[Senate Hearing 115-390]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-390

                           NOMINATION HEARING

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

                                HEARING

                                OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                                   ON

  NOMINATIONS OF LANCE ROBERTSON, BRETT GIROIR, M.D., ROBERT KADLEC, 
       M.D., ELINORE F. McCANCE-KATZ, M.D. AND JEROME ADAMS, M.D.

                               __________

                             AUGUST 1, 2017

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
                                
 
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman



MICHAEL B. ENZI, Wyoming		PATTY MURRAY, Washington
RICHARD BURR, North Carolina		BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia			BERNARD SANDERS (I), Vermont
RAND PAUL, Kentucky			ROBERT P. CASEY, JR., Pennsylvania
SUSAN COLLINS, Maine			AL FRANKEN, Minnesota
LISA MURKOWSKI, Alaska			MICHAEL F. BENNET, Colorado
SUSAN M. COLLINS, Maine			SHELDON WHITEHOUSE, Rhode Island
BILL CASSIDY, M.D., Louisiana		TAMMY BALDWIN, Wisconsin
TODD YOUNG, Indiana			CHRISTOPHER S. MURPHY, Connecticut
ORRIN G. HATCH, Utah			ELIZABETH WARREN, Massachusetts
PAT ROBERTS, Kansas			TIM KAINE, Virginia
LISA MURKOWSKI, Alaska			MAGGIE HASSAN, New Hampshire
TIM SCOTT, South Carolina


               David P. Cleary, Republican Staff Director

         Lindsey Ward Seidman, Republican Deputy Staff Director

                  Evan Schatz, Minority Staff Director

              John Righter, Minority Deputy Staff Director

                                  (ii)

  
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                        TUESDAY, AUGUST 1, 2017

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Murray, Hon. Patty, a U.S. Senator from the State of Washington, 
  opening statement..............................................     5
Young, Hon. Todd, a U.S. Senator from the State of Indiana.......     7
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode 
  Island.........................................................     7
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana...    23
Collins, Hon. Susan M., a U.S. Senator from the State of Maine...    27
Murphy, Hon. Christopher, a U.S. Senator from the State of 
  Connecticut....................................................    28
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................    32
Hassan, Hon. Margaret Wood, a U.S. Senator from the State of New 
  Hampshire......................................................    34
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of 
  Pennsylvania...................................................    37
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..    39

                               Witnesses

Robertson, Lance, Nominated to be Assistant Secretary for Aging, 
  Edmond, OK.....................................................     8
    Prepared statement...........................................    10
Giroir, Brett, M.D., Nominated to be Assistant Secretary for 
  Health, College Station, TX....................................    11
    Prepared statement...........................................    13
Kadlec, Robert, M.D., Nominated to be Assistant Secretary for 
  Preparedness and Response, Alexandria, VA......................    14
    Prepared statement...........................................    15
McCance-Katz, Elinore F., M.D., Nominated to be Assistant 
  Secretary for Mental Health and Substance Use, Cranston, RI....    17
    Prepared statement...........................................    18
Adams, Jerome, M.D., Nominated to be Surgeon General of the 
  Public Health Service, Fisher, IN..............................    19
    Prepared statement...........................................    21

                          Additional Material

Statements, articles, publications, letters, etc.
    Burr, Hon. Richard, a U.S. Senator from the State of North 
      Carolina, prepared statement...............................    50
    Letters of support for:
        Lance Robertson..........................................    52
        Brett Giroir, M.D........................................   110
        Robert P. Kadlec, M.D....................................   124
        Elinore McCance-Katz, M.D................................   128
        Jerome Adams, M.D........................................   163

                                 (III)
    Response by Lance Robertson to questions of:
        Senator Murray...........................................   177
        Senator Sanders..........................................   179
        Senator Casey............................................   180
        Senator Franken..........................................   182
        Senator Bennet...........................................   183
        Senator Whitehouse.......................................   183
        Senator Baldwin..........................................   184
        Senator Murphy...........................................   184
        Senator Warren...........................................   185
        Senator Hassan...........................................   188
    Response by Brett Giroir, M.D. to questions of:
        Senator Murray...........................................   189
        Senator Sanders..........................................   190
        Senator Franken..........................................   191
        Senator Bennet...........................................   191
        Senator Whitehouse.......................................   192
        Senator Baldwin..........................................   192
        Senator Warren...........................................   193
    Response by Robert Kadlec, M.D. to questions of:
        Senator Murray...........................................   197
        Senator Sanders..........................................   200
        Senator Casey............................................   200
        Senator Franken..........................................   201
        Senator Whitehouse.......................................   202
        Senator Baldwin..........................................   204
        Senator Murphy...........................................   205
        Senator Warren...........................................   205
    Response by Elinore F. McCance-Katz, M.D. to questions of:
        Senator Murray...........................................   211
        Senator Sanders..........................................   212
        Senator Casey............................................   212
        Senator Franken..........................................   214
        Senator Bennet...........................................   214
        Senator Whitehouse.......................................   215
        Senator Baldwin..........................................   217
        Senator Murphy...........................................   217
        Senator Warren...........................................   220
    Response by Jerome Adams, M.D. to questions of:
        Senator Murray...........................................   223
        Senator Sanders..........................................   226
        Senator Casey............................................   227
        Senator Franken..........................................   227
        Senator Bennet...........................................   227
        Senator Whitehouse.......................................   228
        Senator Warren...........................................   229


 
                           NOMINATION HEARING

                              ----------                              


                        TUESDAY, AUGUST 1, 2017

                                       U.S. Senate,
                    Committee on Health, Education, Labor, 
                                              and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 2:30 p.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, chairman of the committee, presiding.
    Present: Senators Alexander, Murray, Collins, Cassidy, 
Young, Casey, Bennet, Whitehouse, Baldwin, Murphy, Warren, 
Kaine, and Hassan.

                 Opening Statement of Senator Alexander

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order.
    Before we get down to today's business, which is to 
consider five of the President's nominees, I want to begin the 
hearing by saying that while we have not always had hearings on 
nominees for these positions that I especially appreciate 
Senator Murray's agreeing that we will mark-up these nominees, 
or we will consider them for mark-up, tomorrow. I appreciate 
that very much.
    I wanted to say a few words first about healthcare, and 
then give Senator Murray a chance to say a word about that, if 
she wishes. Then we will go on to the business at hand, which 
is the hearing for these five nominees.
    This committee, which is the Senate's health committee, 
will hold hearings beginning the week of September 4, 2017 on 
the actions Congress should take to stabilize and strengthen 
the individual health insurance market so that Americans will 
be able to buy insurance at affordable prices in the year 2018.
    We will hear from State insurance commissioners, from 
patients, from Governors, healthcare experts, and insurance 
companies. Committee staff will begin work this week working 
with all committee members to prepare for these hearings and 
discussions.
    The reason for these hearings is that unless Congress acts 
by September 27--when insurance companies must sign contracts 
with the Federal Government to sell insurance on the Federal 
exchange next year--millions of Americans with Government 
subsidies in up to half our States may find themselves with 
zero options for buying health insurance on the exchanges in 
2018. Many others, without Government subsidies, will find 
themselves unable to afford health insurance because of rising 
premiums, co-pays, and deductibles.
    There are a number of issues with the American healthcare 
system, but if your house is on fire, you want to put out the 
fire, and the fire in this case is the individual health 
insurance market. Both Republicans and Democrats agree on this.
    Our committee had one hearing on this subject on February 
1, and we will work intensively between now and the end of 
September in order to finish our work in time to have an effect 
on the health insurance policies that will be sold next year in 
2018.
    I am consulting with Senator Murray to make these hearings 
bipartisan and to involve as many members of the committee as 
is possible; all who want to be involved. I will be consulting 
with Senator Hatch and Senator Wyden so that the Finance 
Committee is aware of any matters we discuss that might be 
within its jurisdiction.
    In these discussions, we are dealing with a small segment 
of the total health insurance market. Only about 6 percent of 
insured Americans buy their insurance in the individual market. 
Only about 4 percent of insured Americans buy their insurance 
on the exchanges. While these percentages are small, they 
represent large numbers of Americans including many of our most 
vulnerable Americans.
    We are talking about the roughly 18 million Americans in 
the individual market. About 11 million of them buy their 
insurance on the Affordable Care Act exchanges. About 9 million 
of those 11 million Americans have Affordable Care Act 
subsidies. Unless we act, many of them may not have policies 
available to buy in 2018 because insurance companies will pull 
out of collapsing markets.
    Just as important, unless we act, costs could rise once 
again making healthcare unaffordable for the additional 9 
million Americans in the individual market who receive no 
Government support. Roughly 2 million of them buy their health 
insurance on the Affordable Care Act exchanges, but do not 
qualify for a Government subsidy and roughly 7 million buy 
their insurance outside of the exchanges. This means they have 
no Government help paying for their premiums, co-pays, and 
deductibles.
    As we prepare for these discussions, I have also urged the 
President to temporarily continue the cost-sharing reduction 
payments through September so that Congress can work on a 
short-term solution for stabilizing the individual market in 
2018.
    Cost-sharing reduction subsidies reduce co-pays, and 
deductibles, and other out-of-pocket costs to help low-income 
Americans who buy their health insurance on the exchanges. That 
would be those who make under 250 percent of the Federal 
poverty level, or roughly $30,000 for an individual or $60,000 
for a family of four.
    Without payment of these cost-sharing reductions, Americans 
will be hurt. Up to half of the States will likely have bare 
counties with zero insurance providers offering insurance on 
the exchanges, and insurance premiums will increase by roughly 
20 percent, according to America's Health Insurance Plans.
    In my opinion, any solution that Congress passes for a 2018 
stabilization package would need to be small, bipartisan, and 
balanced. It should include funding for the cost-sharing 
reductions, but it also should include greater flexibility for 
States in approving health insurance policies.
    It is reasonable to expect that if the President were to 
approve continuation of cost-sharing subsidies for August and 
September--and if Congress in September should pass a 
stabilization plan that includes cost-sharing for 1 year--it is 
reasonable to expect that the insurance companies in 2018 would 
then lower their rates. They have told us. In fact Oliver 
Wyman, an independent observer of healthcare, has told us that 
lack of funding for the cost-sharing reductions would add 11 to 
20 percent to premiums in 2018.
    If the President over the next 2 months, and Congress over 
the next year, takes steps to provide certainty that there will 
be cost-sharing subsidies, that should allow insurance 
companies to lower the premiums that they have projected. In 
fact, many insurance companies have priced their rates for 2018 
at two different levels; one with cost-sharing and one without 
cost-sharing.
    It is important not only that the President approve 
temporary cost-sharing for August and September, but that we, 
in a bipartisan way, find a way to approve it at least for 1 
year so we can keep premiums down.
    This is only step one in what we may want to do about 
health insurance and the larger question of healthcare costs. 
We will proceed step by step.
    A subsequent step would be to try to find a way to create a 
long term, more robust individual insurance market. For the 
short term, our proposal is that by mid-September see if we can 
agree on a way to stabilize the individual insurance market to 
keep premiums down and to make affordable insurance available 
to all Americans.
    We need to put out the fire in these collapsing markets 
wherever these markets are. I think it is reasonable for the 
President to do that for 2 months and then for us to act during 
the month of September.
    Senator Murray, if you have any comments on our hearings, I 
would welcome them, and then we will go to the business at 
hand.
    Senator Murray. Thank you very much, Chairman Alexander.
    I think it is really clear that the path to improving 
healthcare, lowering premiums, and increasing access and 
quality has to be through working across the aisle, and 
bringing patients and families into the process, and coming 
together to find common ground. There is a lot of work we need 
to do for patients and families we represent, especially when 
it comes to the uncertainty in the markets and threats from the 
Administration, and the potential for significant premium 
increases if we do not act.
    Chairman Alexander, I want to say I really appreciate your 
work with me on this and your commitment to getting a result 
for all of our constituents, particularly when it comes to the 
cost-sharing subsidies and that we do not cutoff premiums and 
spike those for patients and families.
    I think I speak for all of us on this side that we look 
forward to bipartisan hearings, and hearing from patients and 
stakeholders, and working with colleagues both on this 
committee and off to work together in a bipartisan manner to 
stabilize the healthcare market and reduce premiums for our 
families.
    Thank you very much for your work on this.
    The Chairman. Thank you, Senator Murray.
    This committee has proved it works best when it works that 
way. She made an important point I did not make.
    A number of Senators have approached us who are not Members 
of the committee who want to be a part of what is happening. We 
are going to find ways, both this month and next month, to make 
sure that they have an opportunity to be updated on and 
participate in our discussions as much as possible.
    The first nominee we will hear from today is Mr. Lance 
Robertson, the nominee to be Assistant Secretary for Aging.
    In this role, he will oversee grants to States to support 
Meals on Wheels and provide Medicaid recipients homecare and 
financial management. He is currently State Director of 
Oklahoma's Aging Services, a position he has held for the past 
decade. He has received broad support from national and State 
groups.
    We received his ethics paperwork on June 30, concluding he 
is in compliance with applicable laws and regulations governing 
conflicts of interest. The committee received his committee 
paperwork on July 10.
    Welcome, Mr. Robertson.
    Next, we will hear from Dr. Brett Giroir, who has been 
nominated to be the Assistant Secretary for Health.
    He will oversee many public health programs including 
promoting biomedical research regulation and integrity; 
encouraging vaccinations to protect Americans against outbreaks 
of vaccine-preventable diseases, something this committee in a 
bipartisan way has strongly supported; and helping respond to 
the opioid abuse crisis. Last year, Congress provided $1 
billion over 2 years in State grants to address that crisis in 
the 21st Century Cures bill that came out of this committee.
    He is the founder and CEO of Health Science and Biosecurity 
Partners, and an Adjunct Professor of Pediatrics at Baylor 
College of Medicine in Houston.
    He was nominated on May 25. We received his paperwork on 
May 30, and his Office of Government Ethics paperwork on June 
5. The Office of Government Ethics has approved his nomination.
    Then, we have Dr. Robert Kadlec, who has been nominated to 
serve as Assistant Secretary for Preparedness and Response.
    This role was created under the Pandemic and All-Hazards 
Preparedness Act to lead the Nation in emergency preparedness 
and response to protect Americans in the event of public health 
emergencies and disasters. It is vital in ensuring that we are 
prepared at the Federal, State, and local levels for the next 
public health threat, whether natural, such as Ebola or Zika, 
or a bioterror attack. He served as Deputy Staff Director for 
Senator Burr on the Intelligence Committee.
    President Trump nominated him on July 11. We received his 
ethics paperwork on July 19 and his committee paperwork July 
25.
    The next nomination is Dr. Elinore McCance-Katz to be 
Assistant Secretary for Mental Health and Substance Use.
    In 1992, the Substance Abuse and Mental Health Services 
Administration was established within the Department of Health 
and Human Services to, ``Reduce the impact of substance abuse 
and mental illness on American communities.''
    The 21st Century Cures Act last year, which Senator Murphy 
and Senator Cassidy played such a large role in, made some 
significant changes to the agency. It directs the Assistant 
Secretary to focus on evidence-based practices, ensure the 
agency's grants are used effectively, improve the recruitment 
of mental health and substance abuse professionals, and 
collaborate with the criminal justice system to improve 
services.
    She is currently the chief medical officer for the Rhode 
Island Department of Behavioral Healthcare, Developmental 
Disabilities, and Hospitals.
    She was nominated on June 15. The committee received her 
completed paperwork on June 26. OGE concluded she is in 
compliance with the conflicts of interest.
    Finally, we will hear from Dr. Jerome Adams, the nominee 
for Surgeon General. He will also serve as medical director in 
the Regular Corps of the Public Health Service.
    The Surgeon General is often called the Nation's doctor and 
in the past, Surgeons General have addressed important issues 
such as preventing chronic diseases, supporting breast feeding, 
nutrition and exercise, and mental health. Today, he is 
Indiana's State Health Commissioner.
    He was nominated June 29. We received his ethics paperwork 
July 7 and his committee paperwork July 24.
    We are holding the hearing today because our democratic 
members requested it, even though many of these nominees for 
these positions have not had hearings over the last several 
years. Having said that, I want to thank Senator Murray for 
agreeing to mark-up the nominees tomorrow.
    I am going to call on Senator Young and Senator Whitehouse 
when I introduce the witnesses before they speak, because they 
want to also introduce you.
    Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Thank you very much, Chairman Alexander.
    Thank you to all of our nominees for joining us today. I am 
looking forward to discussing your vision for the roles you 
have been asked to fill.
    As my colleagues know well, I have repeatedly stressed the 
importance of a thorough and complete vetting process for 
nominees, and this naturally includes ample time to examine 
nominees' qualifications, and experience, and record of 
previous statements or decisions.
    I am also very interested in whether a nominee has 
demonstrated a commitment to putting everyday people first. I 
want to know if they are going to put science and facts ahead 
of politics and ideology. Critically, I want to know if they 
will truly be independent and will do the right thing no matter 
how much pressure is put on them by their bosses. I am going to 
have several questions on this today as well as questions to 
submit for the record.
    I do want to take just a minute to address some initial 
concerns, because I am deeply troubled by actions President 
Trump and Secretary Price have taken on the issue areas for 
which every one of these nominees will be responsible, if 
confirmed. One thing I am going to want to understand today is 
how they will address these issues.
    Dr. Kadlec, if confirmed, you would hold a critical job 
overseeing our Nation's efforts to prevent, prepare for, and 
respond to public health emergencies and natural disasters. So 
far, the Trump administration has failed to prioritize 
preparedness efforts, which I believe has left us vulnerable to 
public health threats.
    I will want to hear from you how much you would stand up to 
the Administration on this, given you have been an outspoken 
voice on the need to increase investments in our preparedness 
efforts at HHS.
    Dr. McCance-Katz, I am concerned this Administration has 
delayed some very critical steps that could help provide 
immediate relief for families suffering from the opioid 
epidemic.
    The role to which you have been nominated for was created 
by this committee, as Chairman Alexander mentioned, thanks to 
Senators Murphy and Cassidy. It reflects a bipartisan 
commitment to this issue, as well as larger priorities 
regarding mental health and substance abuse.
    If confirmed, you would be the first person to ever serve 
in this role, so I will want to hear from you how much you 
would put patients and families first in that role.
    Mr. Robertson, we are in desperate need of a strong 
advocate for older Americans and for people with disabilities 
in this Administration. I know you have been an outspoken 
advocate for older Americans back in your home State of 
Oklahoma.
    I will want to hear more about your commitment to protect 
and defend the rights of people with disabilities and advocate 
for investments for all of ACL's programs including the 
disability programs.
    Dr. Adams, President Trump's firing of the previous Surgeon 
General just halfway into his term shows to me a lack of 
respect for that office and for the independence of science. 
You and I have talked about this.
    I have made my concerns known, but I want to make clear 
today the next Surgeon General must be an advocate for science 
and facts, and must be able to stand up and correct 
misinformation coming out of this Administration.
    Dr. Giroir, I am deeply concerned with many actions that 
have been taken this year by the office you have been nominated 
to lead and this is particularly true with regards to attacks 
on women's health and the rights of women.
    First and foremost, President Trump has proposed 
underfunding the Title X Family Planning Program and signed it 
into law. That law states to block Planned Parenthood and other 
qualified women's health providers from receiving title X 
funds. We know he has appointed radical anti-choice individuals 
throughout the Administration, including within the office you 
will be charged to lead and just recently, he proposed gutting 
the Teen Pregnancy Prevention Program.
    I want to be clear from the outset, it would be 
unacceptable to confirm someone who would seek to continue 
those actions and be unwilling to stand up to ideological 
attacks on women. I have some varied concerns here. I will be 
asking you direct questions about that today.
    We have a lot to cover, Mr. Chairman. I appreciate you 
doing this hearing and working with you to move nominations 
tomorrow.
    I really want to say I appreciate you being willing to work 
with us on healthcare. I think we have shown time and again 
that we can work through some tough problems and comprise. I am 
ready to get to work and I know our side is as well.
    Thank you.
    The Chairman. Thanks, Senator Murray.
    I think we are too.
    I am going to turn to Senator Young and then to Senator 
Whitehouse. Senator Young to make some comments about Dr. 
Adams, Senator Whitehouse about Dr. McCance-Katz, and then we 
will hear from the nominees.
    Senator Young.

                       Statement of Senator Young

    Senator Young. Thank you, Chairman, for this opportunity to 
say a few words of support of my very good friend, Dr. Jerome 
Adams.
    Dr. Adams, congratulations on your nomination to be the 
next Surgeon General of the United States. Congratulations to 
your family, who is here to support you along the way.
    In the past few years, Dr. Adams has served us Hoosiers 
well as the Indiana State Health Commissioner. I, along with 
Senator Donnelly, believe he has the experience and 
demonstrated leadership to promote public health nationwide and 
bring awareness to some of our most pressing public health 
challenges as our Nation's top physician.
    I want to submit for the record a letter of support from 
Senator Donnelly and I, as well as statements of support from 
our Governor, Eric Holcomb, the Indiana Black Legislative 
Caucus, the American Medical Association, the Association of 
State and Territorial Health Officials, and Ascension.
    The Chairman. Without objection.
    Senator Young. Without objection.
    [The information referred to may be found in Additional 
Material.]
    Senator Young. I look forward to hearing Dr. Adams' 
testimony and I yield back.
    The Chairman. Senator Whitehouse.

                    Statement of Senator Whitehouse

    Senator Whitehouse. Thank you, Chairman, for the 
opportunity to join you in welcoming Dr. Elinore McCance-Katz 
to the committee.
    As you mentioned, Dr. McCance-Katz is an addiction 
psychiatrist. She currently serves as the chief medical officer 
at Rhode Island's Department of Behavioral Healthcare, 
Developmental Disabilities and Hospitals affectionately known 
in Rhode Island as BHDDH. She is also a professor of Psychiatry 
and Human Behavior and Behavioral and Social Sciences at Brown 
University in Providence.
    I have spoken to a number of Rhode Islanders who have been 
impressed by Dr. McCance-Katz's work in our State. She has 
helped expand access to medication-assisted treatment, 
stabilized psychiatric services at Eleanor Slater Hospital, 
served as an expert advisor to the Governor's Opioid Overdose 
Prevention and Intervention Task Force, and much more.
    Thank you, doctor, for your willingness to take on this new 
and important role. I look forward to hearing your testimony.
    If I may take a moment also to welcome Dr. Kadlec, who we 
know from Senator Burr's staff, and whose interest in and 
passion for bioterror preparedness and protection is well-
established and most welcome. To Dr. Adams, who comes extremely 
well-recommended by our director of health in Rhode Island, 
Nicole Alexander-Scott.
    Thank you, Chairman.
    The Chairman. Thank you, Senator Whitehouse.
    We will have testimony from the five nominees. We welcome 
you. We welcome your families, some of whom are here, and you 
are welcomed to acknowledge them, if you would like to.
    If you could keep your remarks to about 5 minutes, we would 
appreciate it because that will leave more time for Senators to 
ask you questions.
    Mr. Robertson, let us start with you.

    STATEMENT OF LANCE ROBERTSON, NOMINATED TO BE ASSISTANT 
                SECRETARY FOR AGING, EDMOND, OK

    Mr. Robertson. Good afternoon.
    Thank you, Mr. Chairman, Ranking Member Murray, and members 
of the Senate Health, Education, Labor, and Pensions Committee 
for allowing me to appear before you today.
    I am honored to be here with my fellow nominees and I am 
grateful for your consideration of my nomination to serve as 
the Assistant Secretary on Aging and the Administrator of the 
Administration for Community Living or ACL.
    I look forward to discussing how we can advance that 
organization's ongoing successful work in serving seniors and 
individuals living with a physical and/or intellectual and 
developmental disability. I appreciate the wisdom many of you 
and your staff members shared with me in advance of this 
hearing.
    I would like to thank so many family members, friends, and 
colleagues who have supported me through this nomination. As 
the Chairman allowed us to do, I would like to recognize and 
especially thank my wife of 23 years, who is with me today, 
Lori and then also the tremendous support from our daughters 
Brooke and Kaitlyn.
    ACL's mission, and I quote, is to,

          ``Maximize the independence, well-being, and health 
        of older adults, people with disabilities across the 
        lifespan, and their families and caregivers,''

and that is timely and critical. ACL represents populations 
that number more than 140 million Americans and these 
populations continue to grow. Ensuring choice, independence, 
and meaningful community inclusion is the hallmark of ACL's 
work and my life's mission.
    As Assistant Secretary, my vision would involve a four-
pronged strategy, an overarching strategy that positively 
impacts all populations.
    The first strategy is to improve access to information 
about long-term services and supports. Many Americans are 
unsure where to turn when confronted with an illness, a 
disability, service need, or when they stumble into the role of 
caregiver.
    The next strategy focuses on supporting caregivers. The 
informal caregiver, and the service he or she provides, is the 
epicenter of the long-term services and support system. Our 
Nation must recognize how critically important it is that we 
help these 44 million unpaid family caregivers whose work to 
the care system is valued at $470 billion a year.
    Under my leadership we will continue to bolster evidence-
based solutions and build support systems that work. We will 
continue to seek ways to meet caregivers where they are and 
equip them with the tools needed to be successful in their 
roles.
    The third strategy is dedicated to strengthening elder 
justice. Far too many Americans are exploited and abused, and 
we must continue to aggressively fight this growing epidemic. 
Strong momentum can be seen through the work of the multiagency 
Elder Justice Coordinating Committee, the recent release of 
innovation grants funded through ACL, and the bipartisan 
congressional caucus focused on this important issue.
    The final strategy is increasing our network's business 
acumen. Nonprofit aging and disability community-based 
organizations work hard every day to feed, support, transport, 
and assist individuals. These organizations are the backbone of 
our effort to promote independence, well-being, and quality of 
life for older adults and people living with disabilities.
    If confirmed, I look forward to working with the great team 
at ACL. As a collective body, ACL boasts a cadre of 
intelligent, committed, and impressive individuals. I look 
forward to listening, learning, and working together, if 
confirmed.
    As you fulfill your important role of confirming nominees, 
I am certain you look for individuals who not only have the 
requisite experience and skills, but preferably convince you 
that their commitment is unmatched and possibly even galvanized 
by personal experience.
    I humbly submit to you that I meet such criteria with 
nearly a quarter century of public service experience, a 
graduate degree in public administration, holding national 
leadership roles, and comprehensive experience in directing 
aging and disability network programs.
    I am humbled and appreciative of the endorsements that I 
have received from organizations across the aging and 
disability networks. It is my hope that when you review these 
letters of support, it will assure you of the abilities I will 
bring to this position, if I am confirmed.
    Having been partially raised by my grandparents, served as 
a caregiver, and having a niece living with significant 
disability affords me a personal view of ACL's important work.
    Never does a day go by that I am not impressed with the 
resiliency of those we serve. In most cases, particularly 
through programs offered by ACL, these individuals just need a 
little help: a meal, assistance with employment, transportation 
to the doctor, a referral to a community organization, a bit of 
respite, et cetera. We help by supporting the least expensive 
and preferred home and community-based care where it is 
desired.
    I believe wholeheartedly in our work to offer choices, 
empower people, and support families across the care spectrum. 
We help Americans live healthy, productive, and independent 
lives in their community. Our work is vital.
    In closing, I wish to thank President Trump for his 
nomination, support, and confidence and I am excited to work 
under Secretary Price's leadership, if confirmed.
    Thanks to each of you for the outstanding leadership and 
passion you provide each day on behalf of our great country. If 
confirmed, I look forward to working with you and your staff.
    Mr. Chairman, thank you for the opportunity to be with you 
today.
    [The prepared statement of Mr. Robertson follows:]
                 Prepared Statement of Lance Robertson
    Thank you Chairman Alexander, Ranking Member Murray, and members of 
the Senate Health, Education, Labor, and Pensions (HELP) Committee for 
allowing me to appear before you today. I am honored to be here with my 
fellow nominees and am grateful for your consideration of my nomination 
to serve as the Assistant Secretary on Aging and Administrator of the 
Administration for Community Living (ACL). I look forward to discussing 
how we can advance that organization's ongoing successful work in 
serving seniors and individuals living with a physical and/or 
intellectual and developmental disability. I appreciate the wisdom many 
of you and your staff members shared with me in advance of this 
hearing.
    I would also like to thank so many family members, friends, and 
colleagues who have supported me through this nomination. I wish to 
especially thank my wife of 23 years, Lori, who joins me here today. I 
am grateful beyond words for her unwavering love and support and that 
of our daughters Brooke and Kaitlyn.
    ACL's mission of maximizing ``the independence, well-being, and 
health of older adults, people with disabilities across the lifespan, 
and their families and caregivers'' is critical. ACL currently serves 
more than 140 million Americans and this population continues to grow. 
Ensuring choice, independence, and meaningful community inclusion is 
the hallmark of ACL's work and my life's mission.
    As Assistant Secretary, my vision would involve a four-pronged, 
overarching strategy that positively impacts all populations.

    1. The first strategy is to improve access to information about 
long-term services and supports that are available both with publicly 
funded and private-sector resources. Many Americans are unsure where to 
turn when confronted with an illness, disability, service need, or when 
they stumble into the role of a caregiver.
    2. The next strategy focuses on supporting caregivers. The informal 
caregiver and the service he or she provides is the epicenter of the 
long-term services and supports system. Our Nation must recognize how 
critically important it is that we help the 44 million unpaid family 
caregivers whose work to the care system is estimated at $470 billion a 
year. Under my leadership we will continue to bolster respite vouchers, 
promote evidence-based solutions, and build support systems that work. 
We will continue to seek ways to meet caregivers where they are and 
equip them with the tools needed to be successful in their roles.
    3. The third strategy is dedicated to strengthening elder justice. 
Far too many older adults are exploited and abused, and we must 
continue to aggressively fight this growing epidemic. Strong momentum 
can be seen, however, through the work of the multi-agency Elder 
Justice Coordinating Committee, the recent release of innovation grants 
funded through ACL, and the new bipartisan congressional caucus focused 
on this issue.
    4. The final strategy is increasing our network's business acumen. 
Non-profit aging and disability community-based organizations work hard 
every day to feed, support, transport and assist individuals. These 
organizations are the backbone of our effort to promote independence, 
well-being and quality of life for older adults and people living with 
disabilities.

    If confirmed, I look forward to working with the great team at ACL. 
As a collective body, ACL boasts a cadre of intelligent, committed and 
impressive individuals.
    As you fulfill your important role of confirming nominees, I am 
certain you look for individuals who not only have the requisite 
experience and skills but preferably convince you that their commitment 
is unmatched and possibly even galvanized by personal experience. I 
humbly submit to you that I meet such criteria with nearly a quarter 
century of public service experience, a graduate degree in public 
administration, holding national leadership roles, and comprehensive 
experience in directing aging and disability network programs. I am 
humbled and appreciative of the endorsements that I have received from 
organizations across the aging and disability networks. It is my hope 
that when you review the letters of support it will assure you of the 
abilities that I would bring to this position if I am confirmed. Having 
been partially raised by my grandparents, served as a caregiver, and 
having a niece living with significant disability affords me a personal 
view of ACL's important work.
    Never does a day go by that I'm not impressed with the resiliency 
of those we serve. In most cases, particularly through programs offered 
by ACL, these individuals just need a little help--a meal, assistance 
with employment, transportation to the doctor, a referral to a 
community organization, a bit of respite, etc. We help by supporting 
the least expensive and preferred home and community-based care where 
it is desired. I believe whole-heartedly in our work to offer choices, 
empower people, and support families across the care spectrum. We help 
Americans live healthy, productive and independent lives in their 
community. Our work is vital.
    I wish to thank President Trump for his nomination, support and 
confidence and I am excited to work under Secretary Price's leadership 
if confirmed. Thanks to each of you for the outstanding leadership and 
passion you provide each day on behalf our great country. If confirmed, 
I look forward to working with you and your staff. Mr. Chairman, I 
thank you for the opportunity to be with you today.

    The Chairman. Thank you, Mr. Robertson.
    Dr. Giroir.

  STATEMENT OF BRETT GIROIR, M.D., NOMINATED TO BE ASSISTANT 
           SECRETARY FOR HEALTH, COLLEGE STATION, TX

    Dr. Giroir. Chairman Alexander, Ranking Member Murray, 
members of the committee.
    Thank you for the invitation to testify before you here 
today.
    I am especially grateful to the many committee members who 
spent time meeting with me individually to engage in truly 
substantive discussions about important health issues facing 
our Nation.
    I am honored to appear before you as the President's 
nominee to be the Assistant Secretary for Health, and I am very 
pleased to be joined here today by my wife, Jill, of 32 years; 
my mother Freida, a retired police officer and cancer survivor; 
and our younger daughter Madeline. Not here today is our older 
daughter Jacqueline, who just recently delivered our first 
grandchild, Isabel; her husband Erik, an Iraq veteran; and my 
late father Frank, also a police officer and a veteran, who 
would have been truly honored to be here today.
    As this committee well knows, the Assistant Secretary for 
Health is the senior advisor to the Secretary of Health and 
Human Services on issues of public health and science. 
Component offices--including the Office of the Surgeon General, 
the National Vaccine Program Office, the Office of Disease 
Prevention and Health Promotion, the President's Council on 
Fitness, Sports and Nutrition, and the Offices of Adolescent 
Health, Minority Health, Women's Health, Population Affairs, 
and HIV/AIDS and Infectious Disease Policy--provide leadership 
and coordination across the U.S. Government for a vast array of 
science and public health issues that touch nearly every single 
American.
    Should I be fortunate enough to gain your confidence and be 
confirmed, I will be a passionate advocate for policies, 
programs, research, and innovative solutions to enhance the 
health of all Americans, and especially support initiatives 
that reduce our current disparities in mortality and suffering.
    There are no silver bullets, but I believe the pathway is 
clear, emphasize prevention and early detection by empowering 
individuals and groups; embrace science and data; welcome new 
data; listen to all stakeholders, especially those with diverse 
viewpoints; foster an innovative environment that maximizes the 
creativity of academia and the private sector; remain humble; 
and as a physician, I always focus on patients and their 
families.
    Because of my parents' emphasis on education, I became the 
first member of my family to attend college and graduated from 
Harvard University. I chose to attend medical school in Dallas 
at the University of Texas Southwestern Medical Center, not 
only for their renowned faculty, but for the opportunity to 
provide compassionate care to patients at one of our Nation's 
preeminent safety net public hospitals, that is, Parkland 
Memorial Hospital.
    I completed a residency and chief residency in pediatrics 
and then a fellowship in pediatric critical care medicine. I 
remained on the faculty at UT Southwestern for 10 years, 
becoming a tenured professor, associate dean, and chief medical 
officer at Children's Medical Center where I was privileged to 
care for thousands of critically ill children and their 
families.
    My career then took an unexpected turn when I was recruited 
by the Defense Advanced Research Projects Agency, also known 
commonly as DARPA. I joined a science and technology assessment 
committee, and ultimately DARPA itself as the Deputy Director, 
and then the Director of the Science Office. I learned very 
quickly that when the Government can effectively collaborate 
with academic and industry partners, there can be unimagined 
advances in medicine and human health.
    In this regard, one of the most meaningful accomplishments 
of our DARPA team was the development of a revolutionary 
prosthetic upper limb that restored near-normal human 
capabilities, and could be controlled by muscles, by nerves, or 
even directly by the brain.
    Following my assignment at DARPA, I have remained dedicated 
to disease prevention, patient empowerment, and the development 
of new vaccines and treatments for infectious diseases and 
cancer.
    I am called to the Assistant Secretary for Health position 
for one reason, and that is to do whatever I can to enhance the 
health of our Nation. To do so will require broad 
collaboration, public engagement, and bold initiatives.
    I will do everything also in my authority and ability to 
support, advance, and advocate for the Commissioned Corps of 
the U.S. Public Health Service, which for more than 200 years 
has been America's warriors against disease with the enduring 
mission to protect, promote, and advance the health and safety 
of our Nation.
    I thank you again for the opportunity to appear before you 
and welcome your questions.
    [The prepared statement of Dr. Giroir follows:]
                Prepared Statement of Brett Giroir, M.D.
    Chairman Alexander, Ranking Member Murray, members of the 
committee, thank you for the invitation to testify before you today. I 
am especially grateful to the many committee members who spent time 
meeting with me individually to engage in substantive discussions about 
important public health issues facing our Nation.
    I am honored to appear before you as the President's nominee to be 
Assistant Secretary for Health, and am pleased to be joined here by my 
wife of 32 years, Jill, my mother Freida--a retired police officer and 
cancer survivor--and our younger daughter Madeline. Not here today is 
our older daughter Jacqueline, who just recently delivered our first 
grandchild, her husband Erik--an Iraq veteran--and my late father 
Frank, also a police officer and a veteran, who would have been truly 
honored to attend this hearing.
    As this committee well knows, the Assistant Secretary for Health is 
the senior advisor to the Secretary of Health and Human Services on 
issues of public health and science. Component offices--including the 
Office of the Surgeon General, the National Vaccine Program Office, the 
Office of Disease Prevention and Health Promotion, the President's 
Council on Fitness, Sports and Nutrition, and the Offices of Adolescent 
Health , Minority Health, Women's Health, Population Affairs, and HIV/
AIDS and Infectious Disease Policy--provide leadership and coordination 
across the U.S. government for a vast array of science and public 
health issues that touch nearly every single American.
    Should I be fortunate enough to gain your confidence and be 
confirmed, I will be a passionate advocate for policies, programs, 
research, and innovative solutions to enhance the health of all 
Americans, and especially support initiatives that reduce our current 
disparities in mortality and human suffering. There are no silver 
bullets, but the pathway is clear: elevate prevention and early 
detection by empowering individuals and groups; embrace science and 
welcome new data; listen to all stakeholders especially those with 
diverse viewpoints; foster an innovative environment that maximizes the 
creativity of academia and the private sector; remain humble; and 
always focus on patients and their families.
    Because of my parent's emphasis on education, I became the first 
member of my family to attend college, and graduated from Harvard 
University. I chose to attend medical school in Dallas at the 
University of Texas Southwestern Medical Center in Dallas, not only for 
their renowned faculty, but mainly for the opportunity to provide 
compassionate care to patients at one of our Nation's preeminent safety 
net public hospital--Parkland Memorial Hospital. I completed a 
residency and chief residency in pediatrics and then a fellowship in 
pediatric critical care medicine. I remained on the faculty at UT 
Southwestern for 10 years, becoming a tenured professor, associate 
dean, and chief medical officer at Children's Medical Center where I 
was privileged to care for thousands of critically ill children and 
their families.
    My career then took an unexpected turn, when I was recruited by the 
Defense Advanced Research Projects Agency, commonly known as DARPA. I 
joined a science and technology assessment committee, and ultimately 
DARPA itself as the Deputy Director, and then Director, of the Science 
Office. I rapidly realized that when the government collaborates with 
academic and industry partners, there can be unimagined advances in 
medicine and human health. In this regard, one of the most meaningful 
accomplishments of our DARPA team was the development of a 
revolutionary prosthetic upper limb that restored near-normal human 
capabilities, and could be controlled by muscles, nerves, or even 
directly by the brain.
    Following my assignment at DARPA, I have remained dedicated to 
improving disease prevention, patient empowerment, and the development 
of new vaccines and treatments for infectious diseases and cancer. I 
truly feel called to the Assistant Secretary for Health position for 
one reason, and that is, to do whatever I can to enhance the health of 
our Nation. To do so will require broad collaboration, public 
engagement, and bold initiatives. I will also do everything in my power 
and abilities to support and advance the Commissioned Corps of the U.S. 
Public Health Service, which for more than 200 years, has been 
America's warriors against disease, with the mission to protect, 
promote, and advance the health and safety of our Nation.
    I thank you again for the opportunity to appear before you and 
welcome your questions.

    The Chairman. Thank you. Is it Giroir?
    Dr. Giroir. Yes, sir.
    The Chairman. I said it right. Good. Thank you. I did not 
want to say it wrong. Thank you very much.
    Dr. Kadlec.

  STATEMENT OF ROBERT KADLEC, M.D., NOMINATED TO BE ASSISTANT 
    SECRETARY FOR PREPAREDNESS AND RESPONSE, ALEXANDRIA, VA

    Dr. Kadlec. Thank you, Chairman Alexander, and Ranking 
Member Murray, members of the Senate HELP Committee.
    It is a privilege to appear before you today as you 
consider my nomination for the position of Assistant Secretary 
for Preparedness and Response.
    Mr. Chairman, there are many I need to thank for this 
opportunity; President Trump and Secretary Price for their 
confidence in my abilities and nominating me for this position. 
The many who have encouraged, and supported, and assisted me 
through this process, and my family--my wife Ann, daughters 
Margaret and Samantha, who are rising high school seniors and 
who are currently on the Bataan Death March of college tours. 
They have supported me and will enable me to take on this 
responsibility, should I be confirmed.
    I would also like to acknowledge classmates, colleagues, 
friends, and fellow committee staff who are here or watching 
from their offices. I want to specifically recognize my 
colleagues at the Senate Intelligence Committee who, like many 
congressional staff, get far too little recognition for their 
dedicated, selfless, and important service to our Nation.
    The prospect of becoming the ASPR is both exciting and 
daunting. Having been a HELP Committee staffer who assisted 
drafting the original position description under the great 
leadership of Senator Richard Burr and the late Senator Ted 
Kennedy, I have firsthand insight into the rationale of why HHS 
and the Nation needed someone to be in charge of coordinating 
medical and public health preparedness and response.
    A decade ago, incidents like September 11, the anthrax 
letters, Hurricane Katrina, and the potential for a deadly 
influenza all demanded that we improve the Federal Government's 
ability to assist State and local health authorities, and 
mobilize the private sector in responding to future events. The 
need now is as real and urgent as it was then.
    The mission of ASPR can be distilled in just a couple of 
words, and that is, to save lives. I can conceive of no greater 
duty or higher calling than this.
    If confirmed, I will fully accept the responsibility to do 
everything reasonable and appropriate to prepare for and 
respond to the spectrum of threats that endanger Americans, our 
national security, and our way of life.
    If confirmed, I pledge to you my all in pursuit of this 
mission and will work 24-7-365 to fulfill the ASPR's duties.
    Having spent the last 2\1/2\ years on the Senate 
Intelligence Committee, I have had the unique privilege to 
learn in exquisite detail the many threats and challenges that 
confront our country, in particular those emerging as clear and 
present dangers today. The threat landscape before us is more 
diverse and more lethal than the one after September 11.
    When I last sat in this hearing room in 2006 as a HELP 
staffer, ISIL did not exist; North Korea did not possess both 
the nuclear weapons, and the missiles and means to attack our 
homeland; the use of chemical weapons by terrorists and by the 
Syrian government on defenseless citizens was a concern, not a 
routine occurrence; and the risks of cyber warfare were still 
largely hypothetical. Today, all these and other challenges 
exist in a way that makes the mission of ASPR more important.
    If confirmed, there are five priority issues that I will 
pursue.
    First, provide strong leadership. Lead the capable and 
dedicated men and women of ASPR, provide them clear policy 
direction, improve their threat and situational awareness, 
advocate for, and secure, adequate resources for the ASPR 
mission.
    Second, create a national contingency healthcare system 
that better organizes, trains, and equips our State and local 
healthcare systems, facilities, and providers to ensure that 
they cannot only better respond to routine emergencies, but to 
extraordinary events that are likely to occur.
    Here we have an opportunity to better integrate Emergency 
Medical Services, the tip of the spear of our national medical 
response, into these efforts, and to increase effective 
coordination across HHS and the Federal departments, such as 
the Department of Defense and the Department of Veterans 
Affairs, to support State and local responders.
    Third, support CDC and the sustainment of robust and 
reliable public health security capabilities that include an 
improved ability to detect and diagnose infectious diseases and 
other threats, as well as the capacity to rapidly characterize 
and attribute them.
    Fourth, reinvigorate and advance an innovative medical 
countermeasure enterprise. We must capitalize on advances in 
biotechnology and science to develop and maintain a robust 
stockpile of safe and efficacious vaccines, medicines, and 
supplies to respond to emerging disease outbreaks, pandemics, 
and chemical, biological, radiological, and nuclear incidents 
or attacks.
    Finally, work with you and your staff on the 
reauthorization of the Pandemic and All-Hazards Preparedness 
Act in 2018 to further strengthen our Nation's readiness and 
response for 21st century threats.
    I would like to close by simply thanking you for your 
consideration and the prospect of continuing to serve our great 
Nation, if confirmed.
    [The prepared statement of Dr. Kadlec follows:]
               Prepared Statement of Robert Kadlec, M.D.
    Chairman Alexander and Ranking Member Murray, members of the Senate 
HELP Committee, it is both a privilege and special opportunity to 
appear before you today as you consider my nomination for the important 
position of Assistant Secretary for Preparedness and Response (ASPR) at 
the U.S. Department of Health and Human Services (HHS).
    Mr. Chairman there are many I need to thank for this opportunity: 
President Trump and Secretary Price for their confidence in my 
abilities and nominating me for this position; the many who have 
encouraged and assisted me through this process; and my family--my wife 
Ann, daughters Margaret and Samantha--who have supported me and will 
enable me to take on this responsibility should I be confirmed.
    I would also like to acknowledge classmates, colleagues, friends 
and fellow committee staff who are here or watching from their offices. 
I want to specifically recognize my colleagues at the Senate 
Intelligence Committee who, like many congressional staff, get far too 
little recognition for their dedicated, selfless and important service 
to our Nation.
    As I sit here, the prospect of becoming the ASPR is both exciting 
and daunting. Having been a HELP Committee staffer who assisted 
drafting the original position description under the great leadership 
of Senator Richard Burr and the late Senator Ted Kennedy, I have 
firsthand insight into the rationale why HHS and the Nation needed a 
single leader to be responsible for coordinating medical and public 
health preparedness and response.
    Ten years ago, incidents like the September 11, 2001 attacks on our 
country, the deadly anthrax letters, Hurricane Katrina, and the 
potential for an influenza pandemic all demanded that we improve the 
Federal Government's ability to assist State and local health 
authorities and mobilize the private sector in responding to future 
events. The need now is as real and urgent as it was then.
    To distill the ASPR mission to just a couple of words, it is to 
``save lives.'' As a physician, I can conceive of no greater honorable 
duty or higher calling than this. If confirmed, I fully accept the 
responsibility to ensure that we do everything reasonable and 
appropriate to prepare for and respond to a spectrum of 21st century 
threats that endanger Americans, our national security, and our way of 
life. If confirmed, I pledge to you my all in pursuit of this mission 
and will work 24-7-365 days a year to fulfill the ASPR's duties.
    Having spent the last 2\1/2\ years working on the Senate 
Intelligence Committee, I have had the unique privilege to learn in 
exquisite detail the many threats and challenges that confront our 
country, in particular those emerging as clear and present dangers 
today. The threat landscape before us is more diverse and more lethal 
than the one that we confronted after September 11.
    When I last sat in this hearing room in 2006 as a HELP staffer ISIS 
did not exist; North Korea did not possess both nuclear weapons and the 
missiles to attack our homeland; the use of chemical weapons by 
terrorists and by the Syrian Government on defenseless citizens was a 
concern, not a routine occurrence; and the risks of cyber warfare were 
still largely hypothetical. Today, all these and other challenges exist 
in a way that makes the mission of ASPR more important and urgent. We 
must redouble our readiness efforts and improve capabilities for these 
and other threats.
    There are five priority issues that I will pursue if confirmed. 
First, provide strong leadership, including clear policy direction, 
improving threat and situational awareness, advocating for and securing 
adequate resources.
    Second, seek the creation of a ``national contingency health care'' 
system. There is an urgent need to better organize, train and equip our 
State and local healthcare systems, facilities and providers to ensure 
that they cannot only better respond to routine emergencies but to 
extraordinary events that are likely to occur. Here we have an 
opportunity to better integrate Emergency Medical Services, the ``tip 
of the spear'' of our national medical response into these efforts and 
to increase effective coordination across HHS and the Federal 
departments, such as the Department of Defense and the Department of 
Veterans Affairs, to support State and local responders.
    Third, support the sustainment of robust and reliable public health 
security capabilities that include an improved ability to detect and 
diagnose infectious diseases and other threats, as well as the capacity 
to rapidly characterize and attribute them.
    Fourth, re-invigorate and advance an innovative medical 
countermeasures enterprise. We must capitalize on advances in 
biotechnology and science to develop and maintain a robust stockpile of 
safe and efficacious vaccines, medicines and supplies to respond to 
emerging disease outbreaks, pandemics, and chemical, biological, 
nuclear and radiological incidents and attacks.
    Finally, work with you and your staff on the reauthorization of the 
Pandemic and All-Hazards Preparedness Act in 2018 to strengthen our 
Nation's readiness and response for 21st century threats.
    Last, I simply wish to thank you all for your consideration and the 
prospect of continuing to serve our great Nation.

    The Chairman. Thank you, Dr. Kadlec.
    Dr. McCance-Katz, welcome.

  STATEMENT OF ELINORE F. McCANCE-KATZ, M.D., NOMINATED TO BE 
   ASSISTANT SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE, 
                          CRANSTON, RI

    Dr. McCance-Katz. Chairman Alexander, Ranking Member 
Murray, and members of the committee.
    I am honored to be here today. I want to thank you for 
inviting me here today to consider my nomination as Assistant 
Secretary for Mental Health and Substance Use.
    I come from a family that has placed service to our country 
as their highest calling, starting with my late grandfather, 
William J. McCance, who served in World War II and participated 
in both the North African and the D-Day invasions. My father, 
William Thomas McCance, is a career Navy submarine force 
veteran who rose to the highest enlisted ranks as Master Chief 
Hospital Corpsman. My mother, Anna McCance, as the wife of a 
navy chief of the boat, comforted and cared for the families of 
sailors on the submarines on which my father served, faithfully 
demonstrating that spouses also share in the defense of our 
Nation.
    I am happy to have my husband, Michael Katz, sitting behind 
me, here with me today, as well as my daughters, Anna and 
Heather. Our son, Josh, could not be here today, but they have 
all been a source of support and joy to me. Service to our 
country was modeled to me in my family, and I look forward to 
continuing this tradition, if I am confirmed.
    I am a psychiatrist, and I am sub-specialized in addiction 
psychiatry. From my 30 years of caring for patients, I have had 
the opportunity to learn a significant amount about mental and 
substance use disorders.
    I have also had the opportunity to work in both State and 
Federal Government, so I have unique insight into the 
challenges the current regulatory regime poses for assisting 
people with these illnesses; experiences that I believe have 
helped prepare me to implement the statutes enacted by Congress 
and signed into law by the President.
    Our country faces very serious challenges in mental health 
and substance use, and the position for which I am being 
considered heralds a new era in the treatment and care needs of 
Americans through recent landmark legislation including the 
21st Century Cures Act and the Comprehensive Addiction and 
Recovery Act. These laws, in addition to other congressional 
legislative guidance, will allow more effective use of Federal 
funds at SAMHSA and coordination of funding initiatives at 
other agencies to better serve Americans.
    If confirmed, I would prioritize two areas, addressing the 
opioid epidemic and focusing on those with serious mental 
illness.
    Our Nation is afflicted by a crisis of opioid addiction, 
overdose, and death. Sadly, to a large extent, this is a crisis 
that has grown out of ill-informed and misguided attempts to 
address issues of pain.
    Data from the National Survey on Drug Use and Health tell 
us that 54 percent of mis-users obtained opioid medications 
free from friends and relatives, while 34 percent admit to 
misusing opioids prescribed by their doctor for pain 
management.
    The data teaches us important lessons about prevention and 
treatment issues. We must educate Americans on safe and 
appropriate use of pain medications. Innovative approaches to 
healthcare practitioner training should address effective pain 
management, identification, and treatment of substance use 
disorders, as well as frequently co-occurring mental disorders.
    Increasing access to care and recovery services is 
critically important to addressing the opioid epidemic. 
Evidence-based, medication-assisted treatment, peer 
specialists, and a growing array of community supports are 
essential underpinnings of recovery and form the basis of a 
collaborative care model that can best serve Americans.
    For too long, the care and treatment needs of the most 
seriously mentally ill Americans have been neglected. SAMHSA 
national survey data indicate that 35 percent of Americans with 
the most serious mental illnesses receive no treatment 
whatsoever. In addressing this, SAMHSA must assure that program 
funding supports evidence-based early intervention, treatment, 
and recovery services.
    We are fortunate to have stakeholders from many 
complementary disciplines who are ready and willing to 
collaborate to help meet this goal. We must focus on evidence-
based services including psychiatric care, medication, and 
psychotherapy treatments in collaboration with peer support and 
other community-based services designed to provide the 
resources needed to assure the best possible outcomes. We must 
also work to include the families of those with serious mental 
illness in the discussion of their loved one's needs.
    If confirmed, I would look forward to working with Congress 
and stakeholder groups on how to share information urgently 
needed to assure care and safety of a person, while also paying 
attention to their privacy needs and their rights.
    If confirmed, I will be attentive to the concerns of 
Congress. I look forward to your guidance and input, and I will 
work very hard to implement Congress' vision informed by 
stakeholders and enacted through legislation.
    I look forward to answering your questions.
    [The prepared statement of Dr. McCance-Katz follows:]
          Prepared Statement of Elinore F. McCance-Katz, M.D.
    Chairman Alexander, Ranking Member Murray, and members of the 
committee, I am honored to be here today. I want to thank you for 
inviting me here today to consider my nomination as Assistant Secretary 
for Mental Health and Substance Use.
    I come from a family that has placed service to our country as 
their highest calling, starting with my late grandfather, William J. 
McCance, who served in World War II and participated in both the North 
African and the D-Day invasions. My father, William Thomas McCance, is 
a career Navy submarine force veteran who rose to the highest enlisted 
ranks as Master Chief Hospital Corpsman. My mother, Anna McCance, as 
the wife of a Navy Chief of the Boat, comforted and cared for the 
families of sailors on the submarines on which my father served--
faithfully demonstrating that spouses also share in the defense of our 
Nation.
    I am happy to have my husband, Michael Katz, here with me today as 
well as my daughters, Anna and Heather. My son, Josh, could not be 
here. They have all been a source of support and joy. Service to our 
country was modeled to me in my family and I look forward to continuing 
this tradition, if I am confirmed.
    I am a psychiatrist, and I am subspecialized in Addiction 
Psychiatry. From my 30 years caring for patients, I have had the 
opportunity to learn a significant amount about mental and substance 
use disorders. I have also had the opportunity to work in both State 
and Federal Government, so I have unique insight into the challenges 
the current regulatory regime poses for assisting people with these 
illnesses--experiences that I believe have helped prepare me to 
implement the statutes enacted by Congress and signed into law by the 
President.
    Our country faces very serious challenges in mental health and 
substance use, and the position for which I am being considered heralds 
a new era in the treatment and care needs of Americans through recent 
landmark legislation including the 21st Century CURES Act and the 
Comprehensive Addiction and Recovery Act. These laws, in addition to 
other congressional legislative guidance, will allow more effective use 
of Federal funds at SAMHSA and coordination of funding initiatives at 
other agencies to better serve Americans. If confirmed, I would 
prioritize two areas: addressing the opioid epidemic and focusing on 
those with serious mental illness.
    Our Nation is afflicted by a crisis of opioid addiction, overdose 
and death. Sadly, to a large extent, this is a crisis that has grown 
out of ill-informed and misguided attempts to address issues of pain. 
Data from the National Survey on Drug Use and Health tell us that 54 
percent of mis-users obtained opioid medications free from friends and 
relatives while 34 percent admit to misusing opioids prescribed by 
their doctor for pain management. The data teaches important lessons 
about prevention and treatment issues. We must educate Americans on 
safe and appropriate use of pain medications. Innovative approaches to 
healthcare practitioner training should address effective pain 
management, identification and treatment of substance use disorders as 
well as frequently co-occurring mental disorders. Increasing access to 
care and recovery services is critically important to addressing the 
opioid epidemic. Evidence-based medication-assisted treatment, peer 
specialists and a growing array of community supports are essential 
underpinnings of recovery and form the basis of a collaborative care 
model that can best serve Americans.
    For too long, the care and treatment needs of the most seriously 
mentally ill Americans have been neglected. SAMHSA national survey data 
indicates that 35 percent of Americans with the most serious mental 
illnesses receive no treatment whatsoever. In addressing this, SAMHSA 
must assure that program funding supports evidence-based early 
intervention, treatment and recovery services. We are fortunate to have 
stakeholders from many complementary disciplines who are ready and 
willing to collaborate and help meet this goal. We must focus on 
evidence-based services including psychiatric care, medication and 
psychotherapy treatments, in collaboration with peer support and other 
community-based services designed to provide the resources needed to 
assure the best possible outcomes. We must also work to include the 
families of those with serious mental illness in the discussion of 
their loved one's needs. If confirmed, I would look forward to working 
with Congress and stakeholder groups on how to share information 
urgently needed to assure care and safety of a person while also paying 
attention to their privacy rights.
    If confirmed, I will be attentive to the concerns of Congress. I 
look forward to your guidance and input, and I will work very hard to 
implement Congress's vision informed by stakeholders and enacted 
through legislation. I look forward to answering your questions.

    The Chairman. Thank you, Dr. McCance-Katz.
    Dr. Adams.

   STATEMENT OF JEROME ADAMS, M.D., NOMINATED TO BE SURGEON 
        GENERAL OF THE PUBLIC HEALTH SERVICE, FISHER, IN

    Dr. Adams. Chairman Alexander, Senator Murray, members of 
the committee.
    Thank you for the invitation to testify today. I also wish 
to thank President Trump, Vice President Pence, Governor 
Holcomb, and the Indiana congressional delegation, friends, and 
supporting organizations, and my family.
    Especially my very well-dressed mother and father, who you 
see behind me, and my beautiful little daughter, Millie. I had 
to pay her a whole lot to do that.
    [Laughter.]
    I am taking her to your office afterwards to get Good 
Humor, Chairman Alexander. He has a whole ice cream 
refrigerator in his office, in case you all did not know.
    [Laughter.]
    And my wonderful wife, Lacey, without whose support I would 
not be here today. Thank you, honey.
    Both the position of Surgeon General, and the U.S. Public 
Health Corps that the Surgeon General leads, are integral to 
our national health education and response capabilities. The 
U.S. Public Health Corps is an elite team of over 6,500 highly 
qualified health professionals. The Corps serves as our 
national health army, deploying whenever man-made or natural 
crises place our public's health at risk.
    Whether we are facing infectious diseases like Ebola and 
Zika, or natural disasters like Hurricane Katrina, or human-
caused tragedies like the opioid epidemic, our country and 
world deserve and need this ready to respond army of health 
experts.
    Many people call the U.S. Surgeon General the Nation's top 
doctor. This title does not do justice to the professions 
represented in the Health Corps: nurses and doctors, dentists 
and therapists, scientists, and some of the country's best 
doctors. The further suggestion that as a top doctor, I can be 
all things to health does not give proper consideration to the 
vital role partnerships play in the success of this position.
    The position of Surgeon General carries with it a 
tremendous power to convene and to facilitate important health 
and wellness discussions. Therefore, the real power of the 
position comes from the wide array of national health crusaders 
that can be mobilized if the platform is used properly.
    I would next like to share with you why I feel I can 
uniquely contribute to the role of Surgeon General. Not only 
have I earned a Master's Degree in Public Health with an 
emphasis in chronic disease prevention from Berkeley, but I 
have served as the Indiana State Health Commissioner, in 
essence the Surgeon General for Indiana, for the past 2\1/2\ 
years.
    In that role, I have personally overseen our State's 
response to Ebola and Zika, and a rural HIV outbreak related to 
injection drug use, and also overseen the State's Health and 
Human Services and Tobacco Cessation Commissions, the State's 
Public Health Laboratory, and its Health Care Quality and 
Regulatory division.
    I also continue to practice as a physician anesthesiologist 
at Eskenazi Health, a Level One trauma center and a safety net 
hospital, and serve as clinical associate professor of 
anesthesia at Indiana University School of Medicine. In these 
dual roles as both clinician and educator, I see the impact of 
health policy decisions on both providers and patients each and 
every day.
    My final and toughest, but also my most important, job is 
serving as father and mentor to my 7-, 11-, and 13-year-old 
children. That means for every policy decision, I not only 
sympathize, but empathize with all parents regarding the 
potential impact.
    With a bit more of your indulgence, I will briefly address 
what I hope to be my priorities, if confirmed.
    Our Nation is facing a crisis. The addictive properties of 
opioids are a scourge on our country. Secretary Price has 
declared the opioid epidemic and the untreated mental illness, 
which lie at the root of much of the current situation, as top 
priorities. I share his urgency, and feel I bring to this 
discussion a unique perspective, and a proven track record of 
partnering with various groups to address the problem.
    If confirmed, I also hope to make wellness, and community, 
and employer engagement centerpieces of my agenda. We will not 
successfully tackle the opioid epidemic, or obesity, or 
healthcare access and cost, if we continue to focus downstream. 
Too much of our focus is on providing care after a person has 
already developed a disease, but this frequently represents 
many missed opportunities for prevention.
    Our health starts in the communities where we live, learn, 
work, play, and go to school. We need to partner with 
communities and empower them to implement local solutions to 
their toughest problems. I know it may sound like a cliche, but 
if confirmed, I truly hope to make America healthier. Healthy 
people and communities are more productive, and profitable, and 
in turn attract more jobs and prosperity.
    Unfortunately, however, American prosperity and 
competitiveness are being compromised by America's poor health. 
Major corporations know this, and in many ways, they are doing 
better than our own health institutions to address the health 
and wellness of their employees.
    We must work with the business community to share best 
practices and to reach beyond the workplace. Our goal should be 
to truly develop and rebuild communities around wellness and 
prosperity.
    I would like to close my remarks by saying I cannot promise 
you that we will be in agreement on all health and health 
policy matters. The truth is we will not. I cannot promise you 
that the office of the Surgeon General can fix all of the 
health and healthcare problems plaguing our Nation.
    What I can, in fact, promise you is my unwavering 
commitment to finding the best, and presenting the best 
scientific evidence, in both internal policy discussions and 
external educational endeavors. I promise you I will continue 
my strong and well-documented track record of reaching out to 
everyone regardless of their politics, beliefs, culture, or 
geography.
    I promise you that, if confirmed, I will truly seek to be 
the Surgeon General for all of our United States to the best of 
my ability, a champion for everything our country aspires to be 
in terms of health and wellness.
    I look forward to your questions, and thank you for the 
opportunity, Mr. Chairman and Madam Ranking Member.
    [The prepared statement of Dr. Adams follows:]
                Prepared Statement of Jerome Adams, M.D.
    Chairman Alexander, Ranking Member Murray, members of the 
committee: Thank you for the invitation to testify before you today. I 
also wish to thank President Trump and Vice President Pence, Governor 
Holcomb and the Indiana congressional delegation, my family, friends, 
and supporting organizations.
    It is a tremendous honor and opportunity to appear before you today 
as the President's nominee to be our Nation's next Surgeon General. If 
confirmed I would serve as our country's 20th Surgeon General, 
representing 180 years of public health leadership from the position. I 
assure you I do not take this legacy lightly.
    Both the position of Surgeon General, and the U.S. Public Health 
Corps that the Surgeon General leads, are an extremely important 
component of our national health education and response capabilities. 
The Commissioned Corps of the U.S. Public Health Service Corps is one 
of the seven uniformed services, and is an elite team of over 6,500 
highly qualified health professionals. The Health Service Corps serves 
as our national health army, ready to deploy whenever a man-made or 
natural crisis has placed our public's health at risk.
    Whether we are facing infectious diseases like Ebola and Zika, or 
natural disasters like earthquakes and Hurricane Katrina, or human-
caused tragedies like 9/11 and the opioid epidemic, our country and our 
world deserve and need this ready-to-respond army of health experts. 
This army deserves and needs a qualified leader--the U.S. Surgeon 
General.
    Many people call the U.S. Surgeon General the Nation's ``Top 
Doctor.'' This moniker doesn't do justice to the diversity of 
professions represented in the Health Corps--nurses, pharmacists, 
therapists, scientists, and many others, in addition to some of the 
country's best doctors. The further insinuation that one person can be 
all things to health also doesn't give proper consideration to the 
vital role partnerships play in the success of this position.
    The position of Surgeon General carries with it a tremendous power 
to convene supporters (as well as detractors), and to facilitate 
important health and wellness discussions. The power of the position 
comes not merely from the individual occupying it, but rather from the 
even wider array of health crusaders that can be mobilized from a 
multitude of sectors across our country, if the platform is used 
properly.
    Having shared a little of what I think the position of Surgeon 
General represents, I'd next like to share with you why I feel I can 
make a unique contribution in this role. The position of Surgeon 
General must have ``specialized training or significant experience in 
public health programs.'' Not only have I earned a Master's Degree in 
Public Health with an emphasis in Chronic Disease Prevention from UC 
Berkeley, but I have served as the Indiana State health commissioner--
in essence the surgeon general for Indiana--for the past 2\1/2\ years. 
In that role, I have overseen our State's response to Ebola, Zika, and 
a rural HIV outbreak related to injection drug use, and also overseen 
Indiana's tobacco cessation efforts, the State's Public Laboratory, and 
its Health Care Quality and Regulatory division.
    In addition to serving as Health Commissioner, I continue to 
practice as a physician anesthesiologist at Eskenazi Hospital--a level 
one trauma center with a busy obstetrical service--and serve as 
Clinical Associate Professor of Anesthesia at Indiana University School 
of Medicine. In this dual role as both clinician and educator, I see 
the impact of health policy decisions on both providers and the 
patients we serve, and I have been honored to receive awards from my 
institution and peers for my ability to educate, empower, and excite, 
our next generation of health leaders.
    My final and toughest, but also my most important, job is to serve 
as father and mentor, to my 7-, 11-, and 13-year-old children. My 
status as a father is significant as you consider my nomination, 
because for every policy discussion I take part in, I not only 
sympathize, but empathize, with parents regarding the potential impact. 
When making decisions, I literally have no choice but to think about 
both the immediate impact on our Nation's children--my own children 
included--and the world I am leaving for future generations.
    With a bit more of your indulgence, I will now briefly address what 
I hope to be my priorities if I'm confirmed. Our Nation is facing a 
drug crisis. The addictive properties of prescription opioids is a 
scourge in America and it must be stopped. Secretary Price has declared 
addressing the opioid epidemic, and untreated mental illness, which lie 
at the root of much of the current situation, as among his top 
priorities. I share the Secretary's urgency at addressing this crisis 
and feel I bring to this discussion a unique perspective, and a proven 
track record of bringing together various groups to address the 
problem.
    I also would make wellness and community and employer engagement a 
centerpiece of my agenda, if confirmed. We will not successfully tackle 
the opioid epidemic, or obesity, or healthcare access and cost, if we 
continue to focus on how we handle these problems after they've taken 
hold. Much of our national focus is on providing care after a person 
has already developed a disease, but far too often this represents 
multiple missed--and more cost-effective--opportunities to have 
mitigated or even prevented the problem.
    We also won't be able to solve these problems from Washington, DC. 
Our health starts in the communities where we live, learn, work, play, 
and go to school. We need to get out into those communities, learn 
about their obstacles and successes, share best practices, and help 
empower them to implement local solutions to their toughest problems. I 
know it may sound like a cliche but if confirmed, I hope to make 
America healthier. Healthy people and communities are more productive, 
and profitable, and in turn attract more jobs and prosperity.
    Poor health, however, is proving to be a drag on our country's 
prosperity and worldwide competitiveness. Major corporations know this, 
and in many ways are doing better than our own health institutions to 
address the health and wellness of their employees. We need to work 
with the business community in a reciprocal relationship, to share best 
practices, and go beyond the workplace. Our goal should be to truly 
develop and rebuild communities around wellness, and prosperity.
    I'd like to close my remarks by saying that I can't promise you 
that we will be in agreement on all health and health policy matters--
we won't. I can't promise you that the office of the Surgeon General 
can fix all of the health and healthcare problems plaguing our Nation. 
What I can in fact promise you is my unwavering commitment to finding 
and presenting the best scientific evidence, in both internal policy 
discussions, and external health education endeavors. I promise you 
that I will continue my strong and well-documented track record of 
reaching out to EVERYONE--regardless of their politics, beliefs, 
culture, or geography. I promise you that, if confirmed, I will truly 
seek to be the Surgeon General for all of our United States--to the 
best of my ability a champion for everything our country aspires to and 
can be in terms of health and wellness.
    I look forward to your questions, and, if confirmed, I look forward 
to working closely with all of you to improve our country's health.

    The Chairman. Thank you, Dr. Adams. Thanks to each of you.
    We will now go to a 5-minute round of questions for the 
witnesses. We will begin with Senator Cassidy and then go to 
Senator Murray.

                      Statement of Senator Cassidy

    Senator Cassidy. Thank you all and I have had a chance to 
speak with many of you.
    Dr. Giroir, I actually know how to pronounce your name; 
that comes from being from Louisiana. Dr. Adams, I enjoyed our 
conversation.
    Dr. McCance-Katz, of everybody, you are the one I am most 
interested in because Senator Murphy and I heard from 
stakeholders across the country that our Nation's response to 
mental illness and addiction was failing. We spend billions of 
dollars and it was failing.
    You have a great pedigree and I know you have worked in 
SAMHSA, but it is a big, dysfunctional organization. You cannot 
throw them under the bus, but I will.
    What would be your approach, if you can be just specific? 
How are we going to make it better for the mentally ill person, 
so that her one episode of psychosis becomes her only episode 
of psychosis?
    Dr. McCance-Katz. Thank you for that question, Senator 
Cassidy.
    There are a number of things that we need to do. One thing 
that is really critical is that we need to increase the number 
of healthcare providers, mental healthcare providers in this 
country. We will probably never have enough psychiatrists or 
addiction psychiatrists. There are just not that many being 
produced every year.
    Senator Cassidy. So, then? Just because I only have a 
couple of minutes.
    Dr. McCance-Katz. Yes.
    Senator Cassidy. If that is the case, what do we do to 
mitigate that? What do we do to expand the effectiveness of 
those whom we have, knowing that the development of a workforce 
takes years and we have a problem now?
    Dr. McCance-Katz. Yes, and so we can train allied health 
professionals much more rapidly than psychiatrists: nurse 
practitioners, advanced practice registered nurses, physician 
assistants.
    Senator Cassidy. I accept that. Moving on from workforce 
development, what next? I do not mean to be rude. I just have a 
few minutes and he is about to rap me.
    Dr. McCance-Katz. Yes. Also, innovative ways of delivering 
care such as telemedicine where physicians can be extended 
through those allied health professionals to lots of areas in 
the country.
    Senator Cassidy. Kind of a build out of manpower and woman 
power shortage.
    Dr. McCance-Katz. Yes.
    Senator Cassidy. Moving beyond healthcare worker shortage, 
what next?
    Dr. McCance-Katz. To integrate mental health and substance 
use disorder treatment into primary care settings.
    Senator Cassidy. The 21st Century Cures, in our bill that 
Senator Murphy and I had, had that provision to further 
integrate addressing things such as same day rule, allowing 
Medicaid to pay both.
    May I ask, what next? Because all of that, I think we give 
the tools and the license, if you will, through 21st Century 
Cures. I think what we are just yearning for is leadership 
within the Department that will begin to effect these changes.
    We have given you these tools. Share further about your 
approach, please.
    Dr. McCance-Katz. I will just finish by saying that one of 
the roles of SAMHSA is to disseminate all of this and to speak 
to the medical community and to American communities about 
these issues.
    I think that in doing all of those things, focusing on all 
of those things, we will be able to expand treatment.
    Senator Cassidy. That sounds--I think I might have asked 
the previous director, and he or she may have given the same 
answer.
    I do not mean to be harsh. It just is incredible 
frustration about the lack of a coordinated, efficient, 
effective response on the Federal bureaucracy side. 
Particularly, perhaps, one thing we are asking is that you will 
coordinate across all Federal agencies different services.
    Any thoughts on how best to execute that?
    Dr. McCance-Katz. That is one of the parts of the position 
that was very important to me in reading about it.
    I think that one of the first things I will be doing is 
convening with the other Federal agencies that have funding in 
substance use and mental disorders care, and determining what 
they are doing, and whether these programs work. One of the 
things we are going to have to do is look at metrics and 
determine whether some of the programs we have really work.
    These things take time to do, but we can do it, and we can 
make use of the expertise within and also from our communities 
to help us to do that. States also, they know their communities 
best, and SAMHSA knows what is going on in States, and so can 
help in that way as well to disseminate.
    Senator Cassidy. In some cases, SAMHSA was apparently 
giving grants to organizations which were skeptical of 
medications. That would be counterproductive.
    By the way, I hope I did not seem rude. You are going to 
have no bigger advocate on this committee to support you except 
maybe Senator Murphy because we are both incredibly invested in 
your success. I hope I did not come across as brusque.
    Dr. McCance-Katz. No.
    Senator Cassidy. We just feel passionately about the need 
to address this problem in our society. We thank you all for 
taking your jobs and thank you in particular.
    Thank you.
    The Chairman. Thank you, Senator Cassidy. Thank you, again, 
for the work that you and Senator Murphy did with Senator 
Murray, and I, and others last year on the 21st Century Cures 
bill.
    A bill is not worth the paper it is written on unless it is 
implemented properly. We will be watching.
    Senator Murray.
    Senator Murray. Thank you very much.
    Dr. Giroir, let me start with you. If you are confirmed, 
you are going to oversee both the Office of Population Affairs, 
which administers Title X Family Planning grants, and the 
Office of Adolescent Health, which manages the Teen Pregnancy 
Prevention Program. As I said earlier, I am very concerned by 
the actions taken by both of these under this Administration.
    Recently, the Administration notified the grantees that run 
Teen Pregnancy Prevention programs of plans to terminate their 
grants 2 years early. These are competitive. They are evidence-
based programs. They have reached hundreds of thousands of 
people nationwide and trained thousands of healthcare 
professionals.
    I, along with Senators Baldwin and Booker, led over 30 
Senators in writing to Secretary Price to request information 
on that decision. We have not gotten an answer yet.
    I wanted to ask you, if you are confirmed, do you commit to 
providing information to me and other concerned Senators about 
why the Administration is trying to terminate these grants when 
they are meant to continue for an additional 2 years? What do 
you plan to do regarding the Teen Pregnancy Prevention Program?
    Dr. Giroir. Thank you very much, Senator Murray, for that 
question.
    First of all as a pediatrician, I share your concern about 
teen pregnancy. The good news is that since 2007, the rates of 
teen pregnancy have been reduced by about 50 percent. The bad 
news is that in 2015, we still had over 250,000 pregnancies of 
teen mothers and there are long-term consequences both for the 
young mother and also for the children.
    To answer your first question, you have my commitment to 
work with you and provide information. I think public health is 
a common goal for all of us. We have to work together. Public 
health is a team sport. You have, certainly, my commitment as 
does everyone on the committee.
    As part of the second part of the question, you certainly 
have my commitment. The budgetary justification from the 
Administration stated that the programs in the Teen Pregnancy 
Program did not significantly influence the drop in teen 
pregnancy rate. That is all I know about the rationale.
    Senator Murray. Do you believe that?
    Dr. Giroir. I have not been able to review the evidence or 
the assessments that were made in order to achieve that 
conclusion.
    The only information I have is the public review, which was 
very well done in 2015, that looked at the first 5 years of the 
program. The program was evidence-based. It was community-
based. There were many programs that were successful. There 
were many programs that could not be repeated, but even the 
lack of repeatability of a program is information we need to 
know. We need to know what works and does not work.
    Once I have more information, I look forward to engaging in 
this discussion vigorously. If fortunate enough to be 
confirmed, this is certainly very high on my agenda.
    Senator Murray. I appreciate that.
    I just want to say for over 40 years, the title X program 
has provided family planning services across the country. In 
2015, the health centers under title X provided nearly 800,000 
PAP tests, nearly 5 million tests for sexually transmitted 
infections, and 1.1 million HIV tests. The Guttmacher Institute 
estimates that for every dollar invested in family planning, 
taxpayers save $7.
    Supporting the title X programs, to me, is really common 
sense and maintaining the funding for that is one of my top 
priorities.
    I wanted to ask you, do you believe that all providers who 
qualify to provide the services should be considered for 
inclusion in that program?
    Dr. Giroir. Thank you for that question, and I know how 
that is intended.
    I will absolutely implement the laws as is passed by 
Congress and given to me faithfully and as they are intended. 
If there are restrictions that are passed down to me, I am 
obliged to follow the laws as passed down to me.
    It is my intent to assure that everyone who needs these 
services, they are critically important services. They do 
prevent disease. They prevent cancer. They provide early 
detection, that those are allowed to be given to women across 
the board in an affordable way and in an accessible way.
    Senator Murray. OK. I just have a few seconds, so I am just 
going to ask for yes or no answers.
    Making sure that science is priority over politics is 
important in every one of the offices that you hold. We have 
seen under this Administration a Surgeon General who was fired 
before the end of his term. We have seen promotion of theories 
that have been disproven about immunizations. We have seen 
hostile efforts to combat HIV and AIDS. Six members of the 
Presidential Advisory Council on HIV/AIDS felt they had no 
choice but to quit.
    I want to make sure that each one of you understands that 
picking science over politics is a critical part, and I just 
want a yes or no from each of you.
    Will you commit to publicly supporting and advocating for 
science over politics and ideology? I will just go down the 
row.
    Dr. Adams.
    Dr. Adams. An emphatic yes, Senator.
    Senator Murray. Dr. McCance-Katz.
    Dr. McCance-Katz. Yes. Absolutely.
    Senator Murray. Dr. Kadlec.
    Dr. Kadlec. Yes. Absolutely.
    Senator Murray. Dr. Giroir.
    Dr. Giroir. Absolutely, yes.
    Senator Murray. Mr. Robertson.
    Mr. Robertson. Yes, Senator Murray.
    Senator Murray. OK. Thank you very much to all of you.
    The Chairman. Thank you, Senator Murray.
    Senator Collins.

                      Statement of Senator Collins

    Senator Collins. Thank you, Mr. Chairman.
    Dr. Kadlec, as a member of the Intelligence Committee, I 
want to thank you for your service there on the staff and let 
you know how much your expertise will be missed, but I feel 
like we are giving you up for an even greater cause. 
Congratulations to you.
    To Dr. Adams, I want to say that I am certain that it was 
your testimony before the Aging Committee last year, which I 
Chair, that led to your appointment to be the next Surgeon 
General.
    Dr. Adams. I am absolutely certain of that too, Senator.
    Senator Collins. That was the right answer.
    [Laughter.]
    Dr. McCance-Katz, we discussed in my office the terrible 
opioid epidemic that my State is struggling with along with so 
many others. The epidemic affects people of all ages, but it is 
especially heartbreaking when it affects newborns.
    According to the CDC, Maine has among the highest rate of 
Neonatal Abstinence Syndrome in the country. We know that 
hospital costs for newborns born to addicted mothers average 
$66,700 nationally compared to $3,500 for those who are without 
NAS, and most of those costs are paid by the Medicaid program.
    Even more tragic, I always worry what happens to these 
children after they go home, these babies who are born to 
addicted mothers.
    What special efforts should be undertaken to direct 
programs toward helping pregnant women who are addicted?
    Dr. McCance-Katz. There are programs across the country 
that are for pregnant postpartum women. Those programs have 
services coordinated for women with childcare issues, and with 
addiction issues, and they have been very effective.
    In terms of Neonatal Abstinence Syndrome, we are learning a 
great deal about how best to treat that. We know that women who 
have opioid addiction, who do not get medication-assisted 
treatment, have much higher rates of obstetrical adverse events 
up to, and including, miscarriage and fetal death.
    If the standard of care is to give a pregnant woman, who is 
opioid dependent, medication-assisted treatment, that would be 
either methadone or buprenorphine. We are starting to learn 
that not only is methadone effective, but buprenorphine is as 
effective. There are studies that show that buprenorphine 
treatment is associated with less severe symptoms of neonatal 
abstinence, as well as fewer hospital days.
    Recently, I will say in the last year, we have heard of a 
new treatment called presumptive treatments, so we do not wait 
until the infant shows symptoms of neonatal abstinence, which 
can prolong and make the course more difficult, but start to 
treat presumptively if we know the mom has been on opioids.
    Making those kinds of best practices available across this 
country will do a great deal to address neonatal abstinence 
syndrome and to reduce the effects on these infants and their 
families, their moms and their family members.
    Senator Collins. Thank you.
    Mr. Robertson, when there is a situation where there is an 
opioid crisis within a family and the parents are unable to 
care for the child, it is the grandparents who often come to 
the rescue. I was listening to your testimony and learning 
about your own experience in being raised by your grandparents.
    The number of these kinship families is increasing across 
the Nation. In Maine alone, the number of such families 
increased by 24 percent between 2010 and 2015 due to the opioid 
crisis.
    We held a hearing in the Aging Committee, Senator Casey and 
I, and a clear message from that hearing was the need for 
kinship parents to have greater access to information about the 
resources that are available to assist them.
    Senator Casey and I have introduced the Supporting 
Grandparent Raising Grandchildren Act. It creates a Federal 
taskforce charged with the development and distribution of 
information designed to help kinship parents. We think this 
would help families navigate the school system, plan for their 
family's financial future, address mental health issues, and 
build support networks.
    Do you think that such legislation would be helpful?
    Mr. Robertson. Thank you, Senator Collins, for that 
question, and certainly for your ongoing advocacy for 
caregivers to include grandparents raising grandchildren.
    I cannot thank you enough for, again, the opportunity to 
expose an issue that often, in our communities, goes 
unrecognized or unnoticed and that is that cadre of individuals 
who offer that kinship care--many grandparents and others who 
are raising children.
    You are absolutely right. I think their biggest challenge 
on Day One is to begin navigating the systems, whether that is 
the school system, or the medical system, or many other systems 
they must navigate to successfully raise those children.
    I think our society depends on it and I know at ACL, we 
have some programs dedicated to help kinship families and 
grandparents who are raising grandchildren. Certainly, that 
would be a priority for me, not just in a professional role, 
but also with my personal experience as well, and I know that 
Senator Casey feels the same way as well.
    I cannot thank you both enough for your championing of 
caregivers in general and know that I will be right there 
alongside you doing all that I can.
    Senator Collins. Thank you.
    The Chairman. Thank you, Senator Collins.
    Senator Murphy.

                      Statement of Senator Murphy

    Senator Murphy. Thank you, Mr. Chairman.
    I want to thank the Chairman and Senator Murray for their 
work in helping to pass, at the end of last year, the 
legislation which authorizes the position for which Dr. 
McCance-Katz is being nominated for. I look forward to 
supporting her through the process. The weight on your 
shoulders will be great as the first Assistant Secretary for 
Substance Use and Mental Health, but I know that you will be up 
to the job.
    I wanted to ask you a question about a subject that we 
talked about in my office, and that is the sections of the bill 
which authorizes your positions on the issue of parity, making 
sure that the insurance companies are covering mental illness.
    The President's Commission on Combating Drug Addiction and 
the Opioid Crisis just released their interim report, and in it 
are recommendations on increasing parity enforcement, 
especially when it comes to these non-quantitative treatment 
limitations.
    I just wanted to ask you to talk for a moment about the 
steps that your office and the steps that SAMHSA and HHS can 
take to increase enforcement of the parity law, especially when 
it comes to these non-quantitative treatment limitations. The 
ways in which the bureaucracy is often used to restrict 
someone's access to the mental health or substance abuse 
system, especially now given that it is part of the President's 
Commission's recommendations.
    Dr. McCance-Katz. Thank you, Senator Murphy, for that 
question.
    The issue of parity for the treatment of mental and 
substance use disorders has been an ongoing problem. We hear 
frequently about families and their loved ones who cannot 
access the care that they need for any number of reasons. The 
inability to access payment for those services that they need 
is certainly a very common theme that is, unfortunately, heard 
too much.
    One of the things that I would want to do is spend some 
time with CMS around issues of how treatment is paid for at 
this time, and various ways that we might look at facilitating 
the care of individuals with mental and substance use disorder.
    Often, there are not a lot of treatment options available. 
When there are not a lot of treatment options available, there 
tend to be limits placed that are not appropriate, but are 
placed because insurers and payers are not as familiar with 
those interventions.
    By working collaboratively with CMS, I think that we can 
come up with some different ways of paying for services and 
different kinds of services.
    What do I mean by that?
    There are often two types of treatments: hospitalization or 
community outpatient programs. What we need are levels of care 
and those levels of care can be very difficult to get services 
paid for. There are economies and efficiencies to be had, and 
they can be less costly.
    Senator Murphy. I just want to get another question. I 
appreciate that.
    I just would recommend to you that you have new enforcement 
powers under this piece of legislation. Working collaboratively 
with CMS is great, but you have new enforcement powers, 
guidance that you can issue, audits that you can conduct along 
with other partners named in the legislation. I look forward to 
working with you on that.
    Dr. McCance-Katz. Senator, I look forward to your guidance. 
This would be something that would be very important for me to 
be made aware of, and I will certainly do those things.
    Senator Murphy. Thank you very much.
    Dr. Adams, you have an impressive list of organizations 
that have endorsed you. Two of them are the American Public 
Health Association and the American Medical Association, both 
of which have listed the epidemic of gun violence in this 
country as a public health hazard. I appreciate our 
conversation about that in which you noted that you, yourself, 
are a gun owner.
    I wanted to ask you about the ability of your office, the 
ability of you as Surgeon General to address this issue as a 
public health hazard, as it has been named by several of the 
leading public health and medical organizations in the country.
    Dr. Adams. Thank you very much for the question, Senator, 
and I appreciated the opportunity to speak with you and your 
staff.
    As I did mention to you, the caveat is that I am a gun 
owner and I have my lifetime gun permit. I also work in a Level 
One trauma center, took care of a gentleman last week who was 
shot six times. I see it each and every day.
    I think what we have to do is separate the tool from the 
perpetrator. Cars are not a public health problem. Car 
accidents are a public health problem. Guns and gun owners are 
not inherently a public health problem, but the violence that 
results absolutely is.
    There are evidence-based programs, some good ones out in 
Colorado, where they are bringing law enforcement, gun owners, 
and the public health community together to look at solutions 
to lowering the violence. It is not just homicides; it is also 
suicides. There are more suicides than there are homicides in 
this country.
    I think that there are lots of partners out there, if we 
are just willing to stop demonizing each other and really work 
together to look at evidence-based programs that help lower 
violence in children and throughout the country.
    Senator Murphy. I appreciate your answer.
    The Chairman. We are running out of time.
    Senator Murphy. Thank you, Mr. Chairman.
    I hope you will just look at the evidence that suggests 
that the propensity to commit a crime with a gun is directly 
connected to the likelihood that a gun is in close proximity to 
you. It is a little bit deeper than the problem that you 
suggest.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Dr. Adams. I look forward to following up with you.
    The Chairman. Thank you, Senator Murphy.
    Senator Young.
    Senator Young. Thank you, Mr. Chairman.
    Dr. Adams, I commend you for the partnerships I have seen 
you develop with law enforcement and other stakeholders, and 
for the evidence-based programming that you catalyzed, that you 
helped bring to bear as Indiana's State Health Commissioner.
    I am speaking specifically about the opioid epidemic that 
afflicted Austin, IN. I represented Scott County, IN when I was 
a Member of Congress, so I spent a lot of time on the ground 
there with you discussing this crisis. You helped educate me. 
You led in a very big way.
    This was one of the worst documented HIV outbreaks in the 
entire country. Many here present, colleagues and others who 
are watching, read about this crisis in the ``New York Times''. 
The response to it, both by our Federal Government in 
partnership with State authorities like yourself, is serving as 
a national model in a positive way in so many ways as we look 
to continue tackling this opioid epidemic.
    What lessons, Doctor, were learned from your experience 
with this HIV outbreak following the opioid crisis in Scott 
County? What can we do to prevent crises like this working with 
folks like you in the future?
    Dr. Adams. I think the biggest lesson that I learned is 
that the science and the evidence is necessary, but it is not 
always sufficient to motivate change.
    One of the things that was really successful for both me 
and Vice President Pence, then Governor Pence, was to go down 
to the community and to listen to the folks down there. Not 
demonize them because of the beliefs that they had. Not to call 
them bad people because of what was going on in their 
community. Find out why they thought it was happening and how 
they thought they could solve the problem.
    I remember I had a beer and a sandwich with the sheriff, 
and the sheriff shared with me his concern about the 
possibility of starting a syringe exchange program, but also 
his concern about the revolving door of his jail. I spoke with 
him about how we can utilize a syringe exchange program as a 
touch point to connect people to care.
    We have connected over 100 people from that HIV outbreak in 
Scott County to addiction and recovery services. We have given 
Hepatitis C testing. We have provided HIV testing. We have 
connected people with job training.
    I always want to lead with the science and represent the 
science, both as a physician and, if I am confirmed, as Surgeon 
General. I also want to listen to what stakeholders are saying 
and what my patients, if you will, the people of this country 
are saying and speak to them in a way that resonates with what 
their goals are. That is the lesson that I learned.
    I think partnerships, again, are the key. One of the great 
things about the Surgeon General position is you do get to go 
out into communities. I hope that for everyone on this 
committee, you all will invite me to your communities if you 
feel, and I should be confirmed, and that we can talk about 
this opioid epidemic because no one has the solution alone.
    The solution is going to look different in each and every 
community throughout the country. What worked in Scott County 
is not the same thing that is going to work in different areas 
of this country.
    Thank you so much for the opportunity.
    Senator Young. You always took great care, as you still do 
today, to get a command of the details. You understand that 
every context is different and every crisis has its unique 
features.
    In Scott County, IN and dealing with this opioid epidemic, 
you were looking at the evidence base related to syringe 
exchange programs.
    Dr. Adams. Yes.
    Senator Young. Right? This is an evidence-based practice, 
but you understood, based on your consultation with various 
stakeholders, that Scott County, IN was different than other 
areas where this intervention had been used.
    Could you speak to that uniqueness of Scott County and how 
you adapted the syringe exchange model to these unique 
circumstances?
    Dr. Adams. Thank you for the opportunity there.
    I grew up on the East Coast, trained at U.C. Berkley, and 
now live in the Midwest. I was fortunate to grow up on a family 
farm. Folks do not understand that a lot of the science is 
developed in urban areas. Then when we try to apply it to rural 
areas, we have to understand that there are different cultures, 
different beliefs, and different barriers. There are not as 
many physicians around.
    We had to work with a lot of the folks from the Federal 
Government and State Government to provide access to care in 
Scott County, IN.
    I think that understanding, again, that not all 
environments are the same and that we cannot impose our 
beliefs, even if they are based in science, on people without 
first sitting down with them and having a conversation with 
them. That is the key. That is the real key to success, whether 
you are talking about HIV, or hepatitis, or opioids.
    Senator Young. We are out of time here.
    You had those conversations. You persuaded people of the 
merits of the science and you improved health and saved lives 
in the process. I commend you for that.
    I am going to be voting affirmatively for your 
confirmation. Thank you.
    Dr. Adams. It all started with lunch with the sheriff. 
Thank you.
    The Chairman. Thank you, Senator Young.
    Senator Warren.

                      Statement of Senator Warren

    Senator Warren. Thank you, Mr. Chairman.
    Thank you all for being with us today and your willingness 
to serve.
    I want to followup on where Senator Young started and that 
is, I want to talk about another part, though, of tackling the 
opioid crisis. That means making sure that people have access 
to treatment.
    As Senator Murphy noted, the law says that insurers must 
cover treatment for mental health and for substance use 
disorders on a par with the coverage provided for physical 
health treatment.
    Insurance policies are required to treat mental health 
needs and addiction the same way they treat broken bones or a 
busted knee. They are all medical conditions. They all get 
covered. That is the law, but it does not always play out that 
way on the ground.
    A 2015 study found that nearly twice as many respondents 
were denied coverage for mental health treatment as for other 
medical treatment, and the numbers are not great on addiction 
either. Let me start there.
    Dr. McCance-Katz, you have been nominated as Assistant 
Secretary for Mental Health and Substance Use. Is trouble 
getting insurance coverage for mental health or addiction 
treatment a problem in effectively treating these disorders?
    Dr. McCance-Katz. Coverage is a problem for many. Access to 
care is a problem perhaps, I would say, for most.
    Senator Warren. For most. OK.
    Dr. McCance-Katz. With these issues.
    Senator Warren. I want to underline this because I think it 
is really important that we do more to make sure that insurance 
companies follow the law.
    Right now, patients are often on their own trying to do 
battle with insurance companies. We are not helping them out by 
backing them up in these battles.
    When I helped create the Consumer Financial Protection 
Bureau, the CFPB, we had a problem with consumer financial 
products like credit cards, and mortgages, and student loans 
where lenders just did not follow the law.
    CFPB set up a complaint system. We tracked those complaints 
and it helped make sure that companies address those 
complaints, and we made it all public. Anybody can go online at 
CFPB.gov, and they can search and see what companies follow the 
law and see what companies do not. Let me ask you this, Dr. 
McCance-Katz.
    Do you think that making sure that insurance companies 
follow the law, when it comes to parity for mental health 
conditions and addiction treatment, would help in our efforts 
to tackle the opioid crisis?
    Dr. McCance-Katz. I do. I do believe that. I believe that 
there has been a history of--I think the word ``capricious'' is 
not too strong--restrictions on the kinds of evidence-based 
treatments that people should have access to.
    You and I discussed this when we met and I believe that 
people should have access to knowledge based on what their 
peers and community members have experienced to help them to 
make decisions. In doing that, that can bring a simple kind of 
enlightenment, if you will, to insurers as to how they need to 
do things in a way that better serves Americans and follows the 
law.
    Senator Warren. Good. I like that.
    In fact, another way to say it is it helps make the market 
work better because everybody can see right out there in 
public. You had a place to file a complaint, what happened to 
that complaint, which insurers are getting lots of complaints, 
and which insurers are not, and trying to change their 
behavior.
    I think that is, at least, one way to try to take the 
parity that is in the law and make it a reality for families 
who are struggling with this.
    Congressman Kennedy and I introduced a bill for this in the 
last session and it had an online portal to be able to track 
complaints about failure to cover mental health and addiction 
coverage. I think we can go even further, making sure that 
patients actually get responses to their complaints and making 
the data public about which insurance companies are the worst 
offenders.
    Dr. McCance-Katz, if you are confirmed, I hope we can 
continue to work together on this. I think we could do a lot of 
good for a lot of families.
    Thank you.
    Dr. McCance-Katz. I would look forward to it, Senator.
    Senator Warren. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren.
    Senator Hassan.

                      Statement of Senator Hassan

    Senator Hassan. Thank you, Mr. Chair and Ranking Member 
Murray.
    Good afternoon to all of the nominees. Congratulations on 
your nominations and thank you to all the family members who 
are here, too, for supporting your loved ones. We need all 
hands on deck in this business and we appreciate you very much.
    Dr. McCance-Katz, I wanted to just start with a couple of 
more questions. New Hampshire has been terribly hard hit by the 
opioid, fentanyl, and heroin epidemic. The science certainly 
tells us, and I think your statements today have supported 
this, that medication-assisted treatment like buprenorphine 
plays an important role in recovery along with access to other 
services and supports.
    I have been concerned that Secretary Tom Price has been 
critical about medication-assisted treatments suggesting it is 
not very effective. Recently, during a trip to West Virginia, 
Secretary Price said, ``If we are just substituting one opioid 
for another, we are not moving the dial much.''
    I know that you have been supportive of medication-assisted 
treatment in the past and here today. You have called it an 
effective form of care and you have argued that healthcare 
providers should educate themselves on medication-assisted 
treatment.
    Do you agree with Secretary Price's sentiments? If not, how 
would you address the concerns he has raised?
    Dr. McCance-Katz. Yes, thank you for that question, Senator 
Hassan.
    I have not had the opportunity to speak with Secretary 
Price about his comments, but here is what I thought when I 
read--as I did in the paper--his comments.
    Senator Hassan. Right.
    Dr. McCance-Katz. Just giving an opioid is not treatment. 
That is not going to solve the problem.
    Senator Hassan. Right.
    Dr. McCance-Katz. You have to have other psychosocial 
services in place. They include individual counseling, family 
therapy, group therapy, peer supports, community supports. 
Those things need to be in place with those opioid therapies in 
order for a person to be successfully treated.
    If you look at the diagnostic criteria for opioid use 
disorder, what you will see is that two of those criteria are 
addressed by the opioid therapy, and that is tolerance and 
withdrawal.
    Senator Hassan. Right.
    Dr. McCance-Katz. By addressing tolerance and withdrawal, 
we then give people the ability to engage in the psychosocial 
therapies that they need to then move on and get into 
productive lives.
    Senator Hassan. I thank you for that. Like all of us, I 
have time constraints.
    I also think it is fair to say, and I am hoping for a yes 
or no answer here, that it is also really important that people 
have access to an integrated healthcare system if they are 
going to successfully control their substance use disorder.
    Is that fair?
    Dr. McCance-Katz. Yes, ma'am.
    Senator Hassan. Thank you.
    Dr. Giroir, welcome, and it was very nice to visit with 
you.
    Dr. Giroir. Thank you.
    Senator Hassan. Some time ago, I think.
    You have spoken about the value of vaccines, and in your 
career, you have been successful in getting funding for mass 
production of vaccines.
    On the other hand, at least at one point in time, President 
Trump has seemed to perpetuate a conspiracy theory around 
vaccines, including saying that they were linked to autism.
    Dozens of studies, following hundreds of thousands of 
children around the world, have shown no connection between 
vaccines and autism.
    I am interested if you agree with President Trump on this 
issue? Do you believe that vaccines can cause or contribute to 
autism?
    Dr. Giroir. Thank you, sincerely, for this question.
    As a pediatrician, I want it to be very clear that vaccines 
save lives. They are the most important public health advance 
of our time, and they are not associated, with a high degree of 
medical certainty, with any form of autism.
    Senator Hassan. Thank you.
    Dr. Giroir. That is done by epidemiological studies that 
you referred to with hundreds of thousands of children being 
followed. There have also been experimental studies with 
nonhuman primates to show that the vaccine regimen, when given 
to animals, do not induce behaviors of autism.
    We are getting more and more evidence from research by the 
NIH and NIH-funded investigators that the brain abnormalities 
of autism start very early in fetal life. It is absolutely 
incompatible with autism. I am a pediatric care physician.
    Senator Hassan. Yes.
    Dr. Giroir. I took care of children who suffered and died 
of vaccine-preventable diseases including measles and whooping 
cough. I have also seen diseases disappear because of vaccines 
like H. influenzae B.
    There will be no stronger advocate for vaccines than I will 
be, but I also think we need to continue to support the FDA in 
monitoring vaccine safety so we can give honest and transparent 
assurance to the population that vaccines will remain safe in 
the future.
    Senator Hassan. I appreciate that very much.
    To the other nominees, I do have some questions that I will 
submit for the record.
    Dr. Giroir, to your last answer, I am the granddaughter of 
a pediatrician who started practicing in 1921. He could talk a 
lot about what it was like before penicillin and vaccines. I am 
very grateful for your work.
    Thank you.
    The Chairman. Thank you, Senator Hassan.
    Senator Whitehouse.
    Senator Whitehouse. Thank you, Chairman.
    Welcome to all of you.
    Dr. Kadlec, I particularly look forward to working with 
you, and I want to thank you for the terrific work you have 
already done to try to make sure our country is prepared for 
bioterror threats. I want to recognize Senator Burr and Senator 
Casey, who have been really good bipartisan leaders in that. I 
know that there is work to be done. I look forward to working 
with you on that.
    Dr. McCance-Katz, welcome. Great to have a Rhode Islander 
here.
    We have recently passed the Comprehensive Addiction and 
Recovery Act. We, shortly after the passage of that, agreed on 
a billion dollars that would be put through to fund and support 
for opioid treatment and intervention.
    The first half billion went through already and the States 
are in the process of distributing that. We hope very much that 
the second half will move in September when we have our next 
piece of funding legislation. When we do, I hope that you will 
consider working within the Administration to see to it that 
those funds are distributed in some manner consistent with the 
new goals and principles of CARA.
    I do not think we are going to be able to direct the 
funding to be consistent with CARA through appropriations. But, 
I do believe that HHS has the authority to say that grant 
applications will be considered based on how well they align 
with CARA's principles, and I hope that you would support an 
Administration effort to align on that point.
    Dr. McCance-Katz. Yes, I do.
    Senator Whitehouse. Good.
    Dr. Adams, welcome. We had a great conversation in my 
office and I wanted to followup on it because I think one of 
the areas where we have enormous bipartisan potential here is 
in that very delicate, tender, and important period when a 
person is nearing the end of their life and has to make 
decisions about how much treatment they wish to undergo versus 
how much time they want to spend with their families, and how 
much comfort care versus intervention they will choose.
    What many of us have seen as circumstances in which, like 
getting your sleeve caught in the machinery, unintendedly you 
are dragged off and before you know it, the healthcare system 
is doing lots of things to you that you did not want.
    Because the expression of your views was not either timely, 
or complete, or filled every box, very often people are taken 
on very unpleasant journeys at a time when, really as human to 
human, the last thing we can do for people is to honor their 
wishes on their way out. I think, by and large, we do a 
terrible job of doing that.
    To that end, Senator Collins has really showed a lot of 
passion and leadership in the Aging Committee. Senator Isakson 
has been outstanding on this. We have a huge group called C-
TAC, the Coalition to Transform Advanced Care, which is truly a 
who's who of the American corporate and interest group power 
structure.
    Faith communities are gathering around this issue all 
around the country. I want to particularly commend the Dioceses 
in my home State. Everywhere you go, you hear from regular 
folks who have come across this problem and remember tragedies 
in their family.
    There is a big opportunity here and I wanted to ask you to 
consider having it be one of the ``bully pulpit sermons'' of 
your tenure as Surgeon General to help catalyze that enormous 
potential to help Americans get the care that they want. If it 
is a lot of care, great; get a lot of it. If it is not, get the 
care that you want and get your promises and your wishes 
honored at that time.
    I think we can help with that and I hope that you can help 
us with that.
    Dr. Adams. Thank you, Senator. I really appreciate you 
saying that.
    One of my priorities is prevention and I can tell you as a 
physician, the absolutely worst and wrong time to be having a 
discussion with someone about their end of life wishes is when 
they have a tube in their mouth, and they are on a ventilator, 
and they cannot communicate.
    You are correct. We consistently fail our citizens in this 
regard and there are best practices out there. In Indiana, we 
led the way with physician orders for scope of treatment. You 
all have similar forms in your States.
    Senator Whitehouse. We have in Rhode Island and Gunderson 
Lutheran does a great job up in Wisconsin. There is a lot of 
good leadership.
    Dr. Adams. Exactly. I think partnering with the faith-based 
community is ever so important; the hospital associations in 
our States and nationally; the medical associations, the AMA, 
and the Indiana State Medical Association in our State.
    In other States, I think we can bring together stakeholders 
and go after some low hanging fruit here, and help people reach 
the end of life with dignity. Ultimately die according to their 
wishes and not according to a doctor or a medical professional 
doing something that they would not otherwise want.
    Senator Whitehouse. Thank you very much. My time is up.
    The Chairman. Thanks, Senator Whitehouse.
    Senator Casey.

                       Statement of Senator Casey

    Senator Casey. Thank you, Mr. Chairman.
    I want to start by saying how much we appreciate what 
Chairman Alexander and Ranking Member Murray agreed to with 
regard to bipartisan hearings before we started today. I was 
not here for the announcement, but know of the substance of it, 
and I think the country is grateful to hear that news, and we 
are appreciative of that.
    I want to thank Senator Collins for her reference to our 
grand-families bill. Mr. Robertson, we are grateful for your 
words about that as well.
    Dr. Giroir, I wanted to start with a little known part of 
the Affordable Care Act that I fought hard to make sure was 
part of the law. It is called the Pregnancy Assistance Fund 
which was both authorized and had an appropriation attached to 
it in the bill for 10 years, $250 million over 10 years. To 
provide support, in this case, in the form of competitive 
grants to States and to tribes, a few tribes across the 
country, in addition to States to provide a seamless network of 
supportive services to young families.
    Since 2010, the Office of Adolescent Health has awarded 
these grants to 27 States and 4 Tribes to improve the 
educational health, social, and economic outcomes for expectant 
and parenting teens, young women, fathers, and their families.
    It has been funded in a multiyear fashion in the three 
previous times that the grantees have been awarded money. The 
programs are already making a difference since the time it has 
been implemented.
    Folks who participate are more likely to complete high 
school, even with a pregnancy. More likely go to higher 
education and less likely to have a repeat unwanted pregnancy.
    I was surprised to learn that this fund--the Pregnancy 
Assistance Fund--which recently the announcement was for 15 
States getting the grants and one tribal entity, but now it has 
been proposed as a 1-year grant.
    It is puzzling since Congress had provided funding through 
fiscal year 2019 starting in 2010. The funding opportunity 
announcement indicated that funding would be for 3 years.
    I guess my question on this is, do you agree that it is 
unusual to provide a 1-year grant when Congress has provided 
funding through 2019 and the funding opportunity announcement 
was listed as 3 years? Do you have any sense of that or do you 
think that makes sense?
    Dr. Giroir. Thank you for that question.
    I am certainly aware of the Pregnancy Assistant Fund and I 
think we can all agree that the goals of providing assistance 
to pregnancy that could be troubled both physically or having 
long-term effects is absolutely something critical that we need 
to focus on.
    I would certainly hope that aside from the very important, 
but relatively limited scope of this program, that this type of 
program would be available across the country because everyone 
understands that the prevention of problems, as you have heard, 
are much more important. I cannot comment on whether it is 
usual or unusual because I have not been involved in this 
specific decision. It is something I would certainly look at.
    One thing of concern is that many research programs where 
you are gathering data, may have multiple years in order to 
have validity of the data independent of whether they are 
servicing the patients or not.
    It is something I know. I know the principles of the 
program are very important and should be throughout the 
healthcare system. It is something I would look at once, if I 
were confirmed, because I do not have firsthand knowledge of 
what was the decision tree to shorten that program and the 
grants.
    Senator Casey. I would also ask, Doctor, your commitment to 
continuing the program and especially continuing it as a 
multiyear program.
    Dr. Giroir. At this point, because I have not been involved 
in discussions, you certainly have my commitment that this area 
is extremely important, and I understand the value of it, and 
will argue for such programs to be scaled, and they should be 
across the country.
    I am not in a position to commit to support this program as 
this program, in and of itself, until I really get within HHS 
and have discussions. We have not been able to have those kinds 
of discussions about the rationale, whether this is being moved 
into a different program or under another auspice, but you have 
my commitment to give it high priority.
    As a pediatrician, this area of work is very high priority 
for me and you also have my commitment that I understand the 
importance of this type of program.
    Senator Casey. Thank you, and we will followup.
    Thank you, Mr. Chair.
    Dr. Giroir. Thank you.
    The Chairman. Thanks, Senator Casey, and thank you for your 
comments.
    Senator Baldwin.

                      Statement of Senator Baldwin

    Senator Baldwin. Thank you, Mr. Chairman, and Ranking 
Member Murray.
    I also want to appreciate and recognize the opening 
statements regarding our path forward on the things that we 
need to do in our healthcare system. I welcome the opportunity 
for hearings and input. I welcome the opportunity to work 
across the party aisle.
    I hope you will give us assignments before the end of the 
week. I do not want to wait until the first week in September, 
but I want you to know that I stand ready to do my part to work 
with you to find solutions that stabilize our insurance 
markets, that lower health costs, and improve coverage for our 
constituents. Thank you both for setting that tone and 
direction.
    I am going to follow the suit of most of my colleagues in 
talking about the opioid, and heroin, and now fentanyl epidemic 
across this country and in my State.
    I hosted a large number of roundtables and stakeholder 
meetings across the State in urban, and suburban, and rural 
settings to learn as much as I can. As we have discussed, there 
are several measures and steps that Congress has taken that I 
am proud of, and yet the crisis grows worse. I have several 
questions on this.
    I met recently with a constituent, Jesse Heffernan, of 
Appleton, WI. He is in long-term substance use and mental 
health recovery since 2001. His experience inspired him to 
start something called the Recovery Corps Program. It is 
modeled after AmeriCorps and the idea is to integrate recovery 
coaches into the entire substance use disorder care spectrum. 
He recently received some funding to pilot his program with a 
Wisconsin health system.
    I heard the exchange, Dr. McCance-Katz, with Senator 
Cassidy about expansion of the very limited resources we have 
and how we really need to do that. To improve clinical 
treatment, we have to do more to break down silos also.
    How would you expand and prioritize local efforts to 
integrate peer support and recovery services into the substance 
use disorder spectrum?
    Dr. McCance-Katz. Thank you, Senator Baldwin, for that 
question.
    There are a number of programs now that train peers. They 
are peer professionals and they are being integrated into 
treatment programs across the country. There are many 
demonstration programs of that at this point. What we can do at 
a Federal level is to help disseminate what those programs look 
like.
    I believe that every State is different, every community is 
different. States know best what their communities need. What 
they need is access to the information as to how to establish 
these kinds of programs.
    I personally believe that peers are really an essential 
part of recovery just as important as treatment.
    Senator Baldwin. I was glad to hear you reference that in 
your opening statement. We had a chance to talk about that.
    Dr. McCance-Katz. Yes.
    Senator Baldwin. I want to move onto a question for Dr. 
Adams.
    This past weekend, I had the opportunity to visit a V.A. 
Medical center in my State at Tomah, WI. Sadly, a few years 
back, Tomah had been an outlier with regard to over-prescribing 
opioids. Working with colleagues in the Senate, I authored and 
we passed the Jason Simcakoski Memorial Opioid Safety Act.
    Actually, I toured and got reporting on the implementation 
of this Act. The facility has significantly reduced its 
reliance on opioids in treating pain and provided hopeful 
alternatives to the veterans they serve.
    It tells me that one of the keys to fighting our opioid 
epidemic is the engagement of prescribers and health 
professionals, retraining to the latest guidelines of the CDC.
    Your role provides a real platform to do that, and I would 
ask you how you would see your leadership in that regard?
    Dr. Adams. Thank you, Senator, very much.
    I want to, first of all, say thank you for your courage and 
your leadership. As someone who has often been the only 
minority in the room, I really sincerely appreciate what you 
have accomplished and what you have done. For those who may be 
watching and you do not know, Senator Baldwin is the first 
openly gay Senator. Growing up as the only one in the room, I 
know how it feels.
    To your point, or to your question, I think the Surgeon 
General's position has a tremendous opportunity to bring folks 
together. I have done it, not just as surgeon general, not even 
just as Indiana's State Health Commission, but as a physician. 
As a leader in the American Medical Association partnering with 
the Hospital Association, partnering with other entities to try 
to bring the right folks together to make sure we are educating 
people.
    As an anesthesiologist, a physician anesthesiologist, I 
teach people every day about proper prescribing and the dangers 
of over-prescribing. One of my clinical focuses is on 
alternatives to opioid pain management.
    I think we need to look at how we are paying for different 
modalities to make sure the easy choice is also the right 
choice. Far too often, the easy choice is just to give out 60 
Vicodin. We need to make the right choice the easy choice for 
physicians.
    I intend to go out to communities, to medical schools, to 
dental schools, to nursing schools because we cannot forget the 
prescribing community is more than just physicians and partner 
with all the folks who are part of this chain. It is not just 
one group that we want to point our finger at, but we all are 
part of this problem.
    I apologized, when I came before the committee on aging, to 
all the committee for the part that I and my colleagues played 
in the opioid epidemic. I go around telling folks, ``I do not 
care if you are 1 percent responsible or 99 percent 
responsible, what I care about is what you bring to the table 
in terms of a solution.'' Hospitals, providers, legislators all 
can play a part in this solution.
    I look forward to the opportunity, if confirmed, to being a 
convener, to bring those folks together.
    Thank you.
    The Chairman. Thank you, Senator Baldwin.
    I think some Senators may have additional questions.
    Senator Murray.
    Senator Murray. I just have one additional, Dr. Kadlec. I 
did not want you to get off free here.
    Dr. Kadlec. Thanks for noticing, ma'am.
    Senator Murray. As a staffer to Senator Burr, I know that 
you played a key role in drafting the Pandemic and All-Hazards 
Protections Act, which critically addressed both domestic and 
international public health preparedness capacity and 
capability. We have often seen this tested in recent years.
    I was really concerned when I saw the President's 2018 
budget request, which proposed significant cuts to CDC's public 
health emergency preparedness grants to health departments and 
to the Hospital Preparedness Program, which you would oversee 
if you are confirmed.
    The 2018 request proposes eliminating hospital preparedness 
funding from 26 jurisdictions including my home State of 
Washington.
    Do you agree with the proposed cuts to those programs?
    Dr. Kadlec. Ma'am, I was not part of those discussions or 
deliberations, so I cannot give you color commentary to what 
may have happened or what was represented there.
    I can only assure you one thing, that I will be an advocate 
for these programs and I will fight very hard to basically 
represent them in the policy halls in HHS with Secretary Price 
and the White House when the time comes.
    I have done it before in OMB, and I have done it before in 
the White House, and I certainly have not had the chance in HHS 
yet, but I am looking forward to it, if confirmed.
    I do have to tell you this, ma'am, is that we do have to do 
some things, as raised by the Chairman, in terms of creating 
certainty around funding for some of these programs. As is for 
the health insurance programs, the same are required for 
preparedness, whether it is for public health preparedness, 
hospital preparedness, or for the development of 
countermeasures.
    That kind of certainty is required to ensure that the State 
and local authorities--the private sector can do the things 
that they need to do to ensure that, God forbid, when these 
things happen, and they will as you know, ma'am, that we can do 
that.
    The only assurance I can give you right here, right now is 
that if you support me, I am going to be a fighter for these 
things. I know that States like yours have often led the way on 
these issues, and I am certainly respectful of that. Also will 
commit to the idea of, again, advocating for the programs and 
for your constituents on these issues.
    Senator Murray. Thank you. Thank you very much. I 
appreciate that.
    The Chairman. Senator Warren, did you have additional 
comments?
    Senator Warren. I do, but I yield to Senator Hassan?
    The Chairman. Senator Hassan, do you have additional?
    Senator Hassan. Thank you. Thank you, Senator Warren.
    To the Chair and Ranking Member, also, count me in. 
Obviously, I think all of us are eager to work on a bipartisan 
process on healthcare and we are very, very grateful for your 
leadership to both of you.
    Dr. Kadlec, I do not have a question for you, but as a 
former Governor, I can tell you I am right there with you on 
the importance of preparedness, and certainty, and funding for 
preparedness. You have an ally here and I look forward to that 
work.
    Dr. Kadlec. Thank you, ma'am.
    Senator Hassan. Dr. Adams, I wanted to explore another area 
with you.
    Last year, the former Surgeon General issued a report 
concluding that the use of electronic cigarettes, also called 
e-cigarettes, pose a risk to Americans particularly to our 
youth and our young adults.
    The Surgeon General's report called for action to reduce e-
cigarette use among young people, including actions by Federal, 
State, and local governments.
    Just last week, though, the FDA announced it would delay 
what is called the deeming rule to review products like e-
cigarettes that are on the market. Under the deeming rule, FDA 
could take into account, for instance, the impact of e-
cigarette flavors like cotton candy and bubblegum on the 
product's appeal to youth. It is an important tool that the FDA 
has to protect children and the public health.
    I am worried that delaying the deeming rule is 
contradictory to what the 2016 Surgeon General's report called 
for.
    Do you agree?
    Dr. Adams. I was not privy to the discussion within the 
FDA, Senator, but I do thank you for the question. It is an 
important one.
    Decreasing the number of people who are consuming both 
tobacco- and nicotine-related products is of utmost importance 
from a public health point of view.
    I think it is important that we distinguish between never 
smokers and current smokers. There is actually a debate going 
on in the public health community worldwide about the benefits 
of e-cigarettes and vaping, and I think it is because people 
are confusing the two.
    Senator Hassan. Just because we are constrained for time, I 
think this, though, is very specific. Because when you think 
about it--while we can talk about the value or not of e-
cigarettes and vaping for somebody who might be trying to quit 
the nicotine habit with regular cigarettes--this is about 
flavoring e-cigarettes in a way that will get young people 
hooked on the habit in one form or another to begin with.
    Can we agree that that is harmful?
    Dr. Adams. We can absolutely agree and I want to do 
everything possible to prevent young people from starting down 
the pathway of nicotine addiction. I commit to working with you 
and, if confirmed, with the FDA to make sure we do that.
    Senator Hassan. Thank you.
    Here is a question for both Dr. Adams and Dr. Giroir. It 
goes back to one of the other mentions of this that, I think, 
Senator Murray made.
    The Office of the Assistant Secretary for Health directs 
the Presidential Advisory Council on HIV/AIDS. On June 16, 2017 
six members of the Presidential Advisory Council on HIV/AIDS 
announced their resignation in ``Newsweek''.
    Here is what they said. Here are the quotes.

          ``The Trump Administration has no strategy to address 
        the ongoing HIV/AIDS epidemic, seeks zero input from 
        experts to formulate HIV policy. And most concerning, 
        pushes legislation that will harm people living with 
        HIV and halt or reverse important gains made in the 
        fight against this disease.''

    They also said that they could not effectively fight HIV/
AIDS, and this is their quote, ``Within the confines of an 
advisory body to a President who simply does not care.''
    Further, there is also not yet a director of the White 
House Office of National AIDS Policy.
    Dr. Giroir and Dr. Adams, I am interested on your thoughts 
about how you would address the concerns expressed by these 
advisory council members and what you see as your role in 
making sure that we are confronting and having a robust HIV/
AIDS policy and program in this country that can help people 
living with the disease.
    Why do I not start with Dr. Giroir?
    Dr. Giroir. Thank you for that question.
    I read that in the papers as well and I took it quite 
personally. I took it personally because much of the complaint 
was because of a lack of leadership in the office. This office 
is under the office of the Assistant Secretary for Health.
    Senator Hassan. Right.
    Dr. Giroir. I remain in waiting, if confirmed, for that 
position.
    Senator Hassan. Sure.
    Dr. Giroir. One of the first things I will do will be to 
speak with those individuals to assure them that there is a 
national HIV strategy. I have not discussed it within the 
office, but it is a very robust one. There has been tremendous 
gains.
    I am absolutely committed to moving forward with those 
gains, as well as the other important viral diseases that are 
under that office's purview. Many of you have spoken to me 
about Hepatitis C.
    Senator Hassan. Sure.
    Dr. Giroir. A very important disease with millions affected 
and millions still left untreated, even though there is a 
potential cure for it.
    All I can say, if fortunate enough to be confirmed, is that 
office will have all the attention that I can give it. We will 
look very critically at the advisory committee to make sure 
that it is appropriately staffed so that we get a diversity of 
opinions grounded in science to move the successes we have had 
with HIV even further.
    Senator Hassan. Thank you.
    I know I am out of time, but perhaps, Dr. Adams, if you 
could just address it.
    Dr. Adams. Mr. Chairman, if you do not mind.
    Senator Hassan. I am out of time, but I would ask the 
question of both Dr. Adams and Dr. Giroir.
    The Chairman. If we do a third round, you can.
    Senator Hassan. Perfect. Yes, that is fine.
    The Chairman. Let us let the other Senators have their 5 
minutes.
    Senator Hassan. Thank you.
    The Chairman. For Senators' knowledge, we have two votes at 
5 p.m.
    Senator Warren.
    Senator Warren. Thank you, Mr. Chairman.
    I want to continue our focus on the opioid. Last year, more 
than 2,000 people died in Massachusetts alone. This is 
powerfully important to me, and to the people I represent, and 
to everybody who sits on this committee, and I think in the 
United States Senate.
    Dr. Adams, as Indiana Health Commissioner, you saw the 
epidemic up close when you dealt with the HIV outbreak in Scott 
County, IN. There has been a lot of discussion about that 
today, several references to your work there.
    You established a syringe exchange program, which was 
illegal in Indiana at the time when you first recommended it. 
The consequence is that you helped save lives and helped 
contain that outbreak. I just want to ask you a question, Dr. 
Adams.
    Why did you press for such a program even though it was 
controversial and, in some quarters, politically unpopular?
    Dr. Adams. Thank you so much for the opportunity to answer 
that question.
    I pressed for it because it was the right thing to do. It 
was the scientifically sound thing to do. It was what I felt 
was necessary to save lives and stop disease transmission. As I 
mentioned earlier, I also recognized that the knowledge base 
oftentimes is not enough and that we had to partner.
    The most important thing, as I mentioned earlier, that the 
Governor and I did was to go down to Scott County and talk to 
folks.
    I do not want to take up your time, but I do want to say 
very quickly. Ask yourself if I said to you, ``I am going to 
open up a syringe exchange program across the street from where 
you live.'' The first thing you are going to say is, ``Oh, no. 
You are not.'' Then you are going to say, ``Come down and 
explain to me why this is necessary.''
    Senator Warren. Right.
    Dr. Adams. Partnerships are critical. The science has to be 
there, but it has to be given in a sympathetic and empathetic 
way.
    Senator Warren. The way I read this, your response, is you 
said you are willing to do something that is innovative, data-
based even if it turns out to be politically controversial.
    Dr. Adams. I feel a trap coming, Senator.
    Senator Warren. No, no.
    [Laughter.]
    No, we can be friends here, Dr. Adams.
    Dr. Adams. We are friends.
    Senator Warren. Good, good.
    Here is what I am going to ask you. Are you aware that the 
American Medical Association recently endorsed developing pilot 
facilities where people who use their own drugs can do so 
safely under medical supervision?
    Dr. Adams. I am. I was there when they debated it.
    Senator Warren. What is your view on that?
    Dr. Adams. My view on that is that the science is not quite 
there to the extent that it is for syringe exchange programs, 
but we have two natural pilot programs, one in Massachusetts 
and, I believe, one in Seattle and I look forward to carefully 
reviewing the data.
    Even if we do have compelling data, just as I said with 
syringe exchange programs, we still have to come back to local 
control and local conversations.
    Senator Warren. Reviewing the data, and studying it, and 
perhaps expanding the studies of supervised injection 
facilities as a public health tool in the fight against the 
opioid epidemic.
    Dr. Adams. I think it is one of many tools that should be 
considered in the tool chest and communities need to be leading 
that conversation about whether it is right for their 
community.
    Senator Warren. We need a Surgeon General who is also going 
to lead that conversation.
    Dr. Adams. I would love that conversation across the 
country and quite frankly, across the world because of the 
unfortunate HIV outbreak that occurred in Scott County.
    Senator Warren. Thank you, Dr. Adams.
    You were right. I hope that we very much are friends 
because you are an evidence-based, committed physician even if 
it is politically unpopular. I think that is what we need right 
now in addressing the opioid crisis.
    We truly do need all hands on deck whether they are 
politically acceptable or not politically acceptable. We have 
got to do what the evidence tells us may have an effect. We 
study it, we find out, and then we follow through. I think that 
is powerfully important and that is what I want to see in a 
Surgeon General.
    Thank you, Dr. Adams.
    I will be submitting other questions for the record.
    I am going to yield back my time, Mr. Chairman.
    The Chairman. Senator Warren, that is the second time you 
have done that today.
    [Laughter.]
    Senator Warren. Well, you know.
    The Chairman. I commend you as a succinct professor, as a 
terrific addition to the committee. I admire Dr. Adams for 
seeing where you were going too.
    I have a couple of questions.
    Dr. Giroir, I talked with you earlier, and with Secretary 
Price, and with Secretary Perry, and Seema Verma about using 
the Government's super computers to identify waste, fraud, and 
abuse which seemed like a no-brainer.
    There was basically a pilot program done at CMS in the 
Obama administration--which if we began to look for waste, 
fraud, and abuse using the same techniques that we used to look 
for terrorists in a needle in a haystack sort of search--that 
we might get some good results.
    According to ``The Economist,'' as much as $272 billion 
across the entire health system is swindled each year and some,

          ``Criminals are switching from cocaine trafficking to 
        prescription drug fraud because the risk-adjusted 
        rewards are higher, the money is still good, the work 
        safer, and the penalties lighter.''

    Are you willing to try to take another look at using our 
super computers and our data at CMS to identify waste, fraud, 
and abuse in the system?
    Dr. Giroir. Mr. Chairman, thank you for that question.
    I think it opens an even broader discussion--in that I was 
in the Department of Defense for a period of time. We worked 
very closely with DOE. We have to break down the silos between 
the tremendous capabilities we have among our Government 
agencies. The Department of Energy has super computers, not 
only super computers but the world's best expertise on how to 
program and ask questions.
    What can be done by collaborating with the Department of 
Energy for CMS, for the V.A. health system, for understanding 
risk behaviors and outcomes cannot be understated. This is 
something, certainly, I want to do and want to promote, which 
is the work among the interagency.
    I actually spent quite a period of time talking to national 
leaders on the science side in the Department of Energy, and 
what they told me was quite surprising to me. Not only do they 
want to work on health problems, not just this problem of fraud 
and abuse, but on health problems. The complexities of the 
health problems that they have to deal with are making them 
more capable of dealing with their primary missions of nuclear 
security.
    This is a win-win across the board.
    The Chairman. Yes, I would hope.
    I would imagine that the pushback from CMS will be, ``These 
computer people do not know enough about healthcare.'' That is 
true, but they can learn it. They can learn enough. To find 
criminals in the haystack stealing money that could be better 
spent caring for people, just as they have learned how to use 
computers to catch terrorists who might be trying to blow us 
up.
    Dr. Giroir. I have not spoken to CMS, but I think you are 
exactly correct.
    The Chairman. Will you pursue this?
    Dr. Giroir. I absolutely will pursue it.
    The Chairman. You have at least two cabinet members and 
Senator Blunt and I are very interested in this. Seema Verma 
seems interested. She has had other things to do the last few 
weeks.
    Dr. Giroir. We have to understand that the tools of 
mathematics and big data analysis cross all disciplines.
    The Chairman. Good.
    Dr. Kadlec, I want to give you a chance. We talked about 
how the primary purpose of ASPR is to lead the public health 
emergency preparedness and response. The question Senator Burr 
often says here, ``who is in charge?''
    What are you going to do about the ``who is in charge?'' 
question when it comes to a public health emergency?
    Dr. Kadlec. Sir, I would just simply say, if confirmed, I 
would be in charge for clarity, No. 1.
    No. 2, it is really important to work with my colleagues.
    The Chairman. Do you have an understanding with others, who 
think they might be in charge, that you are in charge?
    Dr. Kadlec. Sir, I think that is an issue that is set with 
Secretary Price right from the get go.
    The Chairman. Yes.
    Dr. Kadlec. As I see it.
    The Chairman. I agree with you about that.
    Hyman Rickover, we have never had anyone die from a nuclear 
reactor on a submarine or the ships since Rickover started it 
in the 1950s, and it is because he told the captains in his 
interview that, ``You have two responsibilities. One is the 
ship, one is the reactor, and if anything happens with the 
reactor, your career is over.'' There have been a lot of good 
careers and there has never been a death as the result of a 
reactor.
    Who is on the flagpole makes a difference.
    Dr. Kadlec. Yes, sir. It does. Sir, I would consider myself 
to be that, but it takes more than one person to make this 
work.
    Clearly people like Dr. Fitzgerald at the CDC, folks at the 
FDA, clearly these colleagues here are all going to have 
something to add and collaborate with on these issues 
particularly Dr. Giroir and Dr. Adams.
    My interest is really building a team, or to help build a 
team, under Secretary Price to kind of do the things 24-7-365 
that nobody else really has the bandwidth to do honestly on a 
day-to-day activity unless something bad happens.
    My job is to think of those bad things and work with a 
tremendous group of people at ASPR right now and kind of do the 
arduous, predictive work that has to be done well in advance of 
a crisis to ensure we have the means.
    Sir, I will end my comments with a caution--which is one 
that General Schoomaker, former Chief of Staff of the Army and 
former Commander of Special Operations Command often used--
which was, ``Do not confuse enthusiasm with capability.''
    The one thing I need, sir, to give you confidence in and 
for Senator Murray as well, and your other members here, and 
Secretary Price, is that we have the capabilities. Job one for 
me--first, when I hit the ground--is really to evaluate, kick 
the tires on the capabilities that we have and to see if they 
are sufficient to deal with the likely crises we may encounter.
    To Senator Murray's point, funding will always be 
important. Right now, we spend about two-thirds of what we 
spend on a single aircraft carrier for preparedness and 
response. That imagery is kind of important to me because you 
do not get very far on two-thirds of an aircraft carrier.
    The Chairman. Thank you, Dr. Kadlec. I let the time run 
over, but that is both my rounds of questions.
    Dr. Kadlec. Thank you, sir.
    The Chairman. I have remarks from Senator Burr who could 
not be here today, expressing his support for Dr. Robert 
Kadlec's nomination for Assistant Secretary for Preparedness 
and Response.
    I ask for consent for his remarks to be submitted for the 
record, and they will be introduced.
    [The information referred to may be found in Additional 
Material.]
    The Chairman. I also ask consent to introduce 43 letters of 
support for Mr. Lance Robertson, 8 for Dr. Brett Giroir, 2 for 
Dr. Kadlec, 25 for Dr. McCance-Katz, and 10 for Dr. Jerome 
Adams into the record, and they will be introduced.
    [The information referred to may be found in Additional 
Material.]
    Are there other questions before we conclude?
    Senator Hassan.
    Senator Hassan. Perhaps we could just let Dr. Adams speak 
to the earlier question about HIV and AIDS policy and then I am 
all set.
    The Chairman. Sure. Dr. Adams.
    Dr. Adams. Thank you for the question.
    I very quickly and briefly will say, I oversaw the response 
to the largest HIV outbreak related to injection drug use in 
the history of the United States as declared by CDC Director 
Tom Frieden. I am supported by the Damien Center, which is the 
largest provider of HIV care in the State of Indiana. There is 
a letter of endorsement from them.
    The best thing that you can do to help improve what some 
people perceive as a lack of direction in regards to HIV care 
is to confirm this panel, including Dr. Giroir and I, so that 
we can get to work.
    Senator Hassan. Thank you very much.
    Dr. Adams. Thank you.
    The Chairman. Thank you, Senator Hassan.
    Senator Murray. Mr. Chairman, could I----
    The Chairman. Senator Murray.
    Senator Murray [continuing]. Could I just say?
    I know there may be some additional questions and due to 
the uncertainty and timing on when we are voting on these, I 
would just ask all the nominees to respond. If we could work 
out a time that we could make sure that we get answers back to 
those questions.
    The Chairman. It might be hard to do it by tomorrow.
    Senator Murray. I totally understand that.
    The Chairman. We will work it out.
    Senator Murray. We will work it out.
    The Chairman. Yes, that is the way we will do that.
    First, let me thank each of you for being here and 
congratulate you on your nominations.
    If you are confirmed, this will complete Senate approval of 
all of the Assistant Secretary positions in the Department of 
Health and Human Services in the Trump administration. There 
will be a full team ready to go to work as far as we are 
concerned.
    We have talked a lot today about implementing laws. We have 
been pretty busy the last couple of years in this committee on 
mental health, on 21st Century Cures, on electronic healthcare 
records, a whole variety of health-related issues.
    We know the laws are not worth anything unless they are 
implemented properly, so we hope and expect that if Senators 
ask questions--I had a little discussion with Senator Warren 
about this the other day involving another department--if 
Senators ask questions, we would like for you to answer them.
    If you feel you cannot, or the question is unreasonable, 
well then, I would call the Senator and say, ``Look. I got this 
from your office. Maybe somebody is writing letters under your 
name,'' or something like that.
    [Laughter.]
    Do not ignore the question. It is perfectly understandable 
if you cannot answer a question for some reason. Why, just call 
the Senator and say, ``Here is my problem,'' and discuss it 
with that person because it is important for us to be able to 
communicate with you.
    It fills all the Assistant Secretary positions under our 
jurisdiction, maybe I did not say it that way, but that is what 
I meant.
    If there are any other Assistant Secretaries who are not 
confirmed, it is not our fault.
    [Laughter.]
    Senator Murray has agreed that we can go ahead with the 
mark up tomorrow, and then hopefully, you might be confirmed, 
and in your jobs soon thereafter.
    Senators who wish to ask additional questions of the 
nominees, questions for the record, are due at a time that 
Senator Murray and I will agree on.
    For all other matters, the hearing record will remain open 
for 10 days. Members may submit additional information for the 
record within that time.
    We will meet again, tomorrow, at a time convenient for 
Senators for an executive session to consider these nominations 
and additional nominations up for consideration.
    Thank you for being here today.
    The committee stands adjourned.
    [Additional Material follows.]

                          ADDITIONAL MATERIAL

                   Prepared Statement of Senator Burr

    Mr. Chairman, when Senator Ted Kennedy and I designed the 
role of the Assistant Secretary for Preparedness and Response 
(ASPR) under the Pandemic and All-Hazards Preparedness Act, we 
envisioned an official solely focused on the singular 24/7 
mission of making sure we are prepared for the public health 
threats we may face, whether naturally occurring like Ebola and 
H1N1, or the result of a deliberate attack on our country. The 
role of the ASPR was designed to answer the simple and critical 
question: Who is in charge? It is critical for the individual 
serving as the ASPR to recognize this singular focus, and 
execute the role of the ASPR with a daily vigilance. We cannot 
wait until a threat is upon us to respond, and the ASPR serves 
to prepare for and respond to these threats in order to save 
American lives. Put simply, Dr. Robert Kadlec is well-prepared 
for and well-suited to fulfill every aspect of this role.
    Dr. Kadlec brings with him a deep and thorough 
understanding of the role served by the Assistant Secretary for 
Preparedness and Response at the Department of Health and Human 
Services. He has had the opportunity to serve in numerous 
biosecurity, intelligence, and policy positions that will 
inform his work as the ASPR. Notably, he has served under 
President Bush as an advisor on the Homeland Security Council 
and on my staff in the Senate Select Committee on Intelligence. 
His years of honorable service show his dedication to country 
and his work in the White House, military service, and 
leadership of the Senate Select Committee on Intelligence have 
helped to shape and grow his unique understanding of the 
threats faced by our country. Each of the steps he has taken 
throughout his noteworthy career will be valuable assets should 
he be confirmed as the next ASPR, and each of the goals he 
outlines in his statement are consistent with the vision 
Senator Kennedy and I worked to get signed into law over a 
decade ago.
    The first goal Dr. Kadlec mentions is providing strong 
leadership and clear direction. While the statute clearly 
defines who is in charge during a public health emergency, 
there have been multiple instances in recent public health 
crises where the coordination and communication roles of the 
ASPR were not operationalized effectively. I am pleased that 
this is his first priority and goal, and I am confident that 
Dr. Kadlec will bring to the role of ASPR the dedication, 
vigilance, and urgency it requires.
    Further, another critical role of the ASPR is to oversee 
the Biomedical Advanced Research and Development Authority 
(BARDA), which brings forward medical countermeasures to 
prevent and respond to emerging infectious disease outbreaks 
and other chemical, biological, radiological and nuclear 
threats.
    Bringing these medical countermeasures through the 
research, development, approval, and procurement processes is a 
long, difficult, and often risky task for manufacturers and 
innovators in this space. In order to realize the full 
potential of the medical countermeasure enterprise in our 
country, we must ensure that the Federal Government is sending 
a clear signal that we are a good-faith and willing partner in 
this endeavor. Dr. Kadlec has the firsthand knowledge necessary 
to achieve this goal, and will provide industry the confidence 
needed to invest in much-needed medical countermeasures to 
address the threats facing our Nation today and tomorrow.
    Ultimately, the ASPR must properly coordinate and 
communicate with other officials throughout the Administration 
and manage all of the tools at our disposal to effectively and 
efficiently prepare for and, if necessary, respond to a 
chemical, biological, radiological, or nuclear attack. This 
will only grow more challenging in the years to come and Dr. 
Kadlec is uniquely prepared for this challenge. I urge each of 
my colleagues to support Dr. Kadlec's nomination. He is the 
right person to serve as the next Assistant Secretary for 
Preparedness and Response. I thank the Chair.
                           Letters of Support
                            lance robertson
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 ______
                                 
  Response by Lance Robertson to Questions of Senator Murray, Senator 
   Sanders, Senator Casey, Senator Franken, Senator Bennet, Senator 
Whitehouse, Senator Baldwin, Senator Murphy, Senator Warren and Senator 
                                 Hassan
                             senator murray
    Question 1. As the Assistant Secretary for Aging, you will also 
serve as the Administrator for the Administration for Community Living 
(ACL). This agency was created in 2012 by bringing together the 
Administration on Aging, the Office on Disability, and the 
Administration on Developmental Disabilities. The purpose of the 
agency, therefore, is to address the full spectrum of community living, 
health care, and long-term service and support needs for both the aging 
and disability populations. However, your professional experience has 
largely been established by administering aging service programs.
    Describe your professional experience working with individuals with 
disabilities and their families and the disability service providers 
and programs in Oklahoma.
    How have you bridged the silos that are often created between aging 
and disability service programs in State government?
    How will you ensure equity in resource allocation between programs 
for people with disabilities and programs for older adults in ACL?
    Answer 1. As I mentioned in my testimony, having a close family 
member who lives with a significant disability and a mother who is a 
career Intellectual and Developmental Disabilities case manager has 
given me a personal view of the importance of ACL's work for people 
with disabilities. Through my work as president of the National 
Association of States United for Aging & Disability (NASUAD), we 
decided to include a ``D'' in the organization's name to fully reflect 
our work and commitment to the disability community.
    Together, we are better able to leverage learnings and best 
practices for meeting those similar needs. Further, the disability and 
aging communities together have a larger voice than either community on 
its own. Silos are not helpful within any organization, and I look 
forward to working effectively at ACL to better unify our populations 
and strengthen our programs.

    Question 2. The President's 2018 budget proposal called for a 
number of cuts to and restructuring of programs for individuals with 
disabilities and their families. Specifically, the President's budget 
recommended a cut of $23 million to the Independent Living program, 
thereby eliminating funding for the Independent Living State Grants 
program. The House Appropriations Committee fiscal year 2018 Labor, 
Health, Human Services, and Education bill restores this funding to the 
Independent Living program.
    What efforts will you take to ensure the Centers for Independent 
Living and the Statewide Independent Living Councils have the necessary 
funding and administrative support to fulfill their responsibilities as 
required by the Rehabilitation Act of 1973, and fully implement the new 
core transition services required by the Workforce Innovation and 
Opportunity Act (WIOA)?
    Answer 2. The work of the Centers for Independent Living and the 
Statewide Independent Living Councils is important. I look forward to 
working with ACL team members, HHS leaders, and Congress to ensure 
these programs are funded in the most responsible way.

    Question 3. The President's 2018 budget proposal called for the 
merging of several disparate disability programs, namely the State 
Councils on Developmental Disabilities, the State Independent Living 
Councils, and the State Advisory Boards on Traumatic Brain Injury into 
the Partnership for Innovation, Inclusion, and Independence. The House 
Appropriations Committee fiscal year 2018 Labor, Health, Human 
Services, and Education bill does not consolidate these programs.
    Do you agree that each of these programs plays a unique role in 
facilitating the mission of ACL?
    Would you support an effort to consolidate these programs to save 
money?
    Answer 3. The work of all three entities is important. The ultimate 
goal is achieving the highest possible outcomes with the programs and 
for the populations we serve. I look forward to being a part of the 
coming conversation and working with all parties to deploy whatever is 
decided and following the guidance given by the President and Congress.

    Question 4. Older adults and people with disabilities experience 
unique barriers during a crisis. As the director of the Aging Services 
Division in Oklahoma, how did you engage individuals, service 
providers, and communities in emergency preparedness? How will you 
ensure emergency preparedness and response programs are accessible to 
all individuals with disabilities?
    Answer 4. Oklahoma ranks as one of the top States in disaster 
declarations, giving me ample exposure to the importance of emergency 
preparedness. For the past decade, I have served on several of our 
State's top preparedness committees and many of my staff members are 
directly tied to response plans. Building on the plans ACL already has 
in place is critical, and my commitment to ensuring the safety of the 
populations we serve during a time of crisis is very strong. I look 
forward to working with the Assistant Secretary for Preparedness and 
Response (ASPR) to make sure that programs are accessible to all 
individuals.

    Question 5. WIOA transferred the National Institute on Disability, 
Independent Living, and Rehabilitation Research (NIDLIRR) from the 
Department of Education's Office of Special Education and 
Rehabilitative Services (OSERS) to ACL. NIDILRR's mission is to 
generate new knowledge and promote its effective use to improve the 
abilities of people with disabilities to perform activities of their 
choice in the community.
    What is your position on evidence-based programs and policy?
    As director of the Aging Services Division in Oklahoma, how have 
you used data to make program and policy decisions?
    Answer 5. NIDLIRR has a commendable history of producing important 
work, generating new knowledge, and contracting with partners to 
provide assistance to people with disabilities for activities of their 
choice in the community. Evidence-based programs and policies are 
important to ACL, and I will certainly continue that focus.

    Question 6. The President's 2018 budget proposal called for an 
elimination of the Senior Community Service Employment Program (SCSEP). 
The House Appropriations Committee 2018 Labor, Health, Human Services, 
and Education bill transfers the program to ACL and also cuts $100 
million in funding. The SCSEP is the only employment program targeted 
for older adults and has been successful in assisting millions of low-
income job seekers find work.
    Answer 6. If confirmed as the Assistant Secretary for Aging, will 
you commit to protecting the SCSEP and advocate for robust funding to 
ensure the program reaches all eligible older adults who experience 
barriers to employment?
    I am committed to removing barriers to employment, regardless of 
age or disability. Ensuring that everyone who wants to work has as many 
opportunities as possible to do so is a critical element of supporting 
the ability of all people to live their lives as integrated members of 
their communities. Increasing access and eliminating barriers to 
employment has been part of ACL's mission since its creation, and I 
look forward to continuing that important work.

    Question 7. The Leadership Council of Aging Organizations (LCAO) 
wrote a letter opposing ACL's proposal to eliminate LGBT older adults 
from the National Survey of Older American Act Participants. Do you 
agree with LCAO that,

          ``ACL must continue collecting data on whether the aging 
        network is reaching LGBT older adults in order to ensure the 
        maximum inclusion of LGBT older adults in programs funded under 
        the Older Americans Act?''

    As the Assistant Secretary for Aging, would you stand up for LGBT 
individuals and prevent any systematic effort by this Administration to 
eliminate data necessary for the full inclusion of the LGBT community 
in Federal programs?
    Answer 7. Throughout its existence, ACL has been committed to 
ensuring that all people touched by or eligible for our programs have 
access to the high quality services and supports they need to be able 
to live where they choose and with the people they choose, and to fully 
participate in their communities, and I share that commitment. We will 
continue to work with grantees and stakeholders in the aging and 
disability networks to help them best serve older adults and people 
with disabilities, particularly those with the greatest social and 
economic needs.

    Question 8. As you know, the Older Americans Act specifically 
establishes the role of the Assistant Secretary for Aging with a direct 
reporting relationship to the Secretary of the Department of Health and 
Human Services (HHS). In the dual role for which you are nominated, how 
do you anticipate being a leader and advocate on behalf of the Older 
Americans Act and the Aging Services Network, while also providing 
stewardship of the programs and services that both older adults and 
individuals with disabilities rely upon?
    Answer 8. I know from the State perspective that bringing together 
aging and disability work at the Federal level has worked remarkably 
well. The aging and disability networks have embraced the concept and 
have committed to making it successful. There are a lot of similarities 
in the services and supports older adults and people with disabilities 
need to live independently. Together, we are better able to leverage 
learnings and best practices for meeting similar needs. Further, the 
disability and aging communities together have a larger voice than 
either community on its own. At the same time, neither network loses 
the unique elements of its individual mission.
    When there are issues that affect both people with disabilities and 
older adults, we can join forces to address them in a consistent and 
holistic way. There also are issues that affect only older adults, or 
only people with disabilities. I am committed to ensuring that ACL 
continues to develop and manage programs that best serve each 
population individually, as well.

    Question 9. As a result of the Americans with Disabilities Act and 
the U.S. Supreme Court's decision in Olmstead v. L.C., there has been a 
national trend toward deinstitutionalization and community inclusion of 
older adults and people with disabilities.
    Do you agree with the Supreme Court's ruling that it is 
discrimination to deny people with disabilities services in the most 
integrated setting possible?
    Do you agree that for older adults and people with disabilities, 
having the option to live and receive services in their homes and 
communities can be vital to their well-being?
    If confirmed, will you defend and broaden access to home and 
community-based services and supports for both older adults and people 
with disabilities?
    Answer 9. I am fully committed to implementing the laws passed by 
Congress that provide ACL with tools to assist older and disabled 
Americans to live where they choose and with the people they choose, 
and to participate as they choose in their communities.
    For this to be possible, home- and community-based services and 
supports must be robust enough that individuals with even the most 
complex medical and behavioral needs who desire to live in the 
community can be appropriately and effectively supported in their own 
home- or other community-based settings. While this has been 
demonstrated in many communities, it is not reality everywhere.
    ACL advocates for the expansion and coordination of home- and 
community-based services and improvements in quality so that older 
adults and people with disabilities have more and better options about 
how and where to receive the long-term services and supports they need. 
I look forward to continuing that work.

    Question 10. The President's 2018 budget proposal called for a 
number of cuts to programs for older adults and people with 
disabilities under ACL, raising questions whether this Administration 
values the programs ACL supports. If confirmed, will you be a vocal 
advocate internally for funding for ACL and push back in future budget 
cycles against cuts to programs that support these communities?
    Answer 10. I have been an advocate for older adults and people with 
disabilities throughout my career. I look forward to continuing that 
role at the Federal level to help ensure the long-term sustainability 
of the critical programs that support older adults and people with 
disabilities and help them live independently.
                            senator sanders
    Question 1. Mr. Robertson, this position plays a pivotal role in 
assessing, planning and advocating for a variety of programs and 
initiatives that are aimed at improving the health, health care, 
wellness and lives of older individuals. As you know, as most Americans 
age, they do so wanting to age in their own homes. Often times, this 
means that they will require a variety of critically important support 
services--like meal programs, community-based care, and assistance 
provided to their care givers--many of which you strongly advocated for 
in your previous positions. In fact, your past positions on the 
importance of supporting and robustly funding these programs show that 
you understand how vital they are to older people, especially to those 
who are trying to age at home. Unfortunately, based on the budget he 
proposed, President Trump seems far less supportive of these types of 
very important programs. How do you plan to ensure that the very 
programs that you have expressed strong support for in the past--
programs that make a very real difference to millions of older 
Americans--do not get drastically cut or eliminated altogether in this 
Administration? What are your plans to ensure that older Americans will 
have the support services that they need to age with dignity in their 
own homes?
    Answer 1. ACL's work to help older adults and people with 
disabilities live independently in their communities has never been 
more important. There are 65 million people age 60 and older. All but a 
tiny percentage of them live in non-institutional settings, as do 
nearly 57 million people with disabilities.
    Older Americans are one of the fastest-growing demographic groups 
in the country. Maintaining service levels in the face of a growing 
population is always a challenge. I believe that the use of innovation 
and evidence-based practices will be critical to keeping these programs 
vital, and to meeting the evolving needs of older Americans.

    Question 2. In detail, please share the top three efforts or 
initiatives that you plan to launch to address the unique and pressing 
health and health care issues facing people with disabilities during 
this time when the current health care system is being reformed?
    Answer 2. I am looking forward to working with my colleagues at ACL 
and throughout HHS to learn more about the programs and initiatives 
already in place. The strategy I shared in my testimony applies to both 
older adults and people with disabilities. For both populations, 
navigating the systems of services and support, identifying what is 
available, and understanding how to access those services, can be 
overwhelming. We have to streamline that process and ensure the needs 
of the person are kept at the forefront of our focus.
    Families and friends play a critical role in supporting older 
adults and people with disabilities alike. Supporting those people is 
essential to helping older adults and people with disabilities continue 
living independently in the community. It is imperative that we ensure 
the community-based organizations, that form the aging and disability 
networks, are able to survive in the increasingly complex health care 
environment. ACL has been investing in helping the networks develop the 
business acumen necessary to integrate the services they provide into 
the overall health care spectrum. I believe that work is absolutely 
critical.
                             senator casey
    Question 1. During the campaign, President Trump said that he would 
``do everything in [his] power to protect LGBT citizens.'' As we have 
seen, the President and the Administration are failing to live up to 
that promise. Last week, over Twitter, President Trump announced 
transgender individuals would be banned from serving in the military. 
Sadly, that is far from the only Administration action that would have 
adverse consequences for LGBT Americans. In April, ACL eliminated 
sexual orientation and gender identity questions on two important 
surveys that are used to assess Older Americans Act and disabilities 
programs. Mr. Robertson, if you are confirmed, will you ensure that ACL 
programs meet the needs of the entire LGBT community and will you 
commit to collecting data on both sexual orientation and gender 
identity on ACL surveys that are used to assess the effectiveness of 
ACL programs?
    Answer 1. I am committed to working with the aging and disability 
networks to help them best serve older adults and people with 
disabilities, particularly those with the greatest social and economic 
needs. I am committed to better understanding these issues and ensuring 
that ACL's programs serve all people, including LGBT older adults and 
people with disabilities.

    Question 2. The President's budget included language that would 
merge several disability programs, including the State councils on 
independent living and the State developmental disabilities councils, 
which are authorized under separate statutes and are currently 
administered by ACL. At the same time, the administration has 
significantly recommended cutting the funding for these programs. The 
greater disability community is very concerned about this proposal. Do 
you support this approach and how would you merge these programs while 
ensuring congressional intent is maintained? Given that you do not have 
extensive experience with the disability community, do you commit to 
personally reaching out to them to obtain their input on this proposal?
    Answer 2. I support the idea of delivering services that help to 
achieve independence, productivity, integration, self-determination, 
and inclusion in the community while eliminating silos that make it 
harder for people to access the services they need. It is critical that 
we work closely with the aging and disability networks to ensure we are 
best meeting the needs of the people we serve. I look forward to 
working with you to implement the law faithfully and to give full 
consideration to the input from our partners across the disability 
communities.

    Question 3. While the number of older Americans is growing 
exponentially daily, aging programs have been cut or flat lined in the 
President's proposed budget. How are you going to ensure that vital 
programs important to aging Americans are protected, are not subject to 
arbitrary drastic cuts, and grow according to the needs of seniors 
during your tenure in this Administration?
    Answer 3. I have been an advocate for older adults and people with 
disabilities throughout my career, and I look forward to continuing 
that role at the Federal level to help ensure the long-term 
sustainability of the critical programs that support older adults and 
people with disabilities and help them live independently.
    Maintaining service levels in the face of a growing population is 
always a challenge. I believe that the use of innovation and evidence-
based practices, such as the flexibility Congress provided to allow up 
to 1 percent of ACL's nutrition funding to explore innovative ways to 
provide services, or the requirement that preventive health dollars be 
used for evidenced-based approaches, will be critical to keeping these 
programs vital and to meeting the evolving needs of older Americans.

    Question 4. During your opening statement at the hearing on August 
1 you stated that your goal is to provide services for those who are 
aging and those with disabilities via the least expensive means 
possible. You did not mention the quality of those services. Why not? 
How is quality of services important for those who are aging and those 
with disabilities? How will you balance the demands of cost efficiency 
and quality of services?
    Answer 4. Establishing quality standards and ensuring our programs 
meet them is absolutely critical. Many of ACL's programs already have 
outcome measures related to service quality. This must of course be 
woven into the fabric of everything we do.

    Question 5. During your opening statement at the hearing on August 
1 you mentioned four goals you would work to achieve if you were 
confirmed as Assistant Secretary for Aging and Administrator of 
Community Living. These included (a) access to treatment and service 
information, (b) support for caregivers, (c) elder justice, and (d) 
increasing the network's business acumen. How will you plan to ensure 
everyone who wants to receive care in their homes and communities can 
do so? Will you commit to reviewing these goals with the aging and 
disability communities and amending the goals depending upon the needs 
identified by the communities?
    Answer 5. Since its creation, ACL has advocated for the expansion 
and coordination of home- and community-based services and improvements 
in quality so that older adults and people with disabilities have more 
and better options about how and where to receive the long-term 
services and supports they need. I am excited to continue this work as 
the ACL administrator.
    To do that most effectively and efficiently, we have to work 
together across all levels of government, within the aging and 
disability networks, and with all potential partners to establish 
strategies for meeting these goals. Through my work at the State level 
and as a leader within NASUAD, I have spent many years working in 
partnership with my colleagues in other organizations to do exactly 
that. I am looking forward to continuing to work with my colleagues in 
the disability community to ensure we are doing the right things to 
best serve the greatest number of people with the greatest needs.

    Question 6. While a number of the goals you identify for ACL 
address aging concerns, they do not specifically call out the needs for 
individuals with disabilities and their families. There are many 
barriers that people with disabilities face, including continued 
prejudice and discrimination in services, employment, treatment and 
supports. How will you ensure ACL prioritizes people with disabilities 
as well as aging issues?
    Answer 6. The strategy I shared in my testimony applies to both 
older adults and people with disabilities. For both populations, 
navigating the systems of services and support, identifying what is 
available, and understanding how to access those services, can be 
overwhelming. We have to streamline that process and ensure the needs 
of the person are kept at the forefront of our focus.
    Families and friends play a critical role in supporting older 
adults and people with disabilities alike. Supporting this community is 
essential to helping older adults and people with disabilities continue 
living independently in the community. It is imperative that we ensure 
the community-based organizations that form the aging and disability 
networks are able to survive in the increasingly complex healthcare 
environment. ACL has been investing in helping the networks develop the 
business acumen necessary to integrate the services they provide into 
the overall healthcare spectrum. I believe that work is absolutely 
critical.

    Question 7. Your experience with the disability community at a 
national level is very limited. How will you go about engaging the 
community and learning what issues are most important to the community? 
Will you commit to personally have quarterly meetings with leaders of 
the disability community for at least the first 18 months of your 
tenure?
    Answer 7. I look forward to getting to know my colleagues in the 
disability field and I am committed to working closely with them to 
ensure we are best meeting the needs of the people we serve. I expect 
to establish an ongoing dialog, and we will meet as frequently as 
necessary.

    Question 8. This Administration has proposed cutting Medicaid 
funding both through repealing the PPACA and through the budgeting 
process. The latest budget bill coming out of the House of 
Representatives calls for $1.4 trillion in cuts to Medicaid. Included 
in ACL's mission is the statement that,

          ``All Americans--including people with disabilities and older 
        adults--should be able to live at home with the supports they 
        need, participating in communities that value their 
        contributions.''

    After unpaid family supports, Medicaid is the largest funder of 
home and community-based long-term services and supports. It makes it 
possible for individuals to live in their own homes, independently move 
about their communities, and obtain and retain jobs. How will you 
advocate for protecting Medicaid funding and how will you ensure the 
mission to have all Americans who are aging and/or have disabilities, 
live at home in their communities?
    Answer 8. ACL's work to help older adults and people with 
disabilities live independently in their communities has never been 
more important. There are 65 million people age 60 and older. All but a 
tiny percentage of them live in non-institutional settings, as do 
nearly 57 million people with disabilities. Both populations are 
growing, and older Americans are one of the fastest-growing 
demographics in the country; by 2020, there will be more than 77 
million people over the age of 60.
    I have been an advocate for older adults and people with 
disabilities throughout my career. I look forward to continuing that 
role at the Federal level to help ensure the long-term sustainability 
of the critical programs that support older adults and people with 
disabilities and help them live independently.

    Question 9. ACL recently published three requests for comments in 
the Federal Register, for both aging and disability datasets, regarding 
the removal of data collection elements on Sexual Orientation and 
Gender Identity (SOGI). Both Office of Management and Budget and 
Healthy People 2020 recognize the need for collecting data on this 
underrepresented group as a way to measure unmet need. Will you commit 
to restoring the LGBTQ questions to these surveys?
    Answer 9. I am committed to working with the aging and disability 
networks to help them best serve older adults and people with 
disabilities, particularly those with the greatest social and economic 
needs. I am committed to better understanding these issues and ensuring 
that ACL's programs serve all people, including LGBT older adults and 
people with disabilities.

    Question 10. Over the last several months, I have sent multiple 
letters to HHS about the Administration's ongoing efforts to undermine 
and sabotage the Affordable Care Act through executive action. HHS has 
failed to provide responses to many of my letters. If HHS has 
responded, the response letters have been wholly inadequate and have 
not been responsive to my requests. If you are confirmed, do you commit 
to respond in a timely manner to all congressional inquiries and 
requests for information from all Members of Congress, including 
requests from Members in the Minority?
    Answer 10. Yes, I will appropriately respond to all Member 
requests. I look forward to working with all Members of Congress to 
address the needs and concerns of older adults and people with 
disabilities.
                            senator franken
    Question 1. Do you support the use of Medicaid home and community-
based services for both older adults and people with disabilities? What 
will you do to make sure seniors and people with disabilities can stay 
in their communities and remain independent as long as possible?
    Answer 1. Since its creation, ACL has advocated for the expansion 
and coordination of home- and community-based services and improvements 
in quality so that older adults and people with disabilities have more 
and better options about how and where to receive the long-term 
services and supports they need. I am excited to continue this work.

    Question 2. How will you work with Congress to shape the next Older 
Americans Act legislation? What priorities do you think the legislation 
should address?
    Answer 2. We need to tackle one of the most critical issues facing 
us today--the role of the aging services network and its capacity to 
truly partner with the healthcare system in order to provide and 
partner in an integrated service delivery model. I look forward to 
working with the aging network and Congress to this end.
                             senator bennet
    Question 1. Many chronic diseases are preventable or better managed 
when caught early. When they are not, there is a large cost burden on 
our society. The American Diabetes Association estimates that the 
economic cost of diabetes was nearly $250 billion in 2012, a 41 percent 
increase since 2007. In Medicare, 15 percent of the sickest enrollees 
that often have multiple chronic conditions, account for 50 percent of 
Medicare spending.
    What is your strategy around prevention so that certain chronic 
diseases are avoided or better managed in order for us to improve 
outcomes and save Medicare dollars?
    Answer 1. Under Title III-D of the Older Americans Act, ACL 
supports a number of evidence-based programs that help older adults 
maintain their health and wellness. This includes programs that help 
older adults learn to effectively manage chronic diseases like 
diabetes, programs that help prevent falls, and other such programs. 
Centers for independent living and university centers of excellence on 
developmental disabilities offer similar programs for people with 
disabilities. Programs like these that use evidence-based models help 
to avoid the far higher costs associated with advancing disease, and I 
look forward to continuing to build on these efforts.
                           senator whitehouse
    Question 1. President Trump's budget eliminates Senior Corps, a 
program that engages a quarter of a million older adults who volunteer 
almost 75 million hours of service each year to community programs that 
serve seniors, children, veterans and others. Although the Assistant 
Secretary for Aging does not oversee Senior Corps, the Administration 
for Community Living has a memorandum of understanding with the 
Corporation for National and Community Service to promote volunteerism 
by older adults and people with disabilities.
    Do you believe the elimination of Senior Corps will benefit 
seniors?
    Will you advocate within the administration for funding for 
programs like Senior Corps that help keep seniors engaged in their 
communities?
    Answer 1. I believe strongly in the value that older adults provide 
to their communities, and I believe we are stronger when we harness the 
power of everyone's talents. ACL is different from many Federal 
agencies in that advocacy is explicitly included in several of the 
statutes that authorize its programs. I am looking forward to 
continuing that role at the Federal level to help ensure the long-term 
sustainability of the critical programs that support older adults and 
people with disabilities and help them to fully participate in their 
communities.

    Question 2a. President Trump's budget cuts almost $80 million from 
disability programs within the Administration on Community Living, 
which is overseen by the Assistant Secretary for Aging. The President 
himself has publicly mocked a disabled person.
    Do you believe these budget cuts will lead to better outcomes for 
people with disabilities?
    Answer 2a. I support the idea of delivering services that help to 
achieve independence, productivity, integration, self-determination and 
inclusion in the community while eliminating silos that make it harder 
for people to access the services they need. I look forward to working 
with ACL team members, HHS leaders, and Congress to ensure these 
programs are funded in the most responsible way.

    Quesion 2b. Please list three things you will do if confirmed to 
support disabled Americans and the Federal programs that serve them.
    Answer 2b. I am looking forward to working with my colleagues at 
ACL and throughout HHS to learn more about the programs and initiatives 
already in place. The strategy I shared in my testimony applies to both 
older adults and people with disabilities. For both populations, 
navigating the systems of services and support, identifying what is 
available, and understanding how to access those services, can be 
overwhelming. We have to streamline that process and ensure the needs 
of the person are kept at the forefront of our focus.
    Families and friends play a critical role in supporting older 
adults and people with disabilities alike. Supporting those people is 
essential to helping older adults and people with disabilities continue 
living independently in the community. It is imperative that we ensure 
the community-based organizations that form the aging and disability 
networks are able to survive in the increasingly complex health care 
environment. ACL has been investing in helping the networks develop the 
business acumen necessary to integrate the services they provide into 
the overall health care spectrum. I believe that work is absolutely 
critical.
                            senator baldwin
    Question 1. In 2012, the Administration on Aging (AOA) issued new 
guidance on the definition of the term ``greatest social need'' in the 
Older Americans Act that included ``individuals isolated due to sexual 
orientation or gender identity.''
    Do you support AOA's guidance that States can classify LGBT older 
adults as a greatest social needs population? Please explain your 
answer.
    Should ACL do more to ensure States are assessing and meeting the 
needs of the LGBT older adult population?
    What, if anything, did you do as the director of the Aging Services 
Division in Oklahoma to both assess and meet the needs of LGBT older 
adults under your tenure?
    Answer 1. I am committed to working with the aging and disability 
networks to help them best serve older adults and people with 
disabilities, particularly those with the greatest social and economic 
needs. I am committed to better understanding these issues and ensuring 
that ACL's programs serve all people, including LGBT older adults and 
people with disabilities.

    Question 2a. I am concerned with ACL's proposals to eliminate data 
on key demographic populations, including LGBT older adults as well as 
transgender older adults, from this year's National Survey of Older 
Americans Act Participants. This critical survey is used to evaluate 
the effectiveness of the Older Americans Act programs funded through 
HHS, including who is able to access the programs.
    Answer 2a. Older LGBT and transgender individuals face many 
challenges including financial insecurity, social isolation, 
discrimination, and barriers to access for aging and accessibility 
services. I believe that removing sexual orientation and gender 
identity questions from these surveys will limit HHS's ability to 
address these issues. In fact, NASUAD sent a statement to ACL 
addressing their data collection efforts on LGBT individuals which 
reads,

          ``. . . we believe that there is opportunity to improve the 
        data collection regarding the needs and prevalence of different 
        populations served by the aging network [and] recommend that 
        ACL continue to refine this data collection in order to provide 
        meaningful analysis rather than eliminate the questions.''

    While, I am encouraged that HHS has decided to retain the sexual 
orientation question, I remain very troubled by the proposed 
elimination of the gender identity question. Further, I am concerned 
that these actions reveal a troubling pattern by HHS to rollback 
efforts to improve community care and address health disparities for 
these vulnerable populations.

    Question 2b. Do you believe HHS and ACL should do more to improve 
data collection on LGBT individuals? Will you commit to enhancing ACL's 
efforts to collect data on LGBT older adults and people with 
disabilities?
    Answer 2b. I am committed to working with the aging and disability 
networks to help them best serve older adults and people with 
disabilities, particularly those with the greatest social and economic 
needs. I am committed to better understanding these issues and ensuring 
that ACL's programs serve all people, including LGBT older adults and 
people with disabilities.

    Question 3. Former HHS Secretary Kathleen Sebelius played a leading 
role in establishing ACL and stated that, ``. . . we now recognize that 
LGBT older adults also represent a community with unique needs that 
must be addressed''. Do you agree with this statement?
    Answer 3. I am committed to working with the aging and disability 
networks to help them best serve older adults and people with 
disabilities, particularly those with the greatest social and economic 
needs.
                             senator murphy
    Question 1. As you may know, State Health Insurance Assistance 
Programs (SHIPs) play an essential role in helping Medicare 
beneficiaries, who are often low-income or have complex health 
conditions, navigate make informed decisions about their Medicare 
coverage.
    Answer 1. In Connecticut, the SHIP program, known as CHOICES, 
helped 34,200 seniors, people with disabilities, and family caregivers 
last year find the health care program that works for them and their 
families. Connecticut received over $676,000 in Federal funding last 
year through the SHIP program. There are five regional offices that 
administer the program.
    SHIP counselors provide personalized, one-on-one assistance to 
seniors and their families that cannot be replicated by 1-800-MEDICARE 
or other broad outreach activities, because it is often the Medicare 
beneficiaries with the most complex cases and fewest resources who seek 
their help. SHIP counseling assistance can save individual Medicare 
beneficiaries hundreds, or even thousands, of dollars every year, and, 
as a result, can save some seniors from having to choose between paying 
for their health care and essentials such as their rent or groceries. 
Unfortunately, Federal funding for SHIPs has been targeted for 
elimination or reduced funding over the years.
    As Assistant Secretary of Aging, will you advocate for adequate 
Federal funding for the State Health Insurance Assistance Program 
(SHIP) in light of the need for critical SHIP services for seniors--
particularly low-income seniors navigating an increasingly complicated 
Medicare system?
    For older adults, people with disabilities, and their families, 
navigating the systems of services and support, identifying what is 
available, and understanding how to access those services can be 
overwhelming. Similarly, determining the best Medicare elections for 
individual situations can be challenging, and many people who are 
eligible for Medicare need assistance understanding the various 
options. I look forward to working with all parties to ensure that 
older adults, people with disabilities, and their families understand 
the choices and services available to them and how to access them.

    Question 2. A recent report by the National Academies of Sciences, 
Engineering and Medicine found that close to 18 million Americans of 
working age help disabled or older family members or friends with 
activities of daily living on an ongoing basis. In Connecticut, 1 in 6 
residents are providing care for a relative, and 70 percent believe 
they will at some point. The report forecast that the numbers of family 
caregivers will continue to rise, not taking into account any potential 
cuts to Medicaid that would likely exacerbate our country's caregiving 
crisis.
    As you may know, family caregiving obligations have a substantial 
economic impact, as workers in this situation often have to take time 
off from jobs, cut back on working hours, or leave the paid workforce 
altogether. Unfortunately, this lowers their future Social Security 
benefit, threatening their own retirement. Studies indicate that on 
average, total wage, private pension, and Social Security losses due to 
caregiving add up to more than $300,000. In Connecticut, an estimated 
459,000 caregivers in 2013 spent 427 million hours providing nearly $6 
billion in unpaid caregiving.
    I believe that family caregivers deserve our gratitude, not 
punishment for taking time off to care for a loved one. That's why, 
after hearing concerns from family caregivers around Connecticut, I 
introduced the Social Security Caregiver Credit Act, which would add a 
credit to caregivers' lifetime earnings to determine how much they 
should receive in Social Security benefits. By creating a Social 
Security Caregiver credit, caregivers who had to leave the workforce 
entirely, or continue to work with significantly reduced hours, would 
receive modest retirement compensation.
    What specific initiatives will you, as Assistant Secretary on Aging 
and Administrator of the Administration for Community Living, undertake 
to facilitate family caregiving?
    Answer 2. As I shared in my testimony, my vision includes a 
strategic focus on supporting caregivers. Informal caregivers of 
individuals with disabilities and older adults and the services and 
supports they provide them are the epicenter of the long-term services 
and supports system. Under my leadership we will continue to promote 
evidence-based solutions, and build support systems that work. We will 
continue to seek ways to meet caregivers where they are and equip them 
with the tools they need to be successful in this important role.
                             senator warren
Medicaid
    According to the Centers for Medicare and Medicaid Services (CMS), 
8.3 million low-income seniors and people with disabilities receive 
health care coverage through both Medicare and Medicaid, making them 
``dually eligible.'' People who are dually eligible receive financial 
assistance to help pay their premiums, out-of-pocket costs, nursing 
facility care, eyeglasses, and hearing aids.\1\ Medicaid also provides 
the backbone for coverage of long-term services and supports (LTSS), 
including home and community-based services (HCBS) that help seniors 
and people with disabilities live independently.\2\ Two-thirds of 
Americans living in nursing homes rely on Medicaid.\3\
---------------------------------------------------------------------------
    \1\ Centers for Medicare and Medicaid Services, ``Seniors & 
Medicare and Medicaid Enrollees'' (online at: https://www.medicaid.gov/
medicaid/eligibility/medicaid-enrollees/index.html). Accessed August 1, 
2017.
    \2\ Erica L. Reaves, MaryBeth Musumeci, ``Medicaid and Long-Term 
Services and Supports: A Primer,'' Kaiser Family Foundation (December 
15, 2015) (online at: http://www.kff.org/medicaid/report/medicaid-and-
long-term-services-and-supports-a-primer/).
    \3\ Ina Jaffe, ``Nursing Homes Worry Proposed Medicaid Cuts Will 
Force Cuts, Closures,'' NPR (June 28, 2017) (online at: http://
www.npr.org/sections/health-shots/2017/06/28/534764940/proposed-
medicaid-cuts-likely-to-put-pressure-on-nursing-homes).
---------------------------------------------------------------------------
    President Trump has supported legislation that would cut Medicaid 
by more than $700 billion, converting it to a per capita cap or block 
grant system.\4\ His budget proposal for fiscal year 2018 (FY18) also 
proposed an additional cut to Medicaid of over $600 billion.\5\
---------------------------------------------------------------------------
    \4\ Philip Bump, ``By 2026, Annual Medicaid Cuts under the Senate 
Health-Care Replacement Plan are Steeper than Under Repeal,'' 
Washington Post (July 19, 2017) (online at: https://
www.washingtonpost.com/news/politics/wp/2017/07/19/by-2026-annual-
medicaid-cuts-under-the-senate-health-care-replacement-plan-are-
steeper-than-under-repeal/?utm_term=.27c6f093a793); Danielle Kurzleben, 
``GOP Health Plan Would Leave 23 Million More Uninsured, Budget Office 
Says,'' NPR (May 24, 2017) (online at: http://www.npr.org/2017/05/24/
529902300/cbo-republicans-ahca-would-leave-23-million-more-uninsured).
    \5\ Iris J. Lav, Michael Leachman, ``The Trump Budget's Massive 
Cuts to State and Local Services and Programs,'' Center on Budget and 
Policy Priorities (June 13, 2017) (online at: https://www.cbpp.org/
research/state-budget-and-tax/the-trump-budgets-massive-cuts-to-state-
and-local-services-and).
---------------------------------------------------------------------------
    As Assistant Secretary for Aging, as well as the Administrator for 
Community Living (ACL), you will be responsible for addressing the 
concerns and advancing the interests of America's seniors and people 
with disabilities.

    Question 1. Do you agree that Medicaid plays an essential role in 
ensuring that seniors and people with disabilities can get access to 
affordable high-quality services that allow them to live independently 
at home and in their communities?
    Answer 1. Medicaid plays an essential role along with other public 
and private resources at the Federal, State and local level and support 
provided by family members and other caregivers to assist individuals 
to live independently and participate fully in society.

    Question 2. Do you agree that hundreds of billions of dollars in 
cuts to Medicaid would have a negative impact on the ability of seniors 
and people with disabilities to access health care?
    Answer 2. Medicaid plays an essential role along with other public 
and private resources at the Federal, State and local level and support 
provided by family members and other caregivers to assist individuals 
to live independently and participate fully in society.
Long-term services and supports
    The Assistant Secretary for Aging oversees the Administration on 
Aging (AOA), which includes the Office of Elder Justice and Adult 
Protective Services and the Office of Long-Term Care Ombudsman 
Programs. These two offices work together to advocate for the rights 
and protection of the elderly and adults with disabilities from 
``abuse, neglect, self-neglect, or financial exploitation.''\6\ The 
Long-Term Care Ombudsman Program works to resolve problems and promote 
policies that protect patients in LTSS settings, including assisted 
living facilities. This program is required to identify and investigate 
complaints of residents in LTSS settings, provide administrative and 
legal services for residents, and ``analyze, comment on, and recommend 
changes in laws and regulations pertaining to the health, safety, 
welfare, and rights of residents.''\7\
---------------------------------------------------------------------------
    \6\ Administration for Community Living, ``Supporting Adult 
Protective Services'' (online at: https://www.acl.gov/programs/elder-
justice/supporting-adult-protective-services). Accessed August 1, 2017.
    \7\ Administration for Community Living, ``Long-Term Care Ombudsman 
Program'' (online at: https://www.acl.gov/node/68). Accessed August 1, 
2017.

    Question 3. Do you agree that America's seniors, people with 
disabilities, and their families deserve to know that when they or 
their loved ones are in a nursing home or assisted living facility, it 
is a safe, high-quality care facility?
    Answer 3. All people have the right to live their lives with 
dignity and respect, free from abuse of any kind, regardless of the 
setting.

    Question 4. Nursing homes are regulated at the State level and via 
CMS, and CMS has established the Nursing Home Compare Web site to 
provide information to help seniors and families choose the facility 
that best suits their needs. How does the AOA work with CMS to ensure 
that seniors have access to this and other information that they need?
    What other actions does the AOA take to improve the quality of 
nursing home care?
    If confirmed, what additional steps will you take to improve the 
quality of nursing home care?
    Answer 4. CMS and ACL work closely together on several nursing home 
initiatives to support quality care, including initiatives to reduce 
the misuse of antipsychotic medications, reduce inappropriate discharge 
and evictions, and to foster person-centered care practices.
    ACL has also worked with its National Ombudsmen Resource Center to 
develop consumer education materials for individuals and their families 
regarding residents' rights and other provisions related to the revised 
nursing home regulations in order to inform consumers and to support 
quality, individualized care.

    Question 5. The Federal Government pays for care in assisted living 
facilities via Medicaid waiver programs that allow payments for such 
care. However, there is limited or no Federal oversight of these 
facilities. What actions does the AOA currently take to improve the 
quality of care in assisted living facilities and to ensure that 
seniors have access to the information they need to choose the best 
facility for their needs?
    Answer 5. State Long-Term Care Ombudsman programs offer complaint 
resolution services, information and assistance, and training to both 
consumers and staff of assisted living facilities. In assisted living, 
board and care, and other residential care communities, Ombudsman 
programs most frequently work on complaints such as, medication errors, 
food concerns, improper eviction or inadequate discharge, lack of 
dignity or respect for residents, poor staff attitudes and building or 
equipment hazards or need for repair. Through the National Ombudsman 
Resource Center technical assistance and training related to assisted 
living facility settings is provided through Web materials and through 
webinars and other training.

    Question 6. What additional steps do you believe that AOA can take 
to ensure that the care provided to seniors at Assisted Living 
Facilities is both high quality and cost-effective?
    Answer 6. Key steps include further promoting person-centered care 
practices and educating and training facility staff on the indicators 
of and how to report abuse, neglect and exploitation.

    Question 7. Will you commit to advocating on behalf of seniors and 
people with disabilities living in nursing homes or assisted living 
facilities, including advocating for robust funding and policies that 
ensure consumer protections?
    Answer 7. ACL is different from many Federal agencies in that 
advocacy is explicitly included in several of the statutes that 
authorize its programs. The Long-Term Care Ombudsman in every State 
works with residents of long-term care facilities, including nursing 
homes, to protect their rights and resolve disputes. Further, State 
Long-Term Care Ombudsmen also serve as advocates for people living in 
facilities, providing input on State and local legislation and policy 
that affects facilities.

    Question 8. What specific steps will you take to ensure that 
seniors and people with disabilities, as well as their families, know 
about the Long-Term Care Ombudsman Program and the services it 
provides?
    Answer 8. ACL will continue to promote the Long-Term Care Ombudsman 
Program and its services and supports in partnership with national, 
State and local grantees and stakeholders. This includes ensuring 
information and referral through phone, internet, and in-person contact 
with individuals with disabilities, older adults, and their families 
and caregivers. Social media is an area where a new and additional form 
of outreach is occurring.

    Question 9. Between 2010 and 2014, more than 100 cases of abuse, 
medical malpractice, or wrongful death related to skilled nursing 
facilities were forced into arbitration.\8\ Forced arbitration 
clauses--often buried in confusing paperwork signed under duress--bar 
residents from taking these facilities to court. Last fall, the Centers 
for Medicare and Medicaid Services (CMS) banned skilled nursing 
facilities from compelling new residents to enter into such agreements, 
but a new CMS proposal rescinds that ban, allowing SNFs to take 
advantage of our Nation's most vulnerable citizens through this 
predatory and opaque practice.\9\ Do you agree that arbitration should 
be transparent and agreed to voluntarily, without threat of being 
turned down or kicked out from residence of a skilled nursing facility 
where a patient would like to receive services?
---------------------------------------------------------------------------
    \8\ Jessica Silver-Greenberg, Michael Corkery, ``In arbitration, a 
`privatization of the justice system' '' The New York Times (November 
1, 2015) (online at: http://www.nytimes.com/2015/11/02/business/
dealbook/in-arbitration-a-privatization-of-the-justice-system.html).
    \9\ Virgil Dickson, ``CMS Lifts Ban on Nursing Home Arbitration 
Agreement,'' Modern Healthcare (June 5, 2017) (online at: http://
www.modernhealthcare.com/article/20170605/NEWS/170609949).
---------------------------------------------------------------------------
    Answer 9. All people have the right to live their lives with 
dignity and respect, free from abuse of any kind, regardless of the 
setting.
State Health Insurance Assistance Program (SHIP)
    The Administration on Aging oversees the State Health Insurance 
Assistance Program (SHIP), which ``provides Medicare beneficiaries with 
information, counseling, and enrollment assistance.''\10\
---------------------------------------------------------------------------
    \10\ Administration for Community Living, ``State Health Insurance 
Assistance Program (SHIP)'' (online at: https://www.acl.gov/node/162). 
Accessed August 1, 2017.
---------------------------------------------------------------------------
    Medicare provides quality health care coverage to millions of 
American seniors and Americans with disabilities. State Health 
Insurance Programs help direct individuals to the right care options by 
providing support and information for beneficiaries. SHIPs help 
beneficiaries enroll in the Medicare plans that are right for them, 
resolve billing issues, report fraud, and otherwise help beneficiaries 
navigate the Medicare system.
    These programs operate in all 50 States. In recent years, 7 million 
individuals were provided assistance with Medicare through SHIPs.\11\ 
However, President Trump's budget proposal for fiscal year 2018 
proposed gutting the program.\12\
---------------------------------------------------------------------------
    \11\ ``NCOA Issue Brief: FY 2018 Medicare SHIP Funding,'' National 
Council on Aging (July 2017) (online at: https://www.ncoa.org/
resources/ncoa-issue-brief-fy18-medicare-ship-funding/).
    \12\ ``President's FY 2018 Budget Eliminates Key Federal Programs 
Supporting Older Adults and Caregivers,'' Area Agency on Aging (May 24, 
2017) (online at: http://info4seniors.org/presidents-fy-2018-budget-
eliminates-key-Federal-programs-supporting-older-adults-caregivers/).

    Question 10. Do you agree that SHIP is an important program for 
seniors and individuals with disabilities?
    Answer 10. For older adults, people with disabilities, and their 
families, navigating the systems of services and support, identifying 
what is available, and understanding how to access those services can 
be overwhelming. Similarly, determining the best Medicare elections for 
individual situations can be challenging, and many people who are 
eligible for Medicare need assistance understanding the various 
options. I look forward to working with all parties to ensure that 
older adults, people with disabilities, and their families understand 
the choices and services available to them and know how to access them.

    Question 11. Will you advocate for these individuals by supporting 
the continued funding of SHIPs?
    Answer 11. For older adults, people with disabilities, and their 
families, navigating the systems of services and support, identifying 
what is available, and understanding how to access those services, can 
be overwhelming. Similarly, determining the best Medicare elections for 
individual situations can be challenging, and many people who are 
eligible for Medicare need assistance understanding the various 
options. I look forward to working with all parties to ensure that 
older adults, people with disabilities, and their families understand 
the choices and services available to them and how to access them.
                             senator hassan
    Question 1. As you know, President Trump's budget proposal include 
steep cuts to a number of important programs that make meaningful 
community inclusion possible for individuals who experience 
disabilities. These cuts include billions of dollars from Medicaid and 
significant reductions to programs across the government that assist 
individuals who experience disabilities, including cuts to the 
Administration for Community Living, such as the elimination of funding 
for State Councils on Developmental Disabilities. Will you stand up 
against the President to protect funding for vital programs that 
support individuals who experience disabilities?
    Answer 1. I have been an advocate for older adults and people with 
disabilities throughout my career. I look forward to continuing that 
role at the Federal level to help ensure the long-term sustainability 
of the critical programs that support older adults and people with 
disabilities and help them live independently.
    In addition, I believe that the use of innovation and evidence-
based practices will be critical to keeping these programs vital and to 
meeting the evolving needs of older Americans and those with 
disabilities.

    Question 2. In our one-on-one meeting, you and I discussed that a 
marked difference between individuals who are aging and those with a 
disability is fully integrated employment. Individuals with 
disabilities have a labor participation rate of around 20 percent, 
which is less than a third of the labor participation rate of 
individuals without a disability. What do you think the Administration 
for Community Living can do to help ensure more individuals who 
experience disabilities become gainfully employed?
    Answer 2. ACL strives to assure that older adults and people with 
disabilities do not face barriers to employment. Ensuring that everyone 
who wants to work has opportunities to do so is a critical element of 
helping people to live their lives fully integrated into their 
communities. Increasing access and eliminating barriers to employment 
has been part of ACL's mission since its creation, and I look forward 
to continuing that important work.

    Question 3. While Governor of New Hampshire, I signed a law which 
made New Hampshire the first State to eliminate the payment of sub 
minimum wage for individuals who experience disabilities. Do you 
support the closure of sheltered workshops and ending the practice of 
paying a sub minimum wage to individuals who experience disabilities?
    Answer 3. Ensuring that everyone who wants to work has full 
opportunities to do so is a critical element of helping people to live 
their lives fully integrated into their communities. Increasing access 
and eliminating barriers to employment has been part of ACL's mission 
since its creation, and I look forward to continuing that important 
work.
Response by Brett Giroir, M.D., to Questions of Senator Murray, Senator 
 Sanders, Senator Franken, Senator Bennet, Senator Whitehouse, Senator 
                       Baldwin and Senator Warren
                             senator murray
    Question 1. The Office of the Assistant Secretary for Health (OASH) 
has a key role to play with regards to our Nation's response to both 
HIV and hepatitis. What is your vision and plans to continue our 
Nation's response to these public health issues? Will you continue to 
implement the National HIV/AIDS Strategy and the National Viral 
Hepatitis Action Plan? Will you commit to focusing efforts on areas 
where we know more needs to be done while sustaining and building on 
programs and activities that have been proven effective?
    Answer 1. If confirmed, it is my intent that OASH will continue its 
strong leadership role in implementing and extending both the National 
HIV/AIDS Strategy and the National Viral Hepatitis Action Plan. There 
is much work to be done to reduce the number of new infections with 
increased prevention, diagnosis, and treatment. While we have made 
enormous progress, we should strive to do more.

    Question 2. Secretary Price has indicated that combating childhood 
obesity is among his top three clinical priorities, and yet we've seen 
little action from the Administration on this issue. In fact, Secretary 
Price praised FDA's recent delay in implementing key menu labeling 
requirements. Under his watch, we've also seen a delay in important 
deadlines for updating the nutrition facts panel on packaged food. What 
role does access to accurate and comprehensive nutrition information 
play in supporting families' healthy eating efforts? What role does 
such information play in combating childhood obesity? What would your 
priorities be with regards to addressing childhood obesity?
    Answer 2. As a pediatrician--and exercise enthusiast--with 
programmatic experience in obesity and diabetes, I fully support the 
Secretary's prioritization of childhood obesity as one of his top 
objectives. If confirmed, I plan to work alongside the Secretary in 
developing, coordinating, and implementing effective initiatives to 
reduce childhood obesity through the programs that the Office of the 
Assistant Secretary for Health administers.
    In terms of food labeling, I certainly agree that it is important 
to provide parents and children with meaningful, easily understood 
information.

    Question 3. Recent outbreaks have underscored the dangers of 
delaying or avoiding recommended vaccines. If confirmed, you would 
oversee the National Vaccine Program Office (NVPO). What do you view as 
the key priorities for NVPO? Can you describe specific strategies NVPO 
can take to improve vaccine usage? What can NVPO do to increase 
adolescent and adult vaccination rates? HPV vaccination rates remain 
much lower than other adolescent vaccines, even though the vaccine 
prevents infections that can lead to cancer. What can be done, 
including by NVPO, to improve adolescent HPV vaccination rates 
specifically?
    Answer 3. Vaccines save lives. They are the most important health 
innovation of modern times. If confirmed, I will be a passionate 
advocate for vaccines while working to continue our effective and 
transparent monitoring systems to provide American families assurance 
that vaccines remain safe. While no public health intervention, 
including vaccinations is 100 percent risk-free, vaccines are the gold 
standard of disease prevention. It's our job to provide parents high-
quality, scientifically accurate information so that they can feel 
confident in the safety of the vaccines we recommend for American 
children.

    Question 4. Will you provide continued support for the current 
revision of our Physical Activity Guidelines and similarly, would you 
find ways under the current fiscal environment to optimize 
communication and release of those guidelines?
    Answer 4. As a fitness enthusiast, I understand the importance of 
physical fitness for healthy living. If confirmed, I will work 
collaboratively with the relevant agencies, including the CDC and NIH, 
to ensure that Americans have scientifically sound information about 
physical fitness and will support efforts to continue developing 
research initiatives to improve our evidence base.

    Question 5. The National Public Health Commissioned Corps is key to 
the defense of public health in our country and played an important 
role in Katrina, Ebola, and many other national and global crises. How 
will you work to elevate the National Public Health Commissioned Corps 
and their expertise in a modern way to assist in the response during 
the next public health emergency? What do you view as the greatest 
assets of the Corps?
    Answer 5. I am proud of the honorable and hard-working members of 
the Commissioned Corps. They are certainly an impressive and dedicated 
group of professionals. I look forward to working with them more to 
advance the President's and the Secretary's public health agenda and to 
protect the health of all Americans.

    Question 6. Title X is the only Federal grant program dedicated 
solely to providing individuals with comprehensive family planning and 
related preventive health services. It is designed to prioritize the 
needs of low income families or uninsured people, including those who 
are not eligible for Medicaid. These individuals may not otherwise have 
access to these health care services. It promotes positive birth 
outcomes and healthy families by enabling individuals to decide the 
number and spacing of their children. Secretary Price has warned 
current multi-year title X grant recipients that their funding ends 
after this year, mid-way through the grant period, and they must 
compete again for funding that they have already been awarded. As 
Assistant Secretary for Health, you would oversee multiple grant making 
programs. Can you assure future grant recipients that if they receive 
grants for a certain term of years, the agency will not act to 
prematurely terminate those grants, which the recipients rely on to 
serve the highest need populations? Can grant recipients trust that 
they can rely on the funding they have been awarded by you?
    Answer 6. If confirmed, I commit to implementing the laws passed by 
Congress and signed by the President effectively and faithfully, and 
following the grant making rules and procedures of the Department.

    Question 7. HHS regional offices are incredibly important to the 
work the Department does in States and communities. How do you view the 
role of regional offices in supporting the priorities of the 
Department?
    Answer 7. It is certainly true that the majority of the Nation's 
wisdom does not reside inside the borders of Washington, DC. I will 
definitely seek counsel and intelligence from the field, including from 
Departmental offices as well as, and perhaps especially, from State and 
local public health agencies and officials who are doing the bread-and-
butter public health work protecting Americans every day.
                            senator sanders
    Question. As you know, one in five Americans between the ages of 19 
and 64 years, cannot afford the medicines that their doctors prescribe 
to them. Additionally, more than 7 in 10 Americans support the idea of 
being able to purchase prescription drugs that are imported from 
Canada. In detail, please share your position on drug importation from 
Canada? Are you familiar with the recent CBO analysis that has shown 
that importation would save the government $6.5 billion over 10 years? 
What would it mean for the health outcomes of the 35 million Americans 
who currently are unable to afford their medicines?
    Answer. The President and the Secretary have made reducing the 
financial pain at the pharmacy counter a major priority. As we carry 
out that initiative, the safety and quality of medicines that Americans 
take, as well as their affordability, will be our guide.
                            senator franken
    Question 1. The President's proposed budget and actions taken so 
far have sought to undermine the very programs that you will be charged 
with supporting. What will you do to ensure that public health and 
effective prevention measures remain a top priority at the Department 
of Health and Human Services?
    Answer 1. Preventable diseases and chronic diseases account for a 
majority of American health disparities and healthcare expenditures. 
Protecting the public's health will of course involve a strong 
commitment to prevention, and the President's budget recognizes this 
reality. If confirmed, I will work to keep prevention at OASH a top 
priority.
                             senator bennet
    Question 1. I was recently in Otero County, CO where drug overdoses 
have been increasing. The entire community was engaging to address the 
rise in opioid abuse. This included coordinating hospitals, the courts, 
schools and foster care services. Even when we see a decrease in 
prescription overdoses, it is usually countered with an increase in 
heroin overdoses. In the 1960s, more than 80 percent of heroin users 
started with heroin. In contrast, currently, about 80 percent of heroin 
users first started using prescription opioids.
    What are practical steps you plan to take to address the opioid 
crisis?
    How can we ensure that Americans are not becoming addicted in the 
first place while making it easier for people who currently have an 
addiction to obtain access to treatment?
    Answer 1. The Secretary has laid out a robust five-point plan for 
combating the opioid epidemic, grounded in expanding access to 
treatment, prevention and recovery services, promoting the use of 
overdose-reversing drugs, better and more real-time data, innovative 
research to develop new products in addiction prevention and treatment, 
and better provider practices when it comes to pain management. I am 
fully committed to helping him implement his plan--it is the right one 
and we must step up the fight to protect American communities from the 
terrible scourge of opioid addiction and overdose.

    Question 2. As you know, ``super bugs,'' or bacteria that are 
resistant to multiple antibiotics, are increasingly becoming a public 
health threat. Antibiotic innovation is failing to keep up with patient 
needs. This has left many patients struggling with severe and life-
threatening infections without effective treatment options. At the same 
time, economic challenges have caused most pharmaceutical companies to 
stop investing in research and development for antibiotics. Last year, 
I worked with Senator Hatch to pass the PATH Act in 21st Century Cures. 
The bill created a new drug approval pathway to streamline access and 
encourage innovation for lifesaving antibiotics.
    What else can we do to encourage the research and development of 
antibiotics that treat life-threatening infections?
    Overuse of antibiotics is a main driver of antibiotic resistance. 
As the Assistant Secretary for Health, how would you help reduce 
inappropriate or excessive antibiotic use?
    Answer 2. You are absolutely right about the threat represented by 
antimicrobial resistance. If confirmed, I intend to engage in a 
personal way to support the Presidential Advisory Council on Combating 
Antibiotic-Resistant Bacteria (PACCARB), which is overseen by OASH, as 
well as the important work on this issue being done by CDC, FDA, ASPR, 
and other Federal partners.

    Question 3. Many chronic diseases are preventable or better managed 
when caught early. When they are not, there is a large cost burden on 
our society. The American Diabetes Association estimates that the 
economic cost of diabetes was nearly $250 billion in 2012, a 41 percent 
increase since 2007. In Medicare, 15 percent of the sickest enrollees 
that often have multiple chronic conditions, account for 50 percent of 
Medicare spending. What is your strategy around prevention so that 
certain chronic diseases are avoided or better managed in order for us 
to improve outcomes and save Medicare dollars?
    Answer 3. Preventable diseases and chronic diseases account for a 
majority of American health disparities and healthcare expenditures. 
There is clearly room for additional focus on preventive care to 
improve health and competitiveness, while being fiscally responsible 
and preserving our safety net and entitlement programs for future 
generations. If confirmed, I will work to keep prevention at OASH a top 
priority.
                           senator whitehouse
    Question 1. The Centers for Disease Control and Prevention 
estimates that two million people develop antibiotic-resistant 
infections in the United States every year, resulting in at least 
23,000 deaths. The Assistant Secretary for Health oversees the 
Presidential Advisory Council on combating Antibiotic-Resistant 
Bacteria, which will expire on September 30 unless it is extended by 
Executive order of the President.
    Do you believe the Presidential Advisory Council on combating 
Antibiotic-Resistant Bacteria has done effective work? If not, why not?
    Will you encourage the President to continue this important council 
and its work to combat antibiotic resistance?
    Answer 1. If confirmed, I intend to engage in a personal way to 
support the Presidential Advisory Council on Combating Antibiotic-
Resistant Bacteria (PACCARB), which is overseen by OASH, as well as the 
important work on this issue being done by CDC, FDA, ASPR, and other 
Federal partners.

    Question 2. As the Assistant Secretary for Health, you would 
oversee the National Vaccine Program Office. You've been vocal about 
your support for childhood vaccinations, and their safety and 
importance to public health. President Trump, however, has repeated 
disproven claims about the dangers of vaccines--a position that seems 
at odds with your informed professional judgment. Will you work to 
ensure that only scientifically accurate information about vaccines is 
communicated to the public and to others in the Administration?
    Answer 2. Vaccines save lives. They are the most important health 
innovation of modern times. If confirmed, I will be a passionate 
advocate for vaccines while working to continue our effective and 
transparent monitoring systems to provide American families assurance 
that vaccines remain safe. While no public health intervention, 
including vaccinations is 100 percent risk-free, vaccines are the gold 
standard of disease prevention. It's our job to provide parents high-
quality, scientifically accurate information so that they can feel 
confident in the safety of the vaccines we recommend for American 
children.

    Question 3. The Assistant Secretary for Health oversees the Office 
of Population Affairs, which administers the title X family planning 
program and provides guidance on a range of reproductive health topics. 
President Trump's pick to lead this office is someone who has called 
contraceptives ``medically irresponsible,'' despite the fact that she 
has no medical training. She has also said that the birth control pill 
doesn't work, despite overwhelming evidence to the contrary.
    In your professional opinion, are the statements above about 
contraception true?
    Do you believe statements like these should be used to inform 
policies of the Department of Health and Human Services?
    What will you do as Assistant Secretary for Health to ensure the 
Department's policies on women's health are guided by science rather 
than ideology?
    Answer 3. I look forward to working with HHS staff if I am 
confirmed. I am committed to promoting the public's health and applying 
evidence and common sense to our policymaking process.
                            senator baldwin
    Question. There has been incredible progress in the fight against 
HIV/AIDS over the last 30 years. Through investments in HIV prevention, 
hundreds of thousands of new infections have been prevented, savings 
billions of dollars in treatment costs. While HIV prevention efforts 
are working, there are still an estimated 37,600 new infections each 
year. Similarly, hepatitis C (HCV) kills nearly 20,000 people in the 
United States each year and complications, and HCV-associated deaths 
now exceed the number of deaths from 60 other nationally notifiable 
diseases. Rates of new cases of HCV have increased nearly threefold 
from 2010, particularly as the opioid epidemic proliferates.
    Can you please discuss how you would continue our Nation's response 
to these public health issues?
    Will you continue to implement the National HIV/AIDS Strategy and 
the National Viral Hepatitis Action Plan?
    Answer. If confirmed, it is my intent that OASH will continue its 
strong leadership role in implementing both the National HIV/AIDS 
Strategy and the National Viral Hepatitis Action Plan. There is much 
work to be done to improve over the status quo and reduce the number of 
new infections with increased prevention, diagnosis, and treatment. 
While we have made enormous progress, we should strive to do more.
                             senator warren
Evidence-Based Reproductive Health
    The Assistant Secretary for Health oversees multiple offices within 
the Department of Health and Human Services that promote the 
reproductive health of women, men, and teens across the Nation, 
including the Office of Women's Health, the Office of HIV/AIDS and 
Infectious Disease Policy, the Office of Population Affairs, and the 
Office of Adolescent Health.
    National reproductive health experts agree that evidence-based, 
scientifically accurate sexual education is critical to the control of 
sexually transmitted infections (STIs), including HIV/AIDS, as well as 
to the reduction in teen pregnancy rates: according to the Guttmacher 
Institute, ``comprehensive sex education programs . . . have been shown 
to delay sexual debut, reduce frequency of sex and number of partners, 
increase condom or contraceptive use, or reduce sexual risk-taking.'' 
\1\ To the contrary, ``abstinence-only'' sex education programs have 
proven to be ineffective, if not detrimental, to efforts to reduce teen 
pregnancy and STI rates.\2\
---------------------------------------------------------------------------
    \1\ Heather D. Boonstra, ``What Is Behind the Declines in Teen 
Pregnancy Rates?'' Guttmacher Institute (September 3, 2014) (online at 
https://www.guttmacher.org/gpr/2014/09/what-behind-declines-teen-
pregnancy-rates).
    \2\ Sexuality Information and Education Council of the United 
States, ``What the Research Says . . . Abstinence--OnlyUntil--Marriage 
Programs'' (online at http://www.siecus.org/index
.cfm?fuseaction=Page.ViewPage&PageID=1195).
---------------------------------------------------------------------------
    As the Assistant Secretary for Health, it is essential that you 
understand--and act upon--the plethora of evidence showing that 
abstinence-only education does not promote the Department's mission to 
``enhance and protect the health and well-being of all Americans.'' \3\
---------------------------------------------------------------------------
    \3\ U.S. Department of Health and Human Services, ``About HHS'' 
(online at https://www.hhs.gov/about/index.html).

    Question 1. Do you agree that policies demonstrated to increase the 
number of unintended pregnancies and STIs among teenagers should not be 
supported by HHS?
    Answer 1. If confirmed, I intend to develop and implement evidence-
based policies and programs to, among other things, decrease unintended 
pregnancies, and STDs among all Americans, especially among teenagers.

    Question 2. As HHS Assistant Secretary for Health, would you commit 
to implementing and expanding evidence-based programs that improve 
teenagers' reproductive health?
    Answer 2. See above.

    Question 3. Please provide a detailed description of steps you 
would take as HHS Assistant Secretary for Health to improve teenagers' 
access to evidence-based reproductive health education and services.
    Answer 3. See above.
Teen Pregnancy Prevention Program
    Though teen pregnancy has reached historic lows, around 25 percent 
of teen girls in the United States will become pregnant by age 20.\4\ 
To combat teen pregnancy rates, the Office of Adolescent Health 
administers the Teen Pregnancy Prevention (TPP) Program, an ``evidence-
based program that funds diverse organizations that are working to 
prevent teen pregnancy across the United States.''\4\ Since the 
program's implementation in 2010, teen childbearing has declined by 35 
percent nationwide, suggesting that the program is ``highly 
effective.'' \5\
---------------------------------------------------------------------------
    \4\ The National Campaign to Prevent Teen and Unplanned Pregnancy, 
``Fast Facts: Teen Pregnancy in the United States'' (April 2016) 
(online at https://thenationalcampaign.org/sites/
default/files/resource-primarydownload/
fast_facts_teen_pregnancy_in_the_united_states
.pdf).
    \5\ U.S. Department of Health and Human Services, Office of 
Adolescent Health, ``Teen Pregnancy Prevention Program (TPP)'' (online 
at https://www.hhs.gov/ash/oah/grant-programs/teen-pregnancy-
prevention-programtpp/index.html).
---------------------------------------------------------------------------
    Despite the effectiveness of the TPP Program, the Office of 
Adolescent Health announced on July 5, 2017, that it would cut short 
all 81 TPP grants and defund TPP grantees on June 30, 2018.\6\ OAH 
provided no rational for this decision. On July 21, I joined my Senate 
colleagues in sending a letter to Secretary Price, requesting detailed 
information on the justification behind OAH's decision.\7\
---------------------------------------------------------------------------
    \6\ Christine Dehlendorf, ``Successful teen pregnancy prevention 
program threatened by funding cuts,'' STAT News (April 20, 2017) 
(online at https://www.statnews.com/2017/04/20/successful-teen-
pregnancy-prevention-programthreatened-funding-cuts/).
    \7\ Christine Dehlendorf, ``Successful teen pregnancy prevention 
program threatened by funding cuts,'' STAT News (April 20, 2017) 
(online at https://www.statnews.com/2017/04/20/successful-teen-
pregnancy-prevention-programthreatened-funding-cuts/).

    Question 4. As Assistant Secretary for Health, would you commit to 
re-implementing the TPP grants that OAH cut short without explanation 
on July 5th?
    Answer 4. If confirmed, I commit to implementing the laws passed by 
Congress and signed by the President effectively and faithfully, and 
following the grant making rules and procedures of the Department. I 
also believe that the reasoning for decisions be transparent to 
Congress and the American people.

    Question 5. Will you commit to ensuring that Secretary Price, 
through the Office of Adolescent Health, provides a detailed response 
to the July 21st letter requesting OAH's justification for shortening 
TPP Program grant agreements?
    Answer 5. See above.
Title X Family Planning Program
    The Assistant Secretary for Health oversees the Office of 
Population Affairs, which runs the Title X Family Planning Program 
(Title X). The title X program funds basic reproductive health 
services--including cancer screenings, STI testing, and birth control--
to over 4 million low-income Americans every year.\8\
---------------------------------------------------------------------------
    \8\ U.S. Senate Committee on Health, Education, Labor, & Pensions, 
``Murray, Senate Dems Challenge Trump Administration Over Move to Slash 
Teen Pregnancy Prevention; Dems Say Action `Short-Sighted,' Will Make 
it Harder to Prevent Unintended Pregnancies'' (July 21, 2017) (online 
at https://www.help.senate.gov/ranking/newsroom/press/murray-senate-
dems-challenge-trump-administration-overmove-to-slash-teen-pregnancy-
prevention-dems-say-action-short-sighted-will-make-it-harder-to-
preventunintended-pregnancies-).
---------------------------------------------------------------------------
    In recent years, some States have attempted to exclude reproductive 
health centers that also provide abortion services from receiving title 
X funds. In December 2016, the Obama administration issued a rule 
clarifying that title X recipients cannot be barred from receiving 
funds ``on bases unrelated to their ability to provide title X services 
effectively.'' \9\ In spite of the critical services that title X 
provides, a Republican Congress--after calling in Vice President Pence 
for a tie-breaking vote--nullified this rulemaking through the 
Congressional Review Act.\10\
---------------------------------------------------------------------------
    \9\ Planned Parenthood Action Fund, ``Title X: America's Family 
Planning Program'' (online at https://www.plannedparenthoodaction.org/
issues/health-care-equity/title-x).
    \10\ Health and Human Services Department, Compliance With Title X 
Requirements by Project Recipients in Selecting Subrecipients (December 
19, 2016) (online at https://www.federal
register.gov/documents/2016/12/19/2016-30276/compliance-with-title-x-
requirements-byproject-recipients-in-selecting-subrecipients).
---------------------------------------------------------------------------
    Teresa Manning, Deputy Assistant Secretary for Population Affairs, 
has stated that ``contraception doesn't work'' and that ``its efficacy 
is very low.'' \11\ She has also--incorrectly--stated that a ``dominant 
. . . mechanism of the morning-after pill is the destruction of a human 
life already conceived.''\12\
---------------------------------------------------------------------------
    \11\ Colin Dwyer, ``Trump Signs Law Giving States Option to Deny 
Funding for Planned Parenthood,'' NPR (April 13, 2017) (online at 
http://www.npr.org/sections/thetwo-way/2017/04/13/523795052/trump-
signs-law-giving-states-option-to-deny-funding-for-planned-parenthood).
    \12\ Juliet Eilperin, ``Trump picks antiabortion activist to head 
HHS family planning section,'' Washington Post (May 2, 2017) (online at 
https://www.washingtonpost.com/news/powerpost/wp/2017/05/01/trump-
picks-antiabortionactivist-to-head-hhs-family-planning-program/?utm_
term=.292889b81423).
---------------------------------------------------------------------------
    If confirmed as Assistant Secretary for Health, it will be your 
responsibility to ensure that the Office of Population Affairs makes 
policy decisions regarding title X based on scientific evidence--not 
falsehoods.

    Question 6. Do you believe that ``contraception doesn't work'' and 
that ``its efficacy is very low''?
    Answer 6. I look forward to working with HHS staff if I am 
confirmed. I am committed to promoting the public's health and applying 
evidence and common sense to our policymaking process.

    Question 7. Do you believe that emergency contraception is akin to 
``the destruction of human life already conceived''?
    Answer 7. See above.

    Question 8. As Assistant Secretary for Health, would you push back 
against attempts in the Office of Population Affairs to implement 
policies based on inaccurate, scientifically disproven assumptions 
about contraception, regardless of efforts by others in the 
administration to implement policies based on falsehoods?
    Answer 8. See above.

    Question 9. As Assistant Secretary for Health, would you advocate 
for adequate funding for the title X program?
    Answer 9. See above.

    Question 10. As Assistant Secretary for Health, would you advocate 
for increased funding for the title X program?
    Answer 10. See above.

    Question 11. As Assistant Secretary for Health, would you revive 
efforts within the Department to ensure that States do not deny title X 
funding to health providers for reasons other than their ability to 
provide reproductive health services?
    Answer 11. See above.
Contraception and the Affordable Care Act
    Section 2713 of the Affordable Care Act (ACA) requires qualified 
health plans to cover ``preventive services'' for women (considered an 
``essential health benefit'') without imposing cost-sharing.\13\ 
``Preventive health services,'' for women, include FDA-approved 
contraceptive methods, with some limited exceptions for religious 
organizations.\14\
---------------------------------------------------------------------------
    \13\ Juliet Eilperin, ``Trump picks antiabortion activist to head 
HHS family planning section,'' Washington Post (May 2, 2017) (online at 
https://www.washingtonpost.com/news/powerpost/wp/2017/05/01/trump-
picks-antiabortionactivist-to-head-hhs-family-planning-program/?utm_
term=.292889b81423); Planned Parenthood, ``The Difference Between the 
Morning-After Pill and the Abortion Pill'' (online at https://
www.plannedparenthood.org/files/3914/6012/8466/
Difference_Between_the_MorningAfter_Pill_and_the_Abortion_Pill.pdf).
    \14\ Kaiser Family Foundation, ``Preventive Services for Women 
Covered by Private Health Plans under the Affordable Care Act'' 
(December 20, 2016) (online at http://files.kff.org
/attachment/Fact-Sheet-Preventive-Servicesfor-Women-Covered-by-Private-
Health-Plans-under-the-Affordable-Care-Act).
---------------------------------------------------------------------------
    Prior to the full implementation of the ACA, one in five women 
reported that they ``put off or postponed preventive services''--
including contraception--due to cost.\15\ As a result of the ACA, over 
55 million women with private health insurance have guaranteed coverage 
of these preventive services with no co-pays.\16\ And since the ACA was 
implemented, women have saved $1.4 billion in out-of-pocket cost 
spending for oral contraceptives. Yet in May 2017, a leaked rule from 
the Department suggests that HHS may be planning to overhaul the 
limited exceptions to the ACA's contraceptive mandate, creating a 
``very, very broad exception for everybody'' that would ``allow[] any 
employer to seek a moral or religious exemption from the requirement.'' 
\17\
---------------------------------------------------------------------------
    \15\ HealthCare.gov, ``Preventive care benefits for women'' (online 
at https://www.health
care.gov/preventive-carewomen/).
    \16\ Kaiser Family Foundation, ``Preventive Services for Women 
Covered by Private Health Plans under the Affordable Care Act'' 
(December 20, 2016) (online at http://files.kff.org/attachment/Fact-
Sheet-Preventive-Services-for-Women-Covered-by-Private-Health-Plans-
under-the-Affordable-Care-Act).
    \17\ Adelle Simmons, Jessammy Taylor, Kenneth Finegold, Robin 
Yabroff, Emily Gee, and Andrew Chappel, ``The Affordable Care Act: 
Promoting Better Health for Women,'' ASPE Issue Brief (June 14, 2016) 
(online at https://aspe.hhs.gov/sites/default/files/pdf/205066/ACA
WomenHealthIssueBrief.pdf).
---------------------------------------------------------------------------
    As the Assistant Secretary for Health, you would oversee the Office 
on Women's Health, which ``coordinates women's health efforts across 
HHS and addresses critical women's health issues.'' \18\
---------------------------------------------------------------------------
    \18\ Dylan Scott and Sarah Kliff, ``Leaked regulation: Trump plans 
to roll back Obamacare birth control mandate,'' Vox (May 31, 2017) 
(online at https://www.vox.com/policy-and-politics/2017/5/31/15716778/
trump-birth-controlregulation).

    Question 12. As Assistant Secretary for Health, would you work with 
the Office on Women's Health and other Department partners to oppose 
policies that would reduce women's access to contraceptive services?
    Answer 12. I am fully supportive of women's access to healthcare 
services. The system we ought to have in place is one that equips women 
and men to obtain the healthcare and preventive services that they need 
at an affordable price.

    Question 13. As Assistant Secretary for Health, what initiatives 
would you prioritize to ensure that women's access to preventive health 
services, including contraception, breast and cervical cancer 
screenings, and STI screening, is maintained and expanded?
    Answer 13. See above.
HIV/AIDS Programs
    The Assistant Secretary for Health oversees the Office of HIV/AIDS 
and Infectious Disease Policy. Along with the Office of HIV/AIDS and 
Infectious Disease Policy, the Office of the Assistant Secretary for 
Health provides ``management and support services'' for the President's 
Advisory Council on HIV/AIDS (PACHA).\19\ Yet in June 2017, six members 
of PACHA resigned, stating that the ``Trump Administration has no 
strategy to address the on-going HIV/AIDS epidemic, seeks zero input 
from experts to formulate HIV policy, and--most concerning--pushes 
legislation that will harm people living with HIV and halt or reverse 
important gains made in the fight against this disease.'' \20\
---------------------------------------------------------------------------
    \19\ U.S. Department of Health and Human Services, Office on 
Women's Health, ``Who we are'' (online at https://www.womenshealth.gov/
about-us/who-we-are).
    \20\ HIV.gov, ``What is PACHA?'' (online at https://www.hiv.gov/
Federal-response/pacha/about-pacha).

    Question 14. As Assistant Secretary for Health, would you 
prioritize HIV/AIDS initiatives and provide support to PACHA?
    Answer 14. Access to care for HIV/AIDS and related conditions is 
vital for the health of such patients. If confirmed, I commit to 
working within the capabilities of OASH to improve access to care for 
HIV/AIDS patients, as well as for all those in need of prevention or 
treatment services.

    Question 15. As Assistant Secretary for Health, will you commit to 
ensuring that all Americans maintain access to existing levels of care 
for HIV/AIDS and related conditions?\21\
---------------------------------------------------------------------------
    \21\ Scott Schoette, ``Trump Doesn't Care About HIV. We're Outta 
Here,'' Newsweek (June 16, 2017) (online at http://www.newsweek.com/
trump-doesnt-care-about-hiv-were-outta-here-626285).
---------------------------------------------------------------------------
    Answer 15. See above.

    Question 16. Will you commit to expanding access to care for HIV/
AIDS patients?
    Answer 16. See above.

    Question 17. As Assistant Secretary for Health, will you commit to 
maintaining existing levels of funding for HHS programs within your 
purview that combat HIV/AIDS?
    Answer 17. See above.
Inclusion of Women and Underrepresented Minorities in Clinical Trials
    The Assistant Secretary for Health aims to ``optimize the Nation's 
investment in health and science to advance health equity and improve 
the health of all people'' and oversees the Office of Women's Health 
(OWH) and the Office of Minority Health (OMH).\22\ These two offices 
are responsible for promoting the health of women and racial and ethnic 
minorities and helping coordinate efforts across HHS and other Federal 
agencies to support policies and programs that reduce health 
disparities.
---------------------------------------------------------------------------
    \22\ Office of the Assistant Secretary for Health, ``Office of the 
Assistant Secretary for Health (OASH)'' (online at: https://
www.hhs.gov/ash/index.html).
---------------------------------------------------------------------------
    Disparities in biomedical research are one factor exacerbating 
existing health disparities. Clinical trials are an essential component 
of drug innovation and development, and data from clinical trial 
research is used to shaping health care decisions, including coverage 
decisions. In July 2016, the OMH awarded a grant to ``develop and begin 
implementing an education program on clinical trials that educates and 
recruits minorities and/or disadvantaged populations, particularly 
groups underrepresented in clinical research.''\23\
---------------------------------------------------------------------------
    \23\ Department of Health and Human Services Office of Minority 
Health, ``HHS Office of Minority Health Awards $2M to Help Reduce Lupus 
Related Health Disparities'' (July 5, 2016) (online at: https://
minorityhealth.hhs.gov/omh/content.aspx?ID=10338). Accessed August 1, 
2017.

    Question 18. Do you agree that the inclusion of women and 
minorities in clinical trials is important to developing new drugs and 
therapeutics, improving medical treatments, and addressing health 
disparities?
    Answer 18. As a physician and scientist, I have spent my career 
focusing on this area and believe it is vital that we strike the right 
balance between inclusiveness of potentially affected populations in 
clinical trials with the need to speed cures to patients. We have to 
work harder to achieve both goals. It is important for all Americans to 
know if they are eligible for clinical trials, and to particularly 
focus on rare diseases and minority populations. If confirmed, I commit 
to seek a broad diversity of opinions and include them in the public 
health decisionmaking process, consistent with my role.

    Question 19. As Assistant Secretary of Health, what specific steps 
will you take to educate women and minorities about clinical trials? 
What specific steps will you take to help recruit them for the trials?
    Answer 19. See above.

    Question 20. Do you agree that women and minority health concerns 
should be tightly integrated within all aspects of the Federal 
Government's approach to health care and health research, including in 
the development of policy and programs?
    Answer 20. See above.

    Question 21. As Assistant Secretary of Health, what specific steps 
will you take to ensure that women and minorities are included in 
public health decisionmaking processes?
    Answer 21. See above.
Combating Antibiotic Resistance
    The 2014 National Strategy for Combating Antibiotic-Resistant 
Bacteria brought together the Secretaries of Health and Human Services, 
Agriculture, and Defense to declare that, ``the misuse and over-use of 
antibiotics in health care and food production continue to hasten the 
development of bacterial drug resistance, leading to the loss of 
efficacy of existing antibiotics.'' \24\ Through this initiative, we've 
made some significant progress establishing policies that better 
protect lifesaving antibiotics.
---------------------------------------------------------------------------
    \24\ ``National Strategy for Combating Antibiotic-Resistant 
Bacteria,'' The White House (September 2014) (online at: https://
www.whitehouse.gov/sites/default/files/docs/carb_national
_strategy.pdf), p.4.
---------------------------------------------------------------------------
    There is strong and growing evidence that antibiotic use in food 
animals can lead to antibiotic resistance in humans, yet the use of 
medically important drugs in food animals continues to grow. According 
to the FDA, ``Domestic sales and distribution of medically important 
antimicrobials approved for use in food producing animals increased by 
26 percent from 2009 through 2015, and increased by 2 percent from 2014 
through 2015.'' \25\
---------------------------------------------------------------------------
    \25\ Food and Drug Administration, ``2015 Summary Report on 
Antimicrobials Sold or Distributed for Use in Food-Producing Animals'' 
(December 2016) (online at: http://www.fda.gov/downloads/ForIndustry/
UserFees/AnimalDrugUserFeeActADUFA/UCM534243.pdf).

    Question 22. Do you agree that curbing the misuse and over-use of 
antibiotics in health care and food production should be a public 
health priority?
    Answer 22. If confirmed, I intend to engage in a personal way to 
support the Presidential Advisory Council on Combating Antibiotic-
Resistant Bacteria (PACCARB), which is overseen by OASH, as well as the 
important work on this issue being done by CDC, FDA, ASPR, and other 
Federal partners.

    Question 23. As Assistant Secretary for Health, what specific steps 
will your office take to prevent the development of bacterial drug 
resistance?
    Answer 23. See above.
   Response by Robert Kadlec, M.D., to Questions of Senator Murray, 
 Senator Sanders, Senator Casey, Senator Franken, Senator Whitehouse, 
           Senator Baldwin, Senator Murphy and Senator Warren
                             senator murray
    Question 1. During the last reauthorization of the Pandemic and 
All-Hazards Preparedness Act (PAHPA), this committee included key 
provisions to ensure the unique needs and considerations of ``at-risk 
individuals'' are incorporated into preparedness and response 
activities and planning. Do you think these needs have been 
sufficiently incorporated into ASPR's activities? What more could be 
done to ensure the needs of at-risk individuals are met? What 
populations do you view as being at especially high risk in the event 
of a public health emergency?
    Answer 1. The reauthorization of PAHPA in 2013 provided additional 
authorities to address the needs of at-risk individuals. ASPR continues 
to work with its Federal, State, local, and community partners to 
better integrate the needs of at-risk populations, particularly those 
with access and functional needs, into its planning and its 
preparedness and response activities. ASPR does this by providing 
guidance and ensuring State and local public health grants include 
preparedness and response strategies to address at-risk population 
needs; ensuring the Strategic National Stockpile considers the needs of 
at-risk populations; overseeing the progress of, and considering the 
recommendations of, the Advisory Committee on At-Risk Individuals and 
Public Health Emergencies and many other work groups; and by developing 
training and best practices for preparing for, and responding to, the 
needs of at-risk individuals prior to, during and after a public health 
emergency.
    ASPR also created the Nation's first interactive map that 
integrates big data on healthcare, real-time weather data, and 
Geographic information system (GIS) to help communities prepare for the 
needs of over 2.5 million people who rely on electricity-dependent 
medical equipment and other critical medical devices in every zip code.
    At-risk populations are those that could experience more severe 
effects from a disaster or attack. Easily identified are the very young 
and old or individuals with pre-existing disorders or chronic 
conditions, which place them at greater risk for detrimental health 
effects in a disaster or public health emergency. Regardless of the 
underlying factor, as President John F. Kennedy noted, society will 
judge how well we address at-risk and vulnerable populations and afford 
them the appropriate care whatever the circumstance.
    I plan to fully assess ASPR's current activities, and determine 
what ASPR is doing well, and what should be improved. Assisting at-risk 
populations will be incorporated into any improvements made to the work 
ASPR performs.

    Question 2. The more rapidly we can detect an emerging infectious 
disease threat, the more effectively we can protect the public from the 
spread of disease. This requires well-resourced tools, including a 
highly skilled public health workforce, state-of-the-art surveillance 
and diagnostic techniques, and research to deliver effective medical 
countermeasures. What gaps do you believe exist in our outbreak 
preparedness and response capabilities, and how should they be 
addressed?
    Answer 2. Since its creation, ASPR has helped coordinate the public 
health emergency, public health preparedness and response activities 
across HHS. The Hospital Preparedness Program (HPP) helps prepare our 
local medical workforce to prepare for public health threats as well as 
provide situational awareness in the event of an emergency. We must 
continue to buildupon the foundation at ASPR in these areas. Part of 
the evolution at ASPR in this area should be the creation of a 
``national contingency health care'' system. There is an urgent need to 
better organize, train and equip our State and local healthcare 
systems, facilities and providers to ensure that they cannot only 
better respond to routine emergencies, but also to extraordinary events 
that are likely to occur. Here we have an opportunity to better 
integrate Emergency Medical Services, the ``tip of the spear'' of our 
national medical response into these efforts, and to increase effective 
coordination across HHS and the Federal departments, such as the 
Department of Defense and the Department of Veterans Affairs, to 
support State and local responders.
    To achieve this, we need to support the sustainment of robust and 
reliable public health security capabilities that include an improved 
ability to detect and diagnose infectious diseases and other threats, 
as well as the capacity to rapidly characterize and attribute them.

    Question 3a. One of the issues we have seen time and again is that 
the response to major crises, like the Ebola outbreak, Zika outbreak, 
and Flint water contamination, crosses agency lines.
    As you are well familiar, ASPR is intended to be the health lead 
during major disasters. How do you envision the coordinating role of 
ASPR?
    Answer 3a. The Assistant Secretary for Preparedness and Response 
serves as the Secretary's principal advisor on all matters related to 
Federal medical preparedness, response, and recovery for public health 
emergencies, as well as activities throughout HHS including human 
services. The Secretary has expressed a passionate commitment to public 
health security and resiliency and has high expectations for ASPR and 
its role in emergencies and disasters that affect HHS's health, public 
health, and human services mission.
    In this position, I will be the leader for preparing for and 
responding to emergencies and disasters, including public health 
emergencies, which implicate HHS's mission. I intend to maintain 
visibility and accessibility in order to direct coordination, within 
HHS and across other Federal agencies, to prevent duplication or 
uncoordinated efforts. The challenges we face today demand more 
effective Federal coordination to assist State and local health 
authorities and fully mobilize the private sector in response to such 
disasters and emergencies, especially public health emergencies. It 
will be my priority to integrate and support the capabilities of the 
Centers for Disease Control and Prevention, the National Institutes of 
Health, the Food and Drug Administration, the Public Health Service 
Commissioned Corps, and other agencies as well as increase coordination 
with external partners such as the Departments of Defense, Homeland 
Security, Veterans Affairs, and State and local responders, among 
others.

    Question 3b. How would you work with the directors of the Centers 
for Disease Control and Prevention (CDC) and other relevant agencies 
both within and outside of the Department of Health and Human Services 
(HHS) to ensure appropriate management of a disaster response?
    Answer 3b. Appropriate management of response and recovery 
activities is contingent on both strong leadership and the fostering of 
effective routine, pre-crisis working relationships with the CDC 
Director and other senior leaders inside and outside of HHS. These 
relationships need to be framed by clear and documented expectations of 
ASPR's and others' roles and responsibilities, and a governance 
approach that can be effective in fully utilizing the equities and 
capabilities of each individual agency to elicit a more effective 
response effort. Additionally, I believe practice makes perfect. That 
is why I plan to increase the number of public health emergency 
exercises ASPR coordinates to ensure we are ready across HHS and other 
departments to respond when called upon.
    ASPR coordinates and collaborates across HHS through the Disaster 
Leadership Group (DLG). The DLG brings together senior leaders from 
across HHS, including the Director of CDC (or her representative(s)), 
to make decisions on policy issues that affect medical and public 
health systems during disasters which includes coordination on issues 
that impact national health security.

    Question 3c. How will your office work with the White House--which 
has not prioritized public health preparedness--to ensure coordination 
and avoid duplication of efforts?
    Answer 3c. ASPR has an impressive cadre of medical, public health, 
and other professionals, with both technical and policy expertise, who 
work closely with the National Security Council (NSC) staff through 
Policy Coordination Committees in preparedness matters and during 
responses. This ensures that ASPR provides the public health 
preparedness and response expertise that NSC needs to align these 
efforts with overarching administration policies. ASPR has worked 
closely with NSC to develop a series of frameworks for responding to 
emerging infectious diseases and chemical, biological, radiological, 
and nuclear (CBRN) threats that delineate the roles and 
responsibilities of the NSC and the Federal departments and agencies.

    Question 4. In light of the growing threat of antibiotic 
resistance, how can the United States play a leadership role in 
combating this threat to national and international security? In what 
ways do you think the Combating Antibiotic Resistant Bacteria 
Biopharmaceutical Accelerator (CARB-X) has helped or will help to 
combat the spread of antimicrobial resistance (AMR)?
    Answer 4. I believe antibacterial drugs underpin every facet of 
modern medicine and public health emergency preparedness and response. 
Antibiotics would be relied upon in the event of an attack with a 
bacterial threat agent like anthrax or pneumonic plague, but also in 
events where prolonged hospitalization was required or a patient's 
immune system was impaired (e.g., exposure to immune-compromising 
agents, burn injury, radiation exposure). ASPR's Biomedical Advanced 
Research Development Authority (BARDA) has advanced six antibiotic 
candidates into Phase III clinical development. The U.S. Food and Drug 
Administration (FDA) review of one will be complete by the end of 
August and may represent the first BARDA supported antibiotic to enter 
the market.
    CARB-X in its first year has supported 18 different companies 
developing 17 candidate therapies and one point of care diagnostic that 
is capable of determining if an individual has viral or bacterial 
pneumonia. The 17 candidates are quite novel in their approach. There 
are 8 novel classes, 10 novel bacterial targets, and 5 nonantibiotic-
based approaches that are capable of treating the infection. 
Collectively, the purpose of CARB-X is to build and maintain a robust 
preclinical pipeline of novel antibacterial therapies that will mature 
into promising candidates for advanced development support and eventual 
FDA approval.

    Question 5. As I'm sure you know, last week Texas officials 
reported the first local case of mosquito-transmitted Zika since last 
fall. If confirmed, this would be the first case of nontravel-related 
Zika within the continental United States this year. The Zika virus 
presents a number of discrete challenges to any public-health 
response--for example, only about one-fifth of people infected with the 
virus experience symptoms. It is additionally the first mosquito-
transmitted virus in history with the ability to cause birth defects, 
including microcephaly. Do you believe a robust family planning support 
network is necessary to your ability to address the Zika pandemic? If 
so, how do you respond to agency attempts to reduce access to family 
planning services? If not, why not?
    Answer 5. The challenge from the Zika virus remains an active 
ongoing concern for HHS. The risk it poses to pregnant females demands 
our best efforts to understand the risks to the unborn. We have to 
pursue a firm understanding of the etiology of all forms of the disease 
and a better understanding of the spectrum of complications that occurs 
in exposed babies. Until we have a vaccine that FDA has licensed as 
safe and effective, our best efforts must be focused on protecting 
expectant mothers from being exposed. Family planning support is only 
one arm of that effort. Aggressive environmental surveillance for Zika-
infected mosquitos, eliminating their breeding grounds, and reducing 
the risk of pregnant women being exposed is our best course of action 
until we have a vaccine.
                            senator sanders
    Question 1. Climate change is a serious threat to human health. 
Climate change can harm our health by threatening the quality and 
safety of our water supply and by increasing the risk and spread of 
vector-borne disease, extreme weather events and air pollution. 
Vulnerable populations--including low-income communities, communities 
of color, the elderly, young children, and those with chronic 
illnesses--bear the greatest burden of injury, disease and death 
related to climate change. President Trump has stated that ``nobody 
really knows'' whether climate change is real, yet the overwhelming 
scientific evidence shows that not only are climate change and its 
associated negative health impacts occurring, it also points to human 
activity as the primary cause of global warming over the past 50 years.
    How would you characterize the health threats posed by climate 
change and what will you do to address these threats? What can the 
Federal Government do to make sure State and local health departments 
have the tools and resources they need to protect the public from the 
immediate and long-term health threats associated with climate change?
    Answer 1. ASPR identifies, analyzes, prepares for, and responds to 
changing or emergent threat landscapes across an array of risk areas 
including natural and human-caused disasters and public health 
emergencies. This includes provision of technical assistance and 
guidance to key partners such as State and local public health agencies 
as well as participation in interagency efforts to ensure that public 
health concerns are appropriately integrated into overall planning and 
preparedness. Specific weather and climate-related public health 
concerns may include changing the severity or frequency of health 
problems that are already affected by climate or weather factors and 
unanticipated health threats in places where they have not previously 
occurred.
                             senator casey
    Question 1. Many existing medical countermeasures (MCMs), including 
both vaccines and therapeutics, are only approved for use in adults, 
and lack pediatric formulations, dosing information or safety 
information. This poses serious challenges to our ability to protect 
children in the event of a disaster or disease outbreak. What steps can 
you take, if confirmed, to collaborate with industry, academia, Federal 
agencies and other BARDA partners to ensure that all MCMs available 
include appropriate pediatric formulations or doses, as appropriate?
    Answer 1. ASPR's Biomedical Advanced Research and Development 
Authority (BARDA) continues to pursue and support expanding the 
indications of medical countermeasures (MCMs) to address ``at-risk'' 
individuals, including children, as mandated under the Pandemic and 
All-Hazards Preparedness Act. Many of the products that have been 
developed under Project BioShield (PBS) or for pandemic preparedness 
can be administered to pediatric populations or have ongoing or planned 
pediatric trials to expand their label indications. In addition, the 
Strategic National Stockpile has numerous products that can be 
administered to pediatric patients. Some of the products may have to be 
administered under an Investigational New Drug (IND) or through the 
issuance of an Emergency Use Authorization (EUA) by the FDA. ASPR also 
participates in the National Advisory Committee on Children and 
Disasters. Protecting children will be a priority issue during my 
tenure as ASPR.

    Question 2. During our meeting, we talked about the role of the 
ASPR in our public health preparedness efforts, and you shared some 
suggestions for steps you might take to improve coordination among 
Federal agencies, such as supporting a staff member at CDC to liaise 
between the CDC Director and yourself. What other steps would you take 
to ensure maximum coordination between Federal agencies and State and 
local partners, both vertically and horizontally? How would you ensure 
that all of HHS's agencies working on preparedness and response are 
learning from previous emergency responses?
    Answer 2. What I learned about creating more effective coordinated 
responses comes from my time in U.S. special operations at a particular 
formative period after the failure at DESERT ONE. One of the findings 
of the Holloway Commission was that the stove piping and the lack of 
integration in planning and operations contributed to the failure. I 
personally saw and experienced this in the mid-1980s. Creating greater 
transparency by exchanging personnel, jointly working on planning for 
emergencies, and committing to regular joint exercises goes a long way 
to overcoming parochialism and uncoordinated efforts and to better 
integrated operations. In special operations, commanders must commit to 
this. It starts at the top. Having not been at the Department, I do not 
mean to suggest that the same kind of problems exist at the Department, 
or between ASPR and CDC, but these lessons would guide my efforts to 
ensure maximum coordination between agencies.

    Question 3. There is a saying in health care, ``children are not 
small adults.'' This holds true when we are talking about public health 
preparedness and biodefense. The Hospital Preparedness Program (HPP) is 
administered by the Assistant Secretary for Preparedness and Response 
and provides funding to every State and territory to support health 
system preparedness, whether the system is responding to a pandemic, a 
terrorist attack or a natural disaster. HPP is the primary Federal 
funding program for hospital emergency preparedness and has provided 
critical resources to improve health care surge capacity. Can you 
describe how you plan to use the existing Federal funding mechanisms 
through the Hospital Preparedness Program (HPP) to ensure that the 
States and cities receiving HPP funding are prepared to meet the needs 
of children?
    Answer 3. In 2016, the Hospital Preparedness Program (HPP) began an 
intensive effort to revise its core guidance, namely the 2017-22 Health 
Care Preparedness and Response Capabilities. Throughout the revision 
process, ASPR engaged the American Academy of Pediatrics and the 
Children's Hospital Association to ensure that the needs of children 
are optimally integrated into HPP's planning guidance. In addition, in 
HPP's fiscal year 2017 funding opportunity announcement, awardees were 
required to submit a joint letter of support with their jurisdiction's 
Emergency Medical Services for Children (EMSC) program, detailing how 
the two programs will work together during this budget period to meet 
the needs of children during emergencies. HPP and EMSC also have a 
joint performance measure to evaluate awardees' capabilities to respond 
to pediatric emergencies. The specific program measure is the percent 
of hospitals with an emergency department recognized through a 
statewide, territorial, or regional standardized system that are able 
to stabilize and/or manage pediatric medical emergencies. I will 
continue ASPR's work with the HPP to ensure that it will meet the needs 
of pediatric patients in public health emergencies and disasters.

    Question 4. Over the last several months, I have sent multiple 
letters to HHS about the Administration's ongoing efforts to undermine 
and sabotage the Affordable Care Act through executive action. HHS has 
failed to provide responses to many of my letters. If HHS has 
responded, the response letters have been wholly inadequate and have 
not been responsive to my requests. If you are confirmed, do you commit 
to respond in a timely manner to all congressional inquiries and 
requests for information from all Members of Congress, including 
requests from Members in the Minority?
    Answer 4. I intend to respond appropriately to all Member requests.
                            senator franken
    Question 1. You have called for increased attention to public 
health and for funding for preparedness efforts. The President's budget 
proposed an emergency fund for infectious disease response but it drew 
its funding from transfers from existing programs. Would that emergency 
fund be sufficient for preparedness efforts? Based on your experience 
are additional funds needed? If so, what funding level would be ideal 
for such a fund?
    Answer 1. The fiscal year 2018 President's Budget requests the 
authorization of the ``Federal Emergency Response Fund,'' to support 
the following priorities for domestic preparedness and global health:

    1. To prevent, prepare for, or respond to a chemical, biological, 
radiological, or nuclear threat, and,
    2. To prevent, prepare for, or respond to an emerging infectious 
disease.

    The Fund may be used for a public health threat or emergency that 
the Secretary of HHS determines has significant potential to occur. As 
such, the Fund may be used for preparedness efforts and to prevent a 
public health emergency. The Fund provides flexibility to the Secretary 
of HHS to address potential threats at earlier stages, thereby reducing 
the likelihood of a more severe impact on the health and security of 
American citizens.
    Public health and medical emergencies are unpredictable in nature, 
specifically with regard to the scope and magnitude of potential 
disease, injury, or death. Consequently, emergency supplemental 
appropriations, such as those used to respond to the Ebola and Zika 
outbreaks, could still be needed. However, the fund provides the 
Secretary of HHS the capability to respond quickly and nimbly, while 
the needs and resources of an emergency supplemental are determined.
    As the new Assistant Secretary for Preparedness and Response, it 
will be one of my top priorities to ensure our public health, health 
system, and scientific research infrastructures are strong. This will 
be critical to mitigating the impact of potential public health 
emergencies, as well as to improve the overall health and well-being of 
U.S. citizens. To this end, I will actively identify where additional 
investments are needed and work with my HHS and Administration 
colleagues to communicate those needs to Congress.
                           senator whitehouse
    Question 1a. Preparedness for a naturally occurring global disease 
outbreak presents distinctly different challenges than preparedness for 
an intentional bioweapon attack.
    What are the key differences in being adequately prepared for a 
pandemic disease outbreak versus a bioweapon attack?
    Answer 1a. The basic capabilities required to prepare and respond 
to naturally occurring pandemics and bioweapon attacks are generally 
similar. For example, both require strong public health systems that 
are able to detect an event and respond with appropriate medical and 
non-medical interventions. Each also has unique differences. The scale, 
scope, and speed needed for a response to a bio-attack differ 
significantly from a naturally occurring pandemic. In addition, the 
national security consequences of a bio-attack are of greater 
consequence. Pandemic disease outbreaks generally affect populations 
across geographic and healthcare delivery system boundaries. In 
contrast, bioweapon attacks may be more localized, but can also 
immobilize entire healthcare delivery systems. A major difference, 
however, is that an adversary using a biological weapon is intent on 
affecting our national will, our economy and confidence in our 
government. In doing so, they would likely try to achieve maximum 
psychological and physical effects and use other attack modalities such 
as cyber and/or conventional weapons as well. As a result, pandemic 
disease outbreaks and bioweapon attacks differ in requirements for 
support and operational coordination.
    From an operation's standpoint, ASPR's preparedness for both an 
emerging infections disease and bioweapon attack must be multifaceted. 
ASPR requires clinical, pharmaceutical, and non-pharmaceutical tools to 
build capacity at the State, local, healthcare sector, and private 
sector levels. ASPR must have the capacity to develop (with its 
governmental and industry partners) the medical countermeasures 
necessary to respond to biological threats, to build the tools to 
support the immediate consequences of a biological threat, and to 
support States and communities in recovering from and mitigating the 
risk of future biological threats.

    Question 1b. What immediate steps will you take to improve our 
preparedness for both types of emergencies?
    Answer 1b. I will immediately work with government partners to 
assess our current capabilities for responding to global disease 
outbreaks and intentional bioweapon attacks that pose a threat to our 
homeland. Global disease outbreaks are different for an intentional 
bioweapon attack, primarily in timing. Global disease outbreaks occur 
in waves that potentially provide some time to prepare, unlike an 
intentional bioweapon attack that would be an acute event with numerous 
individuals exposed in a very short timeframe requiring an immediate 
response. However, both types of emergencies require preparedness 
efforts to ensure an appropriate response.
    For global outbreaks such as pandemic influenza, ASPR's Biomedical 
Advanced Research and Development Authority (BARDA) maintains 
stockpiles of pre-pandemic influenza vaccine, bulk product, and 
adjuvant that may be quickly manufactured into vaccines and antiviral 
drugs. To prepare for a bioweapon attack, ASPR works with its 
government partners to develop and stockpile medical countermeasures to 
address the negative health impacts of exposure to various threat 
agents. These include vaccines, therapeutics, and diagnostics. For 
example, ASPR/BARDA is supporting the development of early, in-home 
diagnostic technologies to be able to rapidly identify an outbreak, as 
well as platform-based production systems that will enable a more rapid 
medical countermeasure response to a known or unknown threat.
    One area that will receive my initial serious evaluation is our 
ability to rapidly distribute the medical countermeasures we have in 
our stockpile.
    Additionally, ASPR is working with its U.S. Government stakeholders 
to develop the first-ever National Biodefense Strategy, a comprehensive 
plan for how the United States will work across the executive branch to 
prepare for, prevent, detect, respond to, and recover from biological 
events, regardless of their source. I am committed to both the 
development of the Strategy, as well as to working within the 
Department to ensure that both ASPR and the Department take the 
necessary steps to implement the Strategy.

    Question 1c. How would you describe this administration's current 
level of preparedness for a pandemic and for a bioweapon attack?
    Answer 1c. I intend to conduct a rapid assessment of the State of 
biodefense preparedness upon my entry on duty as the ASPR.

    Question 2a. BARDA uses its ``TechWatch'' program to work with 
smaller companies on the development of medical countermeasures, but I 
have heard from companies in my State that BARDA and other divisions of 
HHS could do more to support small companies in this space.
    How would you instruct BARDA to improve its engagement with small, 
innovator companies?
    Answer 2a. Capitalizing on the rapidly advancing biotechnology and 
life science is an essential element of a strategy to not just keep 
even with, but get ahead of the threats confronting the Nation. I will 
ensure that BARDA continues to invest in innovative technologies to 
address some of the most serious threats faced by our Nation. The 
TechWatch program has been successful in providing, to companies of all 
sizes, the opportunity to meet face-to-face with BARDA. BARDA's mission 
is to support advanced research and development. In case technologies 
are not mature enough for consideration for BARDA, other PHEMCE 
partners such as the National Institutes of Health and the Department 
of Defense are invited to the meetings to provide additional avenues 
for potential partnerships. ASPR continues to exceed its small business 
goals and will invest in companies that have promising technologies, 
regardless of their size. BARDA subject matter experts work closely 
with all companies to support development of candidate products, 
especially those companies that may not have much experience in 
developing products.

    Question 2b. In addition to the TechWatch program, ASPR holds a 
yearly BARDA Industry Day which provides everyone the opportunity to 
interact with BARDA and ASPR's Office of Acquisitions, Management, 
Contracting, and Grants. This venue provides opportunities for 
companies to ask questions regarding how to work with the Federal 
Government.
    The 21st Century Cures Act contains a provision called the 
Strategic Investor Initiative that offers new opportunities for ASPR 
and BARDA to invest in promising new technologies. I will ensure that 
we implement this provision and that the initiative receives the 
appropriate priority and resourcing to be successful.
    How will you ensure BARDA's development and procurement activities 
don't overlook small innovator companies that have less experience 
working with Federal partners?
    Answer 2b. Please see (a) above.

    Question 3. You have long advocated for a strong Federal role in, 
in your words, ``confronting the risk from deliberate biological 
threats.'' Although many programs overseen by the ASPR were spared from 
proposed cuts in the President's fiscal year 2018 budget, in my view 
the Trump administration has done little else to demonstrate its 
commitment to biodefense. Will you advocate for robust funding for and 
the prioritization of biodefense work within HHS and with other members 
of the administration?
    Answer 3. ASPR plays a critical role in preparing the Nation to 
face biological threats. My previous experience as Deputy Staff 
Director of the Senate Intelligence Committee and numerous other roles, 
have made clear the need for strong national biodefense capabilities. 
The threats we face are real, and the Department of Homeland Security 
has identified, through the material threat assessment, those of 
greatest concern. To prepare for these threats, we must continuously 
invest in the development of new medical countermeasures and ensure we 
are sustaining the production of countermeasures already developed. The 
Trump administration recently announced its intention to draft an 
updated national biodefense strategy. I look forward to being a part of 
that policy discussion and ensuring a comprehensive strategy with an 
accompanying implementation and resource plan is produced.

    Question 4a. Antibiotic resistance is a growing threat to our 
health security. The Centers for Disease Control and Prevention 
estimates that two million people develop antibiotic-resistant 
infections in the United States every year, resulting in at least 
23,000 deaths.
    Do you believe combating antibiotic resistance is a matter of 
national preparedness?
    Answer 4a. Antibiotics underpin nearly every facet of modern 
medicine, and their continued effectiveness would be heavily relied 
upon in a mass public health emergency. Antibiotic resistance is a 
matter of national public health and a national security concern. 
Antibiotics would be relied upon in the event of an attack with a 
bacterial threat agent-like anthrax or pneumonic plague, but also in 
events where prolonged hospitalization was required or a patient's 
immune system was impaired (e.g., exposure to immune-compromising 
agents, burn injury, radiation exposure).
    The development of new antibiotics will remain a priority for me. 
ASPR will continue to make progress in mitigating the threat posed by 
drug resistant infections through a number of mechanisms, including 
ASPR's Biomedical Advanced Development Authority's (BARDA) clinical 
stage program, which has progressed six candidate antibiotics into 
Phase III clinical development, and CARB-X's novel public-private 
partnership aimed at building an innovative preclinical stage pipeline 
of antibacterial therapies, diagnostics, and vaccines,. There are a 
number of ways the Federal Government can spur innovation in antibiotic 
research and development. Currently, the Federal Government provides 
push incentives that lower the research and development costs for new 
antibiotics. While push incentives are helpful, in order to adequately 
address the market challenges that BARDA's industry partners face 
developing and marketing new antibiotics, completely new business 
models are needed. These models need to create a strong pull incentive 
that provides a known return on investment for the development of an 
antibiotic that addresses unmet medical need(s). If companies can rely 
on a certain level of return on their investment, it will drive 
additional private sector investment in research and development for 
this critical area. Under my leadership, ASPR will work to develop and 
implement such business models.

    Question 4b. As ASPR, will you prioritize the development of new 
antibiotics?
    Answer 4b. Please see (a) above.

    Question 4c. How can the Federal Government best encourage 
investments in antibiotic research?
    Answer 4c. Please see (a) above.
                            senator baldwin
    Question 1. Our country has recently seen some of the most extreme 
public health outbreaks--from Ebola to Zika--and we know that the next 
outbreak could be right around the corner or just a plane ride away. I 
am particularly concerned about our country's preparedness efforts for 
pandemic influenza. In 2004, we saw a dangerous shortage of influenza 
vaccine in the United States due, in part, to disruptions in vaccine 
production overseas, and we saw a deadly pandemic of H1N1 in 2009.
    Dr. Kadlec, what lessons did we learn from these experiences and 
how will you strengthen and maintain our stockpile of vaccines before 
we face the next influenza pandemic?
    Answer 1. The H1N1 influenza pandemic of 2009 and the more recent 
public health emergencies for Ebola and Zika have shown that pandemic 
influenza and emerging infectious diseases are serious and 
unpredictable. The disease can spread rapidly and, in most cases, 
funding to rapidly ramp-up response is dependent upon supplemental 
funding that often takes months to approve. This is why a Public Health 
Emergency Fund is essential for a quick response. Although the amounts 
in such a Fund may not be sufficient to complete the job, such funds 
would allow for efforts to begin immediately. The most effective 
mitigation requires deployment and vaccination before the peak of virus 
spread. The faster we can initiate product development and 
manufacturing activities, the quicker a vaccine will be available.
    ASPR's Biomedical Advanced Research and Development Authority 
(BARDA) has supported new cell- and recombinant-based technologies for 
pandemic influenza vaccines that have received U.S. Food and Drug 
Administration (FDA) approval. ASPR/BARDA-supported development of 
adjuvanted pandemic influenza vaccine technologies serve to increase 
the number of vaccine doses that will be available by reducing the 
amount of antigen that is necessary to generate a protective immune 
response. ASPR/BARDA and its Federal partners are funding and 
conducting clinical trials to evaluate the safety and immunological 
response of pre-pandemic influenza vaccine stockpiles to make sure they 
remain safe and effective after long-term storage. This element of the 
strategy is particularly important. By working closely with our CDC and 
NIAID partners who identify potential pandemic influenza strains 
emerging globally, BARDA can commission the initial production of a 
pre-pandemic stockpile that (1) demonstrates the ability to produce an 
effective vaccine against that potential strain, and (2) creates an 
emergency stockpile that permits an immediate response should that 
strain emerge as a pandemic.
    ASPR/BARDA is also developing novel antiviral drugs and novel 
influenza therapeutics to mitigate the emergence of antiviral drug 
resistance often observed in influenza. The most important lesson 
learned is that an immediate response is necessary to mitigate the 
spread of disease.
                             senator murphy
    Question 1. In the event of a pandemic, it is critical for the 
public health to be able to respond quickly and in a way that does not 
adversely impact the rest of the health care delivery system. To that 
end, we must ensure there are an appropriate number of drug delivery 
devices available to deploy therapies to patients in real time. The 
Biomedical Advanced Research and Development Authority (BARDA) has the 
ability to manage this with existing contracts, but without regular 
task orders to maintain a viable level of product at-the-ready, I'm 
concerned we won't be prepared.
    How will you ensure BARDA not only has contracts in place to 
provide a sufficient amount of drug delivery devices, but that BARDA 
also issues task orders against those contracts so that an adequate 
level of product is always on hand?
    Answer 1. ASPR's Biomedical Advanced Research Development Authority 
(BARDA) maintains indefinite deliverable/indefinite quantity (IDIQ) 
contracts with producers of ancillary supplies for vaccine delivery. 
Periodically, ASPR/BARDA issues task orders to procure additional 
ancillary delivery supplies to refresh outdated inventory that is 
maintained for rapid response for pandemic preparedness. I plan to 
continue this approach to ensure these materials will be available when 
needed for a pandemic response.
                             senator warren
Pandemic Flu
    The Department of Health and Human Services (HHS) would lead the 
Federal Government response to a pandemic flu. Before leaving the 
Centers for Disease Control and Prevention (CDC) in January 2017, the 
former Director, Dr. Thomas Frieden, stated his concerns about such a 
pandemic, noting that the greatest public health threat we face is 
``always for an influenza pandemic,'' and that ``[I]f the resistant 
organisms emerge in one part of the world, they will inevitably come to 
other parts of the world.''\1\
---------------------------------------------------------------------------
    \1\ Lena H. Sun, ``Outgoing CDC Chief Talks about Agency's 
Successes--and His Greatest Fear,'' Washington Post (January 16, 2017) 
(online at: https://www.washingtonpost.com/news/to-your-health/wp/2017/
01/16/outgoing-cdc-chief-talks-about-the-agencys-successes-and-his-
greatest-fear/?tid=a inl&utm_term=.8ca1cf116944).
---------------------------------------------------------------------------
    President Trump's fiscal year 2018 budget proposal included $1.3 
billion in cuts for the CDC and substantial cuts for key public health 
programs including $107 million in cuts for the CDC's Public Health 
Emergency Preparedness Cooperative Agreements, $2 billion in State 
Department global health assistance.\2\ President Trump's budget--and 
legislation attempting to repeal the Patient Protection and Affordable 
Care Act (ACA) would eliminate the Prevention and Public Health Fund 
and impose substantial cuts to the Medicaid program.
---------------------------------------------------------------------------
    \2\ Facher, Lev, ``HIV programs, mental health: 8 ways Trump's new 
budget might affect public health,'' STAT (May 24, 2017) (online at: 
https://www.statnews.com/2017/05/24/trump-public-health/).

    Question 1. Do you agree with Dr. Frieden about the risks of a 
pandemic flu outbreak?
    Answer 1. I have the greatest respect for Dr. Frieden, as I have 
known him since he was New York City's Public Health Commissioner. I 
would note that influenza is not the only pandemic threat. As we have 
witnessed, SARS and MERS (alpha coronaviruses) also represent potential 
pandemic threats. I would also add that a deliberate re-introduction of 
smallpox, either from retained cultures or synthetically produced, 
would present an equal or potentially greater risk.

    Question 2. What impact could substantial budget cuts have on 
pandemic flu preparedness?
    Answer 2. ASPR has invested significantly to establish domestic 
preparedness and response capacity and capabilities for an influenza 
pandemic. Substantial budget cuts could have an immediate impact on the 
Nation's preparedness posture and, in the very near term, risk 
investments made in the past decade on infrastructure and medical 
countermeasure development and stockpiling.
    State and local jurisdictions and the U.S. healthcare system rely 
on ASPR's Hospital Preparedness Program (HPP) funding to prepare for 
all hazards, including pandemic influenza. Substantial budget cuts to 
HPP could lead to a diminished capability to enhance preparedness 
across the public health and medical continuum. Without the proper 
funding, there may be limited ability to validate plans, processes or 
procedures through exercises and to evaluate and identify strengths, 
gaps and shortfalls which could enhance preparedness.

    Question 3. What specific HHS programs under the purview of the 
Office of the Assistant Secretary for Preparedness and Response receive 
funding that is used for pandemic flu preparedness?
    Answer 3. ASPR's Biomedical Advanced Research and Development 
Authority (BARDA) uses HHS funds to develop and procure medical 
countermeasures for pandemic influenza preparedness, including 
vaccines, adjuvants, antiviral drugs, diagnostics, respiratory 
protection devices, and ventilators.
    ASPR's Hospital Preparedness Program (HPP) receives funding to 
prepare the Nation's healthcare system for all hazards, including 
pandemic influenza. HPP enables healthcare systems to save lives during 
emergencies that exceed day-to-day capacity of health and emergency 
response systems. HPP promotes a sustained national focus to improve 
patient outcomes, minimize the need for supplemental State and Federal 
resources during emergencies, and enable rapid recovery.
    Last, the international division within ASPR's Office of Policy and 
Planning receives pandemic influenza funding which supports 
preparedness and response to pandemic influenza and other emerging 
infectious diseases with simultaneous domestic and international health 
security impacts.

    Question 4. How are these funds used in each program?
    Answer 4. See (3) above and the following: HPP grants enable 
recipients to prepare their healthcare systems to save lives through 
the development and sustainment of regional healthcare coalitions 
(HCCs) that incentivize diverse and often competing healthcare 
organizations with differing priorities and objectives to work 
together. Events that cause a surge in patients require healthcare 
facilities, including those that are not part of the same corporate 
network, to work together as part of a coalition to ensure that 
patients receive optimal and timely care. HPP grants enable HCCs to 
enhance surge capacity within hospitals, alternate care systems, and 
outpatient clinics to increase the number of patients that can be cared 
for during an emergency. ASPR's international division also utilizes 
pandemic influenza funding.

    Question 5. What impact will the President's budget have on funding 
in each of these program areas?
    Answer 5. As I have not been inside the Department, I have not been 
involved in budget discussions. In the role of the ASPR, I plan to 
ensure that we efficiently execute the Department's core preparedness 
program missions.

    Question 6. How will you address the impact of these proposed cuts?
    Answer 6. Budget and funding reductions, across government, are a 
reality during times of fiscal restraint. I intend to approach this 
challenge as an opportunity to creatively find new efficiencies in our 
operations and collaborate with partners to achieve the highest levels 
of readiness. This effort requires coordination within ASPR, HHS, and 
across the government to pinpoint areas where we can maximize the 
effective use of preparedness funding to get ``more bang for the 
buck''.
    ASPR will remain committed to preparing States, local 
jurisdictions, and healthcare systems for emergencies by providing 
substantive preparedness and response technical assistance to them, and 
by connecting them with resources and subject matter experts through 
ASPR's Technical Resources Assistance Center and Information Exchange 
(TRACIE). TRACIE provides evidence-based applications, technology, and 
proven best practices to help States and communities build enhanced 
capacity and improve their knowledge and effectiveness.
    In addition to TRACIE, HHS's emPOWER map provides de-identified 
data on populations reliant on lifesaving electricity-dependent medical 
equipment and healthcare services to inform disaster response. We will 
use these resources and others to support both Federal partners and 
partners at the State, local, tribal, and territorial levels in 
preparing for, mitigating, and responding to emergencies and disasters.

    Question 7. Specifically, what would be the impact of elimination 
of the Prevention and Public Health Fund on pandemic flu preparedness?
    Answer 7. It is important that we prepare for all threats, 
including pandemic flu. I am not aware of the extent to which current 
preparedness efforts are funded by the Prevention and Public Health 
Fund. I plan to be a strong advocate for ensuring that the agency has 
the resources it needs to address all threats.

    Question 8. How would you address these potential cuts if they are 
imposed on the Agency by the White House and Congress?
    Answer 8. Budget and funding reductions, across government, are 
unpleasant but necessary during times of fiscal restraint. I intend to 
approach this challenge as an opportunity to creatively find new 
efficiencies in our operations and reduce duplicative and unnecessary 
spending. This effort requires coordination to pinpoint areas within 
ASPR, HHS, and across the government where we can consolidate funding 
and responsibilities and more effectively and efficiently use our 
resources.

    Question 9. What do you believe are the most important steps needed 
to insure that the Nation is prepared for a potential pandemic flu 
outbreak?
    Answer 9. All aspects of pandemic influenza preparedness, response, 
mitigation, and recovery strategies are essential to our national 
preparedness. I believe the important steps to ensure our Nation is 
prepared for a pandemic flu outbreak include maintaining and improving 
our surveillance systems; improving processes for delivery, dispensing, 
and administration of medical countermeasures; advancing healthcare 
system surge capacity through greater coordination of inpatient and 
community-based healthcare service delivery; and having a dedicated 
workforce, trained and ready to operate when needed.
Pandemic Flu and Hiring Freeze
    In January 2017, President Trump issued a Federal hiring freeze, 
resulting in 700 vacancies at the CDC. While the hiring freeze has 
since been lifted, Secretary Price has left the hiring freeze in place 
at the Department of Health and Human Services, of which the CDC is a 
part.\3\ What will be the long- and short-term impacts on pandemic flu 
preparedness of President Trump's hiring freeze?
---------------------------------------------------------------------------
    \3\ Ranking Members Pallone and Engel letter to President Trump on 
the hiring freeze and impacts on preparedness (July 26, 2017) (online 
at: https://democrats-foreignaffairs.house.gov/sites/
democrats.foreignaffairs house.gov/files/Pallone-
Engel%20CDC%20%staffing%20letter%200
72617.pdf).

    Question 10. Does this Executive order apply to the Assistant 
Secretary for Preparedness and Response (ASPR)?
    Answer 10. I am aware of the hiring freeze issued by the President 
that was administered across the government. The Executive order, and 
the guidance issued by the Office of Management and Budget (OMB) and 
the Office of Personnel Management (OPM) on the Executive order, 
included exemptions to the hiring freeze for positions relating to 
public health/safety and national security. My understanding is that 
HHS created and implemented a process to exempt such positions from the 
hiring freeze. I also understand that the hiring freeze, to the extent 
applicable, has now been lifted.

    Question 11. Has the Executive order prevented ASPR from hiring any 
employees since it was put in place in January 2017?
    Answer 11. I have not been privy to ASPR's hiring decisions during 
my confirmation process.

    Question 12. Will this Executive order cause ASPR to reduce the 
projected number of staff employed by the agency to address pandemic 
flu preparedness and other emergencies?
    Answer 12. The Executive order, and the guidance issued by the 
Office of Management and Budget (OMB) and the Office of Personnel 
Management (OPM) on the Executive order, included exemptions to the 
hiring freeze for positions relating to public health/safety and 
national security. My understanding is that HHS created and implemented 
a process to exempt such positions from the hiring freeze. I also 
understand that the hiring freeze, to the extent applicable, has been 
lifted.

    Question 13a. Has the OMB provided clear guidance and a clear 
timeline on implementation of the exemption process?
    In the event of a pandemic flu outbreak, will you exempt any 
positions at ASPR from the hiring freeze because they are necessary 
``to meet national security or public safety responsibilities''?
    Answer 13a. The Executive order, and the guidance issued by the 
Office of Management and Budget (OMB) and the Office of Personnel 
Management (OPM) on the Executive order, included exemptions to the 
hiring freeze for positions relating to public health/safety and 
national security. My understanding is that HHS created and implemented 
a process to exempt such positions from the hiring freeze. I also 
understanding that the hiring freeze, to the extent applicable, has 
been lifted.

    Question 13b. How many positions will be exempted in this manner? 
Please provide a detailed list of these positions.
    Answer 13b. The Executive order, and the guidance issued by the 
Office of Management and Budget (OMB) and the Office of Personnel 
Management (OPM) on the Executive order, included exemptions to the 
hiring freeze for positions relating to public health/safety and 
national security. My understanding is that HHS created and implemented 
a process to exempt such positions from the hiring freeze. I also 
understand that, as of June 2017, to the extent applicable, the hiring 
freeze was lifted and ASPR has been able to resume hiring for all 
requested positions.

    Question 13c. Does the exemption apply to prevention personnel 
engaged in preparedness activities, or does it only apply to an 
emergency once a pandemic has begun?
    Answer 13c. The Executive order, and the guidance issued by the 
Office of Management and Budget (OMB) and the Office of Personnel 
Management (OPM) on the Executive order, included exemptions to the 
hiring freeze for positions relating to public health/safety and 
national security. My understanding is that HHS created and implemented 
a process to exempt such positions from the hiring freeze. My 
understanding is that the exemption process applied to both 
preparedness and emergency response personnel.
Pandemic Flu and Regulatory Freeze
    On January 20, 2017, President Trump imposed an Executive order 
freezing all regulations in progress,\4\ and on January 30, 2017, he 
issued a second Executive order, imposing a new requirement that 
``whenever an executive department or agency publicly proposes . . . a 
new regulation, it shall identify at least two existing regulations to 
be repealed.'' \5\ OMB guidance on this order allows exemptions ``for 
emergency situations or other urgent circumstances relating to health, 
safety, financial, or national security matters, or otherwise.'' \6\ It 
is not clear how those exemptions will apply to regulation or guidance 
from CDC or other HHS agencies and programs, whether they apply to 
prevention efforts, or how they will be implemented in the event of a 
pandemic flu outbreak.
---------------------------------------------------------------------------
    \4\ Reince Priebus, ``Memorandum for the Heads of Executive 
Departments and Agencies,'' White House Office of the Press Secretary 
(January 20, 2017) (online at: https://www.whitehouse.gov/the-press-
office/2017/01/20/memorandum-heads-executive-departments-and-agencies).
    \5\ ``Presidential Executive Order on Reducing Regulation and 
Controlling Regulatory Costs,'' White House Office of the Press 
Secretary (January 30, 2017) (online at: https://www.whitehouse
.gov/the-press-office/2017/01/30/presidential-executive-order-reducing-
regulation-and-controlling).
    \6\ Mark Sandy, then-Acting Director of the Office of Management 
and Budget, ``Memorandum: Implementation of Regulatory Freeze,'' White 
House Office of the Press Secretary (January 24, 2017) (online at: 
https://www.whitehouse.gov/the-press-office/2017/01/24/implementation-
regulatory-freeze).

    Question 14. In previous outbreaks, has the ASPR needed to impose 
any new regulations--either to address short-term concerns, to respond 
to ``lessons learned'' during the outbreak, or to prevent future 
outbreaks?
    Answer 14. It is my understanding that ASPR compiles lessons 
learned following every emergency. With those lessons in hand, we can 
work to inform decisionmakers about what is needed to help us better 
prepare for the next response. My intent is to ensure these lessons 
learned can be collected quickly and be evaluated and shared across 
Federal agencies and with State and local authorities.

    Question 15. Would the Executive orders imposing a regulatory 
freeze and requiring the repeal of two existing regulations for every 
new regulation put in place potentially prevent ASPR from imposing 
similar regulations in a future pandemic flu outbreak?
    Answer 15. HHS already has the powers and authorities necessary to 
address a pandemic influenza outbreak, or other public health 
emergency, under the Public Health Service Act. However, each emergency 
is different. If confirmed, you have my commitment that we will conduct 
a thorough review following every emergency to pinpoint areas for 
improvement, including any obstacles that need to be addressed.

    Question 16. Has OMB provided clear guidance and a clear timeline 
on implementation of the Executive order's exemption process ``for 
emergency situations or other urgent circumstances relating to health, 
safety, financial, or national security matters, or otherwise?'' \7\ In 
the event of a pandemic flu outbreak, will these exemptions be 
necessary for ASPR to impose new regulations?
---------------------------------------------------------------------------
    \7\ Mark Sandy, then-Acting Director of the Office of Management 
and Budget, ``Memorandum: Implementation of Regulatory Freeze,'' White 
House Office of the Press Secretary (January 24, 2017) (online at: 
https://www.whitehouse.gov/the-press-office/2017/01/24/implementation-
regulatory-freeze).
---------------------------------------------------------------------------
    Answer 16. Under the Public Health Service Act, ASPR has the powers 
and authorities necessary to fulfill its mission during a public health 
emergency like pandemic influenza. With that in mind, I will welcome 
any opportunities for improvement and efficiencies provided by the 
Administration or Congress.
Vaccines
    Question 17. President Trump has linked vaccines to autism and has 
embraced vaccine ``skeptics.''
    Do you believe that there is any scientific or medical validity to 
President Trump's concerns about vaccine safety? If so, please indicate 
which sources lend scientific or medical validity to his concerns.
    Answer 17. There is abundant evidence that vaccines are safe. They 
remain a cornerstone of public health and biodefense strategies.

    Question 18. Are you concerned that President Trump's statements 
may dissuade members of the public from receiving flu or other 
vaccines?
    Answer 18. Vaccinations are a critical component of our national 
health resiliency and national security. With that in mind, I am very 
confident in the U.S. Food and Drug Administration's work to uphold 
vaccine safety and efficacy. ASPR works with its industry partners and 
FDA to ensure that all vaccines manufactured under the Biomedical 
Advanced Research Development Authority (BARDA) are safe and effective 
to protect the American people. While BARDA does issue contracts to 
stockpile some items prior to FDA approval, data on patient safety of 
the therapies or vaccines are reviewed prior to stockpiling.
Coordination in Response to Public Health Emergencies
    The Assistant Secretary for Preparedness and Response (ASPR) 
focuses on preparedness and public health emergency response.\8\ The 
President's hiring freeze and fiscal year 2018 budget request would 
impact the U.S.'s ability to properly respond to a public health 
emergency or disaster, such as pandemic flu, Ebola, or a bioterrorist 
attack.\9\
---------------------------------------------------------------------------
    \8\ U.S. Public Health Emergency Web page, ``Office of the 
Assistant Secretary for Preparedness and Response (ASPR)'' (online at: 
https://www.phe.gov/about/aspr/pages/default.aspx).
    \9\ Emily Baumgaertner, ``Trump's Proposed Budget Cuts Trouble 
Bioterrorism Experts,'' New York Times (May 28, 2017) (online at: 
https://www.nytimes.com/2017/05/28/us/politics/biosecurity-trump-
budget-defense.html); Blue Ribbon Study Panel on Biodefense Strategy 
statement on proposed closure of biodefense laboratory (July 12, 2017 
(online at: http://www.biodefense
study.org/news-item/blue-ribbon-study-panel-on-biodefense-statement-on-
proposed-closure-of-biodefense-laboratory); Jeff Schlegelmilch, ``5 
Ways the President's Budget Blueprint Could Change the Way We Respond 
to Disasters,'' The Hill (May 3, 2017) (online at: http://thehill.com/
blogs/pundits-blog/homeland-security/331818-5-ways-the-presidents-
budget-blueprint-could-change-the).

    Question 19. What would substantial budget cuts mean for the 
Administration's ability to coordinate across departments and agencies 
in the event of a public health emergency, such as pandemic flu, Ebola, 
or a bioterrorism attack?
    Answer 19. Without the proper funding, there may be limited ability 
to validate plans, processes or procedures through exercises and to 
evaluate and identify strengths, gaps and shortfalls which could 
enhance preparedness.

    Question 20. What would a hiring freeze mean for the 
Administration's ability to coordinate across departments and agencies 
in the event of a public health emergency?
    Answer 20. Currently, there is no Administration hiring freeze. 
Should a hiring freeze be implemented in the future, it is likely that 
there would be exemptions for public health/safety and national 
security personnel. I would expect HHS to implement such exemptions. 
ASPR needs a trained, qualified and credentialed team to effectively 
and efficiently manage response and recovery operations. I will work 
with partners throughout HHS to ensure ASPR has the workforce it needs 
to prepare and respond to public health emergencies.

    Question 21. The ASPR plays an important role in coordinating 
agencies and departments involved in the response to a public health 
emergency. Does the ASPRs coordinating role change depending on whether 
the emergency event originates domestically or internationally?
    Answer 21. ASPR is the Secretary's principal advisor on all matters 
related to manmade and naturally occurring public health emergencies. 
This includes medical preparedness, response, recovery, as well as 
activities throughout HHS including human services. ASPR, on behalf of 
the Secretary, is also the Emergency Support Function--8 (ESF-8) 
Coordinator under the National Response Framework. The ASPR's role in 
protecting the health security of our Nation is the same whether the 
threat starts within or outside our borders.
Gene Editing and Synthetic Biology
    Researchers in Canada recently reported that they reconstructed the 
currently extinct horsepox virus, an evolutionary relative of the 
smallpox virus, using commercially available genetic material.\10\ The 
researchers are partnering with New York-based Tonix Pharmaceuticals to 
develop a safer human smallpox vaccine, and potentially new cancer 
therapeutics, highlighting the dual-use potential of this and related 
research and development.\11\
---------------------------------------------------------------------------
    \10\ Kai Kupferschmidt, ``How Canadian Researchers Reconstituted an 
Extinct Poxvirus for $100,000 Using Mail-Order DNA,'' ScienceInsider 
(July 6, 2017) (online at: http://www.sciencemag.org/news/2017/07/how-
canadian-researchers-reconstituted-extinct-poxvirus-100000-using-mail-
order-dna).
    \11\ Jeff Bessen, ``GMOs Lead the Fight Against Zika, Ebola and the 
Next Unknown Pandemic,'' AP (July 27, 2016) (online at: https://
apnews.com/a86a1ba205154be4b175a1c11406332e/gmos-lead-fight-against-
zika-ebola-and-next-unknown).
---------------------------------------------------------------------------
    The advent of easy-to-use and relatively cheap biotechnological 
tools, such as rapid DNA sequencing and gene editors, underlines the 
importance of developing a national biodefense strategy, including a 
plan for emergency preparedness and development of medical 
countermeasures. Last month, the White House announced it is developing 
such a comprehensive biodefense strategy,\12\ as required by the fiscal 
year 2017 (FY 2017) National Defense Authorization Act (NDAA).\13\ The 
bill charges the Secretaries of Defense, Health and Human Services 
(HHS), Homeland Security, and Agriculture to develop a strategy and 
implementation plan to address our Nation's biodefense, including 
``prevention, deterrence, preparedness, detection, response, 
attribution, recovery, and mitigation.''
---------------------------------------------------------------------------
    \12\ Jonathan Landay, ``White House Developing Comprehensive 
Biosecurity Strategy: Official,'' Reuters (July 20, 2017) (online at: 
http://www.reuters.com/article/us-usa-security-biodefense-
idUSKBN1A52HZ).
    \13\ S. 2943, National Defense Authorization Act for Fiscal Year 
2017, Section 1086 (online at: https://www.congress.gov/bill/114th-
congress/senate-bill/2943/text).

    Question 22. Do you agree that research, such as that using gene 
editing and synthetic biology technologies, is essential to advancing 
the development of medical countermeasures?
    Answer 22. As the ASPR, I will consider the implications and 
potential advancements that would result from all of the latest 
technologies. Like any new technologies, their potential and 
implications need to be evaluated. It will be a subject that I will 
carefully monitor going forward.

    Question 23. What steps will you take to work across agencies and 
departments and with other stakeholders to ensure that dual-use 
research, such as that using gene editing and synthetic biology 
technologies, is conducted in a responsible and ethical manner, while 
also promoting and supporting such research?
    Answer 23. ASPR has been a leader in the effort to determine how to 
manage and balance the need for scientific research and discovery with 
respect to potential bioterror and pandemic agents, and the potential 
risks posed by this type of research.
    HHS policies provide a mechanism for ongoing oversight and review 
of high risk research to help ensure that important research can 
proceed, while minimizing safety and security risks. I look forward in 
my role to participating and contributing to this important task.
  Response by Elinore F. McCance-Katz, M.D., to Questions of Senator 
   Murray, Senator Sanders, Senator Casey, Senator Franken, Senator 
Bennet, Senator Whitehouse, Senator Baldwin, Senator Murphy and Senator 
                                 Warren
                             senator murray
    Question 1. Access to mental health and substance use disorder 
screening and assessment, and to the full spectrum of evidence-based 
therapeutic services, is necessary to recognize and appropriately 
address mental health and substance use disorder needs for all 
individuals. Untreated mental health disorders lead to higher rates of 
family dysfunction, poor school performance, juvenile incarceration, 
substance use disorder, unemployment, and suicide. For example, in 
2012, more than 5,000 children and youth aged 10 to 24 died by suicide, 
making it the second-leading cause of death in this age range. 
Behavioral health needs are often identified and addressed in different 
settings, not just primary or behavioral health care settings. For 
example, social workers often identify behavioral health needs in 
schools. How do you plan to support and strengthen these activities, 
especially outside primary or behavioral health care settings?
    Answer 1. Given my previous work at SAMHSA, I am aware of the 
agency's long-tenured investment in treating children in their 
communities and in natural settings. Concurrently, SAMHSA has invested 
in prevention and treatment programs for young people that have a 
strong evidence base. Moving these programs and practices to settings 
beyond primary and behavioral health care settings is critical. The 
21st Century Cures Act also provides instruction and funding to address 
issues related to behavioral health in children and families outside of 
healthcare settings. I will work with Federal partners and national 
stakeholder groups such as the National Alliance on Mental Illness 
(NAMI) and Mental Health America, both of which are grassroots, 
community-based organizations that can help with outreach in community 
settings and dissemination of education about issues related to 
behavioral health in communities. I will also be looking to States and 
Congress as partners in helping SAMHSA consider how best to serve our 
families.

    Question 2. You have mentioned the importance of incorporating 
psychosocial variables when engaging the mentally ill. There is concern 
that taking too rigid a view of evidence-based practices will overlook 
critical aspects of everyday life, such as stable housing, education, 
obtaining and maintaining an occupation. If confirmed as the Assistant 
Secretary for Mental Health and Substance Use, how will you ensure 
psychosocial variables are included in the dissemination of research 
findings and evidence-based practices to service providers? In 
addition, how will the new National Mental Health and Substance Use 
Policy Laboratory (NMHSUPL) promote evidence-based practices and 
service delivery models that address psychosocial variables?
    Answer 2. There is a research base for assertive community 
treatment programs that include assisting with psychosocial needs 
including housing, education and employment and even more basic needs, 
such as how to shop for food and other necessities which are associated 
with positive outcomes. My goal is to see psychiatric medical care and 
psychosocial service providers work together to assure that Americans 
receive the spectrum of services necessary for recovery.
    The National Mental Health and Substance Use Policy Laboratory 
(NMHSUPL) was newly stood up as a result of the 21st Century Cures Act 
to promote evidence-based practices and service delivery models, 
including those that address psychosocial variables. I look forward to 
working with my colleagues at SAMHSA in establishing processes for 
coordinating across SAMHSA programs and the Center for Behavioral 
Health Statistics and Quality, and engaging a wide range of 
stakeholders including Federal partners, providers, patients, research 
institutions and others to ensure that SAMHSA policy is guided by the 
best evidence and information about the state of the behavioral health 
field.

    Question 3. For over 40 years the Minority Fellowship Program (MFP) 
at the Substance Abuse and Mental Health Services Administration 
(SAMHSA) has been leading efforts to reduce health disparities and 
improve behavioral health care outcomes for racial and ethnic 
populations. The program was recently authorized in the 21st Century 
Cures Act, which we passed last year. Can you elaborate on how you will 
ensure the program continues as authorized and on the importance of 
having a behavioral health workforce in reducing health disparities?
    Answer 3. The behavioral health workforce continues to have major 
shortages of professionals and care providers that serve minority 
communities. It is vital that we continue to build the behavioral 
health workforce pipeline. I look forward to supporting programs that 
increase the behavioral health workforce and improve behavioral health 
care outcomes for racial and ethnic populations.
                            senator sanders
    Question. The President's budget includes extremely drastic cuts to 
the Substance Abuse and Mental Health block grants during a time when 
other behavioral health programs also are being considered for funding 
cuts. This has the potential to dismantle our country's mental health 
and substance abuse system, and to walk back the progress we have made 
around mental health and substance abuse care in the last decade.
    If confirmed, and as the first Assistant Secretary for Mental 
Health and Substance Abuse, what are you planning to do to strengthen 
the service system and improve access to critically needed substance 
abuse, mental and behavioral health services?
    Answer. I plan to review current programs and determine those that 
are producing positive results for individuals with substance use 
disorders and serious mental illness. I will be a strong advocate for 
the programs that are working.
                             senator casey
    Question 1. Substance use disorder, including the opioid epidemic, 
continues to be one of the most pressing public health problems facing 
our country. Given what we know about the impact of exposure to 
traumatic events in childhood, including an increased vulnerability to 
substance use disorders, what ongoing initiatives or new efforts might 
SAMHSA support to address this critical issue in a comprehensive and 
coordinated way?
    Answer 1. There is evidence showing a strong correlation between 
opioid addiction and traumatic experiences, particularly early 
childhood adversity.
    There are multiple strategies that SAMHSA can implement to address 
addiction in a comprehensive and coordinated way, building on existing 
mechanisms. For example, SAMHSA convenes, in partnership with the 
Department of Labor, an Interagency Trauma Workgroup, consisting of 
multiple departments and agencies. This workgroup coordinates 
collaborative interdepartmental efforts focusing on prevention and 
treatment of mental and substance use disorders that may be associated 
with trauma and is expanding their work to address the connection 
between early adversity, trauma and opioid use and misuse. In taking on 
this leadership role in SAMHSA, I will continue to work with the 
national stakeholder groups representing providers, people living with 
mental and substance use disorders, and families that can provide input 
to SAMHSA regarding whether there are other actions that could be taken 
to better address issues related to childhood adversity, challenges, 
and trauma. We can review State models that have had success in 
addressing these issues and disseminate that information nationally, as 
well as explore what actions in this area other agencies, such as the 
Departments of Labor, Education, and Housing and Urban Development, may 
have pursued.

    Question 2. The Administration has proposed massive cuts to 
Medicaid through its budget proposal and through efforts to repeal the 
ACA. The House's budget bill proposes cutting $1.4 trillion from 
Medicaid. As you know, Medicaid is the primary funder for public mental 
health treatment and the availability of mental health services is 
sorely lacking. Do you support these proposed cuts to Medicaid and how 
will you advocate for more mental health services in an environment 
that is proposing to cut massive amount of funding for the services?
    Answer 2. I support the goal of ensuring that all Americans have 
access to affordable coverage that best meets their needs and those of 
their families, including mental health services. I am committed to 
advocating on behalf of those needing these services. I would see a 
significant part of my role as Assistant Secretary for Mental Health 
and Substance Use as working closely with the States and others to 
improve efficiencies in these programs and to focus the use of funds on 
evidence-based practices to maximize their reach and impact.

    Question 3. Dr. McCance-Katz, the President's budget included 
drastic cuts to both the Substance Abuse and Mental Health block grants 
at a time when other behavioral health programs are also being 
considered for funding cuts. This has the potential to dismantle our 
country's mental health and substance abuse system. As Assistant 
Secretary, and more specifically as the first Assistant Secretary for 
Mental Health and Substance Use, what are you planning to do to 
strengthen the service system and improve access to critically needed 
behavioral health services?
    Answer 3. One of my goals as the Assistant Secretary for Mental 
Health and Substance Use will be to address the integration of care, 
specifically behavioral health and primary care. I look forward to 
meeting with stakeholders across the Department and governmentwide, 
such as the Centers for Medicare & Medicaid Services, to explore 
opportunities to develop strategies for better alignment and 
integration of behavioral health and primary care. One of my primary 
goals will be to reach out to Federal agencies and to providers about 
the need to both integrate and co-locate these services.

    Question 4. What is your view of the role and importance of 
behavioral treatment approaches and peer support versus psychotropic 
medication in the treatment of mental health and substance use 
disorders?
    Answer 4. I don't see behavioral treatment approaches/peer support 
and psychotropic medication treatment as mutually exclusive. My goals 
include focusing on both psychiatric treatment, which is essential to 
restoring one's mental capacity and psychosocial services, which are 
essential to assisting a person in recovery. In leading SAMHSA, I am 
committed to reinforce the understanding that psychiatric care and the 
use of medications along with behavioral treatment is critical to 
patient care.

    Question 5. How do you plan to incorporate and learn from the wide 
range of stakeholders in the mental health and substance use field--
including providers, consumers, and researchers--to help inform your 
vision for the agency during your tenure in this Administration?
    Answer 5. I think it is of paramount importance to engage a wide 
range of stakeholders to help inform SAMHSA's efforts. I plan to listen 
and learn from stakeholders in a variety of ways including one-on-one 
conversations, addressing major conferences and allowing time for 
questions and answers, reaching out to key coalitions such as the 
Mental Health Liaison Group and the Parity Implementation Coalition, 
and visiting prevention, treatment and recovery support organizations. 
I have been a practicing psychiatrist and a funded researcher and have 
worked in State government both in California and Rhode Island. I have 
sought out stakeholders to inform my approach to psychiatry and 
addiction psychiatry and will continue to seek stakeholder input. I see 
these groups representing providers, consumers, and families as 
essential to my success and to helping to assure that SAMHSA is doing 
the best it can to meet the needs of Americans with mental and 
substance use disorders. As a clinical researcher, I will continue to 
keep up to date on research progress and findings and to use SAMHSA to 
help to disseminate these findings so that States/communities can make 
use of evidence-based practices in their programs.

    Question 6. Will you commit to responding to monitoring and 
oversight questions from all committee members and be responsive to our 
requests for information?
    Answer 6. I am fully committed to responding appropriately to 
congressional oversight inquiries and to work cooperatively with 
committee Members and staff to provide accurate and timely responses.

    Question 7. During the questioning at the August 1 hearing you 
mentioned that health insurance plan benefits is a reason why many 
individuals do not receive adequate mental health treatment. What will 
you do to ensure mental health coverage parity and to expand access to 
mental health and substance abuse treatment for those who need it?
    Answer 7. My understanding is that SAMHSA has already begun efforts 
to provide States support through technical assistance, access to 
national experts, individualized coaching, and product development. I 
am encouraged that SAMHSA led these efforts in collaboration with DOL 
and CMS (CMCS/CCIIO) and, with the opportunities afforded by the 21st 
Century Cures Act and the momentum of the Parity Policy Academies, I 
look forward to continuing to lead efforts in assisting States in 
advancing parity implementation.

    Question 8. Over the last several months, I have sent multiple 
letters to HHS about the Administration's ongoing efforts to undermine 
and sabotage the Affordable Care Act through executive action. HHS has 
failed to provide responses to many of my letters. If HHS has 
responded, the response letters have been wholly inadequate and have 
not been responsive to my requests. If you are confirmed, do you commit 
to respond in a timely manner to all congressional inquiries and 
requests for information from all Members of Congress, including 
requests from Members in the Minority?
    Answer 8. I am fully committed to responding appropriately to 
congressional oversight inquiries and to work cooperatively with 
committee Members and staff to provide accurate and timely responses.
                            senator franken
    Question 1. Can you highlight some of the benefits and successes 
that have stemmed from mental health block grant funds? President 
Trump's budget recommends cuts to the mental health block grant. How 
would these reductions affect access to services for people with mental 
illness and substance use disorders, especially at a time when the 
country is facing an opioid epidemic?
    Answer 1. The mental health block grant funds have enabled States 
to provide evidence-based services to those with mental illness and 
substance use disorders. I believe that people with mental illness and 
substance use disorders need access to services, and I will be a 
champion for ensuring that they are able to receive these services.

    Question 2. Can you describe which patients, from your perspective, 
may be able to benefit most from peer support services? Based on your 
review of the evidence, at which stage of treatment are these peer 
support services appropriate for different population groups?
    Answer 2. I believe that peer professionals will, over the coming 
years, become a standard resource available to people struggling with 
mental and/or substance use disorders. Those who participate in 
training programs gain skills in how to work as part of a care team and 
support all aspects of a person's treatment plan including psychiatric 
care. This psychiatric care often includes psychotropic medications 
that are, in my view as a psychiatrist, very valuable. While the 
evidence base is nascent, there are studies that show the benefit of 
peer involvement in a person's care. A person available within the 
community to assist a person in accessing the recommended treatments 
and resources and serving as a source of support is valuable.
                             senator bennet
    Question 1a. I was recently in Otero County, CO where drug 
overdoses have been increasing. The entire community was engaging to 
address the rise in opioid abuse. This included coordinating hospitals, 
the courts, schools and foster care services. Even when we see a 
decrease in prescription overdoses, it is usually countered with an 
increase in heroin overdoses. In the 1960s, more than 80 percent of 
heroin users started with heroin. In contrast, currently, about 80 
percent of heroin users first started using prescription opioids.
    What are practical steps you plan to take to address the opioid 
crisis?
    Answer 1a. I am committed to helping Secretary Price advance his 
five-point plan to address the opioid epidemic. As a leader in the 
field of addiction psychiatry, I plan to engage in each strategy: 
strengthening public health surveillance, advancing the practice of 
pain management, improving access to treatment and recovery services, 
including medication-assisted treatment, targeting availability and 
distribution of overdose-reversing drugs, and supporting cutting-edge 
research. I am also aware that both the 21st Century Cures Act and the 
Comprehensive Addiction and Recovery Act provided specific actions that 
SAMHSA and other HHS and Federal agencies can undertake to address the 
crisis, and I will be working across the government to implement these. 
In addition, I plan to prioritize prevention initiatives in the form of 
education of the American people and continue to advocate for training 
of healthcare practitioners so that they can receive the DATA waiver 
and prescribe buprenorphine/naloxone for opioid use disorder.

    Question 1b. How can we ensure that Americans are not becoming 
addicted in the first place while making it easier for people who 
currently have an addiction to obtain access to treatment?
    Answer 1b. Prevention and treatment are both key components to 
addressing the opioid crisis. I know the Department has issued the 
Opioid State Targeted Response grants that will help States address 
treatment for those struggling with addiction. An important part of 
prevention is the education of providers and the American people--
people need to know about the dangers presented by such activities.
                           senator whitehouse
    Question 1. The President has proposed deep cuts to SAMHSA 
programs. Do you believe cutting funding for SAMHSA will benefit people 
with mental health and substance use disorders?
    Answer 1. I believe that we should ensure that resources spent are 
truly benefiting Americans with mental health and substance use 
disorders. I commit to being an advocate for programs that are proven 
to work and provide help to those in need.

    Question 2. As you know, the opioid epidemic is currently one of 
the biggest public health challenges facing Rhode Island and the States 
of many of my colleagues. Last Congress, we passed The Comprehensive 
Addiction and Recovery Act (CARA), a law I co-authored. CARA authorizes 
several important SAMHSA programs, including programs to treat pregnant 
and post-partum women struggling with addiction, medication-assisted 
treatment programs, naloxone training programs, and peer-to-peer 
recovery programs. I was pleased that these programs received funding 
as part of the fiscal year 2017 appropriations bill, and hope they will 
continue to receive funding in the coming years. Do you support the 
full funding of the programs authorized by CARA, and will you work 
within the Administration and with Congress to ensure funding these 
programs is a priority?
    Answer 2. CARA is an important law that will help SAMHSA to address 
the opioid epidemic head-on. I look forward to implementing these 
programs and will work to ensure that they are implemented consistent 
with the CARA.

    Question 3. You have previously written that SAMHSA spends too much 
time on peer support and recovery services.
    Do you support SAMHSA's current programs related to peer support 
and recovery services?
    As Assistant Secretary for Mental Health and Substance Use, will 
you prioritize SAMHSA's peer support and recovery work?
    Answer 3. I believe that peer professionals will, over the coming 
years, become a standard resource available to people struggling with 
mental and/or substance use disorders. Those who participate in 
training programs gain skills in how to work as part of a care team and 
support all aspects of a person's treatment plan including psychiatric 
care. This psychiatric care often includes important psychotropic 
medications. While the evidence base is nascent, there are studies that 
show the benefit of peer involvement in a person's care. A person 
available within the community to assist a person in accessing the 
recommended treatments and resources and serving as a source of support 
can be valuable.
    Evidence-based medical treatment of serious mental illness must be 
a major focus for SAMHSA. I will prioritize the full spectrum of 
evidence-based services to assist those with serious mental illness and 
substance use disorders. This will include openly embracing evidence-
based medical treatment of these disorders as well as psychosocial 
supports, which include peers.

    Question 4. You have written favorably about the Affordable Care 
Act's expansion of mental health and substance use disorder coverage. 
In the aftermath of last week's votes, I hope that the Senate can begin 
working in a bipartisan way to improve our health care system, without 
jeopardizing the coverage gains we've made under the ACA. As the Senate 
continues its work to reform our health care system, maintaining health 
insurance coverage for mental health and substance use disorders will 
be a priority of mine. If asked for your expertise on this issue, will 
you advocate for policies that help expand access to mental health and 
substance use services?
    Answer 4. I will be a strong advocate for people with mental health 
and substance use disorders and will advocate for policies that promote 
access to coverage and the critical services on which these patients 
rely.

    Question 5. As Assistant Secretary for Mental Health and Substance 
Use, how will you approach the prevention of and screening for mental 
illness and behavioral disorders in children?
    Answer 5. Mental illness, emotional and behavioral disorders tend 
to have their onset in adolescent and young adult developmental periods 
and increasingly we are realizing that early signs of these disorders 
appear even earlier in childhood, but often go unrecognized by 
practitioners.
    There is burgeoning research documenting the capacity to link 
results of early childhood screening with later problematic behaviors, 
including mental disorders, substance use disorders, problematic school 
behavior and subsequent involvement with the juvenile justice system. 
Child, family, societal human and fiscal costs have been documented.
    As Assistant Secretary, it is clear that we will need to look at 
behavioral health as a two-generational issue and that screening for 
these issues in children and families needs to be the standard of care.

    Question 6a. As you know, key members of the behavioral health 
community--psychologists, community mental health centers, and 
psychiatric hospitals, among others--are not eligible to receive 
incentive payments for adopting certified electronic health record 
(EHR) technology under the Medicare and Medicaid EHR Incentive Programs 
(Meaningful Use). Last year's SAMHSA ``Leading Change'' report included 
health information technology as one of six ``Strategic Initiatives.''
    Will you continue to make the dissemination and effective use of 
health IT among behavioral health providers a priority within SAMSHA?
    Answer 6a. I plan to continue to make dissemination and effective 
use of Health IT among behavioral health providers a priority within 
SAMHSA especially in rural and extremely rural areas across the Nation.

    Question 6b. As Assistant Secretary, in what ways will you promote 
the use of health IT among behavioral health providers?
    Answer 6b. As Assistant Secretary, I plan to coordinate on 
Department-wide initiatives focused on IT integration and will assist 
with outreach to the behavioral health provider community.

    Question 7. The Mental Health Parity and Addiction Equity Act 
(MHPAEA) was passed in 2008, and although it has been fully 
implemented, enforcement continues to be a problem. What steps will you 
take to improve Federal enforcement of mental health parity?
    Answer 7. I will continue to ensure that SAMHSA supports efforts at 
mental health parity implementation. SAMHSA's leadership and 
partnership with States, providers, and consumers positions the agency 
uniquely to provide guidance and support in the advancement of MHPAEA.

    Question 8a. In Rhode Island, you created the Centers of Excellence 
program, which brings together doctors, nurses, counselors, peer 
professionals, and others to provide patient-centered care to 
individuals receiving medication-assisted treatment. As you know, the 
medication is just one part of medication-assisted treatment, and 
additional services are often needed to support recovery.
    As Assistant Secretary for Mental Health and Substance Use, how 
would you evaluate promising treatment models being used at the State 
level?
    Answer 8a. In developing the model for the Centers of Excellence 
(COE) for Rhode Island, we also determined outcomes that would help to 
inform whether these programs were providing the impact and benefit we 
hoped for. These variables include: number of people referred into COE 
treatment, number of people who complete admission/induction 
(engagement), number of people receiving medication-assisted treatment 
(MAT), number of successful discharges to community office-based opioid 
use disorder providers, number of negative toxicology screens (opioid), 
number of opioid toxicology screens obtained, number of negative 
toxicology screens (all other illicit substances), number of toxicology 
screens obtained (all other illicit substances), number of patients 
admitted to the emergency department, number of hospitalizations over 
course of treatment, and number of patients remaining in COE until 
referral to another provider (retention). These types of variables can 
be generalized to substance use disorder treatment programs to assess 
effectiveness. SAMHSA can explore with States how to develop systems to 
collect such data.

    Question 8b. How would you share those models with other States or 
communities that could benefit from them?
    Answer 8b. A major and important function of SAMHSA is to be a 
repository of epidemiological data, evidence-based practices, and 
promising models. SAMHSA has information reported to it by the States 
and can facilitate dissemination in a number of ways such as: 
informational webinars and dissemination through other information 
technology tracks, written documents, and use of SAMHSA national 
programs that provide training and peer support including provider 
clinical support systems and addiction technology transfer centers as 
examples.
                            senator baldwin
    Question 1. As HHS implements the 21st Century Cures Act, I hope 
that, if confirmed, you would pay close attention to the mental illness 
with the highest mortality rate--eating disorders. The eating disorder 
provisions included in the law, derived from the bipartisan Anna Westin 
Act of 2015 (H.R. 2515/S. 1865), were designed to improve eating 
disorder early detection by our health professionals, increase access 
to quality and affordable treatment for eating disorders under mental 
health parity, and provide the public with resources to help prevent 
and identify the disorder. Taking swift action to implement these 
provisions is critical to ensuring meaningful access to treatment for 
men and women with an eating disorder, specifically by incorporating 
the eating disorders parity rulemaking into existing mental health 
parity regulations.
    Will you commit to swiftly advancing the rulemaking process to 
implement the eating disorders mental health parity provisions?
    Answer 1. I recognize the importance of provisions enacted by 
Congress and reflected in the 21st Century Cures Act emphasizing that 
Mental Health Parity and Addiction Equity Act (MHPAEA) requirements 
should fully apply to eating disorders. My understanding is that in 
June 2017, HHS published a guidance/frequently asked questions document 
that notes the applicability of parity provisions to eating disorders, 
citing the 21st Century Cures Act and requesting public comment 
regarding ``whether any additional clarification is needed regarding 
how the requirements of MHPAEA apply to treatment for eating 
disorders.'' I will ensure SAMHSA will work with CMS and DOL to review 
comments and to develop further guidance on these issues as necessary.

    Question 2. As a physician, can you discuss the importance of 
intermediate level of care benefits for the treatment of severe eating 
disorders?
    Answer 2. People with eating disorders require high-quality health 
care. Several levels of specialty care may be best for people with 
eating disorders. The goal is to help the person get to a normal weight 
and normal eating. The best treatment option depends on the severity of 
the disorder and the person's past response to treatment. An 
intermediate level of care, such as day treatment or partial 
hospitalization, can address medical conditions and provide 
psychological support. This can be done as a transition from inpatient 
to outpatient care. It can also be an alternative to inpatient care.
                             senator murphy
    Question 1. As you know from your past experiences in Connecticut, 
my State has a proud history of the recovery movement. As I mentioned 
in our meeting, some groups have been critical of your nomination based 
on some of your past writings regarding the recovery model.
    Can you discuss the balance that needs to be struck between 
medication and recovery supports? Also, can you explain the role that 
you believe peers should play?
    Answer 1. I believe that for those with serious mental illnesses, 
such as schizophrenia and bipolar disorder, who experience 
hallucinations and delusions--which are prominent symptoms in these 
disorders and which can be associated with behaviors that can cause 
serious harm to the people affected and/or others--medical treatment 
including psychotropic medication and psychiatric care must be 
available. There is a large evidence base supporting medication 
treatment, and it is the standard of care for those with these types of 
symptoms associated with serious mental illness. However, I also 
strongly support psychosocial interventions including peer support to 
provide encouragement, assistance in getting services needed, and to 
provide a model for recovery instilling hope (all of this is predicated 
on the idea that the peers are supportive of medical care recommended 
for the individual). I do not believe that either medical interventions 
or peer support alone provide for all of the needs of persons affected 
by serious mental illness. Therefore, I will continue to encourage 
partnerships between medical services and recovery-support services--
indeed, I see medical services as a recovery support.

    Question 2. I was fortunate to work with Chairman Alexander, 
Ranking Member Murray and Senator Cassidy on the mental health bill 
that eventually was passed in the 21st Century Cures Act. One of my top 
priorities in that bill was SAMHSA's integration program because 
studies have shown that despite overall gains in life expectancy, 
individuals with serious illnesses is attributable to acute and chronic 
co-morbid physical conditions, such as heart disease.
    I know the Mathematica interim evaluation of this program recently 
showed substantial improvements in physical health outcomes among 
clients who have chronic physical health conditions at enrollment and 
positive trends in functional improvement and substance use. I am 
hopeful that the changes that we made in the Cures Act will also 
improve the outcomes for grantees and lead to States breaking down 
barriers that can discourage integration.
    Unfortunately, the administration has proposed eliminating funding 
for the program in its budget request. Can you talk about the 
importance of integrating mental health and physical health care and 
why the administration would zero out this funding?
    Answer 2. I consider the integration of physical and behavioral 
health services to be very important to improving health outcomes. I 
have not been privy to discussions about the budget prior to my 
confirmation, so I cannot speak to the budget request. I have worked in 
integrated-care systems in my clinical practice, and I have supported 
and encouraged establishment of integrated healthcare systems in my 
government work. I will continue to do so. I also believe that we must 
integrate the treatment of mental and substance use disorders given the 
high rates of co-occurring disorders and look forward to reviewing the 
data on Certified Community Behavioral Health Centers (CCBHCs), which 
SAMHSA has worked to establish with the States.

    Question 3. As you know, Congress has put a focus on the needs of 
individuals with early serious mental illness. As SAMHSA noted in its 
fiscal year 2018 budget justification,

          ``The majority of individuals with serious mental illness 
        experience their first symptoms during adolescence or early 
        adulthood, and there are often long delays between the initial 
        onset of symptoms and receiving treatment. The consequences of 
        delayed treatment can include loss of family and social 
        supports, reduced educational achievement, incarceration, 
        disruption of employment, substance abuse, increased 
        hospitalizations, and reduced prospects for long-term 
        recovery.''

    Most recently, Congress increased this setaside from 5 percent of 
the Mental Health Block Grant to 10 percent. There are promising models 
targeted to this population, including Yale's Specialized Treatment for 
Early Psychosis (STEP) program. STEP patients are hospitalized nearly 
50 percent less than other patients and when they do need a 
hospitalization, the length of stay averages 6 fewer days than standard 
treatment. Additionally, approximately one-third more STEP patients 
were engaged in vocational training and these individuals were more 
involved in outpatient mental health treatment.
    Can you describe the importance of programs like STEP and what 
Congress and SAMHSA should be doing to scale their reach?
    Answer 3. There are now a number of evidence-based approaches that 
can successfully provide services and supports to individuals 
experiencing a First Episode Psychosis (FEP). These approaches, based 
on the evidence-based Coordinated Specialty Care (CSC) model, have a 
number of common elements including an interdisciplinary team approach 
that focuses on the comprehensive needs of the patients served by 
providing rapid access to high-quality treatment and offering support 
in areas such as employment and education. SAMHSA can help to scale the 
reach of these programs through dissemination of information about this 
approach and findings related to use of these approaches from research 
studies and from States' experiences. SAMHSA has a long track record of 
making such information available and will continue this important 
function going forward. Similarly, SAMHSA leadership, given 
opportunities, can speak to the benefit of these programs as another 
means of information dissemination.

    Question 4. Will you prioritize the treatment of emerging serious 
mental illnesses, such as schizophrenia and bipolar disorder, and 
substance use disorders in transitional age youth? If so, how?
    Answer 4. There has been an increasing amount of clinical research, 
such as the North American Prodrome Longitudinal Study, examining the 
prodromal phase in order to understand and develop interventions to 
mitigate psychosis. Transitional-age youth and young adults who present 
with prodromal symptoms are at increased risk for developing clinical 
psychosis, which can be one of the most chronic, debilitating features 
of serious mental illness. Early detection and intervention in people 
at risk for developing psychosis can be successful in delay of the 
first episode and reducing the severity of illness. I believe this is 
an important area for continued research and focus. SAMHSA, working 
collaboratively with NIMH, can assist with dissemination of the 
evidence base for prodrome and approaches/interventions designed to 
ameliorate these symptoms and improve the quality of life for young 
people at high clinical risk for psychosis.

    Question 5. Mass violence events, like the tragedy that occurred in 
my State at Sandy Hook Elementary School, have lasting effects on our 
children, families, and the community at-large. Federal programs like 
the SAMHSA-administered National Child Traumatic Stress Initiative have 
played an important role in supporting the acute and long-term mental 
health needs of our community as we continue to recover from this 
terrible tragedy.
    How will you guide SAMHSA's efforts to strengthen our national 
capacity to prevent and respond to traumatic events like this?
    Answer 5. SAMHSA's strength comes from its collaboration, 
coordination, and communication with community, State, regional, and 
Federal partners in all phases of response and recovery. SAMHSA further 
works to ensure behavioral health is meaningfully addressed in local, 
regional, State, and Federal response plans and provides tools and 
guidance to ease its inclusion.
    I will ensure that SAMHSA continues to update and disseminate tools 
describing best practices, informational materials, and fact sheets 
addressing aspects of response and recovery. I will explore and 
evaluate grant programs that address needs which cannot be met in other 
ways and make sure that lessons from those programs guide our best 
practices and inform disseminated materials as well. I will also 
support evidence-based early intervention programs that SAMHSA has 
overseen in the States. I will support ongoing technical assistance to 
States as they seek the best and most appropriate interventions for 
their communities including education about serious mental illness, 
recognition of potential illness, and how to access resources. I will 
continue to encourage healthcare-practitioner education and explore 
mechanisms for increasing the number of psychiatrists, physicians, and 
allied providers who are trained to provide mental health services in 
communities. I will openly and actively endorse recovery supports 
including psychiatric medical care for those struggling with serious 
mental illness.

    Question 6. Recent research has shown that there is a link between 
childhood exposure to trauma and subsequent substance use problems.
    In what ways can you ensure that issues related to child and adult 
trauma are part of substance use disorder and opioid programs that you 
will oversee in your role as the Assistant Secretary for Mental Health 
and Substance Use?
    Answer 6. SAMHSA has provided significant leadership in the area of 
child and adult trauma. Screening tools, interventions, and 
informational materials, and a framework for addressing trauma and 
implementing a trauma-informed approach in multiple health and human 
service systems has been well-articulated with increasing uptake in 
different sectors. This framework and associated interventions can more 
intentionally and systematically be implemented in our substance use 
disorder and opioid specific programs. Further, substance use disorder 
treatment programs must include evaluation of both substance use and 
mental disorders (as well as assessment of physical illnesses) given 
the high rates of co-occurring mental disorders in those with primary 
substance use disorders (approximately 40 percent). Assessment for 
mental disorders should include assessment for trauma and trauma-
associated mental disorders. SAMHSA can use its existing training 
programs, such as the Providers Clinical Support Systems and the 
Addiction Technology Transfer Centers, to disseminate best practices in 
these areas. Further, SAMHSA can prepare and disseminate special topic 
trainings in this area. SAMHSA has a strong record of high-quality 
presentations with national experts that are well attended by 
practitioners and the public.

    Question 7. Mental Health America's recent launch of a national 
certification program for peer support specialists shows that creating 
a workforce of peers will be a key ingredient in the future of mental 
health and substance use care delivery.
    Do you support an effort to add peer workers to the care workforce 
and, if so, how would you support this effort?
    Answer 7. I believe that for those with serious mental illnesses, 
such as schizophrenia and bipolar disorder, who experience 
hallucinations and delusions--which are prominent symptoms in these 
disorders and which can be associated with behaviors that can cause 
serious harm to the people affected and/or others--medical treatment 
including psychotropic medication and psychiatric care must be 
available. There is a large evidence base supporting medication 
treatment, and it is the standard of care for those with these types of 
symptoms associated with serious mental illness. However, I also 
strongly support psychosocial interventions including peer support to 
provide encouragement, assistance in getting services needed, and to 
provide a model for recovery instilling hope (all of this is predicated 
on the idea that the peers are supportive of medical care recommended 
for the individual). I do not believe that either medical interventions 
or peer support alone provide for all of the needs of persons affected 
by serious mental illness. Therefore, I will continue to encourage 
partnerships between medical services and recovery-support services--
indeed, I see medical services as a recovery support.
                             senator warren
Medicaid
    As the Nation's first Assistant Secretary for Mental Health and 
Substance Use Disorders, you will play a central role in efforts to 
guarantee and expand access to behavioral health services. In 
combination with the Mental Health Parity and Addiction Equity Act of 
2008 (MHPAEA), the Affordable Care Act (ACA) and Medicaid expansion 
have provided critical guarantees of access to behavioral health 
services. Medicaid covers a disproportionate share of individuals with 
individuals with mental illness--22 percent of adults with mental 
illness and 26 percent of adults with serious mental illness received 
Medicaid coverage in 2015.
    President Trump has supported legislation that would cut Medicaid 
by more than $700 billion, converting it to a per capita cap or block 
grant system. His budget proposal for fiscal year 2018 (FY 18) also 
proposed an additional cut to Medicaid of over $600 billion.
    You have previously emphasized the role of the ACA and Medicaid 
expansion in reducing barriers to addiction treatment.

    Question 1. Do you agree that Medicaid plays an essential role in 
ensuring that individuals with mental health and addiction disorders 
can access medically necessary treatment?
    Answer 1. Yes, Medicaid provides access for eligible people with 
mental health and addiction disorders to receive medically necessary 
treatment.

    Question 2. Do you agree that hundreds of billions of dollars in 
cuts to Medicaid would have a negative impact on the ability of 
individuals with mental health and addiction disorders to access health 
care?
    Answer 2. I support the goal of ensuring that all Americans have 
access to affordable coverage that best meets the needs of themselves 
and their families, including mental health services. I see a 
significant part of my role as Assistant Secretary for Mental Health 
and Substance Use as being an advocate for those with mental and 
substance use disorders and to address their treatment and recovery 
service needs.
Opioid Epidemic
    At the core of the opioid epidemic has been the over-prescribing 
and misuse of addictive and dangerous prescription painkillers. CMS 
reported that generic Vicodin was prescribed to more Medicare 
beneficiaries than any other drug in 2013--more than blood pressure 
medication, more than cholesterol medication, more than acid reflux 
medication. The National Institute on Drug Abuse has estimated that 
over 70 percent of adults who misuse prescription opioids get the 
medication from friends or relative, so efforts to reduce the amount of 
unused medications in the home is a powerful new tool to tackle 
prescription drug abuse. The Comprehensive Addiction and Recovery Act, 
passed in July 2016, includes a bipartisan provision that I worked on 
with Senator Capito which empowers patients to talk to their physicians 
and pharmacists about partially filling their prescription medications 
in order to reduce the amount of unused opioids in circulation.
    In Massachusetts, more 2,000 individuals died from opioid overdoses 
in 2016. The illicit distribution, sale, and increased use of fentanyl, 
a dangerous synthetic opioid that is more potent than heroin, has 
further contributed to this public health crisis--particularly in New 
England States like Massachusetts. A November 2016 study by the 
Massachusetts Department of Public Health found that of the opioid-
related fatalities in the State in which toxicology screens were 
available, 74 percent of individuals tested positive for fentanyl.

    Question 3. Do you believe that reducing the number of unused 
medications in the home is an important tool in tackling the misuse of 
prescription medications?
    Answer 3. Yes. Providing education to both prescribers and patients 
is important to reduce the number of unused medications in the home and 
the risks of misuse that come with it, especially with regard to opioid 
medication.

    Question 4. What will you do to work with other agencies and the 
physician community to address the overprescribing and misuse of 
addictive prescription medications, while still ensuring that patients 
who need pain medication can receive it?
    Answer 4. Secretary Price has made the opioid epidemic one of the 
Department's top clinical priorities. I look forward to working across 
agencies to ensure that physicians are educated on the clinical 
guidelines for the prescribing of opioids. I have worked for a number 
of years at the interface of pain management and addiction. I was the 
former medical director of SAMHSA's national training and mentoring 
program, Providers' Clinical Support System for Opioids (PCSS-O). I 
have worked with patients and their families on reducing unsafe opioid 
use in the context of ongoing pain.
    I believe SAMHSA has a major role to play in educating providers 
and the public. I would welcome the opportunity to work with Congress 
on this important issue.

    Question 5. How will you work with States, physicians, pharmacists, 
and patient groups to increase awareness about partial-fill policies?
    Answer 5. I look forward to coordinating across agencies to ensure 
that States, physicians, pharmacists, and patient groups are aware of 
partial-fill policies.

    Question 6. You have advocated for Medication-Assisted Treatment 
(MAT) as an important evidence-based addiction treatment. How will you 
work to ensure that other influential health officials in the 
Administration understand the value of this treatment?
    Answer 6. I know that HHS is committed to bringing everything the 
Federal Government has to bear to address the health crisis opioids 
pose. The first pillar of the HHS opioid strategy is to improve access 
to treatment and recovery services, including medication-assisted 
treatment (MAT), and all health officials in the Administration 
understand the value of this treatment. I look forward to working with 
both my Federal colleagues as well as members of the HELP Committee to 
continue to advance MAT as a component of evidence-based addiction 
treatment. While MAT alone is not enough, MAT addresses tolerance and 
withdrawal and gives many people the ability to participate in 
counseling, psychotherapy, and other necessary recovery supports that 
form the basis of a comprehensive recovery program.

    Question 7. As Assistant Secretary, what specific steps will you 
take to build on HHS's efforts to support communities that are dealing 
with the impact of fentanyl use on the rise in fatal overdose rates?
    Answer 7. I will help coordinate HHS' efforts to assist States and 
communities to identify synthetic opioid-related overdose deaths 
including potential clusters and respond with prevention and treatment 
strategies.
Syringe Exchange Programs and Supervised Injection Facilities
    Syringe exchange programs are locations where individuals can go to 
get sterile needles and syringes and safely disposed of used items, as 
well as get education on safer practices and even treatment for other 
medical, social, or mental health needs. The CDC, the Institute of 
Medicine, among other scientific organizations, report that needle 
exchanges are ``highly effective in preventing the spread of HIV/
AIDS.''

    Question 8. As Assistant Secretary for Mental Health and Substance 
Abuse, would you advocate for the use of Federal funds to support 
syringe exchange programs?
    Answer 8. People who inject drugs are at increased risk of 
acquiring and transmitting HIV, viral hepatitis, and other blood-borne 
infections. The opioid epidemic has focused attention on the dangers of 
sharing needles, as evidenced by the HIV outbreak in rural Indiana in 
2015. Under current law, in some jurisdictions, people who inject drugs 
can access sterile needles and syringes through syringe services 
programs (SSPs) and through pharmacies without a prescription. In 
addition, current law gives States and local communities, under limited 
circumstances, the opportunity to use Federal funds to support certain 
components of SSPs. I look forward to working with Congress on this 
issue and other avenues to address the health crisis opioids pose and 
to improve the health of intravenous drug users.

    Question 9. Research has also shown the benefits of Supervised 
Injection Facilities (SIFs), where people can use their own drugs, 
under medical supervision. Research indicates that SIFs help reduce HIV 
and hepatitis transmission risks, prevent overdose deaths, and increase 
the number of people seeking out addiction treatment. Would you commit 
to advocate for studying safe injection facilities as a tool in the 
fight against the opioid epidemic?
    Answer 9. I am aware that the American Medical Association (AMA) 
approved a resolution calling for the development of pilot SIFs, and 
that there are sites proposed in Seattle, San Francisco, and New York, 
to name a few. There is much we don't yet know about the effectiveness 
of SIFs in saving lives and/or in encouraging people who use 
intravenous drugs to seek treatment, and what little research data is 
available does not, at least at this time, appear promising in the role 
of these programs to assist people to treatment.
Peer Support
    You have said before that ``SAMHSA has supported programs that 
provide little help to those in greatest need,'' giving the example of 
SAMHSA putting ``a major emphasis on developing a `peer workforce,' 
through which individuals with mental disorders offer support to those 
experiencing an acute episode of mental illness.'' \1\ However, 
literature reviews have shown the effectiveness of peer support 
programs for individuals with mental health and addiction disorders.\2\
---------------------------------------------------------------------------
    \1\ McCance-Katz, Elinore, ``New Hope for the Mentally Ill,'' 
National Review (November 22, 2016) (online at: http://
www.nationalreview.com/article/442382/donald-trump-mental-illness-
needs-more-aggressive-treatment).
    \2\ ``Peer Support: Why it Works,'' National Coalition for Mental 
Health Recovery (April 2014) (online at: https://www.ncmhr.org/
downloads/References-on-why-peer-support-works-4.16.2014
.pdf).

    Question 10. Why do you believe that peer support is not helpful in 
treating mental illness?
    Answer 10. I believe that peer professionals will, over the coming 
years, become a standard resource available to individuals struggling 
with mental and/or substance use disorders. I think they have a role in 
the continuum of care. However, as a practicing psychiatrist for 30 
years who has run the Rhode Island State hospital system for the last 2 
years, I can say with great certainty that those with serious and 
persistent mental illness--a population that receives little attention 
yet suffers greatly and, untreated, can be at substantial risk to 
themselves and sometimes others--need evidence-based psychiatric 
interventions to assist them in their recoveries. Peers are a part of 
the recovery process, but peers cannot impact psychosis, 
hallucinations, and/or delusions. I am committed to embracing the 
spectrum of recovery services including medical treatment for those in 
need along with the use of peers as appropriate.

    Question 11. Do you believe that peer support is helpful in any 
context?
    Answer 11. I believe that peer support is an important component of 
recovery. As a physician, I can provide medical care onsite which lasts 
for a very brief period. Peers can be far more available as part of a 
treatment team and as supporters in the community. They can help 
patients to obtain the medical, psychotherapy interventions, and other 
recovery resources recommended. They provide emotional support and, 
through their own recoveries, can provide hope. The value of such 
services cannot be underestimated.

    Question 12. You have been supportive of other community-based 
programs in treating behavioral health disorders at SAMHSA.\3\ Which 
community-based programs do you believe are useful?
---------------------------------------------------------------------------
    \3\ McCance-Katz, Elinore, ``What is SAMHSA's Role in Today's 
Healthcare System?'' SAMHSA (May 29, 2014) (online at: https://
blog.samhsa.gov/2014/05/29/what-is-samhsas-role-in-todays-healthcare-
system/#.WYHieoTytGo).
---------------------------------------------------------------------------
    Answer 12. I support the integration of behavioral health and 
primary care and the integration of treatment for mental disorders and 
substance use disorders. I support programs that provide case 
management and wrap-around services including assistance with 
vocational/educational needs, housing, and assistance with legal issues 
as needed. I support opioid treatment programs that expand to provide 
primary care and mental health services. I support recovery housing and 
programs for pregnant and post-partum women with opioid use disorder. I 
support crisis intervention programs designed to avoid emergency 
department visits and hospitalizations. All of these programs could 
involve peer specialists.

    Question 13. Would you commit to further studying and considering 
the usefulness of peer support programs?
    Answer 13. There is accumulating data on the value of peer support 
programs and, yes, I would commit to further controlled research 
studies aimed at determining the usefulness of peer support programs--
for who and under what conditions.
Response by Jerome Adams, M.D., to Questions of Senator Murray, Senator 
   Sanders, Senator Casey, Senator Franken, Senator Bennet, Senator 
                     Whitehouse and Senator Warren
                             senator murray
    Question 1. Earlier this year, a woman in Nevada died from an 
infection that was resistant to all 26 antibiotics that are available 
in the United States. The Centers for Disease Control and Prevention 
(CDC) have estimated that antibiotic resistant infections infect over 
two million and kill 23,000 Americans each year. A recent report found 
that if we don't take action, drug-resistant infections will kill more 
people worldwide than diabetes and cancer combined by 2050. Do you 
agree that antibiotic resistance is a significant threat to human 
health, and if so, how will you work to reduce this threat as Surgeon 
General?
    What role does the Surgeon General's office play in ensuring 
antibiotics are used effectively and appropriately?
    Answer 1. The issue of antibiotic resistance poses a serious threat 
to public health and clinical care. HHS has been a leader across the 
government in implementing a range of interventions. I am prepared to 
work to address antibiotic-resistant bacteria with my colleagues across 
the Administration to continue to advance these efforts. In particular, 
I believe the Surgeon General is well-positioned to engage with the 
medical community to encourage antibiotic stewardship and appropriate 
antibiotic prescribing, and to help patients and the public understand 
how to appropriately use antibiotics.

    Question 2. In December, the Surgeon General issued a report that 
concluded use of e-cigarettes by youth and young adults is a public 
health concern. It found that use of e-cigarettes by youth is now more 
common than use of regular cigarettes and that e-cigarettes come in a 
wide array of fruit and candy flavors and are marketed in ways that 
appeal to youth. Yet, last week, the Food and Drug Administration (FDA) 
announced they would delay current deadlines for review of these 
products.
    Do you share the view that e-cigarette use by young people is a 
public health concern that requires action at the Federal, State, and 
local levels? Do you agree that FDA has an important role to play to 
reduce youth use of e-cigarettes? What can CDC and other Federal 
agencies do to address this public health concern? What role should the 
Surgeon General play in raising awareness of this problem and spurring 
the adoption of policies and programs that will reduce youth use of e-
cigarettes and all tobacco products?
    Answer 2. Protecting and improving public health is at the core of 
the Department's mission. While serving as the Indiana State Health 
Commissioner, I have overseen Indiana's tobacco cessation efforts. I 
look forward to working with the FDA, CDC, and other Federal agencies 
to protect our children and significantly reduce tobacco-related 
disease and death.

    Question 3. Do you plan to continue the efforts of the National 
Prevention Council and implementation of the National Prevention Plan?
    Answer 3. As Surgeon General, my commitment is to prevention. I 
believe it is the best way to improve the health of Americans and 
decrease the burden on our health system. Once in the office, I will 
work with stakeholders and Department leaders to evaluate the National 
Prevention Council and National Prevention Strategy to ensure goal 
alignment with the Department to better serve the American people.

    Question 4. How will you support CDC's Office for Smoking and 
Health and ensure they have the capacity to continue with and optimize 
their prevention and cessation efforts, particularly their extremely 
successful Tips from a Former Smoker campaign?
    Answer 4. Recognizing the important role of CDC's Office on Smoking 
and Health, I will work with the CDC Director, Dr. Brenda Fitzgerald, 
to collaborate and communicate the available scientific information on 
tobacco use and related diseases to the public, consistent with my role 
as Surgeon General.

    Question 5a. For the first time in two decades, life expectancy in 
the United States has declined. Death rates among middle-aged 
Caucasians in the South are increasing, largely due to drug overdoses, 
liver disease, and suicide. Deaths due to chronic conditions such as 
diabetes and heart disease have also stopped falling after years of 
improvement. These conditions are all fully preventable.
    How will your office work with the CDC and others within the 
Department of Health and Human Services (HHS) to address these 
preventable conditions?
    Answer 5a. I believe it is critically important for all of the 
agencies within the Department to work together in a coordinated 
fashion to address preventable conditions. I look forward to serving as 
Surgeon General and working to bridge the efforts of the various 
agencies to improve the health of Americans, consistent with my role 
and responsibilities.

    Question 5b. How will this work be challenged by the current budget 
environment, considering the proposed deep cuts in the President's 
budget to the CDC and the repeated threats to the Prevention and Public 
Health Fund?
    Answer 5b. It is important that the Office of the Surgeon General 
support efforts to prevent disease and encourage individuals to make 
informed choices about their health. I am committed to working hard in 
my role to advocate for prevention at HHS.

    Question 6. Many health conditions and significant racial and 
ethnic disparities are heavily influenced by various social and 
environmental factors that typically exist outside of the health care 
context. For example, sub-standard housing that promotes mold, 
moisture, and pest infestations can trigger asthma. As Surgeon General, 
how would you help make sure HHS is a leader in actively bridging the 
divide between clinical care and community conditions?
    Answer 6. Tackling disparities such as these is always a challenge, 
especially when taking into account social and environmental factors 
that exist outside of the health care context. As I said in my opening 
statement, we need to get out into our communities and learn about 
their obstacles and successes, share best practices, and help empower 
them to implement local solutions. I am committed to working with 
partners at the Federal, State, and local level to end disparities.

    Question 7. Surgeons General have often depended on the Dietary 
Guidelines for Americans (DGA) to promote healthy eating for families 
across the country. Do you support development of the evidence-based 
DGAs? As you know, the DGAs are currently under review and the review 
process might be subsequently changed. Do you support the current 
process in place to review the evidence that is the underpinning for 
the DGAs? How would you optimize communication of the DGAs to the 
American public? What do you feel the appropriate role for industry and 
other stakeholders is in the process of developing the DGAs?
    Answer 7. The Dietary Guidelines are science-based recommendations 
that give Americans advice on building healthy eating patterns that can 
help prevent chronic diseases and promote and advance their health and 
well-being. The focus of the Dietary Guidelines is on preventing diet-
related health conditions, such as obesity, diabetes, and heart disease 
rather than treating these and other diseases.
    The Dietary Guidelines should be grounded in the strongest 
available scientific evidence and represent our current understanding 
of the connections between food and health. The development process 
includes input from an independent group of nutrition and medical 
experts and practitioners to inform each edition of the Dietary 
Guidelines, public comment, and exhaustive systematic review of the 
literature and current science.

    Question 8. At your confirmation hearing you stated that ``guns and 
gun owners aren't inherently a public health problem, but the violence 
that results absolutely is.'' What public health interventions do you 
think are needed to address gun violence and, as Surgeon General, how 
would you work to promote such interventions?
    Answer 8. When addressing the challenge of violence in our 
communities, we must look at the underlying issues--such as untreated 
mental illness--and address them. As I reiterated in my opening 
statement, I share the Secretary's urgency of addressing untreated 
mental illness, especially serious mental illness. I will work to 
ensure that we are identifying indicators of violent behavior so as to 
promote appropriate interventions, consistent with my role as Surgeon 
General.

    Question 9. Infant mortality is often an indicator for the health 
of a society and the efficacy of its policies. According to the CDC, 
the infant mortality rate in the United States in 2014 was 6.1. This 
means that 6 out of 1,000 infants born will not live to see their first 
birthday. The rate is the higher than 25 other developed countries. 
This is an unsettling statistic. You have been very involved in efforts 
to reduce the number of infant deaths in Indiana, which had one of the 
highest infant mortality rates for individual States. How would you 
translate these efforts to the Federal level? Maternal mortality rates 
in the United States, while improving overall, have also fallen behind 
those of other countries. If confirmed as Surgeon General, how would 
you work to improve the maternal mortality rate in the United States?
    Answer 9. As Surgeon General, I would draw upon my experience in 
Indiana to build relationships across HHS, the States, and local 
communities to identify strategies that are working to improve infant 
and maternal mortality. Many States, much like Indiana, are facing a 
multitude of health challenges that are reflected in these rates. I am 
committed to working with all levels of government and impacted 
communities to better address these two important health concerns.

    Question 10. The African-American infant mortality rate is twice 
the white infant mortality rate. In 2013, the Secretary's Advisory 
Committee on Infant Mortality included in the National Prevention 
Strategy a recommendation on this topic. What recommendations would you 
offer clinicians to address this health inequity in the African-
American community?
    Answer 10. This issue is of great concern to me as a physician and 
a parent. I feel one important step to improving infant mortality in 
any community, but especially the African American community, is 
collaboration and engagement across the community. By leveraging 
interagency, public-private, and multi-disciplinary collaboration and 
partnerships, we can work together to identify targeted strategies to 
reduce infant mortality in the African American community. This is a 
multifaceted problem. Clinicians cannot fully address this problem 
without the help of other partners. To achieve any level of success, it 
will require clinicians working together and with other stakeholders 
across all disciplines to identify models and best practices 
appropriate for the communities we serve.

    Question 11. There unfortunately has been a history of reproductive 
coercion in this country, particularly among Black and Latina women. 
The Surgeon General's office frequently makes recommendations on ways 
that Americans can improve their health outcomes. Do you have any 
recommendations to make sure that all women have the ability to choose 
the birth control--and provider--of their choice?
    Answer 11. As Surgeon General, I would look forward to ensuring 
that women and men can obtain the health care that they need at an 
affordable price.

    Question 12. When you committed to me that you would stand up for 
vaccines, you told me that you will stand up for science where the 
science is settled. You also said there are topics on which people 
think the science is settled but it is not. Can you please elaborate on 
what those topics are and what the outstanding questions are?
    Answer 12. As Surgeon General, science will always guide and be 
reflected in my efforts. I will also convene and work with partners to 
make sure that, where there remains scientific debate, we can talk to 
each other, and come up with a direction that is best for, and accepted 
by, the American people. The Department has a responsibility to ensure 
that the American people are receiving the most up-to-date, science-
based information, and also to make sure we listen to and work with all 
citizens--not just the ones we happen to agree with.

    Question 13. For decades, the Surgeon General has been an outspoken 
voice on the health risks posed by smoking, particularly among children 
and teens. As noted above, the Surgeon General has recently spoken out 
about the risks posed by e-cigarettes. In Indiana, you have led several 
public campaigns to warn of the dangers of tobacco, stating ``quitting 
smoking is the single best thing you can do for your health.'' Yet, 
according to your Public Financial Disclosure Report (OGE Form 278e), 
prior to your nomination you were invested in some of the largest 
manufacturers of tobacco products, including e-cigarettes: Altria Group 
Inc., British American Tobacco PLC, Philip Morris International Inc., 
and Reynolds American Inc. with holdings totaling between $5,005 and 
$75,000. Please explain how you reconcile the past work from the Office 
of the Surgeon General--and your own work--about the public health 
risks posed by tobacco with your decision to hold stock in some of the 
world's largest tobacco companies?
    Answer 13. The majority of my investments are held in managed 
accounts with the investment decisions made by the account managers. I 
hold several smaller investment accounts where I control the 
investments with the advice of my financial advisor. My advisor and 
account managers make decisions that they deem best for my portfolio, 
and which are unknown to me. Following my confirmation, all of my 
accounts will be moved to accounts under my full control. As you 
mention, my commitment to tobacco prevention and cessation is well-
documented.

    Question 14. You have spoken extensively about your experience with 
the opioid epidemic and the resultant HIV outbreak in Indiana. You 
testified before Congress that ``[t]argeted marketing by the 
pharmaceutical industry encouraged providers to use opioids more 
aggressively to treat chronic, non-terminal pain'' and you called on 
the pharmaceutical industry to be held accountable for its role in 
expanding access to opioids. Yet, according to your Public Financial 
Disclosure Report (OGE Form 278e), prior to your nomination you were 
invested in companies that are some of the largest manufacturers of 
opioids in the country, including Allergan, Pfizer, and Novartis. In 
fact, the State of Ohio recently brought a lawsuit against Allergan, 
among others, for their role in the opioid epidemic. Please explain how 
you can reconcile your work speaking out about the dangers of the 
opioid epidemic, specifically your calls to hold the pharmaceutical 
industry accountable, with your decision to hold stock in some of the 
Nation's largest opioid manufacturers?
    Answer 14. The majority of my investments are held in managed 
accounts with the investment decisions made by the account managers. I 
hold several smaller investment accounts where I control the 
investments with the advice of my financial advisor. My advisor and 
account managers make decisions that they deem best for my portfolio, 
and which are unknown to me. Following my confirmation, all of my 
accounts will be moved to accounts under my full control. As you 
mention, my commitment to combating the opioid epidemic is well-
documented.
                            senator sanders
    Question 1. As you know, this Nation has been and remains plagued 
by health disparities. These disparities not only are well-documented 
as it pertains to health status and health outcomes, but also in the 
stark differences that exist between different populations in access to 
reliable, affordable health care. These disparities not only carry a 
significant human health toll, but a financial one, as well. As Surgeon 
General, please share in detail how do you plan on leveraging the 
influence of the office to help make significant strides in ongoing 
efforts to reduce and even eliminate some of our most pressing health 
disparities? Also, please share how you plan to work to reduce health 
disparities while President Trump is seeking to cut or eliminate the 
very programs that are vital to this effort.
    Answer 1. As Indiana Health Commissioner, one of my main areas of 
focus was on health disparities impacting health outcomes, such as 
infant mortality disparities by race and geography. As Surgeon General, 
I would ensure health disparities continues to be an area of focus 
through my communication and convening platforms. I would spotlight 
community and employer engagement on evidence-based programs and 
policies that are reducing health disparities across our Nation in 
order to increase their reach.

    Question 2. There are dire and often immediate public health 
challenges that can be direct results of the lack of access to 
screening, treatment and care for substance abuse, HIV and other STI 
testing, and needle exchange programs. These are issues, as you know, 
that hit rural communities extremely hard, and were highlighted when 
Scott County, in your own State of Indiana, experienced an HIV outbreak 
that has since been linked to opioid misuse and needle sharing. As you 
know, when this HIV outbreak occurred, then-Governor Pence refused to 
support needle exchange programs. Additionally, more than 60 percent of 
rural counties--including Scott County--did not have enough physicians 
qualified to prescribe buprenorphine--an FDA-approved medication to 
treat opioid use disorder. In detail, please share your perspective 
about the importance of the Federal Government's support for programs 
like needle exchange and HIV screening, as well as the Federal 
Government's role in assisting States and local communities to expand 
access to treatment for substance use disorders in rural, underserved 
areas, like Scott County? Additionally, in detail, please share your 
thoughts about the impact that defunding Planned Parenthood--which 
provides not only HIV and STI screening and testing, but also mental 
health and substance abuse counseling and treatment to millions of 
vulnerable Americans--will have on efforts to prevent what happened in 
Scott County from happening in other rural communities across the 
country.
    Answer 2. Our Nation is in the midst of an unprecedented opioid 
epidemic. I share Secretary Price's tremendous sense of urgency to 
combat this public health threat. As Secretary Price outlined in April 
2017, HHS is implementing a comprehensive strategy to reduce opioid 
abuse, addiction, and overdose, including the provision of 
comprehensive services such as substance abuse treatment, testing for 
HIV and hepatitis C, and, where appropriate and effective, access to 
sterile syringes, consistent with Federal, State, and local laws, for 
people who inject opioids and other drugs. Building on my first-hand 
experiences addressing these complex issues in Indiana, I look forward 
to advancing these efforts and helping communities to implement local 
solutions to their toughest problems. I also look forward to working 
with partners across HHS to leverage community health centers in this 
effort. This critical resource plays a vital role in health care 
delivery, especially in rural communities.
                             senator casey
    Question 1. In your opening testimony at the August 1 hearing you 
stated the importance of prevention activities to address many of the 
public health problems in our country. As you know, the Affordable Care 
Act has a significant prevention fund that has been targeted for 
defunding by the Administration. How will you advocate for continuation 
of this program and funding within the Administration?
    Answer 1. A primary focus of the Surgeon General is prevention. I 
look forward to getting into my position and evaluating programs that 
are already in place. As you mentioned, I am eager to ensure that 
prevention is a key focus.

    Question 2. Over the last several months, I have sent multiple 
letters to HHS about the Administration's ongoing efforts to undermine 
and sabotage the Affordable Care Act through executive action. HHS has 
failed to provide responses to many of my letters. If HHS has 
responded, the response letters have been wholly inadequate and have 
not been responsive to my requests. If you are confirmed, do you commit 
to respond in a timely manner to all congressional inquiries and 
requests for information from all Members of Congress, including 
requests from Members in the Minority?
    Answer 2. As Surgeon General, I look forward to working with you 
and Members of Congress on both sides of the aisle. I am eager to 
maintain an ongoing dialog with Congress as we work to improve the 
health of all Americans.
                            senator franken
    Question 1. Can you explain why it is essential and in the best 
interest of the Nation's public health to have an independent Surgeon 
General whose sole focus is promoting and advancing evidence-based 
public health practices rather than the political agenda of the 
administration in which the Surgeon General serves?
    Answer 1. It is important for a Surgeon General to be an 
independent and unbiased authority.

    Question 2. The Surgeon General's office has produced landmark 
reports over the years that have been tremendously influential, 
including last year's report on addiction. What would your priority 
issues be and how do you intend to utilize previous work of the office 
to advance your goals?
    Answer 2. As detailed in my submitted confirmation testimony, my 
priorities will be (1) addressing the opioid epidemic, (2) promoting 
wellness and prevention, and (3) engaging the business community to 
improve health. All of the previous reports of the Surgeons General 
will have relevance to and overlap with my priorities--particularly 
previous reports on addiction and smoking. My intent is to buildupon 
the work of previous holders of this position, to make America 
healthier.

    Question 3. As Surgeon General, you will help lead the Public 
Health Commission Corps. What plans do you have to utilize this group 
to fight the opioid epidemic and other public health crises?
    Answer 3. The USPHS Commissioned Corps is comprised of 
approximately 6,500 licensed, public health and safety professionals 
(doctors, nurses, mental health providers, etc.) trained to respond 
individually or as part of a larger Federal disaster response. As 
Surgeon General, I look forward to working with the Commissioned Corps 
to advance the President's and Secretary's public health agenda and to 
protect the health of all Americans.

    Question 4. The President, while on his campaign echoed the 
concerns raised by anti-vaccine organizations. What will you do to 
educate the President, his administration, and the public about the 
importance of vaccines?
    Answer 4. There is no doubt that vaccines have played a significant 
role in improving public health in our country. I will work to ensure 
that patients have confidence in the immunizations recommended by the 
Department.
                             senator bennet
    Question 1a. I was recently in Otero County, CO where drug 
overdoses have been increasing. The entire community was engaging to 
address the rise in opioid abuse. This included coordinating hospitals, 
the courts, schools and foster care services. Even when we see a 
decrease in prescription overdoses, it is usually countered with an 
increase in heroin overdoses. In the 1960s, more than 80 percent of 
heroin users started with heroin. In contrast, currently, about 80 
percent of heroin users first started using prescription opioids.
    What are practical steps you plan to take to address the opioid 
crisis?
    Answer 1a. The opioid epidemic is one of the greatest health 
threats in recent history. To be successful in ending this crisis, we 
must focus on a comprehensive strategy that addresses the underlying 
drivers of the epidemic and brings together public health, public 
safety, community members, faith-based organizations, and many other 
elements of society. As Surgeon General, I would build on my experience 
in Indiana, to partner with the medical community to increase the use 
of evidence-based addiction treatment, including medication-assisted 
treatment, and support individuals in recovery. A key aspect of this 
work is communication and convening, and the Surgeon General is well-
positioned to bring stakeholders together on this pressing issue. I 
look forward to carrying out these efforts.

    Question 1b. How can we ensure that Americans are not becoming 
addicted in the first place while making it easier for people who 
currently have an addiction to obtain access to treatment?
    Answer 1b. Prevention is a key part of the strategy to combat the 
opioid epidemic. As Surgeon General, I would build on efforts already 
underway at HHS to support community-based prevention programs, and 
work with the medical community to improve opioid prescribing--too 
often a starting point of addiction for many Americans. At the same 
time, the data are clear that most people who have opioid addiction do 
not receive treatment for it. Thus, to turn the tide on the epidemic, I 
would advance efforts to expand access to treatment, including the full 
spectrum of medication-assisted treatment.

    Question 2. Many chronic diseases are preventable or better managed 
when caught early. When they are not, there is a large cost burden on 
our society. The American Diabetes Association estimates that the 
economic cost of diabetes was nearly $250 billion in 2012, a 41 percent 
increase since 2007. In Medicare, 15 percent of the sickest enrollees 
that often have multiple chronic conditions, account for 50 percent of 
Medicare spending.
    What is your strategy around prevention so that certain chronic 
diseases are avoided or better managed in order for us to improve 
outcomes and save Medicare dollars?
    Answer 1. The Office of the Surgeon General's primary function is 
to translate science to ensure the American public is aware of the most 
practical and evidence-based information to prevent disease. For 
example, the Surgeon General's Call to Action on Walking and 
Walkability focuses on increasing physical activity. The Office also 
highlights active living and healthy eating as standards to improve 
chronic diseases. The Healthy Aging in Action report (HAIA) developed 
by the National Prevention Council addresses best practices for 
longevity and improving health costs for seniors. I plan to carefully 
review recommendations such as these and determine the best way during 
my tenure as Surgeon General to promote prevention of chronic disease.
                           senator whitehouse
    Question 1a. You are well aware of the toll the opioid epidemic has 
taken on families across the country. Evidence shows that medication-
assisted treatment can reduce cravings and withdrawal symptoms among 
people suffering from opioid addiction, and help them stop using 
opioids and get back to living productive lives. Despite this evidence, 
Secretary Price has claimed that medication-assisted treatment is 
ineffective, just substituting one opioid for another.
    Do you agree with Secretary Price's statements about medication-
assisted treatment?
    Answer 1a. There are many years of rigorous research documenting 
the effectiveness of medication-assisted treatment. Like Dr. Price, I 
am committed to ensuring that people struggling with opioid addiction 
have access to evidence-based care, including the full spectrum of 
medication-assisted treatment.

    Question 1b. What do you see as the role of medication-assisted 
treatment in combating the opioid epidemic?
    Answer 1b. To turn the tide on the epidemic, we must have a 
comprehensive strategy. A critical component of that is to expand 
access to treatment, in particular all forms of medication-assisted 
treatment. I am prepared to use the role of Surgeon General to help 
educate providers, patients, and the public about opioid addiction, 
what treatments are available, and how people can access treatment.

    Question 2. You have referred to antibiotic resistance as ``one of 
the biggest health threats we face'' and have encouraged the 
responsible prescribing of antibiotics. The Centers for Disease Control 
and Prevention estimates that two million people develop antibiotic-
resistant infections in the United States every year, resulting in at 
least 23,000 deaths. As Surgeon General, will you prioritize combating 
antibiotic resistance, preventing healthcare-acquired infections, and 
raising awareness about this public health threat?
    Answer 2. HHS has been a leader across the government in 
implementing a broad range of activities to curb antibiotic resistance. 
As Surgeon General, I will work with my colleagues across the 
Administration to continue to advance these efforts. In particular, I 
believe the Surgeon General is well-positioned to engage with the 
medical community to encourage antibiotic stewardship and appropriate 
antibiotic prescribing and to help patients and the public understand 
the appropriate role antibiotics play in our health and health care 
system. I look forward to helping raise the visibility of this 
important issue.
                             senator warren
Reproductive Health
    The U.S. Surgeon General, the Nation's top doctor, is responsible 
for offering Americans ``the best scientific information available on 
how to improve their health and reduce the risk of illness and 
injury.'' Reproductive and sexual health are critical components of 
overall wellness.
    Currently, a key priority of the Surgeon General is the ``National 
Prevention Strategy,'' which aims to enhance ``health and well-being'' 
by ``integrating recommendations and actions across multiple settings 
to improve health and save lives.'' The National Prevention Strategy 
includes recommendations for reproductive and sexual health and 
prioritizes support for ``effective sexual health education, especially 
for adolescents,'' the ``early detection of HIV, viral hepatitis, and 
other STIs,'' and the ``increased use of preconception and prenatal 
care.''
    Reproductive health centers--including Planned Parenthood clinics--
are critical to these efforts. Each year, Planned Parenthood's 600 
health centers serve nearly five million people, providing 295,000 Pap 
tests, 320,000 breast exams, and 4.2 million STI tests. In addition, 
Planned Parenthood offers evidence-based, medically accurate sex 
education to 1.5 million teens annually.
    Republicans often claim that federally qualified health centers 
(FQHCs) could fill the gaps in reproductive health care access that 
would result from a defunding of Planned Parenthood. Recent analysis by 
the Guttmacher Institute, however, demonstrates that this claim is 
patently false. The analysis points out FQHC sites providing 
contraceptive care would need to dramatically increase their 
contraceptive client caseloads, taking on an additional two million 
patients nationwide, in order to fill the gap should the Republican 
Congress choose to cut Planned Parenthood health centers out of the 
family planning safety net.

    Question 1. As Surgeon General, would you continue to promote the 
National Prevention Strategy, including its recommendations on 
reproductive and sexual health?
    Answer 1. Reports and strategies often need to be updated to best 
reflect changing evidence. I plan to carefully review all of the 
recommendations of the NPS and determine the best way during my tenure 
as Surgeon General to promote reproductive and sexual health.

    Question 2. Do you agree that policies demonstrated to increase the 
number of unintended pregnancies and STIs among teenagers should not be 
supported by HHS?
    Answer 2. As Surgeon General, I commit to working to decrease 
unintended pregnancies and STIs among all citizens.

    Question 3. As Surgeon General, would you commit to promoting 
evidence-based programs that improve teenagers' reproductive health?
    Answer 3. Yes.

    Question 4. Do you agree that Planned Parenthood health clinics are 
essential to Federal efforts to promote effective sexual health 
education, increase STI detection, and improve reproductive health 
care?
    Answer 4. Women's health is very important to me. As Surgeon 
General, I would strive to ensure that both women and men have access 
to the quality health care they need.

    Question 5. Do you agree that FQHCs cannot fill the gaps left if 
Planned Parenthood health clinics no longer received Federal funding?
    Answer 5. As Surgeon General, I will work to ensure all women have 
access to affordable, high quality health services, consistent with my 
role as Surgeon General.
Zika Response
    The Surgeon General is also responsible for offering the public 
``facts on emerging public health threats'' and ``list[ing] steps 
individuals can take to protect themselves and their families.'' The 
Zika virus is one such ``emerging public health threat'': infection 
during pregnancy can result in microcephaly, a severe brain defect, as 
well as miscarriage and stillbirth. According to the Centers for 
Disease Control and Prevention (CDC), ``[o]ffering family planning 
services, including information and access to the full range of 
contraceptive methods, is a primary strategy to reduce the number of 
unintended pregnancies affected by Zika virus infection.''

    Question 6. As Surgeon General, would you commit to providing the 
American people with evidence-based, scientifically and medically 
accurate information about Zika prevention--including information on 
``the full range of contraceptive methods--regardless of any partisan 
efforts to restrict information on and access to contraceptive 
services?
    Answer 6. As Surgeon General, I will communicate the full range of 
evidence-based, scientifically and medically accurate information on 
all public health topics, including Zika prevention, to help patients 
make informed decisions about their health.

    Question 7. As Surgeon General, would you oppose efforts by the 
Trump administration to reduce access to contraception, including 
efforts to defund Planned Parenthood health clinics?
    Answer 7. As Surgeon General, my role is to communicate evidence-
based health information to the public. I would work with my public 
health and clinical partners to raise awareness about evidence-based 
prevention, including efforts to reduce preventable causes of morbidity 
and mortality, including infant mortality and teenage pregnancy.
Opioid Epidemic
    The opioid epidemic is a public health crisis. In Massachusetts 
alone, an estimated 2,000 people died from opioid overdoses in 2016. 
Addressing addiction and substance use is one of the Surgeon General's 
top priorities. In 2016, the Surgeon General worked to promote a 
national campaign that urged health care professionals and prescribers 
to talk with one another about best prescribing practices. In the same 
year, the Surgeon General presented a report, ``Facing Addiction in 
America: The Surgeon General's Report on Alcohol, Drugs, and Health,'' 
which included a series of recommendations on preventing and treating 
addiction. This report also provided a look into the country's current 
``treatment gap,'' which has helped inform policymakers as they work to 
find solutions and slow the rise in fatal overdose rates.
    At the core of the opioid crisis has been the over-prescribing of 
addictive prescription painkillers. CMS reported that generic Vicodin 
was prescribed to more Medicare beneficiaries than any other drug in 
2013--more than blood pressure medication, more than cholesterol 
medication, more than acid reflux medication. The National Institute on 
Drug Abuse has estimated that over 70 percent of adults who misuse 
prescription opioids get the medication from friends or relative, so 
efforts to reduce the amount of unused medications in the home is a 
powerful new tool to tackle the prescription drug epidemic. The 
Comprehensive Addiction and Recovery Act, passed in July 2016, included 
a bipartisan provision that I worked on with Senator Capito that 
empowers patients to talk to their physicians and pharmacists about 
partially filling their prescription medications in order to reduce the 
amount of unused opioids in circulation.
    In addition to the impact that prescription drug use has had on the 
opioid epidemic, the illicit distribution and sale of fentanyl, a 
dangerous synthetic opioid that is more potent than heroin, has 
contributed to this public health crisis--particularly in New England 
States like Massachusetts. A November 2016 study by the Massachusetts 
Department of Public Health found that of the opioid-related fatalities 
in the State in which toxicology screens were available, 74 percent of 
individuals tested positive for fentanyl.

    Question 8. What will you do to work with other agencies and the 
physician community to address the over prescribing and misuse of 
prescription medications, while still ensuring that patients who need 
pain medication can receive it?
    Answer 8. I firmly believe that most physicians want to do what is 
best for their patients and to relieve suffering without putting their 
patients and families in harm's way. Ensuring that patients with pain 
receive high-quality, evidenced-based pain care must be an essential 
component of the response to the opioid epidemic. As Surgeon General, I 
would engage with the medical community, government partners, and State 
and local stakeholders to ensure that policies and programs aimed at 
reducing opioid abuse, addiction, and overdose do not penalize patients 
with legitimate medical needs.

    Question 9. You have been supportive of Indiana's recent partial 
fill legislation. In the role of Surgeon General, would you work with 
States, physicians, pharmacists, and patient groups to increase 
awareness about Federal partial fill policies?
    Answer 9. Yes.

    Question 10. Will you support the findings of the report, ``Facing 
Addiction in America,'' and will you continue to inform the 
Administration and Congress about the need to fight the opioid 
epidemic?
    Answer 10. It is clear to me that the Administration and Secretary 
Price have taken an early and aggressive approach to combating the 
opioid epidemic. I look forward to working with partners across the 
Administration and external stakeholders to build on the progress that 
has been made in recent years. The Surgeon General's Report on Alcohol, 
Drugs, and Health can serve as a science-based resource to help advance 
evidence-based policies and programs to reduce the burden of opioid 
addiction.

    Question 11. What do you believe are the next steps in tackling 
this opioid crisis?
    Answer 11. At all levels of government and in communities across 
America, health care professionals, parents, people in recovery, first 
responders, and many others are taking action to reduce the harms 
associated with opioid abuse, addiction, and overdose. I look forward 
to leveraging the Office of the Surgeon General to build on these 
efforts. In particular, I believe the Surgeon General is well-
positioned to engage with the medical community to encourage the 
appropriate use of opioids and to advance evidence-based pain care, and 
to help raise awareness of addiction and spur efforts to reduce stigma 
around addiction among patients, providers, and the public.

    Question 12. You have advocated for Medication-Assisted Treatment 
(MAT) as an important evidence-based addiction treatment. How would you 
work to ensure that other influential health officials understand the 
value of this treatment?
    Answer 12. There are many years of rigorous research documenting 
the effectiveness of medication-assisted treatment. Yet, despite the 
evidence base, the vast majority of people with an opioid addiction do 
not receive treatment for it. Expanding access to medication-assisted 
treatment is a key part of the response to the opioid epidemic. I am 
prepared to use the role of Surgeon General to help educate providers, 
patients, and the public about opioid addiction, what treatments are 
available, and how people can access treatment.

    Question 13. What do you plan to do to build on HHS's efforts to 
address a specific component of the opioid epidemic, the illicit sale 
and use of fentanyl?
    Answer 13. The emergence of illicitly made fentanyl and fentanyl 
analogs, largely coming from China, has accelerated the ongoing opioid 
epidemic in the United States. As Surgeon General, building on my 
experiences in combating the opioid crisis in Indiana, I will work 
collaboratively with experts across HHS and with our partners in law 
enforcement to raise awareness about the dangers of illicit fentanyl 
and fentanyl analogs in our communities, encourage the broader use of 
naloxone to reverse overdoses, and use the platform of the Surgeon 
General to reduce stigma around opioid addiction--a key barrier to 
getting people into treatment and stopping their drug use. In addition, 
I will work with the medical community to curb the inappropriate 
prescribing of opioid pain medications, which was the starting point 
for many Americans now addicted to heroin and illicitly made fentanyl.
Tobacco
    Tobacco, the leading cause of preventable death in the United 
States, is traditionally one of the Surgeon General's top priorities. 
The Surgeon General's 2016 report, ``E-Cigarette Use Among Youth and 
Adults,'' concluded that the use of e-cigarettes among youth and young 
adults was a public health concern, and suggested a number of policies 
to impose stricter regulation of e-cigarettes.
    However, in July 2017, the FDA announced that it would further 
delay deadlines for e-cigarettes, cigars, and other previously 
unregulated tobacco products to come into compliance with the 2016 FDA 
deeming rule that imposed stricter oversight of these products.

    Question 14. As Surgeon General, would you continue to promote the 
recommendations of the Surgeon General's 2016 report on e-cigarette 
use?
    Answer 14. Reports and strategies often need to be updated to best 
reflect changing evidence. While the aforementioned report is only a 
year old, at the time of its release there was controversy in the 
public health community about the evidence on e-cigarettes. Since the 
Report's release, a large volume of research that further expands our 
understanding of e-cigarettes has been published. I plan to carefully 
review all of the recommendations of the 2016 report and this new 
research to determine the best way during my tenure as Surgeon General 
both to promote harm reduction for current smokers and to prevent 
smoking initiation, especially among youth.

    Question 15. Do you agree that stricter FDA oversight of e-
cigarettes, cigars, and other previously unregulated tobacco products 
could improve public health outcomes?
    Answer 15. Protecting and improving public health is at the core of 
the Department's mission. While serving as the Indiana State Health 
Commissioner, I have overseen Indiana's tobacco cessation efforts. I 
look forward to working with the FDA, CDC, and other Federal agencies 
to protect our children and significantly reduce tobacco-related 
disease and death.
Combating Antibiotic Resistance
    The 2014 National Strategy for Combating Antibiotic-Resistant 
Bacteria brought together the Secretaries of Health and Human Services, 
Agriculture, and Defense to declare that,

        ``the misuse and over-use of antibiotics in health care and 
        food production continue to hasten the development of bacterial 
        drug resistance, leading to the loss of efficacy of existing 
        antibiotics.''

    Through this initiative, we've made some significant progress 
establishing policies that better protect lifesaving antibiotics.
    There is strong and growing evidence that antibiotic use in food 
animals can lead to antibiotic resistance in humans, yet the use of 
medically important drugs in food animals continues to grow. According 
to the FDA,

          ``Domestic sales and distribution of medically important 
        antimicrobials approved for use in food producing animals 
        increased by 26 percent from 2009 through 2015, and increased 
        by 2 percent from 2014 through 2015.''

    Question 16. Do you agree that curbing the misuse and over-use of 
antibiotics in health care and food production should be a public 
health priority?
    Answer 16. Yes.

    Question 17. As Surgeon General, what specific steps will your 
office take to prevent the development of bacterial drug resistance?
    Answer 17. HHS has been a leader across the government in 
implementing a broad range of activities to curb antibiotic resistance. 
As Surgeon General, I will work with my colleagues across the 
Administration to continue to advance these efforts. In particular, I 
believe the Surgeon General is well-positioned to engage with the 
medical community to encourage antibiotic stewardship and appropriate 
antibiotic prescribing and to help patients and the public understand 
the appropriate role antibiotics play in our health and health care 
system. I look forward to helping raise the visibility of this 
important issue.

    [Whereupon, at 4:45 p.m., the hearing was adjourned.]

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