
    safeguards to ensure that this program--the problem improves,
    not worsens, and that bad actors are not rewarded via Federal
    dollars.
        Additionally, questions have been raised as to whether
    States are requiring evidence-based practices to be used in the
    STR grant program.
        What is HHS doing to ensure rogue actors are not the
    recipient of Federal dollars and evidence-based practices are
    being used so that the funds expended go to providing the best
    possible treatment in recovery services?
        Mr. Burgess. If the gentleman will suspend. The Chair is
    going to ask if he would submit that in writing. We do have
    Members who are----
        Mr. Bilirakis. Yes, can you please do that? I would
    appreciate it if you addressed that.
        Thank you very much, and I yield back, Mr. Chairman.
        Mr. Burgess. And I thank you for your accommodations.
        The Chair recognizes Mr. Cardenas from California for 5
    minutes, please.
        Mr. Cardenas. Thank you, Mr. Chairman. Secretary Azar, I am
    glad you were able to join us today and I look forward to your
    answering some of my questions.
        I'd like to begin by talking about Scott Lloyd, the head of
    the Health and Human Services Office of Refugees Resettlement.
    Tremendous responsibility. This is a man who has shown complete
    disregard for the U.S. Constitution.
        He abuses his authority and tries to enforce his personal
    beliefs on immigrant women in custody over and over again. He
    has tried to control women's bodies and violate their
    constitutional rights to have an abortion.
        Mr. Chairman, at this time, I'd like to ask unanimous
    consent to submit for the record a Washington Post article
    published today that describes an email reporters obtained from
    an official Federal contractor. The contractor is V-E-R-A.
        The email claims that after a conversation with a Federal
    employee at the Office of Refugee Resettlement at Health and
    Human Services, they were directed to prevent their lawyers
    from discussing abortion access even if minors in custody asked
    for help to understand their legal rights, or else their
    multimillion-dollar contract with the Department of Health and
    Human Services would be jeopardized. For the record, please,
    Mr. Chairman.
        Mr. Burgess. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Cardenas. Thank you so much, Mr. Chairman.
        Wow, that sounds like a complete violation of the law to
    me. Scott Lloyd, the Office of Refugee Resettlement chief--his
    actions have put young women's lives in danger, even
    considering subjecting the women to unproven medical
    experiments, and he personally tried to block a rape victim
    from getting an abortion.
        This is in a memo, and I'll quote from that memo. Quote,
    ``Here there is no medical reason for abortion. It will not
    undo or erase the memory of the violence committed against her,
    and it may further traumatize her. I conclude it is not her
    interest,'' end quote.
        To me, it's just ironic that a man would mention the
    violence committed on this young girl while at the same time
    violating her rights.
        Why does Scott Lloyd still have a job at Health and Human
    Services?
        Mr. Azar. Well, first, we don't draw conclusions from media
    reports, but also these are matters in pending litigation. I am
    not going to be able to speak to them, nor do I know the facts
    and circumstances. I have not been able to look into them yet
    at my time at the Department.
        Mr. Cardenas. How committed are you to make it a priority
    to look into the details of this, which you just mentioned that
    is now there is litigation going on over this matter?
        Mr. Azar. The mission that ORR has for these young children
    is a very solemn one, to look out for their health and well-
    being as well as the health and well-being of their unborn
    children.
        That is a very difficult task. It's an unenviable one, and
    I think they are trying to do the best they can under the
    circumstances here to protect both the young girls' health as
    well as the unborn child's health and to make sure they are
    standing in here under their statutory obligations to do this,
    and we will certainly be looking to ensure that our programs
    are consistent with the law, that the way we administer them is
    consistent with court cases as they eventually come out.
        Beyond that, I am not able to really comment. I don't have
    the facts.
        Mr. Cardenas. Well, I am glad you answered that way. So
    maybe you can double down on that answer by expressing before
    this committee, Members of Congress, about the policies that
    the Department of Health and Human Services, of which you are
    now the head, when it comes to following the law and also the
    U.S. Constitution, it appears to me that that consistency would
    be incumbent upon any department, any public servant.
        Mr. Azar. I would agree. We will always attempt to follow
    the law and the court constructions of the law and what our
    obligations are up against that.
        Mr. Cardenas. So are you committed to making sure that not
    only Scott Lloyd but anybody under your Department would
    actually make sure that their actions and their interactions
    with the people that they've been charged in their care that
    they be consistent with following the Constitution of the
    United States and the laws passed by this Congress and by
    Presidents past and present?
        Mr. Azar. We all take an oath. You did. I did. Everyone at
    the Department takes an oath to support and defend the
    Constitution and laws of the United States.
        Mr. Cardenas. OK. So, again, I asked you earlier how
    committed are you to make sure that you look into the specific
    situation that Scott Lloyd has been involved with, that he's
    now under your purview?
        Mr. Azar. So this is a matter in litigation. I am not going
    to be able to comment about my personal activity connected to
    that or the nature of any investigations that we would conduct.
        These are matters that are being litigated in the courts
    right now, and we will follow where the courts end up here, and
    as I am able to, we will look and determine whether our actions
    are consistent with the law and with case law as it evolves.
        Mr. Cardenas. So you mean to tell this committee, Members
    of Congress, that you cannot give your own personal opinion
    about your personal commitment to how much you're going to look
    into this and how quickly, or whether or not you make it a
    priority?
        Mr. Azar. I am the head of the agency. My name is on the
    litigation. I am not able to comment on pending litigation
    matters or actions that'll be taken pursuant to that.
        Mr. Cardenas. I am not asking about actions. I am talking
    about----
        Mr. Burgess. Gentleman's time has expired.
        Mr. Cardenas. I yield back.
        Mr. Burgess. The Chair thanks the gentleman, and the Chair
    recognizes the gentlelady from Indiana, Mrs. Brooks, 5 minutes
    for questions, please.
        Mrs. Brooks. Thank you, Mr. Chairman, and thank you--
    welcome, Secretary Azar, and congratulations on your
    confirmation.
        I am curious. How many hearings have you had this week?
        Mr. Azar. Three in 24 hours.
        Mrs. Brooks. Yes, that's what I thought. I haven't followed
    them all, but I know that you have been in the hot seat. And
    so, congratulations. I hope we are your last for the week, I
    hope.
        Mr. Azar. I believe so.
        Mrs. Brooks. Good. I want to thank you. In your bio, what I
    am really thrilled about is the fact that you mentioned part of
    your work when you were Deputy Secretary focused on advancing
    emergency preparedness and response capabilities.
        It's an issue that I think we don't talk enough about in
    Congress, and I want to--and because at that time you testified
    actually as Assistant Secretary of Health in '06 that, and I
    quote, ``we'll work to streamline and make more effective the
    current BioShield interagency governance process. We will make
    this process more transparent and work to educate the public
    and industry about our priorities and opportunities.''
        A decade has passed since that happened. I don't think we
    are there yet, and as you know the President's budget proposes
    to transfer the strategic national stockpile to the Assistant
    Secretary for Preparedness--ASPR, as you've just talked about
    meeting with--from CDC, and I think you talked about that
    transfer in funding.
        And this move, as I understand it, will consolidate
    strategic decision making around the development and
    procurement of medical countermeasures.
        First, I want to state my support for it, and I've included
    this same proposal in the discussion draft of the PAHPA
    reauthorization that I am working with my colleague and good
    friend, Representative Eshoo, that we look forward to working
    with you and your staff on the reauthorization of PAHPA.
        But I want to just ensure that you are familiar with the
    specific proposal and ensure that you are supporting that
    proposal as it stands.
        Mr. Azar. Absolutely. In fact, when I was general counsel
    and Deputy Secretary, where we ran strategic national stockpile
    out of was something that we thought eventually needed to be
    with the ASPR, but we didn't have yet the developed procurement
    capabilities there and management. We now have a very
    sophisticated program there, and so I think the time is now. It
    integrates the capability on procurement, on threat assessment,
    as well as deployment in an operational setting. So I think
    it's absolutely the right thing to do.
        Mrs. Brooks. Outstanding, and we look forward to working
    with your staff to make sure that we get it right in the PAHPA
    reauthorization and also learn whether or not there are any
    other authorities or things that need to be changed.
        You talked about implementation and delivery. That's
    something I actually want to ask about because we often focus
    on vaccine development, which can often overshadow vaccine
    delivery when it comes time, and in a pandemic it's my
    understanding BARDA said that we could need up to 600 million
    drug delivery devices over a 6-month period, and our current
    excess capacity in the marketplace, it can take years to
    produce different devices.
        We certainly learned that during the Ebola crisis. Across
    the country we did not, for instance, have enough gloves. We
    did not have enough masks. We did not have enough things like
    that, but let alone even the devices that would be needed to
    execute vaccines.
        How do we ensure we have enough drug delivery devices to be
    prepared when we can't rely alone on the excess manufacturing
    capacity?
        Mr. Azar. I think that's an excellent question, and that's
    one of the reasons why it's helpful, I believe, to have the
    strategic national stockpile connected directly into the
    Assistant Secretary of Preparedness and Response, so that we
    line up that holistic sense of genuine care delivery in an
    emergency, thinking of--you know, for want of a nail, a kingdom
    was lost--that we don't lack a vial and have a vaccine or lack
    a needle but have plenty of vaccines. So I think that holistic
    sense is absolutely part of our mission and our assessment for
    procurement purposes.
        Mrs. Brooks. I want to just wrap up with my minute that I
    have left.
        Our fellow Hoosier, Director of National Intelligence Dan
    Coats, said just this week when talking about North Korea's
    nuclear warheads, he also mentioned they are continuing their
    longstanding chemical and biological warfare programs.
        As you know, over a decade Project BioShield's special
    reserve fund has created the only market for medical
    countermeasure development and in 2013, while Congress
    authorized the $2.8 billion in funding for the SRF, so far only
    $1.5 billion has been authorized.
        But I understand that in your budget you've requested SRF
    be advanced funded at $5 billion over the next 10 years. Can
    you talk to us about the consequences if we don't do that to
    national security and if we don't provide that advanced
    funding?
        Mr. Azar. It is absolutely vital in BARDA, which is about
    developing and then eventually for us in BioShield procuring
    countermeasures that only the U.S. Government is likely the
    purchaser for, that we be a predictable purchaser.
        So for us to get entities to develop therapies or
    countermeasures, we need to be able to show that we have the
    money and have the backing of the Congress. And so that's where
    that type of advance appropriations is absolutely vital for us
    to be able to secure the commitment from our development
    partners.
        Mrs. Brooks. Thank you. I am very pleased with your
    background and expertise in this area and raising these issues
    to the forefront.
        Thank you. Look forward to working with you. I yield back.
        Mr. Burgess. The Chair thanks the gentlelady. The
    gentlelady yields back.
        The Chair recognizes the gentleman from New York, Mr.
    Engel, 5 minutes for questions, please.
        Mr. Engel. Thank you, Mr. Chairman. Welcome, Mr. Secretary.
    Congratulations on your appointment.
        The President, when he was running for office, said that he
    would never cut Medicaid and we are, of course, very, very
    unhappy with potential cuts to Medicaid.
        A few months ago, we passed--Republicans passed a tax bill
    that gave massive breaks to big corporations in the top 1
    percent and, when that bill passed, there wasn't a doubt in my
    mind that the administration would use the hole that their tax
    bill blew in the deficit to justify gutting programs that
    support working families.
        And lo and behold, the President's budget cuts are $1.4
    trillion to Medicaid, just shy of the tax bill's $1.5 trillion
    price tag.
        It isn't subtle. It could not be easier to see that the
    administration has ways to pay for their legislation. Some of
    us would say handouts to the wealthiest on the backs of
    Americans who rely on Medicaid for health use and, even if we
    set aside the cuts themselves, the policies in this budget give
    us an idea of the kind of Medicaid experiments that this
    administration might allow States to try.
        If you ask me, those policies are just as distressing as
    the cuts because the administration to Congress has made very
    clear that whatever they cannot cut they will so-called reform
    in ways that will kick people off coverage, and as far as I am
    concerned, those kinds of reforms are simply cuts by another
    name.
        The administration has already chosen to go against the
    Medicaid statute by encouraging States to enact work
    requirements that we know will take health coverage away from
    Americans who desperately need it, and now the administration
    is contemplating letting States put in place lifetime limits on
    Medicaid coverage. That is something that we have fought
    against for many, many years, and it sends an alarming message,
    one that I'd like to address right now.
        I'd like to quote a parent from my district whose daughter
    was born with a rare condition, because I think she put it
    best. This is a quote from what she sent me. She said, ``I
    never thought our family would be in a position to need a
    safety net--a program like Medicaid. We might not be who you
    think of when you think of Medicaid. The safety net is there
    for all Americans.''
        So let me say, again, Medicaid is not a handout. It's a
    health insurance program, and it covers nearly one in five
    adults in my district.
        Medicaid is the single largest insurer for America's
    children, and it is a promise to every American that our
    country will not forsake them even when the going gets tough.
        So I am glad that I welcomed you, because I know you're
    going to do--it's a hard job you have, but I'd like you to
    commit to us now that your Department will not approve requests
    to place lifetime caps on Medicaid health insurance coverage. I
    know Congressman Kennedy a little before was trying to get you
    to say that, but I'd feel much better if you can give us that
    commitment.
        Mr. Azar. So, Congressman, I appreciate your concern there,
    and I think they are difficult issues, and these are so
    complex, difficult issues I really cannot here give you an
    answer on resolving a waiver I have not seen.
        We will take that very seriously. We have not stated an
    invitation or a State Medicaid director approach around that
    type of issue. And so I really need to work with our teams to
    see what the issues are, what the legal constraints even are. I
    don't even know the legal frameworks with regard to any issue
    of lifetime caps and how that would interact with our waiver or
    demonstration authorities.
        So it would just be entirely premature for me to sit here
    and give you an answer on that, except to say I would take it
    very seriously and there has not been a statement of the
    administration's positions or views with regard to any requests
    for lifetime caps in Medicaid.
        Mr. Engel. Well, I hope you will visit this committee many
    times, and I hope you will listen to what some of us on this
    side of the aisle are saying. We have some very--as you've
    heard all afternoon, we have some very serious questions about
    it.
        We don't want any situation where our people are being
    knocked off of Medicaid--people who really need it, and
    lifetime caps is something that we have talked about for a long
    time here, and we were doing the Affordable Care Act when we
    talked about it.
        It comes up quite frequently, and it's really scary. It's
    scary for people who don't know what they are going to do if
    this happens.
        So I take you at your word. I hope next time you come back,
    we can have a more thorough discussion on it. But please hear
    what we are saying today.
        Mr. Azar. I absolutely will, and I appreciate any dialogue
    that we can have. These are important programs and very
    difficult issues, and the more minds that we have at bear, the
    better.
        Mr. Engel. OK. Thank you. Thank you, Mr. Chairman.
        Mr. Burgess. The gentleman yields back. And the Chair would
    observe that there was a repeal of the therapy caps in the bill
    that we passed a week ago, and I hope the gentleman voted for
    that.
        Does the gentleman from Texas continue to reserve?
        Mr. Green. I want to continue to reserve.
        Mr. Burgess. All subcommittees members haven't been
    recognized. The Chair will recognize Mr. Welch for 5 minutes.
    Mine really is 5 minutes, Peter.
        Mr. Welch. Well, I appreciate that and, Mr. Chairman, I
    thank you, and I thank you for the work you've been doing on
    prescription drug prices, and that's what I wanted to talk to
    you about, Mr. Secretary.
        You've got incredible experience in the pharmaceutical
    industry, and that may be something that can be useful. And I
    start by saying that I think all of us acknowledge that the
    pharmaceutical industry has done some good things with life-
    extending and pain-relieving medication. The problem is, they
    are starting to kill us with the cost.
        And if we want to maintain access to healthcare, we have
    got to really stabilize the cost. I don't care whether we have
    a Government aid system, employer-based system, or individual-
    based system. If the price keeps going up way beyond inflation,
    we are going to be broke.
        President Trump has said a lot of tremendous things about
    price negotiation and about bringing down the cost. You, in
    your hearing before the Senate, as I understand it, said the
    core problem is the list prices of the drugs. Am I correct in
    that?
        Mr. Azar. I'd say actually I think list price is one of the
    core problems. The other is insuring that, in various parts of
    our program, we are getting an adequate deal and, for instance,
    Part B, the physician-administered drugs, is one where it's
    actually about, are we even getting a good net price. So I'd
    say----
        Mr. Welch. Right. OK.
        Mr. Azar [continuing]. There are two main parts.
        Mr. Welch. Here's the bottom line. There are a lot of folks
    on both sides of the aisle who want to bring these costs down,
    because all of us have consumers that are getting hammered.
        There is a real dispute about what role the Government is
    going to play in taking action to bring these prices down. But
    sitting on the sidelines, which has essentially been the
    approach we have taken, is not working.
        Two things I want to talk to you about. One is price
    negotiation, and the other is bringing down the list prices. I
    mean, just to quote your boss on price negotiation, ``We are
    the largest drug buyer in the world. We don't negotiate. We
    don't negotiate. You pay practically the same for the country
    as if you're going into a drug store and buy the drugs
    individually. If we negotiated the price of drugs, we'd save
    $300 billion a year.''
        Question: Do you, as the Secretary, support what appears to
    be the position of President Trump to begin price negotiation
    by Medicare, which is the biggest purchaser of drugs in the
    world?
        Mr. Azar. So, in fact, in our budget proposal we have a
    very novel element there. One of the things that I've talked
    about is, how can we take the techniques that we use to
    negotiate in Part D and use them in Part B where we do not
    negotiate--we simply pay a sales price with a markup on it
    under the statute.
        And so we have actually proposed giving me the authority to
    move drugs from Part B into Part D, where the PBMs can
    negotiate on our behalf to secure the kind of great deals. We
    get the best deals of any payer in the commercial marketplace
    right now in Part D because the PBMs negotiate that for us.
        Mr. Welch. Right. But the Government is the biggest
    purchaser.
        Mr. Azar. Yes, in Part B, absolutely, and we are not
    negotiating at all or getting any kind of discounts or deals,
    and that's why we think it's quite important.
        Mr. Welch. So I just want to understand this. Are you in
    favor of your agency, essentially, having the authority to
    negotiate bulk price discounts just like the VA program does,
    just like many of the State Medicaid programs do?
        Mr. Azar. I think it requires an understanding of how VA is
    different. VA is actually acquiring medicine as a purchaser,
    where we're serving as a insurer in Part B and Part D.
        Mr. Welch. Right. Let me interrupt you.
        Mr. Azar. It's a different dynamic and power structure----
        Mr. Welch. I only have 5 minutes. I know it's complicated,
    and I know you know how to do it. You've got the experience.
    But there is something that's really simple and elemental that
    actually was captured by the President's comments.
        If you're buying on behalf of the whole country, you ought
    to get a better price than if you're individually walking into
    the drug store, per unit, right? That's essentially what he's
    saying.
        Mr. Azar. And that's why we say in Part B we'd asked for
    permission for us to use those negotiating techniques in Part
    D.
        Mr. Welch. Well, the negotiating techniques are bargaining.
    I mean, you know, Tommy Thompson, who was one of your
    predecessors, did it when we had the crisis and he had to buy
    an immense amount of----
        Mr. Azar. Well, that was a procurement. I was actually
    involved in that.
        Mr. Welch. Well, you guys did a good job.
        Mr. Azar. That was a procurement.
        Mr. Welch. Right.
        Mr. Azar. The difference in Part D, for instance--if that's
    what you're getting at--is even Peter Orszag, the Democratic
    head of the Congressional Budget Office and President Obama's
    OMB Director, has made clear that in Part D the only way one
    could get better pricing than we do now is if we had a single
    restrictive, exclusionary national formulary where seniors
    get----
        Mr. Welch. OK. All right. Let me--this is my last word.
        That's right, but what I heard you say to Mr. Carter is
    that, essentially, the PBMs impose their own formulary by the
    rebate system they set up, and if you want in, you've got to
    pay that price.
        So they, instead of doctors and pharmacists, are setting a
    formulary. And in Vermont what we do under Medicaid is, we have
    got this commission that sets the formulary, but then there is
    flexibility so that, if a doctor says this particular patient
    use this particular drug, we do it. So I hope you follow
    through.
        Mr. Chairman, thank you.
        Mr. Burgess. Gentleman's time is expired.
        The Chair recognizes the gentleman from North Carolina, Mr.
    Butterfield, for 5 minutes.
        Mr. Butterfield. Thank you very much, Chairman Burgess, and
    I apologize for being late for the hearing, and I know you go
    through this every day. I've been multitasking all day long.
        But Chairman Burgess, thank you for holding this hearing.
    Once again, the administration has shown how out of touch it is
    with most Americans. It is not surprising that this
    administration is proposing more changes--yet more changes--to
    healthcare that will harm the middle class and make it more
    difficult for our citizens to access quality healthcare.
        I am from North Carolina. My constituents want healthcare,
    plain and simple. People across the country want healthcare.
        That is why, despite all the Republican efforts to
    undermine the ACA, the program is still going. In my opinion
    it's still going strong, and more than 1 million Americans
    signed up for the ACA for the first time after President Trump
    pulled the rug, or attempted to pull the rug, from under the
    program.
        This budget ignores the wishes of our constituents who
    flooded our offices with calls, asking us to protect the ACA
    and protect Medicaid from Republican efforts to gut these
    programs.
        It also ignores the bipartisan will of Congress. They just
    approved a 2-year budget with increased funding for important
    health programs like the National Institutes of Health. This
    budget would take healthcare away from my constituents, and I
    strongly oppose it. I voted for the Budget Deal Act last week.
        Since the Affordable Care Act was first implemented, the
    uninsured rates steadily declined year after year. From 2010 to
    2016, 20 million Americans gained health insurance.
    Unfortunately, this administration has done everything it can
    to reverse that, in my opinion.
        Since President Trump took office, the Department of Health
    and Human Services has done its best--in my opinion, again--to
    sabotage health coverage for individuals, make it harder for
    people to get covered.
        As a result, for the first time since the ACA was
    implemented--and it was this committee that implemented the
    ACA, I was part of it--the uninsured rate actually increased
    for the first time.
        According to Gallup, 3 million more Americans were
    uninsured in 2017 compared to the previous year. It was also
    the largest single-year increase that has been observed since
    Gallup began collecting this data. Quite an accomplishment,
    after years of seeing the uninsured rate go down.
        Now, Mr. Secretary, I understand from my staff you've been
    on the job for 14 days, so I won't be brutal with you, even
    though I have some very strong feelings. I understand when
    you're new to something, you have to get acclimated.
        But yes or no, please: Do you agree or disagree, sir, that
    3 million more uninsured does not reflect--well, first of all,
    do you agree with the 3 million number? Is that accurate?
        Mr. Azar. I don't know that that's accurate. I just--I
    don't know. I don't have the current, up-to-date uninsured
    numbers after the enrollment period that came out of the
    Affordable Care Act enrollments.
        We were slightly off this year from the previous year. I
    don't know the aggregate change on the uninsured.
        Mr. Butterfield. I think all of the stakeholders generally
    agree there was a tick down.
        Mr. Azar. Slightly.
        Mr. Butterfield. Now, how sharp it was, I don't know--I
    don't know that answer for sure. But that's not success.
    Anytime the uninsured rate goes down, that is not a measure of
    success. Would you agree or disagree?
        Mr. Azar. I think if reflects the problems that we have
    with the Affordable Care Act on that individual market program.
    That's why we want to work together to try to change it, to
    create a program that actually will work and deliver for those
    28-plus million Americans for whom this program is not giving
    them affordable access to insurance.
        So we want to work together to try to solve that for those
    forgotten men and women. We talk so much about the 10 million
    who are in the individual market there that we are buying
    insurance for, subsidized, and we forget the ones who have been
    priced out of that marketplace that we really have to come up
    with solutions for.
        Mr. Butterfield. But you certainly agree that it's a
    legitimate goal for all of us as leaders to try to make sure
    that the population has access to healthcare? That goes without
    saying.
        Mr. Azar. We all share that goal, yes.
        Mr. Butterfield. OK. And do you make a commitment to us
    that you will work with us to the extent that you can to make
    that happen?
        Mr. Azar. Absolutely.
        Mr. Butterfield. According to HHS, minorities are less
    likely to receive diagnosis and treatment for their mental
    illness, have less access to it, availability of mental health
    services, often receive poor quality of mental healthcare.
        To address these disparities, Congress just authorized a
    minority fellowship in 21st Century Cures. We are very proud of
    that program. This program has been supported for many years to
    improve healthcare outcomes for racial and ethnic populations
    by growing the number of culturally competent professionals to
    serve the underserved.
        Last question--yes or no, please: Is HHS proposing to
    eliminate this program in fiscal year 2019?
        Mr. Azar. I do not recall that program in our budget. I'd
    be happy to get back to you in writing on that.
        Mr. Butterfield. Get back to me. Get back to me, please.
        Mr. Burgess. The gentleman's time has expired.
        Mr. Butterfield. That is very important. Thank you for your
    patience, Mr. Chairman.
        Mr. Burgess. Does the gentleman from Texas continue to
    reserve?
        Mr. Butterfield. I am not from Texas. Oh. Oh. Oh. I am
    sorry.
        Mr. Green. We will be glad for you to come to Texas,
    George.
        Mr. Burgess. I recognize the gentleman from New York for 5
    minutes.
        Mr. Butterfield. He cut me off so sharply, I thought he was
    coming back at me.
        Mr. Burgess. Five minutes.
        Mr. Butterfield. All right. There is always a little
    tolerance when Members are winding down, Mr. Chairman. But
    thank you.
        Mr. Burgess. Mr. Tonko is recognized for 5 minutes.
        Mr. Tonko. Thank you, Mr. Chair, and Secretary Azar, first,
    let me thank you for coming before this committee.
        It is my fervent hope that in the days to come we can find
    ways to work together to make progress on important healthcare
    priorities for our Nation.
        Unfortunately, today you are here to defend what I believe
    is a mean budget that would take us backwards--backwards with
    this budget on opioids, backwards on mental health, and
    certainly backwards on providing affordable, high-quality
    healthcare for all.
        It's often said that a budget is a statement of our values,
    and after reading this year's budget, the values of the Trump
    administration couldn't be any clearer.
        The overreaching, overarching message that I hear is,
    you're on your own. If you are an individual who has struggled
    with opioid addiction and you have put yourself on the path to
    recovery with the help of treatment provided by Medicaid
    coverage, too bad. You're on your own, and Medicaid has been
    cut by $1.4 trillion.
        If you are a senior who paid into Medicare all your life
    and believed this President when he promised over and over
    again that there would be no cuts to Medicare, too bad--you're
    on your own to the tune of $554 billion over the next decade.
        If you are a single mom working two jobs to put a roof over
    your head and using your SNAP benefits to help put nutritious
    food on the table, you're on your own. But don't worry, we will
    send you a box of peanut butter and some Wheaties.
        I could go on and on. But simply put, this budget is not
    reflective of who we are and of our needs, and of our values
    that I hear about when I am home in New York.
        Many of my colleagues have already spoken about the
    devastating cuts to Medicaid, Medicare, and the Affordable Care
    Act this budget contains, and I would like very much to
    associate myself with their remarks.
        It cannot be said enough, but you simply can't put forward
    a legitimate proposal for addressing the opioid epidemic at the
    same time that you are proposing more than a trillion dollars
    in cuts to Medicaid. It just doesn't pass the smell test.
        Medicaid is the largest payer for behavioral health
    services in our country and remains our single best tool to
    address the opioid crisis. The continued partisan attacks on
    this safety net program put lives in jeopardy and needs to stop
    now.
        Now, even after this administration has talked a big game
    about prioritizing the opioid crisis, I'd like to dig a little
    deeper into some specific cuts that I have seen in this budget
    that will send us backwards in this fight.
        First, I'd like to ask about SAMHSA's strategic prevention
    framework initiative. As the name implies, the flexible funding
    is used to support State-based strategies to prevent youth
    substance abuse.
        SAMHSA's own data show that States and communities
    receiving funding from this program have made improvements in
    reducing the impact of substance abuse.
        Secretary Azar, your budget request would cut $60 million
    from the strategic prevention framework initiative, which would
    reduce funding by more than one half. In your budget rationale,
    you state that this cut is made to prioritize other high-need
    programs.
        So, Mr. Secretary, when we have 174 individuals a day dying
    of overdoses, what is more high need than continuing
    investments in proven substance abuse prevention strategies
    that are very much critical to the inclusive formula for
    success?
        Mr. Azar. So we actually are investing new money into
    SAMHSA--$1.24 billion for opioids. So I believe we have
    demonstrated a clear and deep----
        Mr. Tonko. But you're cutting the prevention program, and
    prevention treatment and recovery are all important.
        Mr. Azar. I'd want to investigate more about that
    particular program, but we actually are adding many new
    programs. I do not know the particulars on that program. I
    apologize. But the----
        Mr. Tonko. But it's the point I am making. You're adding
    new programs and at the same time drastically reducing standard
    programs that have really been proven to be successful, and I
    am trying to figure out the rationale and then the outcome--the
    final line in terms of the statistics that I shared--174
    individuals dying per day.
        Mr. Azar. I'd be happy to get back to you on that
    particular program. I can just tell you our commitment around
    the opioid crisis and the SAMHSA's role in it is deep and
    broad, as evidenced by the $1.24 billion commitment there just
    in the 1 year.
        Mr. Tonko. OK. I appreciate that and look forward to your
    response.
        Another program that is targeted for cuts is SAMHSA's
    Screening, Brief Intervention, and Referral to Treatment
    program, also known as SBIRT, an evidence-based practice that
    helps screen for potential substance use problems in
    individuals.
        Funding provided by this program helps medical
    professionals implement SBIRT in their practices and has
    resulted in at least 2.7 million individuals being screened as
    of 2016.
        The fiscal year '19 budget eliminates all funding for the
    SBIRT program, claiming that this successful demonstration that
    has been taken up across the country can be paid for by public
    and third-party insurance.
        I found this rationale extremely odd because one of the
    things I hear from advocates all the time is the need for
    better screening and early intervention.
        Mr. Burgess. The gentleman's time has expired. The Chair
    would ask if he will submit that question in writing. I am
    certain the Secretary will be happy to respond to it.
        Mr. Tonko. I thank the Chair.
        Mr. Burgess. The Chair recognizes the gentleman from Texas
    for 5 minutes.
        Mr. Green. Thank you, Mr. Chairman, and Mr. Secretary,
    thank you for your patience today and being here, and you've
    heard from the folks on our side of the aisle, and I share the
    values.
        And I think I've never met a doctor who didn't just want to
    treat their patients and to make them well. It's hard for us,
    though, to have that goal of making someone well when you start
    talking about lifetime caps, for example.
        In an earlier career here, I remember we had ``death
    panels,'' and if you have a lifetime cap and someone runs out
    of their Medicaid--so those are issues that need to be worked
    out on the elected level.
        I have the concern about the President's budget because,
    again, we all heard there's not going to be any cuts in
    Medicare or Medicaid during the campaign, but today we see
    substantial cuts in Medicaid and Medicare. Cutting $500 billion
    in Medicare and more than $1.4 trillion in Medicaid is just not
    what I think a Health and Human Services Agency ought to be
    doing.
        We need to figure out ways we can do it, and my goal is not
    to have rationed care, and I think that's probably the goal all
    of us ought to share as Americans, because my goal has been to
    expand access.
        I represent a very urban district in Houston, and until the
    Affordable Care Act, 44 percent of the people who worked in my
    district did not get insurance through their employer. And now
    they have that option--in fact, that requirement. We took away
    the requirement, but their employers still need it, so there
    have been some good things.
        Mr. Secretary, particularly in light of the ongoing opioid
    epidemic, does the administration not comprehend the danger of
    cutting these health insurance programs, and do you agree that
    people have access to needed healthcare services through that
    service covered by their insurance?
        Mr. Azar. So we absolutely share the commitment around
    substance abuse treatment for individuals who are suffering in
    the opioid crisis and, again, we share the goal. We just have
    different tactics to get there. We actually believe that our
    approaches will lead to more people having access to affordable
    insurance. Reasonable minds can differ about this, but the goal
    is the same.
        We just differ on what we think would get there, and we do
    believe that it's better for more people to have insurance. We
    think right now the system is locking so many people out of
    that in terms of affordability. But we want them to have that
    access.
        Mr. Green. Well, the affordability--I would hope that the
    administration would not cut the subsidies that some of my
    working poor who, you know, make too much money to get Medicaid
    but they also don't make enough money to pay for an insurance
    without the subsidies.
        But let me go back to the Medicaid program. Medicaid is the
    largest single payer of behavioral health in the United States,
    and financing more than 25 percent of all treatment. But the
    administration's budget cuts Medicaid by more than 25 percent.
        So with cuts like these, it seems like if you cut Medicaid
    and we still say we want to deal with people with behavioral or
    opioid addictions, you can't do it. It's like me going to Aetna
    or Blue Cross and say, ``I want insurance, but I am not going
    to pay for it.'' That just doesn't work.
        The administration continues to pursue repeal and
    replacement of the Affordable Care Act. But that's a
    congressional decision, both the House and the Senate, and I
    would hope the agency would not make decisions on it before it
    gets guidance from Congress, because that's what the law is.
        Can you commit to stopping undermining or sabotaging our
    health insurance markets and take urgent action to reverse the
    increase of the uninsured rate?
        Mr. Azar. So we believe in ensuring that our programs help
    deliver affordable insurance and choice to individuals, and the
    steps that we take are about trying to create stable markets,
    stable risk pools. The challenge that we are having on
    declining enrollment is that our offering is not good. People
    are being shut out by these radically increasing premiums from
    the way the market was designed. So we want to make insurance
    to work for folks.
        Mr. Green. Let me--I only have 45 seconds left, and I am
    next to the last for you, so you'll be out of here soon.
        But we did that bill in this committee, and we didn't get
    everything we wanted on the House version. We ended up with the
    Senate version. But I think we share that. I don't want people
    paying huge premiums or even subsidizing, but there are ways we
    can do it. There needs to be a partnership between the
    administration and the Members of Congress.
        I appreciate that you believe we share the goals. With all
    due respect, it's clear that the budget proposal--we
    fundamentally do not share the same goals. The picture the
    administration budget paints is a harsh one where more and more
    Americans join the ranks of the uninsured every day and, again,
    in an urban area like I have--not a wealthy area--this would be
    devastating to folks who are barely on the edge.
        And Mr. Chairman, I know I am out of time, and I yield back
    what I don't have.
        Mr. Burgess. Chair thanks the gentleman. The gentleman
    yields back and I'll recognize myself for the balance of the
    time, however much time I may consume, right?
        Mr. Green. Well, then I'll ask for more time.
        Mr. Burgess. And you have been very generous with us today,
    and we appreciate it, and historically you've been generous
    with your time, and I appreciate that, as well.
        We did hear a lot today about--and, of course, all of us
    have been here on the dais all afternoon, so we haven't kept up
    with any of the news--but, as we kept up with it yesterday and
    this morning, it did seem, as you listen to those stories, that
    there perhaps were some significant cues or clues that were
    missed somewhere along the way.
        While some of that will involve other agencies and
    municipal agencies and not the Department of Health and Human
    Services, I hope to the extent that there were cues missed to
    the mental health space that you will work with us in this
    committee.
        We did pass a pretty big mental health title in the Cures
    bill, and if there is something that you can tighten up
    administratively or something where you need legislative
    direction, I just want you to know the committee is prepared to
    stand by you with that.
        I'd also make the observation--and this is information that
    is readily available on open source--many of the individuals
    who are involved in this type of crime actually do have some
    type of psychotropic drug in their system, and that is not to
    impugn or disparage the use of these medications. But it means
    that these individuals have intersected with a mental health
    professional at some point, because these are not compounds
    that are available over the counter, not frequently something
    that's bought on the street.
        So it does seem that there has been an opportunity, at
    least, to intersect with a mental health professional, and
    anything we can do from the agency perspective or legislatively
    to tighten that up, I'd certainly commit to you that I am
    willing to work with you on that.
        Your predecessor was a colleague of mine, someone who I
    thought very highly of, and I will tell you from a doctor's
    perspective, across the country there was a lot of anticipation
    when Dr. Price was selected as the Secretary of Health and
    Human Services.
        To the extent, going forward, that we can be cognizant--you
    at the agency and us legislatively--cognizant of things we can
    do to reduce the burden on physicians and people who actually
    provide the care--insurance, yes, that's one thing. But if you
    haven't got someone there to provide the care, the darn
    insurance card doesn't do you a bit of good. And I do worry
    that we have put a lot of burden on our men and women who
    practice medicine in this country.
        The electronic health records have been a significant
    burden. I know there is some concern as we go through some of
    the Medicare structural reforms. Just for the record, it was
    important to get rid of the sustainable growth rate formula. We
    did that. I did think it was going to take longer than 5 years
    for whatever came next. I lost that argument, and it is to be
    done under a 5-year time interval.
        However, I think you can see from last Friday's vote that
    the Congress, the legislature is willing to provide, if there
    is legislative relief that is needed as far as the time line or
    as far as the flexibility, we are prepared to provide that for
    you.
        Remember that this bill, the Medicare Access and CHIP
    Reauthorization Act, passed with 393 House votes, 93 Senate
    votes--big bipartisan majority. A lot of us have a lot of
    equity and ownership of this, and we want it to be done
    correctly. That's probably the most important thing.
        We have had a number of hearings already. We are going to
    have another one as MACRA affects small practices, and
    certainly work closely with Administrator Seema Verma over at
    CMS. And, again, I just commit to you that we want to do what
    we can to alleviate that burden.
        You had mentioned the interplay between prescription drug
    monitoring programs and electronic health records. That, I
    guess, would be one of those opportunities to reduce the burden
    on practicing physicians, if there is a way to seamlessly
    integrate that. I don't know if you can do it as far as the
    privacy concerns. but I think it's something worthwhile to look
    at.
        What I would also say--and I think you've touched on this--
    there is a lot of data that the Center for Medicare and
    Medicaid Services has and, to the extent that you can identify
    a practitioner who is writing an inordinate number of
    prescriptions, a pharmacy that's filling an inordinate number
    of prescriptions, a pharmacy that's taking delivery of an
    inordinate amount of product, these are things that are
    actually knowable within the data that's locked up in the
    Center for Medicare and Medicaid Services.
        So, again, I hope you will work with us as far as trying--I
    think too often we will point to our physician community and
    say, ``You guys have got to tighten this up, because we have
    got an opiate crisis in this country.'' And yet, there are
    places where, from the agency perspective, we could tighten
    things up and perhaps drill down on where some of those
    problems actually occur.
        You've been very generous with us today. There are going to
    be questions coming to you in writing. I have several that I
    will send you.
        With that, the subcommittee stands adjourned and, again,
    thank you, Mr. Secretary.
        [Whereupon, at 3:24 p.m., the committee was adjourned.]
        [Material submitted for inclusion in the record follows:]

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