[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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