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



 
  DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND 
          RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2018

                              ----------            
                              


                        THURSDAY, JUNE 15, 2017

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:05 a.m., in room SD-138, Dirksen 
Senate Office Building, Hon. Roy Blunt (chairman) presiding.
    Present: Senators Blunt, Shelby, Alexander, Moran, Capito, 
Lankford, Kennedy, Murray, Durbin, Shaheen, Merkley, Schatz, 
Baldwin, Manchin, and Leahy.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

                        Office of the Secretary

STATEMENT OF HON. THOMAS PRICE, SECRETARY


                 opening statement of senator roy blunt


    Senator Blunt. Good morning. Thank you, Secretary Price, 
for appearing before the subcommittee today to discuss the 
Department of Health and Human Services' fiscal year 2018 
budget request. We look forward to hearing your testimony.
    This year's budget request for the Labor/HHS Subcommittee 
is reduced by $24 billion. The Department of Health and Human 
Services would take a $15.1 billion reduction, or a reduction 
of about one-fifth of the Department's current funding level. 
This certainly would put a great deal of new restraint on what 
you try to do there.
    Certainly, I agree there are a lot of places in the 
Department's budget we should look to for savings. You bring a 
new viewpoint and frankly, a helpful background to the HHS 
budget. I hope we can work together to identify programs that 
are ineffective and no longer needed and put that funding to 
better use elsewhere.
    However, as the budget request stands today, I'm concerned 
about a path forward if we followed the request that the 
administration has made. The proposal cuts the National 
Institutes of Health by $7.5 billion, eliminates funding for 
LIHEAP (Low Income Home Energy Assistance Program), and reduces 
funding for the Centers for Disease Control and Prevention by 
$1.2 billion. Certainly looking at the history of this 
subcommittee and our commitment in those areas and others in 
the past, it's hard to imagine that we would do that.
    I want to make it particularly clear, as the chairman of 
this subcommittee, that I wouldn't intend to be part of writing 
a bill this year that reduces funding for the National 
Institutes of Health. As you know, this subcommittee spent the 
last 2 years making NIH (National Institutes of Health) a 
priority, and we provided back-to-back funding increases, and 
to do that, eliminated and reduced funding in other areas.
    So the committee is certainly not opposed to setting 
priorities, but we just want to be sure those priorities make 
sense.
    It's important to remember that Congress clearly is not a 
rubber stamp for the President's budget. In fact, the last time 
we voted on President Obama's budget on the floor in fiscal 
year 2016, it failed by a vote of 98 to 1, which is a pretty 
standard vote on Presidents' budgets in recent years. But that 
doesn't mean that the President's budget doesn't have some 
directions in it that we want to talk to you about, that we 
want to look at. We want to set priorities.
    Our goal is for us to work together, and my goal is for us 
to work together, to identify those priorities, to find common 
ground when we can, and then responsibly allocate the amount of 
money that we believe those programs need.
    So we're glad you're here. We'll try to deal with the time 
restraint and the confusion of what I think will be three back-
to-back votes as much as we can, but I think we're going to 
have a lot of cooperation in doing that.
    And I would like to turn now to Senator Murray for her 
opening remarks.
    [The statement follows:]
                Prepared Statement of Senator Roy Blunt
    Good morning. Thank you, Secretary Price, for appearing before the 
Subcommittee today to discuss the Department of Health and Human 
Services' fiscal year 2018 budget request. We look forward to hearing 
your testimony.
    This year's budget request for the Labor/HHS Subcommittee is 
reduced by $24 billion. The Department of Health and Human Services 
takes $15.1 billion of those cuts, or a reduction of about one-fifth 
from the Department's current funding level. This has placed your 
budget under great financial restraints.
    I agree that there are many places in the Department's budget we 
should look to for savings. You bring a new viewpoint to the HHS budget 
and I hope we can work together to identify programs that are 
ineffective or no longer needed and put that funding to better use 
elsewhere.
    However, as the budget request stands today, I am concerned about 
its path forward. The proposal cuts the National Institutes of Health 
by $7.5 billion, eliminates funding for LIHEAP (pronounced lie-heap), 
and reduces funding for the Centers for Disease Control and Prevention 
by $1.2 billion. Looking at the history of this Subcommittee and the 
benefits of many of these programs, I believe it's unlikely this 
Subcommittee will support these specific and significant funding 
reductions and eliminations.
    In particular, I want to be clear that, as Chairman of this 
Subcommittee, I will not write a bill this year that reduces funding 
for the National Institutes of Health. As you are aware, this 
Subcommittee has spent the last 2 years making NIH a priority by 
providing back to back funding increases. NIH funding is important for 
those individuals suffering from life-threatening illnesses as well as 
for the American taxpayer who pays for many of these individuals' care 
through Medicare and Medicaid. I will not erase the gains we have made 
over the past 2 years.
    It is important to remember that Congress is not a rubber stamp for 
the President's budget request--from either party. Every President's 
budget request has concerning aspects and often issues that we cannot 
support. The last time we voted on President Obama's budget on the 
floor in fiscal year 2016, it failed by a vote of 98-1.
    Simply put, I think this is a starting place for negotiations. 
While I appreciate the Department prioritizing limited resources, this 
hearing is an opportunity for us to fully understand whether you made 
many of these cuts because you believe these programs are ineffective 
and not necessary or because your topline budget level forced you to do 
so.
    My goal is for us to work together to identify priorities and find 
common ground while responsibly allocating taxpayers' resources.
    Mr. Secretary, I look forward to hearing your testimony today and 
appreciate your dialogue with us about these important issues.
    Thank you.

                   STATEMENT OF SENATOR PATTY MURRAY

    Senator Murray. Well, thank you very much, Chairman Blunt.
    And, Secretary Price, appreciate your being here today 
because there is a lot to talk about. From your 
administration's proposed budget for the Department of Human 
Services to the secret version of Trumpcare that Senate 
Republicans are rushing to jam through in a matter of days, I 
am deeply concerned the work of your administration on 
healthcare would take our healthcare system and the well-being 
and financial security of families nationwide in a deeply 
damaging direction.
    So I want to start with Trumpcare. There are reports that 
the all-male working group of Senator Republicans actually has 
a bill in draft form. The Democrats haven't seen it. Patients 
and families are being locked out of the process, they haven't 
seen it. Governors and State legislators who need to know what 
is in this bill and what it means for their States are being 
kept in the dark. And it's clear Senate Republicans are doing 
everything they can to make sure it stays that way, and it's 
pretty clear why. Based on the reports we've heard, the Senate 
Trumpcare plan would take the same harmful approach as the--now 
I quote President Trump--``mean House bill.''
    Under Trumpcare, people's healthcare costs, especially for 
seniors and those with preexisting conditions, would go way up. 
Millions of people would lose Medicaid coverage and could lose 
benefits they need if they live in a State that can't afford 
the changes or chooses to get traditional Medicare. Patients 
nationwide, men and women, would lose access to providers that 
they trust at Planned Parenthood. We've seen the consequences 
in Iowa already, where a defund effort has caused four Planned 
Parent centers to close. All of this and more will happen. Why? 
So special interests in the healthcare insurance industry can 
get a massive tax break and so that President Trump can get a 
hollow political win.
    Secretary Price, given President Trump's promises to 
provide coverage for everybody that is higher quality and lower 
cost, I'm very interested in hearing how you plan to defend 
these policies, especially since this budget doubles down on 
them and makes their impact even worse by gutting programs that 
support patients and families in the most need.
    During the President's campaign, he promised not to cut 
Medicaid, and you repeated denial of this fact. Despite that, 
your budget would end the traditional Medicaid program as we 
know it by imposing draconian cuts to coverage for millions of 
children, pregnant women, people with disabilities, and low-
income seniors. And while your budget proposes extending the 
children's health insurance program by 2 years, it includes 
draconian cuts to that program that would most certainly 
jeopardize healthcare for millions more children and families.
    It cuts vital medical research at the NIH by 21 percent, 
which I will focus on in greater detail at our hearing next 
week.
    It slashes public health programs at the CDC (Centers for 
Disease Control and Prevention) by 17 percent at a time when we 
are facing new and emerging diseases and continuing to combat 
threats such as Zika.
    It eliminates safety net programs like LIHEAP and the SSBG 
(Social Services Block Grant) by more than $6 billion.
    And despite the still escalating crisis of opioid and 
heroin addiction, it cuts funding for prevention and treatment 
programs by $84 million.
    And it eliminates healthcare workforce programs that help 
States meet the increasing demand for substance abuse 
counselors.
    I also want to take a few minutes to specifically address a 
few of the ways this budget would impact women. Not only did 
you include a new and expanded poison pill rider to 
specifically exclude Planned Parenthood from Federal funding 
under the budget, but you are secretly, as we know, crafting a 
sweeping revision of the Affordable Care Act's contraception 
coverage mandate to expand the number of employers that could 
deny women coverage for birth control. Coupled with your intent 
to slash Medicaid, which serves one in five women of 
reproductive age, your budget proposals would deny preventive 
and primary care benefits to millions of women nationwide.
    In short, Mr. Secretary, your administration's policies 
from Trumpcare to this proposed budget double down on leaving 
women, seniors, and families sicker and more vulnerable and 
less able to access and afford the care they need. So I am 
deeply concerned about the impact this administration's 
policies will have on our families and our communities' health.
    Now, I'm hopeful Senate Republicans will reject the 
devastating cuts that are presented in this proposed budget, 
and I hope that they will reconsider the impact of Trumpcare, a 
bill the President himself again called mean on patients and 
families, and choose to reverse course. And if they do, as I 
have said time and time again, if they are willing to stop 
undermining the healthcare system and work towards real 
solutions that help lower healthcare costs for families and 
help people get more quality care, we, as Democrats, are ready. 
We will be at the table. We want to take care of our healthcare 
system. We want to take it in the right direction to help 
patients and families, and it is not too late.
    So thank you very much, Mr. Chairman.
    Senator Blunt. Thank you, Senator Murray.
    Senator Leahy, the Ranking Member of the full committee, 
has, I think, a statement you'd like to make.
    Senator Cochran can make one if he's able to attend this 
hearing today.

                 STATEMENT OF SENATOR PATRICK J. LEAHY

    Senator Leahy. Well, thank you, Mr. Chairman, and thank 
you, Senator Murray, for your comments. This is an important 
hearing.
    And Secretary Price, welcome to the Appropriations 
Committee. I do appreciate you reaching out to my office 
earlier this week. Unfortunately between Judiciary and 
Appropriations, we weren't able to connect, but I appreciate 
you doing that.
    It's obvious the purview of the Department of Health and 
Human Services is very, very wide; it touches every American. 
But then I look at the budget. You reduce discretionary 
spending by nearly $8 billion, a 12 percent cut. It cuts 
virtually every agency under HHS (Health and Human Services).
    You have a 17 percent cut to the Centers for Disease 
Control and Prevention, a 21 percent cut to the National 
Institutes of Health, a 23 percent cut to mental health 
programs in the Substance Abuse and Mental Health Services 
Administration.
    You target women's health, and Senator Murray has talked 
about this, by discriminating against providers that serve low-
income women.
    You eliminate funding for teen pregnancy prevention.
    You leave people in the cold by eliminating the Low-Income 
Home Energy Assistance Program, LIHEAP. I know the effect of 
that in my state, where sometimes it gets 20 to 25 below zero.
    And if these cuts weren't bad enough, you also assume 
savings from the repeal of the Affordable Care Act and deep 
cuts to the Medicaid program.
    Now, I mention this because Republicans are working hard 
behind closed--doors, nobody knows what's being said there--to 
make their campaign promises a reality on their healthcare 
bill. Now, the healthcare bill was voted on in the House, but 
most House Members never read it. The President, of course, had 
a big press conference in the Rose Garden, then praised the 
heck out of it, and then yesterday or the day before said it 
was not a good bill. Maybe by then they read it.
    I mention these closed doors as compared to the Affordable 
Care Act, where you had over 50, over 50, open hearings where 
people for and against it could testify. Dozens and dozens and 
dozens of amendments that were voted up and down; many, many 
amendments of Republican Senators that were either accepted or 
voted for.
    Now, there's no Senate bill we can discuss, so let me just 
talk about the House bill for a moment because it's been 
celebrated by your administration. A nonpartisan analysis of 
the bill by the CBO (Congressional Budget Office) said it will 
cause 23 million Americans who currently have coverage to lose 
it. Twenty-three million Americans would lose coverage, and 
your administration celebrated a bill that will do that.
    Now, as a doctor, you surely understand the importance of 
being able to afford healthcare. I hope you've never had to 
turn away a patient who couldn't afford treatment. I meet with 
Vermont doctors regularly, and what they tell me is not that 
they're turning away somebody that can't afford it, but they 
know a lot of people don't go to the doctor because they can't 
afford care. They'll find a lump or they'll find something 
where they should go to a doctor, but they say, ``We can't 
afford it,'' so they don't go. That's the way it was before the 
Affordable Care Act.
    They don't want to go back to those days. And that's why 
virtually every healthcare association in the United States, 
from the right to the left, oppose Trumpcare. The best way to 
create a ``foundation of greatness'' is to support programs 
that lift people up. This is a point they brought up, and as 
the vice chairman of the Appropriations Committee, I'll 
continue to work with my colleagues on both sides of the aisle 
to restore some of these funds.
    Thank you, Mr. Chairman.
    Senator Blunt. Thank you, Senator Leahy.
    And, Secretary Price, welcome to your first appearance 
before this subcommittee. We served together in the House. I 
appreciate your public service. You bring to this your 
experience as an orthopedic surgeon, as a House Member, and as 
a former chairman of the Budget Committee. Certainly, I think 
your experience gives you some insight that others in this job 
have not had. We look forward to hearing your testimony and 
working with you to find better solutions to the challenges we 
face.
    Secretary Price.

                 SUMMARY STATEMENT OF HON. THOMAS PRICE

    Secretary Price. Thank you, Mr. Chairman, Ranking Murray, 
and members of the committee. I want to thank you for inviting 
me here today to discuss the President's budget for the 
Department of Health and Human Services for fiscal year 2018. 
It truly is an honor to be with you today.
    Whenever a budget is released, the most common question 
asked in this town is, how much? How much money does this 
budget spend on this program? How much does it reduce spending 
on another program? And as a former legislator, I understand 
the importance of that question. But too often it's treated as 
the only question worth asking about a budget as if somehow how 
much a program spends is more important and more indicative of 
whether or not the program actually works.
    President Trump's budget request does not confuse 
government spending with government success. The President 
understands that setting a budget is about more than 
establishing top-line spending levels. Done properly, the 
budgeting process is an exercise in reforming our Federal 
programs to make sure that they do their job and use tax 
dollars wisely. The problem with many of our Federal programs 
is not that they're too expensive or too underfunded, the real 
problem is that many of them simply don't work.
    Fixing a broken government program requires redesigning its 
structure and refocusing taxpayer resources to better serve 
those most in need. Consider Medicaid, the primary source of 
medical coverage for millions of low-income American families 
and seniors facing challenging health circumstances. If the 
amount of government spending were truly a measure of success, 
then Medicaid would be hailed as one of the most successful 
programs in the history of the country. But despite investing 
trillions of dollars into the program, one-third, one-third, of 
physicians in this Nation who ought to be seeing Medicaid 
don't. This suggests that we need structural reforms that 
empower States to serve their unique Medicaid populations in a 
way that is both compassionate and sustainable, and that's 
exactly what President Trump's budget will do.
    At HHS, we're taking a similar reform-oriented approach to 
evaluate how we can better serve the American people. Earlier 
this year, we launched an initiative called ``Reimagine HHS'' 
in conjunction with President Trump's executive order on 
reorganizing the executive branch. This is a Department-wide 
effort to evaluate how HHS can better perform our mission and 
increase the effectiveness of our work. And while this has been 
an internal staff-driven process, we welcome the opportunity to 
work with members of this committee and your staffs on this 
effort.
    Building a stronger and more sustainable HHS is especially 
important when we consider the public health side of the 
Department's work. HHS is the world's leader in helping the 
healthcare sector prepare for cyber threats and responding to 
and protecting against public health emergencies. Last month I 
witnessed this important work firsthand, visiting Ebola 
survivors in Liberia and representing the United States at the 
G20 Health Ministerial Meeting in Berlin and the World Health 
Assembly in Geneva.
    The President's budget supports HHS's unique role in public 
health emergency preparedness and response, providing $4.3 
billion for disaster services coordination and response 
planning, biodefense and emerging infectious disease research, 
and development and stockpiling of critical medical 
countermeasures.
    In addition, today America faces a new set of public health 
crises that we've been far less successful in resolving: 
serious mental illness; substance abuse, particularly the 
crisis of opioid addiction; and childhood obesity. As 
Secretary, I am committed to leading HHS to address each of 
these three challenges. The President's budget calls for 
investments in policy reforms that will enable us to do just 
that. The budget calls for investments in high-priority mental 
health initiatives for psychiatric care, suicide, and 
homelessness prevention, and children's mental health, focusing 
especially on those suffering from serious mental illness.
    In 2015, over 52,000 Americans died of overdose, most of 
them from opioids. This budget calls for $811 million to 
support the Department's five-part strategy to fight this 
epidemic. And to invest in the health of the next generation 
and help the nearly 20 percent of school-aged children who are 
obese lead healthy and happy lives, the President's budget 
establishes a new $500 million America's Health Block Grant.
    Additionally, the President's budget prioritizes women's 
health programs by investing in research to improve health 
outcomes for women, and increasing funding for Maternal and 
Child Health Block Grant and Healthy Start. Across HHS, funding 
is maintained for many vital programs serving women, including 
community health centers, domestic violence programs, women's 
cancer screenings and support, as well as mothers and infant 
programs.
    This budget demands some tough choices, there's no doubt 
about it. And in this challenging fiscal environment, there are 
no easy answers. With this budget, however, the new 
administration charts a path toward a sustainable fiscal future 
and ensures the dedicated resources provided and protect the 
health and well-being of the American people.
    I want to thank you for the opportunity to be with you 
today and testify on this budget. It is greatly appreciated, 
your support for the Department of Health and Human Services, 
and it's my incredible privilege to serve as its Secretary.
    [The statement follows:]
                Prepared Statement of Hon. Thomas Price
    Chairman Blunt, Ranking Member Murray, and Members of the 
Committee: thank you for inviting me to discuss the President's Budget 
for the Department of Health and Human Services (HHS) in fiscal year 
2018. It is an honor to be here.
    Whenever a budget is released, the most common question asked in 
Washington is ``how much?'' How much money does the budget spend on 
this program, how much does it cut from that other program?
    As a former legislator, I understand the importance of this 
question. But too often, it's treated as the only question worth asking 
about a budget--as if how much a program spends is more important than, 
or somehow indicative of, whether the program actually works.
                    measuring success, not spending
    President Trump's Budget request does not confuse government 
spending with government success. The President understands that 
setting a Budget is about more than establishing topline spending 
levels. Done properly, the budgeting process is an exercise in 
reforming our Federal programs to make sure they actually work--so they 
do their job and use tax dollars wisely.
    The problem with many of our Federal programs is not that they are 
too expensive or too underfunded. The real problem is that they do not 
work--they fail the very people they are meant to help. In Aid to 
Families with Dependent Children, we had a program that undermined 
self-sufficiency and work. Congress did well when it realized the 
devastating long-term harm this program had on children, in particular, 
and took action by creating the Temporary Assistance for Needy Families 
(TANF)--a program that promoted the empowerment of parents through 
work. By helping more Americans climb out of poverty, TANF caseloads 
have declined by 75 percent through fiscal year 2016. Under the TANF 
program, the employment of single mothers increased by 12 percent from 
1996 through 2000, and even after the 2008 recession, employment for 
this demographic is still higher than before welfare reform. In the 
wake of the recession, the emphasis on work in TANF has increased the 
job entry rate, retention rate, and earnings gain rate for program 
participants.
    Our Budget reduces TANF spending in part because we understand that 
the amount spent in the program has not been the key to its success. 
Our goal is to continue and even expand on the progress made since 
enactment of Welfare Reform. Toward that end, we would welcome an 
opportunity to work with Congress to further strengthen TANF so that 
States, Territories, and Tribes can empower more low-income families to 
achieve financial independence.
    Fixing a broken government program requires a commitment to 
reform--redesigning its basic structure and refocusing taxpayer 
resources on innovative means to serve the people that the program is 
supposed to serve. And sometimes it requires recognition that the 
program is unnecessary because the need no longer exists or there are 
other programs that can better meet the needs of the people that the 
program was originally designed to serve. That's exactly what President 
Trump's Budget will do, at HHS and across the Federal Government.
    Consider Medicaid, a critical safety net program that is the 
primary source of medical coverage for millions of low-income American 
families and seniors facing some of the most challenging health 
circumstances.
    If how much money the government spends on a program were truly a 
measure of success, Medicaid would be hailed as one of the most 
successful in history. Twenty years ago, annual government spending on 
Medicaid was less than $200 billion; within the next decade, that 
figure is estimated to top $1 trillion.
    Despite these significant investments, one-third of doctors in 
America do not accept new Medicaid patients. Some research has shown 
that enrolling in Medicaid does not necessarily lead to healthier 
outcomes for the newly eligible Medicaid population. The Oregon Health 
Insurance Study replicated a randomized clinical trial by enrolling 
some uninsured people in Medicaid through a lottery. Comparing this 
population to those who remained without coverage, the data showed an 
increase in primary care emergency room use, the probability of a 
diagnosis of diabetes, and the use of diabetes medication, but no 
significant effects on measures of physical health such as blood 
pressure, cholesterol, or average glycated hemoglobin levels (a 
diagnostic criterion for diabetes). However, the same Oregon data 
showed a significant reduction in rates of depression among those 
enrolled in Medicaid.
    This mixed impact of Medicaid coverage on health outcomes suggests 
we need structural reforms that equip States with the resources and 
flexibility they need to serve their unique Medicaid populations in a 
way that is as compassionate and as cost-effective as possible.
       saving and strengthening medicaid through state innovation
    That's exactly what the President proposes in his Budget. Under 
current law, outdated, one-size- fits-all Federal rules prevent States 
from prioritizing Federal resources to their most vulnerable 
populations. States are also limited in testing new ideas that will 
improve access to care and health outcomes. The President's Budget will 
unleash State-level policymakers to advance reforms that are tailor-
made to meet the unique needs of their citizens.
    Over the next decade, these reforms will save American taxpayers an 
estimated $610 billion. They will achieve these savings by harnessing 
the innovative capacity of America's governors and State legislators 
who, informed directly by the people and those providing the services, 
have a proven record of developing creative, effective ways to meet the 
healthcare needs of friends and neighbors in need, while empowering 
them to manage their own health.
    Furthermore, the Budget includes provisions to extend funding for 
the Children's Health Insurance Program. The Budget proposes to 
rebalance the Federal-State partnership through a series of reforms, 
including ending the Obamacare requirement for States to move certain 
children from CHIP into Medicaid and capping eligibility at 250 percent 
of the Federal Poverty Level to return the focus of CHIP to the most 
vulnerable and low-income children.
    These reforms will go a long way toward improving access to 
healthcare in America. But there is more work to be done. That's why 
the President's Budget commits to working with Congress to transition 
from the failures of Obamacare to a patient-centered system that 
empowers individuals, families, and doctors to make healthcare 
decisions.
hhs advances the health security of the american people with a focus on 
  preparedness and response for medical and public health emergencies
    As everyone here knows, HHS's mission of protecting and promoting 
the health of the American people involves far more than overseeing the 
Nation's healthcare and insurance systems.
    For generations, HHS has been the world's leader in responding to 
and protecting against public health emergencies--from outbreaks of 
infectious disease to chemical, biological, radiological, and nuclear 
threats--and assisting the healthcare sector to be prepared for cyber 
threats. I recently had the privilege of seeing the importance of this 
work during an international trip to Africa and Europe.
    Visiting with Ebola survivors in Liberia and representing the 
United States at the G20 Health Ministerial Meeting in Berlin and then 
the World Health Assembly in Geneva reinforced just how vital a role 
HHS plays in preparing for, and responding to, domestic and global 
public health emergencies. To support HHS' unique Federal role in 
public health emergency preparedness and response, the President's 
Budget provides $4.3 billion for disaster services coordination and 
response planning, biodefense and emerging infectious diseases 
research, and development and stockpiling of critical medical 
countermeasures. These investments help ensure that State and local 
governments have the support and resources they need to save lives, 
protect property, and restore essential services and infrastructure for 
affected communities.
key public health priorities: serious mental illness, substance abuse, 
                         and childhood obesity
    In addition, today America faces a new set of public health crises 
that--if we're honest with ourselves--we have been far less successful 
in resolving. Those crises are: (1) serious mental illness; (2) 
substance abuse, particularly the opioid abuse epidemic; and (3) 
childhood obesity.
    As Secretary, I am committed to leading HHS to address each of 
these three challenges. The President's Budget calls for the 
investments and policy reforms that will enable us to do just that.
    The Budget invests in high-priority mental health initiatives to 
deliver hope and healing to the 43.1 million adults with mental 
illness,\1\ including nearly 10 million Americans suffering from a 
serious mental illness,\2\ as well as the 19.6 million adults with both 
mental and substance use disorders,\3\ the 3 million adolescents who 
have experienced a major depressive episode,\4\ and 350,000 adolescents 
with both a major depressive episode and substance use disorders.\5\ 
These initiatives will target resources for psychiatric care, suicide 
prevention, homelessness prevention, and children's mental health. For 
example, the Budget proposes $5 million in new funding authorized by 
the 21st Century Cures Act for Assertive Community Treatment for 
Individuals with Serious Mental Illness. The Budget also includes a 
demonstration within the Children's Mental Health Services program to 
test the applicability of new research from the National Institute of 
Mental Health on preventing or delaying the first episode of psychosis.
---------------------------------------------------------------------------
    \1\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16- 4984, NSDUH Series H-51). Pg. 27 Retrieved from 
http://www.samhsa.gov/data/.
    \2\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16-4984, NSDUH Series H-51). Pg 27 Retrieved from 
http://www.samhsa.gov/data/.
    \3\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://
www.samhsa.gov/data/.
    \4\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16-4984, NSDUH Series H-51). Pg 38 Retrieved from 
http://www.samhsa.gov/data/.
    \5\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16-4984, NSDUH Series H-51). Page 40 Retrieved from 
http://www.samhsa.gov/data/.
---------------------------------------------------------------------------
    According to the Centers for Disease Control and Prevention (CDC), 
during 2015 drug overdoses accounted for 52,404 U.S. deaths, including 
33,091 (63.1 percent) that involved an opioid. To combat the opioid 
epidemic sweeping across our land, the Budget calls for $811 million--
an increase of $50 million above the fiscal year 2017 continuing 
resolution--in support for the five-part strategy that has guided our 
Department's efforts to fight this scourge:
  (1)  Improving access to treatment, including Medication-Assisted 
        Treatment, and recovery services;
  (2)  Targeting availability and distribution of overdose-reversing 
        drugs;
  (3)  Strengthening our understanding of the epidemic through better 
        public health data and reporting;
  (4)  Providing support for cutting edge research on pain and 
        addiction; and
  (5)  Advancing better practices for pain management.
    This funding increase will expand grants to Health Resources 
Services Administration (HRSA) Health Centers targeting substance abuse 
treatment services from $94 million to $144 million. Also within this 
total, the Budget continues to fully fund the $500 million for State 
Targeted Response to the Opioid Crisis Grants that were authorized in 
the 21st Century Cures Act, which expand access to treatment for opioid 
addiction. Using evidence-based interventions, these grants address the 
primary barriers preventing individuals from seeking and successfully 
completing treatment and achieving and sustaining recovery.
    Finally, the President's Budget invests in the health of the next 
generation by supporting services that promote healthy eating and 
physical activity, especially among the nearly 20 percent of school-
aged children in America who are obese. The Budget establishes the new 
$500 million America's Health Block Grant, which will provide 
flexibility for States and Tribes to implement specific interventions 
that address leading causes of death and disability facing their 
specific populations. This could include interventions to spur 
improvements in physical activity and the nutrition of children and 
adolescents, and to treat leading causes of death such as heart 
disease.
                        other budget highlights
    The President's Budget prioritizes women's health programs through 
investing in research to improve health outcomes, maintaining support 
for women's health services, empowering women and families, and 
emphasizing prevention. For instance, funding for the Maternal and 
Child Health Block Grant and Healthy Start is increased to improve the 
health of mothers, children, and adolescents, particularly those in 
low-income families. In addition, funding is maintained for a variety 
of vital programs serving women across HHS, including, community health 
centers, domestic violence programs, women's cancer screenings and 
support, mother and infant programs, and the Office on Women's Health.
                               conclusion
    Members of the Committee, thank you for the opportunity to testify 
today and for your continued support of the Department. It is an 
incredible privilege to serve the American people as the Secretary of 
Health and Human Services and support its mission to protect the health 
and well-being of all Americans.

                         SERIOUS MENTAL ILLNESS

    Senator Blunt. Well, thank you. Thank you, Secretary Price. 
You mentioned in your comments that the budget takes into 
consideration serious mental illness challenges. I think NIH 
says one in four adult Americans has a diagnosable behavioral 
health concern and it is almost always a treatable behavioral 
health issue. Substance abuse, we know, is a problem that we're 
not adequately dealing with now, and in fact, we have shifted a 
lot of dollars to over the last 2 years both into mental health 
and into substance abuse.
    I'm concerned that the proposal here for a 23 percent cut 
to the mental health programs in SAMHSA (Substance Abuse and 
Mental Health Services Administration) doesn't seem to me to 
track with either your comments or where we've been headed. Do 
you want to talk a little about what we'd be doing in mental 
health that would recognize the need there?
    Secretary Price. Yes. I think, as I said, that is one of 
the three critical priorities that we have at the Department in 
addition to the opioid crisis and childhood obesity. Mental 
health has been a--especially treatment of serious mental 
illness, has been a significant challenge for our Nation for 
decades. We have, in essence, transferred over the past 30 to 
40 years the treatment of mental health individuals, 
individuals with severe mental illness, from basically 
substandard clinical facilities, hospitals, sanatoriums that 
many of us remember as kids to a remarkably substandard care in 
our criminal justice system. And through both of them, these 
individuals rarely are getting the treatment that they need.
    And so what we're trying to do at the Department is through 
SAMHSA and elsewhere, SAMHSA's budget that we propose is $3.9 
billion, and through SAMHSA and elsewhere is to make certain 
that we have the resources where we can focus on the kinds of 
treatment that work, do a cross-cut across the Department to 
bring to bear the resources that are necessary, to identify 
those areas where we're actually succeeding, and then working 
with the criminal justice system with the incredible programs 
that are being done, many at the local level, that provide for 
identifying those individuals with severe mental illness and 
actually getting them treatment as opposed to just housing them 
in our criminal justice system.
    Senator Blunt. Well, you know, I've spent some time in 
Missouri with the Crisis Intervention teams, something that was 
not part of law enforcement just a few years ago, but clearly 
we have unfairly, to everybody involved, made law enforcement 
and emergency rooms sort of the de facto mental health system 
for the country, and we have got to do better than that.

                        PREVENTIVE CARE MANDATE

    There's a mandate that is out there from the HHS 
regulation, the healthcare mandate from 6 years ago, that 
really I believe unfairly deals with faith-based institutions 
and people of faith where that mandate really has given too 
many individuals of faith and faith groups the choice between 
continuing to operate their business or to serve their 
constituencies, to serve the poor and needy consistent with 
their faith principles, or to be fined millions of dollars by 
the Federal Government. That mandate is still out there. What 
is your plan to deal with that?
    The President on May the 4th signed an executive order 
stating that it shall be the policy of the executive branch to 
vigorously enforce Federal laws' robust protections for 
religious freedom. I don't think the current regulations do 
that. What's your plan with that current regulation?
    Secretary Price. Yes. Although I'm not able to talk 
specifically about proposed rules and regulations, it is the 
Department's belief, it's the administration's belief, the 
President's belief, that in the past individuals with religious 
concerns regarding some of the edicts that came out of 
Washington have been given short shrift. And so our goal is to 
make certain that we're reviewing all of those activities and 
in an open and a transparent and a way consistent with the 
Administrative Procedure Act. We look forward to reviewing and 
coming forward and having the opportunity to engage all in a 
discussion on an appropriate regulation.
    Senator Blunt. I think if we have a chance for everybody to 
be able to ask questions with competing hearings and votes on 
the floor, as much as possible we all need to stay within our 5 
minutes for both the questions and reasonable answers. And so 
I'm going to be the first person to stay within my time and 
turn to Senator Murray.
    Senator Murray. Thank you. We'll all try and comply with 
that.

                        AMERICAN HEALTH CARE ACT

    Secretary Price, when the House of Representatives passed 
their Trumpcare bill, you put out a statement saying the bill 
was ``A victory for the American people.'' You joined President 
Trump in a big Rose Garden victory lap, there was lots of 
laughing and backslapping, and you went on Sunday shows days 
later and said the Trumpcare bill that passed the House would 
``Make certain that every single American, men, women, rich, 
poor, old, young, have the kind of coverage that they want for 
themselves and for their families.''
    You defended the increases in costs that seniors would be 
forced to pay. You defended the Medicaid cuts in the House 
Trumpcare bill. And you said that Medicaid patients would be 
cared for ``A better way under it.'' You were one of the 
biggest cheerleaders for the House bill. And you put your 
credibility on the line when you told people across the country 
that the House Trumpcare bill was a good bill, a bill that 
would help them, and a bill that they should support. So, 
Secretary Price, I wanted to ask you, do you still stand by 
those comments?
    Secretary Price. Senator, I appreciate the question. I 
think what I stand by is the fact that the current system is 
not working for millions of Americans.
    Senator Murray. Well, I'm asking you specifically--that was 
not my question--do you stand by your comments? Do you still--
--
    Secretary Price. I would respectfully disagree with the 
characterization of the comments that you made.
    Senator Murray. Well, I was quoting you. Do you stand by 
the quotes that you made?
    Secretary Price. As I say, I would disagree with the 
characterization that you brought forward.
    Senator Murray. Well, it's a yes-or-no. I'm quoting you. Do 
you still stand by your quotes?
    Secretary Price. No, it's not a yes-or-no answer.
    Senator Murray. Well, I'm disappointed, but I have to say 
I'm not surprised you won't give me a straight answer. You said 
those things. You should feel confident enough to either own 
them or admit you were wrong----
    Secretary Price. I stand by what I said in the context with 
which I said them.
    Senator Murray. Well, this week it was reported that 
President Trump has now changed his tune on the House bill. He 
is telling Senators that he ``thinks it's mean and that he 
wants the Senate to make it more generous.'' So, Secretary 
Price, you are President Trump's top healthcare advisor. Do you 
agree that the House Trumpcare bill is ``mean?''
    Secretary Price. Again, I think what we need to be talking 
about in terms of a health system is the constellation of 
reforms.
    Senator Murray. It's a yes-or-no answer. Do you----
    Secretary Price. No, it's not a yes-or-no answer.
    Senator Murray. Well, it is.
    Secretary Price. It's a constellation of reforms that need 
to be put in place because there are millions of Americans 
right now who are unable to gain the kind of coverage that they 
want----
    Senator Murray. I take it--I take it----
    Secretary Price [continuing]. Are paying higher premiums, 
higher deductibles. They've got insurance coverage, but they 
don't have any care because of that coverage.
    Senator Murray. Mr. Secretary, let me just say it's very 
clear that you're not going to stand by your comments or by the 
President's, but it's pretty clear to me that there has been a 
change since the House bill passed on this administration's 
support. And I think that the President is right, and I hope 
that as his top health advisor, you take that back.

                          AFFORDABLE CARE ACT

    Let me ask you another really critical question. Since 
taking office, this administration has done everything in its 
power to sabotage our healthcare system, deliberately putting 
the healthcare of millions of Americans at risk for partisan 
purposes. It is no secret that the administration's actions are 
the primary reason that insurers are spiking premiums or 
leaving the market. Industry experts and insurers across the 
Nation have been clear, your threats to end the cost-sharing 
subsidies and repeal the ACA (Affordable Care Act) are creating 
too much uncertainty in the market.
    So I want to be very clear. You break it, you own it. We 
would much rather--I want you to know this--we would much 
rather work with you to continue fixing the healthcare system 
for families. I am disappointed that this administration is 
sabotaging our healthcare system as a tactic to jam a partisan 
bill through Congress, and you're going to be held accountable.
    In fact, Senator Warren and I wrote a letter, which I would 
like to include in the record, requesting that the Inspector 
General conduct a thorough investigation into how the Trump 
administration's actions have undermined the healthcare system, 
risking access to health insurance and higher premiums for 
Middle Americans.
    And, Secretary Price, I want to ask you today, will you 
commit that you and your Department will cooperate with the OIG 
(Office of Inspector General) in a timely and transparent 
fashion?
    Secretary Price. Well, Senator, we look forward to working 
with you to make the healthcare system better. We, at our 
Department, will follow the law. We look forward to cooperating 
with any IG investigation or inquiries that they make.
    Senator Murray. Okay. I appreciate that. The bottom line is 
that this administration's effort to undermine working 
families' access to health insurance either deliberately or 
through stunning incompetence is overwhelmingly clear. And 
again I would say Democrats across the board are willing to 
work with Republicans to make sure that the healthcare system 
works better, more affordable, more accessible, but we do not 
want to see it undermined, and we don't want to see it jammed 
through, a mean bill that is celebrated in the White House.
    Thank you.
    Senator Blunt. And without objection that letter will go 
into the record.
    Senator Murray. Thank you.
    [The information follows:]
    
    
    
    
    
    
    
    

    Senator Blunt. Senator Alexander.
    Senator Alexander. Thank you, Mr. Chairman.
    Welcome, Secretary Price.
    Secretary Price. Thank you.

                     NATIONAL INSTITUTES OF HEALTH

    Senator Alexander. I want to congratulate you and the 
President on your reappointment of Dr. Francis Collins to the 
National Institutes of Health, as well as your selection of Dr. 
Scott Gottlieb as Commissioner of the FDA (Food and Drug 
Administration). I think that gives you a remarkable couple of 
really talented people to help implement the 21st Century Cures 
Act that this committee, the HELP committee, and our Senate 
worked so hard on and which Senator McConnell said was the most 
important piece of legislation last year.
    I also want to say that this Appropriations Committee, in a 
bipartisan way, supported the work of Senator Blunt and Senator 
Murray to increase funding at the National Institutes of 
Health, and our goal, my goal, is not to decrease funding, but 
to continue to increase it to support medical miracles.
    I also would like to work with you, and I don't have a 
question on this today, on electronic medical records. The HELP 
Committee did a lot of work on that, Senator Cassidy, Senator 
Whitehouse especially, and we can work together on that in a 
bipartisan way and relieve a lot of burdens on physicians. I 
know you know all about that and are eager to do it. So we look 
forward to that.

                         COST-SHARING REDUCTION

    Now, I have two recommendations that I would like just to 
get your reaction to.
    My first recommendation is that the administration find a 
way either through administrative action or legislation or a 
combination to extend temporary cost-sharing payments under the 
Affordable Care Act at least through 2018, and we should 
probably go ahead and do it through 2019. The payments help to 
reduce the cost of copayments for the roughly 4 percent of 
insured Americans who get their insurance through the exchanges 
in the individual market. The payments will help to avoid the 
real possibility that millions of Americans will literally have 
zero options for insurance in the individual market in 2018, 
next year. We have a collapsing individual market as a result 
of the Affordable Care Act----
    Secretary Price. Right.
    Senator Alexander [continuing]. But is a part of a 
transition from a collapsing market to a stable market in which 
Americans have more choices of insurance at lower cost. I 
believe Republicans will need to do some things temporarily 
that we don't want to do in the long term, and I would hope the 
Democrats would want to do that as well.
    So that's my recommendation, and I wonder if you have a 
reaction.
    Secretary Price. Well, I appreciate that, Senator, and we 
are reviewing. As you know, this is a case that's in the 
courts. And on February 10th, when I was sworn in, it 
transferred from House v. Burwell to House v. Price, so as the 
defendant in this case, I'm not able to comment specifically. 
What I am able to say is that the budget reflects the 
continuation of the CSR (Center for Scientific Review) payments 
until litigation is resolved.
    Senator Alexander. Chairman Brady, of the House, has made a 
similar recommendation, and I have made the recommendation 
directly to the President, and I hope the administration will 
do that sooner rather than later.

                         CMS PROGRAM INTEGRITY

    Here's my second recommendation. I recommend that you work 
with Secretary Perry and use the Department of Energy's 
supercomputers at Oak Ridge to help improve the way that the 
Centers for Medicare and Medicaid Services and its contractors 
identify waste, fraud, and abuse. I recommend that you have a 
3-year pilot project to do what the computer operators say they 
think they can do.
    Senator Blunt and I had the opportunity to visit the Oak 
Ridge National Laboratory. I really wish for the moment it were 
in some other State because it sounds like I'm just promoting 
my home State lab, which I like to do, but I think the chairman 
was as impressed as I was with the pilot program during the 
Obama administration which used these fastest computers in the 
world, and they took 10 percent of the Medicaid claims, and 
within a few weeks, they found $30 million of fraud.
    There are about, I believe, $820 billion of claims every 
year in Medicare and Medicaid. The Economist says one out of 
four of those are swindled. They say, The Economist does, that 
drug smugglers are turning to Medicare and Medicaid fraud and 
abuse because it's less dangerous and more profitable. And we 
Republicans are always going around talking about Medicare and 
Medicaid fraud and abuse. And we actually have our own 
computers that find needles in a haystack when we're dealing 
with terrorists. Why wouldn't we use those similar ways to do 
the same with Medicare fraud and abuse? So I suggest a 3-year 
contract and would be glad to work with you on that.
    Secretary Price. I appreciate that. I'm intrigued by that 
idea, and I look forward to working with you.
    Senator Alexander. Thank you.
    Senator Blunt. Thank you, Senator Alexander.
    Senator Alexander. Thank you, Mr. Chairman.
    Senator Blunt. Senator Leahy.
    Senator Leahy. Thank you, Mr. Chairman.

                          U.S. OPIOID EPIDEMIC

    I compliment you, Secretary Price, for traveling around the 
country to look at the concerns of those who are facing opioid 
addiction. And while I realize a little State like Vermont 
would probably never be on your radar, we do have a model in 
Vermont called ``Hub and Spoke'' because we face the same 
problems there. It provides intensive addiction treatment in 
the hubs, long-term maintenance in the spokes. We're able to do 
this with the flexibility provided in the Medicaid program. We 
have generous treatment options within Medicaid for those 
suffering from addiction.
    Now, you identified one of the five priorities in HHS to 
combat this nationwide crisis, and I certainly hope you're 
successful, one of the priorities, to ``improve access to 
treatment and recovery services,'' from your comments. 
Improving access is essential.
    The massive cuts to the Medicaid program, which your 
administration endorsed in the House-passed bill, and assumed 
in your budget, would have the opposite effect. If Vermont or 
any other State can no longer afford to offer medication-
assisted treatment for Medicaid beneficiaries, what do we do? 
What do we do to get ahead of the opioid epidemic?
    Secretary Price. I appreciate your support of our focus on 
this. We----
    Senator Leahy. I don't--I don't support your enormous cuts 
you've made in Trumpcare in the House bill.
    Secretary Price. No, I said our focus on this.
    Senator Leahy. That I do support.
    Secretary Price. This is an absolute scourge, as you well 
know. 52,000 Americans in 2015, that's the last year that we 
have data on, died of an overdose, 33,000 of those from 
opioids. We've been going around the country. We were in your 
neighboring State of New Hampshire, who have a significant 
challenge.
    Senator Leahy. That's a bigger State. Smaller 
geographically, but bigger in population.
    Secretary Price. And I look forward to coming to Vermont. 
The amount of resources available across the Department for the 
opioid crisis is $811 million. Two years ago, it was $245 
million. So due to the incredible work that's been done on a 
bipartisan fashion here in Congress, more resources are 
available, and we look forward to continuing to work with you 
to do whatever we need to do to bring----
    Senator Leahy. Are you saying that in, for example, a 
program in Vermont where 68 percent of medication-assisted 
treatment is funded through Medicaid, even though you're making 
enormous cuts in Medicaid--reducing national Medicaid spending 
by over $600 billion--we will still be able to get treatment 
for these people?
    Secretary Price. What I would suggest is that the 
flexibility that we envision for the Medicaid program would 
actually allow for the potential to have greater focus on those 
individuals who are suffering from opioid addiction or other 
within the system.
    Senator Leahy. How? Where? Where is that going to come 
from?
    Secretary Price. Well, as you note, in your State, Vermont, 
the Hub and Spoke program, imagine, if you would, a system that 
actually provided the flexibility for States to have greater 
resources go into that Hub and Spoke program.
    Senator Leahy. I'm talking about a program that seems to be 
working now. You're talking about taking the money away from 
this program that's working and saying that somewhere you're 
going to give some flexibility. How, when you're cutting the 
budget?
    Secretary Price. Let me respectfully suggest, Senator that 
the programs that are out there by and large are not working. 
We are losing more Americans today than we did last year to 
opioid addiction and overdose deaths. We're losing more last 
year than we lost the year before, which is one of the reasons 
that I thought it was absolutely imperative that this 
administration and we at the Department of Health and Human 
Services make it a priority because clearly we're moving in the 
wrong direction. So we've outlined a five-point strategy and 
look forward to working with all Senators to try to end this 
absolute scourge.
    Senator Leahy. It will be interesting to see how that 
strategy works with less money. By all analyses, not just 
Vermont, but throughout the country, the problem is increasing, 
the money to attack it is going down. As a child, I believed in 
the Tooth Fairy, but I'm a little bit older now.
    Secretary Price. Two years ago, Senator, the money coming 
into the--from a global standpoint within HHS for opioid crisis 
was $245 million. What we propose is $811 million. And, again, 
that's thanks to every single individual who was supportive of 
the activity over the past Congress.
    Senator Leahy. Well, let's see where it actually shows up 
because I find a lot of your money that you have is being 
double counted in a number of areas. But my time is up, and I 
agree with the Chairman.
    Senator Blunt. Thank you, Senator Leahy.
    Senator Moran.
    Senator Moran. Chairman, thank you very much.

           NATIONAL INSTITUTES OF HEALTH INDIRECT COST POLICY

    Mr. Secretary, thank you for joining us.
    Secretary Price. Thank you.
    Senator Moran. Appreciate your public service.
    Let me begin by agreeing with my colleague from Tennessee, 
I appreciate your continuation of Francis Collins as the 
Director of NIH. I appreciate the way he is able to explain 
science to people like me and to my constituents and the 
leadership he provides at NIH. So thank you for that decision.
    I am an opponent to the administration's reductions in NIH 
spending, and I'll work with my colleagues once again to see if 
we can't continue the progress that we've made in additional 
funding for medical research.
    One of the things that the administration has said in its 
budget, that about 30 percent of the grant money is used for 
indirect expenses. I don't know exactly what indirect expenses 
are, but I would make this case that I made with the Secretary 
of Agriculture the other day in an Appropriations hearing, that 
if there is a suggestion that money is being improperly used or 
it's not being effectively used, rather than suggesting 
dramatic reductions in the overall spending, let's figure out 
how to make sure that the money we do spend is spent in the 
best way possible, that the efficiencies are found, rather than 
in the case of agriculture, eliminating the McGovern-Dole food 
program or, in this case, a $6 billion reduction in NIH.
    One of the things I might point out, it appears to me that 
many universities, particularly our largest, use the grant 
funding to pay salaries of their researchers, and there may be 
an opportunity there to suggest there would be an incentive, 
change the incentive, and have a disincentive when that occurs. 
In my view, the universities and others ought to be paying the 
salaries in general of their researchers, and the money that 
NIH grants to that institution is used for research. And there 
may be a way in the formulary the decision process by which 
grants are accepted that we can incentivize that kind of 
concept.
    I would also say about NIH, I would ask this question. One 
of the points I make when talking about the value of medical 
research is that it's certainly humanitarian or well-being of 
humans, individuals, and their families if we can find cures to 
cancer and cures to Alzheimer's, the delay of Alzheimer's, but 
I also make the point if you're fiscally conservative, this is 
a good investment because it will save us in our health care 
costs. If we could find the delay of the onset of Alzheimer's, 
there is billions of dollars that will not be spent. And I 
would ask you if you know any--if you have any evidence that 
backs up that kind of statement.
    Secretary Price. Oh, there is no doubt about it. I mean, 
the innovation and research that is so vital to continue to 
maintain and have the United States be on the cutting edge of 
solutions and cures for disease is absolutely imperative, and 
the NIH plays a pivotal role in that, and the resources that 
are provided to NIH are absolutely vital for making certain 
that early kinds of investigations and early kinds of studies 
and research are being able to be done. That's where the 
private sector doesn't engage. Until they know that there's an 
opportunity to have some type of return on their investment, 
they don't engage, and that's the critical public role that's 
necessary.

                     ADMINISTRATIVE ACTIONS AT HHS

    Senator Moran. Mr. Secretary, I think in the conversations 
that I've heard regarding the Affordable Care Act and its 
improvement, alteration, whatever the politically acceptable 
terms are and what is trying to be accomplished here, it's 
stabilization. What I would ask is I think we've focused a lot 
of attention on preexisting condition, and it seems to me there 
is a lot of, and rightfully so, a lot of effort being made to 
make certain that individuals who have preexisting condition 
continue to have access to affordable healthcare. I think more 
recently the focus has been on Medicaid.
    And my question to you is, what assurance will the 
Department of Health and Human Services provide that the basic 
care and treatment of individuals who are utilizing Medicare 
for their healthcare will not be harmed when States begin 
making--if legislation allows States to make more decisions, 
what's the threshold? Currently, the Department provides 
waivers, and I don't know what the criteria is for a waiver, 
but I assume it has to do with the healthcare benefits that an 
individual receives or the disability assistance that an 
organization provides those individuals. Is there still a 
standard of care----
    Secretary Price. Absolutely.
    Senator Moran [continuing]. As compared to just asking 
States--to authorizing States to do as they wish?
    Secretary Price. Yes. It's a standard based upon the number 
of individuals covered, the cost of the coverage, and the 
quality of care being provided. And the waivers that are being 
proposed by States come from the States. They suggest that 
there's a better way, they believe, for them to be able to care 
for their Medicaid population, in this instance, the 1115 
waivers, and all we're trying to do is to provide that kind of 
flexibility so that we can save some resources but also make it 
so that the individuals are getting a higher quality of care 
and a higher level of care.
    Senator Blunt. Thank you. Thank you, Senator Moran.
    Senator Durbin.
    Senator Moran. Apparently I'm done. Thank you, Mr. 
Secretary.
    [Laughter.]
    Senator Durbin. Thanks, Mr. Chairman.

                     NATIONAL INSTITUTES OF HEALTH

    Mr. Secretary, I read your testimony. You were very 
explicit, and you told us when it comes to this Trump budget, 
don't look at the spending, look at the success. And I quote 
you when you say, ``The problem with many of our Federal 
programs is not that they're too expensive or too underfunded, 
the real problem is they don't work, they fail the very people 
they are meant to help.''
    One of your most significant cuts, from my point of view, 
is in medical research at the National Institutes of Health. 
What you are proposing is a cut of $7.2 billion, which would 
lower medical research investment at the NIH to the lowest 
level in 15 years. So do I take it from that that you and the 
President have concluded that our medical research programs at 
the NIH have failed the American people?
    Secretary Price. No, sir. Let me peel the onion back a 
little bit because there's an important point. We support NIH. 
We support the research that's being done. What we believe and 
what we propose in the budget is that there are savings to be 
garnered that don't affect the number of grantees that would be 
provided a grant through the research, or the amount of monies. 
We believe that the same or more amount of money could be 
utilized for research, and getting the savings through the 
indirect costs. Now, that's a discussion that we ought to have 
as a government, as a society.
    Senator Durbin. Is that an appropriations discussion?
    Secretary Price. I beg your pardon?
    Senator Durbin. Is that an appropriations discussion?
    Secretary Price. Well, it's an appropriations discussion 
for the amount of monies that Congress would appropriate for.
    Senator Durbin. Let me suggest to you, if you are talking 
about reform in the way that we pay for competitive research 
grants, then I assume that you're going to be putting some 
substantive legislation before us. But how can we argue that 
giving 20 percent less money to the NIH researchers, 18 percent 
less money to health departments and CDC, is going to achieve 
this reform you're talking about? I'll tell you what it does 
achieve, it's a dramatic cutback in research.
    We just took nine Senators, the largest delegation ever, 
under Senator Blunt's leadership out to NIH, and I will tell 
you what they are doing. Mr. Secretary, you ought to go see it, 
you really should see it. And then you could join us in the 
skepticism about why we would ever cut back in medical research 
in America.
    This Chairman, along with the Ranking Member, and I might 
add Senator Alexander into this combination, have really staked 
out a ground in the last 2 fiscal years that I think is the 
right path for America, 5 percent real growth in medical 
research funding across America. I'm ready to debate that in 
any district, any State, in the Nation. That is money well 
spent.
    When we're spending 20 percent of our Medicare budget on 
Alzheimer's and the NIH is trying to delay the onset to save 
money and to spare families from suffering, and your budget 
says no, we need to cut back on medical research, Mr. 
Secretary, that is----
    Secretary Price. That's not what our budget----
    Senator Durbin. Of course it does.
    Secretary Price. Senator, do you really think that I 
haven't been to NIH?
    [Laughter.]
    Senator Durbin. What I really think is you haven't listened 
if you went there, because if you went there, you----
    Secretary Price. I have constant conversations with NIH. I 
met yesterday with Dr. Collins----
    Senator Durbin. I really tell you this, that if you listen 
to Dr. Collins, I asked him explicitly, ``What do you need to 
light up the scoreboard in medical research?'' He said, ``I 
need consistent increases of 5 percent real growth every 
year.'' Under this chairman, Chairman Blunt, we have done that 
now for 2 years. You take a dramatic step 15 years backwards in 
medical research. How can that be in the best interest of the 
health of America and in reducing the cost for these terrible 
things that we're facing, whether it's cancer or Alzheimer's?
    Secretary Price. Senator, let me just suggest that if we 
could get the same level of research for lower amounts of money 
and greater number of research projects being granted, would we 
not do that as a society, as a government? This is a 
conversation that we ought to have. This is a first step in 
that conversation, and the President in the budget proposes 
that there are savings to be had. If you don't agree with that, 
that's fine, but let's have that conversation.
    Senator Durbin. Let me just say that your conversation--
let's cut enough money and see if we get reform out of it. It's 
going to mean that 2,000----
    Secretary Price. That's not true, Senator.
    Senator Durbin. Of course it is. 2,000 competitive research 
grants will be denied because of the Trump budget number. Where 
do I come up with this? I look at what happened with 
sequestration. Your cut is three or four times what 
sequestration did to NIH.

                     BETTER CARE RECONCILIATION ACT

    The last question I have for you is this. You assume that 
there is going to be Trumpcare or Affordable Care repeal in 
your budget. Have you or anyone in your Department seen what 
the Senate Republicans are working on in terms of their version 
of Trumpcare?
    Secretary Price. I've had multiple conversations with 
Senators who are interested in making certain that we have a 
healthcare system that works for patients. My staff has 
provided technical assistance. I haven't seen any legislative 
language.
    Senator Durbin. You have not seen it? You haven't seen it 
either?
    Secretary Price. As I say, my staff has provided some 
technical assistance to individuals, but I haven't seen the 
legislative language.
    Senator Durbin. Well, we haven't seen it either. And we're 
told that we're going to vote on it in a matter of days without 
a CBO (Congressional Budget Office) score and without any 
revelation of what's included in that. Do you think that's a 
responsible thing to do in terms of the healthcare of all the 
people living in America?
    Secretary Price. I'll leave the Article I branch of the 
Constitution--determine how the Article I branch works.
    Senator Blunt. Thank you, Senator Durbin.
    Senator Capito.
    Senator Capito. Thank you.

                    NATIONAL INSTITUTE ON DRUG ABUSE

    And welcome, Secretary Price.
    Secretary Price. Thank you, Senator.
    Senator Capito. Thank you. I want to thank you for your 
visit to Charleston, West Virginia last month. I know, as you 
found there, we are sort of the epicenter of the largest 
percentage of overdose deaths caused by either prescription 
drugs or heroin or other substances. And I'm very concerned 
about this issue, as many of us are on this panel.
    I wanted to ask you, in light of that, one of our greatest 
partners in this fight has been the National Institutes of 
Health and also the National Institute on Drug Abuse, which has 
conducted invaluable research, is contributing to the 
developmental opioid addiction treatments, including some of 
the medical-assisted treatments. But your budget is proposing 
to cut NIDA (National Institute on Drug Abuse) by 210 and other 
addiction, anti-addiction, resources at NIH and the National 
Institutes of Mental Health by 400.
    The same sort of question. I guess I'm having trouble, as 
many of us are, reconciling your stated goal, and I heard your 
response to the last question, your stated goal of opioid being 
one of your top three priorities. With these dramatic cuts 
particularly in this area where the problem is getting larger, 
it's taking on different aspects. We've got fentanyl, we've got 
carfentanyl, and then other substances. How do you reconcile 
that with what we see is a growing problem across our State?
    Secretary Price. A couple points I would make. One is that 
the amount of resources, again if we judge the amount of 
resources as being the success of a program, then we would be 
increasingly successful in the opioid crisis, and we're not, 
the numbers are moving in the wrong direction.
    The amount of resources and the focus that this Department 
and NIH and CDC and SAMHSA and elsewhere will be putting on the 
opioid crisis is significantly greater. And we believe that the 
opportunity to work together across the Department on the 
opioid crisis will bring greater resources than have been put 
in, in the past, partly because of the work being done here in 
Congress, but also because of the focus that the Department 
will be putting on it.
    Senator Capito. You know, I think one of my responses to 
that might be that this is not a new phenomenon, but a 
relatively later developing over the course of, say, the last 
probably 5 or 6 years certainly where we've recognized what's 
really going on with better data, recognizing the cause of 
deaths and other things. So I would say your baseline was 
pretty low to begin with. So increasing resources in that area 
was absolutely critical I think to get to where we are now, and 
we're still in a crisis.

                         21ST CENTURY CURES ACT

    Let me ask you another aspect that certainly Senator 
Shaheen and Senator Manchin and I have talked about, being from 
smaller States that have huge problems. One of our concerns is 
that some of the grant funding and other things are formula 
funded, but we want to see it targeted obviously to the States 
that have some of the deepest and most devastating problems.
    Secretary Price. Yes.
    Senator Capito. What are you doing in the Department to 
meet that challenge?
    Secretary Price. Well, this is of great concern to me and 
our Department. We were essentially locked into the formula 
that the previous administration put in place for the grants 
that went out earlier this year under----
    Senator Capito. And what were those? 70-30, is that 
correct?
    Secretary Price. I beg your pardon?
    Senator Capito. 70-30, like 70 formula and then an 
additional 30 to go targeted to States, something of that 
nature?
    Secretary Price. Essentially. And what I have challenged 
the States to do is to demonstrate where your best practices 
are, demonstrate the challenges that you have, so that the 
grants in the next year will be based on a different formula. 
And we look forward to the input from members of this committee 
about that formula, so that we can be more responsive to those 
States that are having a greater problem.
    Senator Capito. So the recommendation there would be for us 
to go back to our respective health officers and make sure that 
we're gathering statistics, making the case for the greater 
targeted resources.
    Secretary Price. Yes. Absolutely.
    Senator Capito. Well, that's a good task for us.

         CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN

    Another issue along the prescription drug issue, I know CDC 
put out their guidelines for chronic pain and prescribing in 
that area. One of the areas that I've been pushing CDC on is 
not chronic but acute pain, broken arm, toothache, you know, 
shouldn't be going home with 56 oxycodone pills.
    Secretary Price. That's right.
    Senator Capito. Where are you on this? And where is your 
Department on this? And are you making this a high priority? 
Because I think that's a lot of the problem, they're sitting in 
a medicine cabinet.
    Secretary Price. Yes. I mentioned the five-part strategy 
through the Department: recovery and treatment, making sure 
we've got overdose-reversing drugs, the surveillance aspect, 
the public health aspect, and then in response to this, 
research through NIH. They're doing incredible research on non-
euphoric pain treatment, pain treatment that would not be 
addictive. And then the fifth is the whole issue of pain 
management, how we, in this country, manage pain. And this is a 
decades-long problem that one of the main problems, I believe, 
is when we started 20 years ago measuring pain as the fifth 
vital sign, which increased the number of opioid prescriptions 
that were going out.
    And then in the provider community, in the doc community, 
many physicians believe that their reimbursement depends on 
whether or not that patient has complete relief of their pain. 
Pain is oftentimes, as a physician oftentimes, an important 
symptom that must be followed. We don't want individuals to be 
in pain, but we also don't want to do the kinds of things that 
incentivize the use of opioids when they ought not to be. So 
acute pain management is absolute key.
    Senator Capito. Thank you.
    Senator Blunt. Thank you, Senator Capito.
    Senator Shaheen.
    Senator Shaheen. Thank you, Mr. Chairman.

                          U.S. OPIOID EPIDEMIC

    And thank you, Secretary Price, for being here. I know that 
you have been to New Hampshire, and you appreciate that next to 
West Virginia, we are the State with the highest percentage of 
overdose deaths in the country. It has been a scourge that is 
ravaging communities and families in New Hampshire. And you 
sent a letter to me on May 24th where you wrote that the Trump 
administration is committed to bringing everything the Federal 
Government has to bear on this epidemic. And President Trump, 
when he was campaigning in New Hampshire, said the same thing, 
said that he was going to make sure people got access to 
treatment.
    Well, I think this budget goes in exactly the wrong 
direction. There's a 23 percent cut to SAMHSA, and while, as 
you point out, there is more overall money in the budget, 
that's because this Congress last December passed the 21st 
Century Cures Act that included $1 billion dollars, $500 
million this year and $500 million next year, to address the 
heroin and opioid epidemic. That money was meant to be on top 
of what we were already spending.

                                MEDICAID

    And, in fact, you say that the resources--we're not seeing 
outcomes that are improved as the result of these resources, 
because the resources are just getting to communities. In New 
Hampshire, we're just beginning to see the benefits of having 
the expansion of Medicaid to provide treatment for people who 
have substance use disorders. We're just beginning to see a 
pipeline that's developed because there is some certainty 
around pain meds. And you are proposing a budget that with the 
House-passed healthcare plan, would cut $1.4 trillion to 
Medicaid.
    In New Hampshire, those people with substance use disorders 
are overwhelmingly getting treatment through the expansion of 
Medicaid, the bipartisan expansion of Medicaid in New 
Hampshire. What do you tell those people who are in recovery 
who are getting treatment about what they should do when you 
cut off those Medicaid payments that are their sole means of 
getting help for their substance use disorders?
    Secretary Price. Well, the reduction in Medicaid that's 
envisioned, in Medicaid resources that's envisioned, in the 
budget is due to efficiencies and the ability of States to have 
flexibility in caring for those--precisely those individuals 
along with the----
    Senator Shaheen. But, Mr. Secretary, that isn't in effect 
what these cuts would do. What I'm hearing from treatment 
providers and from people in recovery in New Hampshire is that 
they don't have any other options and that flexibility doesn't 
help if there is no other money and no other way to get 
treatment. The one thing that has made a difference for people 
in New Hampshire has been getting the resources to make sure 
they can get treatment, that there are people who can provide 
that network of providers that they need to help them as they 
go through recovery. And I think that's a much better use of 
resources than to cut people off and economically they have no 
place to go.
    I want to switch topics a little bit.
    Secretary Price. I would respectfully disagree with that 
characterization of what the plan is.

                             WOMEN'S HEALTH

    Senator Shaheen. During--in your budget, you would, for the 
first time under any President ever, totally cut all funding 
from going to Planned Parenthood. In New Hampshire, we have 
almost 13,000 patients, both women and men, who receive their 
preventive and primary care through Planned Parenthood centers. 
That's not abortions, that's preventive care, mammograms, 
cervical tests, tests for cervical cancer. It's preventive 
care. And what I've heard the representatives of the 
administration say is that, well, if we cut out those Planned 
Parenthood centers, then community health centers can pick up 
those people who are no longer going to get that preventive 
care. In fact, we don't have that capacity in our community 
health centers in New Hampshire to pick up those patients.
    So, again, what's your proposal for how those women and men 
in New Hampshire who are no longer going to get care because 
those centers are going to shut down when the funding ends, how 
are they going to get their care?
    Secretary Price. Well, again, respectfully, I think that 
the amount of resources that are put forward for women's health 
across the entire Department, $125 billion, would be spent on 
women's health, and that community health centers or health 
centers have actually an increase in funding. So we----
    Senator Shaheen. But they don't have the capacity to 
provide for that coverage. And if the Planned Parenthood 
centers are providing good coverage for people, its preventive 
care, why do you want to shut them down?
    Secretary Price. Again, they may not have the capacity 
today, but that's what the increasing resources are for. And in 
fact, there are more health centers than there are the entities 
that you describe. But the chairman --
    Senator Shaheen. But you haven't answered why you want to 
shut them down.
    Secretary Price. The chairman mentioned at the beginning of 
this hearing the incredible nature of the previous 
administration using taxpayer dollars in ways that many 
Americans find to be abhorrent. And our goal is to try to make 
certain that we're addressing the concerns of all Americans.
    Senator Shaheen. Well, in New Hampshire, there is 
overwhelming public support for those Planned Parenthood 
centers, and I think that's true across the country.
    Thank you, Mr. Chairman.
    Secretary Price. Thank you.
    Senator Blunt. Thank you, Senator Shaheen.
    Senator Shelby.
    Senator Shelby. Mr. Secretary, thank you for your service. 
But thank you for taking such a tough, challenging job as you 
have.
    Secretary Price. Thank you.

                          AFFORDABLE CARE ACT

    Senator Shelby. An overriding question probably in America 
right now, one of them: Are we going to be able to pass a 
healthcare bill? Do you feel optimistic, hopeful, or guarded, 
or what?
    Secretary Price. Well, I'm an eternal optimist, Senator.
    Senator Shelby. You have to be.
    Secretary Price. You have to be in this job, you're right, 
but I believe so strongly that the American people recognize 
that there are huge failings in the current system----
    Senator Shelby. Absolutely.
    Secretary Price [continuing]. Especially in the individual 
and small group market, and that they need to be corrected, and 
I have great confidence and faith in the Members of the House 
and Senate to be able to get that done.

                        MEDICARE AREA WAGE INDEX

    Senator Shelby. Thank you. I want to get into something you 
know a lot about, the Wage Index. The Medicare Area Wage Index 
was instituted, as I understand, to reflect healthcare labor 
costs across different geographic markets. You know of this 
issue because of your service in Congress and probably as a 
physician. The current Wage Index formula has created a number 
of negative effects which have arguably facilitated in the 
closing of a lot of rural hospitals in the country. I believe 
this is a flawed formula, and it punishes rural States while 
helping others.
    I'd like to work with you, a lot of us would, on exploring 
both a short-term and a long-term solution to this pressing 
issue. And I understand its complex, and I understand it's 
difficult, but Alabama, my State, currently has the lowest 
reimbursement rates in the country. So that's challenging for 
us for a lot of reasons, to recruit and retain healthcare 
people, physicians, surgeons, nurses, administrators, you name 
it. You understand where I'm coming from.
    Secretary Price. Absolutely. The rural health challenges in 
this country are major, and we propose across the entire 
Department over $11 billion for rural health services. And our 
goal is to make certain that the programs that the Federal 
Government has actually incentivize and reward individuals who 
are working in the rural health area, whether it's through a 
telemedicine program that we believe is incredibly vital for 
rural health areas to try to bring contemporary medicine and 
knowledgeable individuals into communities large and small 
across the country, whether it's in the area of being able to 
have transportation and the services so that folks can actually 
get to the services that they need. But we also need to 
incentivize those providers, nurses, doctors, other providers, 
to go into the rural communities so that folks all across this 
land have access to the highest quality care.
    Senator Shelby. But from Maine to California, across the 
width of the nation, we have these challenges right here----
    Secretary Price. Absolutely.
    Senator Shelby [continuing]. Big time. Will you work with 
us to try to alleviate this pressing problem to rural America?
    Secretary Price. I look forward to it. And there are ideas 
that I know that you have and many others have that could help 
alleviate the challenges that we've got, and we look forward to 
helping solve those challenges.
    Senator Shelby. Thank you.
    Thank you, Mr. Chairman.
    Senator Blunt. Thank you, Senator Shelby.
    Senator Schatz.
    Senator Schatz. Thank you, Mr. Chairman.

                     BETTER CARE RECONCILIATION ACT

    Mr. Secretary, thank you for being here. I want to follow 
up on a question that was asked earlier. Have you been asked to 
weigh in, and not in terms of reviewing bill text, I understand 
you haven't seen bill text, but have you been asked to weigh in 
on the policy aspects of the Senate repeal bill?
    Secretary Price. As I said, my staff has been engaged in 
conversations with staff.
    Senator Schatz. Right, but what about you?
    Secretary Price. I've had conversations with Members of the 
Senate about what kinds of things we believe need to be done to 
make certain that individuals have access to the highest 
quality care.
    Senator Schatz. And what's your understanding of the status 
of the bill, just process-wise where we are in the--because, 
you know, you may have some insight that Democrats don't have.
    Secretary Price. My----
    Senator Schatz. As you know, there is a 13-person group of 
men, not the HELP Committee, not the Appropriations 
Subcommittee on Labor, HHS, not the leadership, just 13 men 
literally meeting in secret talking about what to do with 
around one-sixth of the economy. So are you participating in 
those conversations personally, either sort of serially, 
consecutive conversations informally over breakfast and coffee? 
What is your level of participation in those conversations?
    Secretary Price. My knowledge about those conversations 
specifically is what your knowledge is, and that is what you 
read in the newspaper when you get up in the morning. I 
understand that the leader's goal is to have a bill come 
through the Senate by the Fourth of July or shortly thereafter.
    Senator Schatz. Right. But the question is--I'm sorry--but 
the question is, are you talking to any of those members in 
that 13-person group of men?
    Secretary Price. Well, I couldn't tell you who the 13 
people are, but I talk to----
    Senator Schatz. You couldn't?
    Secretary Price [continuing]. Senators all the time about 
healthcare issues, and many of them have questions about what 
we think the appropriate--what an appropriate health policy 
would be to solve the incredible challenges that exist out 
there, especially in the individual and small group market.
    Senator Schatz. Right. You're a physician, you're the 
Secretary, you're the former chair of the Budget Committee, and 
you've worked on a bipartisan basis. So I'm just going to ask 
you a couple of questions related to your personal opinion 
around lawmaking. Do you think that that 13-person group would 
benefit from the perspective of a woman?
    Secretary Price. As I said to another question that was 
asked, as a member of the Article II branch of the government, 
I will leave the Article I branch functioning to the Article I 
branch.
    Senator Schatz. You can't answer the question of whether 
you think a healthcare discussion would benefit from having a 
woman involved or not?
    Secretary Price. As I say, this is an internal issue for 
the legislative branch for the Senate of the United States, and 
it's not my role to engage in the processes, the tactics, that 
go on here in the legislative branch.
    Senator Schatz. How many days do you think is a reasonable 
number of either legislative days or calendar days for you and 
your staff to be able to review a bill to determine what your 
position is on the legislation in terms of the Department? How 
many days do you think you need for a bill of this magnitude to 
be able to kind of metabolize it and opine on it?
    Secretary Price. Well, if I take my Secretary hat off and 
put on my congressional hat that I had on for 12 years, I can 
tell you how many days I had for the ACA, and that was about 
two.
    Senator Schatz. How many days do you think you needed?
    Secretary Price. And that was not enough for a 2,500-page 
bill.
    Senator Schatz. How many days do think is reasonable for 
the Department to be able to come to a conclusion about any 
piece of legislation?
    Secretary Price. For the Department to come to a 
conclusion?
    Senator Schatz. Yes, for the Department.
    Secretary Price. Well, the Department is engaged from a 
technical assistance standpoint. It's not the Department's 
role----
    Senator Schatz. On an ongoing basis, right?
    Secretary Price. Sure. On all sorts of issues.
    Senator Schatz. Right. So I guess the question becomes, if 
we were to present--say the Democrats were in charge, and we 
were going to present you with a bill that you hadn't read, 
that you had only heard about through sort of open-source 
reporting, how many days do you think you would need to process 
that bill and to come to a policy conclusion about it?
    Secretary Price. Well, I look forward to a bill coming from 
the Democrats to suggest how we improve the healthcare system.
    Senator Schatz. Well, hold on. No, this is not--we're not 
going back and forth sort of rhetorically, I'm just asking you 
how many days you think you need----
    Secretary Price. It would vary on what the topic was and 
how complicated the issue was.
    Senator Schatz. Right. But we're talking about this issue, 
so it is complicated. You're very intimately familiar with how 
complicated it is. You're in charge of the Department. How many 
days do you think need to process a bill?
    Secretary Price. That's a hypothetical and it's a not 
answerable question.
    Senator Schatz. Thank you.
    Senator Blunt. Thank you, Senator Schatz.
    Senator Merkley.
    Senator Merkley. Thank you, Mr. Chairman and Mr. Secretary.

                     BETTER CARE RECONCILIATION ACT

    In December 2009, after a hundred committee hearings and 
roundtables here in the Senate, more than a hundred--adoption 
of over a hundred minority amendments in committee, and after 
25 consecutive days of debate on the floor of the Senate, you 
called the Senate proceedings a complete invalidation of 
promised transparency.
    What do you call a 2017 Senate process that involves 
developing a healthcare bill in secret, a plan to bring the 
bill to the floor with no public hearings, with zero 
opportunity for minority amendments or majority amendments to 
be adopted in committee, and no chance for Senators to hold 
town halls on the topic?
    Secretary Price. Well, I appreciate the question, Senator, 
but my response is the same. It is not the role of the 
Secretary of Health and Human Services to opine as to how the 
Senate gets its business done. It's just that's not the role.
    Senator Merkley. This bill is coming potentially to the 
President. Does the President care about the process excluding 
the opportunity for regular citizens and for legislators to 
have a chance to be deeply engaged in a very complex topic that 
could potentially eliminate health insurance and coverage for 
millions of Americans? Does the President care about that?
    Secretary Price. The President is passionate about making 
certain that all Americans have access to high-quality coverage 
at a price----
    Senator Merkley. Does he care about public input and public 
review in the process?
    Secretary Price. The President is passionate about making 
certain that every single American has access to the highest 
quality coverage.
    Senator Merkley. You're skipping the question. Do you do 
that deliberately? Are you unable to understand my question, if 
he cares about the public process of citizens having a chance 
to have input?
    Secretary Price. I haven't had that conversation with him. 
You'll have to ask him.
    Senator Merkley. Would you convey to the President your own 
support for an extensive opportunity for the public to weigh in 
on such an important bill?
    Secretary Price. I talk to the President frequently about 
healthcare----
    Senator Merkley. Would you convey that position to him, as 
you share that position?
    Secretary Price. I'm happy to convey your concerns.
    Senator Merkley. Not mine. Do you care about the public 
process? You cared about it when you were a citizen before. Now 
you should care about it as a member of the executive branch 
because the President--this bill will come to him, and you have 
to advise him on whether public input matters and whether it's 
been obtained.
    Secretary Price. Senator, it is not the role of the 
Secretary of Health and Human Services to opine as to the 
processes of the legislative branch.

                        AMERICAN HEALTH CARE ACT

    Senator Merkley. Okay. Let me ask you a different question. 
The President--the President has called Trumpcare bill from the 
House ``mean'' and a ``son of a B.'' Do you agree with the 
President that the House bill was ``mean'' and ``a son of a 
B''?
    [Laughter.]
    Secretary Price. I wasn't at that--I wasn't at that 
meeting----
    Senator Merkley. You share the President's opinion. Do you 
disagree with him?
    Secretary Price. As I say, I wasn't at that meeting and I 
know that----
    Senator Merkley. I don't ask if you were at the meeting. Do 
you agree with him or disagree?
    Secretary Price [continuing]. The President cares about, 
and that is making certain that the American people have access 
to the highest quality care.
    Senator Merkley. So you're telling me you're working for 
the President and you do not share his opinion on this?
    Secretary Price. No. I'm saying that what I know about the 
President's concerns are that he wants the American people to 
have access to the highest quality care----
    Senator Merkley. Did the President--did the President call 
the House bill mean, the Trumpcare bill mean, because it 
potentially eliminates healthcare for millions of Americans? Is 
that the reason?
    Secretary Price. I don't--I don't know why. All I know is 
what I read in the paper on that because I wasn't at the 
meeting.
    Senator Merkley. Was--you talk to the President all the 
time. You haven't asked him why he called it mean?
    Secretary Price. I haven't had this conversation with him.
    Senator Merkley. Did he call it mean because it raises the 
cost of insurance for older Americans, an eightfold increase 
for a man in his sixties earning $26,500? Is that why he called 
it mean?
    Secretary Price. Yes, I would disagree with that 
characterization.
    Senator Merkley. You disagree with the example?
    Secretary Price. I do.
    Senator Merkley. Okay. Well, then maybe you should talk to 
CBO about their calculation because it comes directly from the 
provisions, the premium provisions that were put in by the 
House.
    Did he call it mean because it eliminates the guarantee of 
Americans with preexisting conditions having equal access to 
insurance at the same price?
    Secretary Price. Yes, again I would disagree with the 
characterization.
    Senator Merkley. Did he call it mean because it eliminates 
the guarantee that insurance policies will not--the guarantee 
that they will have essential care benefits?
    Secretary Price. I disagree with the characterization.
    Senator Merkley. But it does eliminate it. So I don't know 
why you would disagree.
    Secretary Price. To the contrary, sir.
    Senator Merkley. I would encourage you to read the House 
bill since you are the Secretary of Health.
    Does it--did he call it mean because it takes a wrecking 
ball to rural healthcare by putting rural clinics and rural 
hospitals into a financial crisis?
    Secretary Price. That's not what it does, sir.
    Senator Merkley. It does indeed. And does he call it mean 
because while stripping healthcare from millions of Americans, 
it gives a tax giveaway of roughly $600 billion to the richest 
Americans? Is that why he called it mean?
    Secretary Price. Yes, I again I would disagree with your 
characterization.
    Senator Merkley. Thank you, Mr. Chairman.
    Senator Blunt. Thank you, Senator Merkley.
    Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman.

                   U.S. OPIOID EPIDEMIC AND MEDICAID

    Mr. Secretary, this last weekend, Vice President Pence 
visited Milwaukee, Wisconsin, in part to promote the partisan 
healthcare legislation that's being written in the Senate 
behind closed doors right now. Secretary Price, you have 
heralded this bill promising that it will, ``Will provide 
coverage for every American,'' but the fact is that it will 
actually make many Wisconsin families pay more for less care.
    By ending the guaranteed protections that people have 
today, reducing tax credits, really gutting Medicaid with caps 
and cuts, the legislation that you support will dramatically 
increase and shift health costs onto Wisconsin and our families 
for substance abuse and mental health services in particular.
    I also want to mention that President Trump was also in 
Wisconsin this week. He was in Milwaukee on Tuesday to also 
promote the partisan legislation that's being written in the 
Senate behind closed doors. I know that Vice President Pence 
was there on Saturday. The President was there on Tuesday, 
about 42 hour--or, sorry, 72 hours between their two visits.
    In a 72-hour period this weekend, the Milwaukee County 
medical examiner announced that they had responded to 12 
probable drug overdoses. 72 hours between their visits. There 
is no correlation there, I'm just saying in that time, in one 
county in the State of Wisconsin, the medical examiner was 
responding to 12 probable drug overdoses.
    I have traveled throughout the State of Wisconsin. I know 
we talked about this prior to your confirmation, holding 
roundtables to get a closer sense of how this narcotic-opioid-
heroin epidemic is affecting the people of my State, and this 
legislation will make it worse, not better.
    And I just have to ask in a different way what several of 
my colleagues have highlighted for you on both sides of the 
aisle. If addressing opioids is a top priority for you and for 
this administration, how can you possibly back a plan that 
would take away coverage and increase costs for people 
struggling with addiction?
    Secretary Price. Yes, that's not the plan. The plan is to 
make certain that all Americans have access to the highest 
quality coverage, including coverage that covers substance 
abuse and addiction. I visited Wisconsin as well----
    Senator Baldwin. There's a difference between intentions 
and plans and reality. So if we weaken the guaranteed insurance 
coverage of substance abuse and mental health services as an 
essential benefit, an essential health benefit, how can you 
believe that that would lead to people continuing to be able to 
access this treatment?
    Secretary Price. Well, there are indeed differences between 
plans and reality, and one of those differences, Senator, as 
you know, is that premiums in the State of Wisconsin are up 93 
percent for individuals in the individual market, and those 
were supposed to go down, as you'll recall, for folks.
    So what we're trying to do is to put in place a system that 
actually responds----
    Senator Baldwin. Significantly----
    Secretary Price [continuing]. To those individuals who are 
having challenges getting coverage, or when they have coverage, 
they can't get care. There are real challenges out there in the 
healthcare arena. You know this. And what we would like to do 
is to be----

                         PREEXISTING CONDITIONS

    Senator Baldwin. I do, and before the passage of the 
Affordable Care Act, as you and I know from working together in 
the House of Representatives, those price spikes were much more 
significant. They're still significant enough that we have to 
continue to work together always, I think, across the aisle. 
But this was a crisis prior and has actually stemmed.
    But do you agree that insurance companies should not be 
allowed to charge individuals struggling with addiction more 
for coverage because of their preexisting condition? And how 
exactly will the Republican plan allow you to keep Vice 
President Pence's promise that he made while he was in 
Milwaukee, that people with preexisting conditions will have 
access to the coverage and care they need?
    Secretary Price. The assurance that individuals can have 
preexisting illnesses and injuries covered is an absolute 
priority of the President, and we have conveyed that to 
individuals in Congress and continue to do so, and I look 
forward to working with you to make certain that that happens.
    Senator Blunt. Thank you, Senator Baldwin.
    We'll begin a second round of questions, and then we'll 
move to other Senators as they come back and go back and forth 
and vote.
    Mr. Secretary, let's talk about electronic healthcare 
records, which, as a practicing physician, I know you care a 
great deal about. The Health, Education, Labor, and Pensions 
Committee cares a great deal about it as well. As we worked on 
the 21st Century Cures Act, we sort of stumbled into the mess 
that electronic healthcare records was in.
    And, Senator Lankford, have you had a chance to ask 
questions yet?
    Senator Lankford. I have not.
    Senator Blunt. Well, then I'm going to abbreviate my 
comments and come back to them later and call on Senator 
Lankford for his 5 minutes.
    Senator Lankford. That's very kind of you. Thank you.
    Dr. Price, good to see you again.
    Secretary Price. Likewise. Thank you.

                               TELEHEALTH

    Senator Lankford. I have about 50 questions I'm going to 
bounce off of you in 5 minutes, and we can have a conversation, 
and I'll pick up the rest and do questions for the record, or 
we'll visit another time.
    Let me open with a conversation about telehealth. This is 
one of the areas that gets brought up frequently by individuals 
as a source, especially for rural America, is doing telehealth. 
There has been ongoing conversation about how to do that 
reimbursement. Where is that process now in the conversation of 
how to do reimbursement? What do you need Congress to do? What 
do you already have authority to do to be able to make 
decisions about reimbursement in telehealth?
    Secretary Price. Telehealth is absolutely vital. We've had 
multiple conversations with CMS (Centers for Medicare & 
Medicaid Services) to see if we can't facilitate and ease the 
ability for CMS to provide reimbursement for telehealth visits. 
I suspect that the Congress could be able to engage in that 
process in a positive way and move that ball down the field.
    Senator Lankford. Is it needed at this point? Do you need 
additional congressional authorities to be able to move it, or 
do you have the authorities you already need?
    Secretary Price. We're in the process of working through 
that. I believe that there is authority that the Department 
has.
    Senator Lankford. Okay. We'll look forward to just 
maintaining that conversation.

                       DURABLE MEDICAL EQUIPMENT

    There was a process that started several years ago on 
competitive bidding for durable medical equipment. It sounds 
like a great, very American idea, but it appeared that what was 
actually occurring was to simplify the process for DHS, or for 
HHS, to have fewer companies to deal with, they're just 
eliminating a lot of family-owned businesses that were 
providing very personal service. It suddenly became not about 
price, but about ease of reporting up here. So a lot of smaller 
businesses that were providing very hands-on care that would do 
it at that price are happening.
    Where are things going in competitive bidding for durable 
medical equipment? Where do you see that in the days ahead? And 
how can companies reengage in that process that didn't win a 
previous bid so we can have more companies in that process?
    Secretary Price. I appreciate your passion for this. This 
is a real concern because, as you know, across the country, 
especially in rural areas, individuals that have provided this 
service to their communities for years and years, oftentimes 
decades, have been destroyed by the rules that were put in 
place by the Federal Government.
    We have delayed any change to the current program until 
2019. We're in the process of determining through an open 
process how to make it so that those individuals can get back 
into the business and also make it so that the end user, the 
patients and the citizens across the land, will be able to have 
access to DME (Durable Medical Equipment) services in the most 
efficient way possible.
    Senator Lankford. Okay. We'll look forward to getting a 
chance to work with you on that. It will be very important, as 
you noted, to rural America, but in urban settings as well. 
There is often only one person that does face-to-face, everyone 
else does it by mail. And with medical equipment, they would 
prefer to have somebody face-to-face as often as possible.

                            WELDON AGREEMENT

    There was a great conversation about the Weldon amendment 
in California a couple of years ago with HHS, and that is that 
California then basically changed their rules on everyone and 
said every insurance company has to provide abortion coverage. 
So suddenly churches that want to get into it, nonprofits that 
had a moral issue with abortion, suddenly had no other product 
they could buy.
    They appealed through HHS, as their right to be able to do 
that through the Weldon amendment. HHS then responded back to 
them, individuals don't matter, their opinion, no insurance 
company has complained, so it's not a problem. And suddenly the 
rights of the individual was taken away and it was only if 
companies don't complain, there is no complaint. That was a 
very creative way to be able to address that for HHS in the 
past.
    Is that being reevaluated, reexamined? Has there been 
conversation coming to your office from groups saying, ``Will 
anyone readdress this?''
    Secretary Price. Yes. And as you know, there's an 
injunction in place for the courts right now, but the 
Department is looking at this and look forward to working with 
members on both sides of the aisle to resolve it.

                         EMERGENCY PREPAREDNESS

    Senator Lankford. Great. So for disaster relief, we have 
for several years in this Congress tried to figure out an 
appropriate amount. It seems like we're trying to budget our 
disasters better to say every disaster that comes doesn't have 
to come to Congress for additional appropriations.
    We will have medical issues in the days ahead, as we have 
had in the past. You can insert Ebola, Zika, multiple others. 
What is the ongoing conversation in the budgeting to say let's 
plan for a medical emergency or an outbreak of some type, set 
aside additional funds to be able to have that there? Is that a 
need or a request that you would make of us? And if so, how 
should we budget for that?
    Secretary Price. Yes, I appreciate that because that is 
indeed a need. The budget requests an emergency fund to be 
available. And we also request the flexibility to allow the 
transfer of up to 1 percent of resources throughout the 
Department, across the entire Department, in the event of an 
emergency, and would appreciate that support.
    Senator Lankford. Okay. Do you feel like the amount that 
you're requesting is an adequate amount for that?
    Secretary Price. At this point, yes.

                       PHYSICIAN-OWNED HOSPITALS

    Senator Lankford. Okay. Final question is on physician-
owned hospitals. As you know, when the Affordable Care Act 
passed, it locked in physician-owned hospitals to a permanent 
size, you can never increase on that. Is there a regulatory 
issue or an ongoing conversation right now for hospitals that 
in many communities are the preferred hospital, in other 
communities are an excellent hospital? There are other great 
big hospitals as well, for-profit and nonprofit as well. I'm 
not degradating any of those. But in a time when it's more and 
more difficult to get doctors to take Medicaid and Medicare, I 
think it's very important we have as many options as we can and 
not limit that.
    Secretary Price. And I would agree with that and would 
respectfully suggest that we believe that legislation is 
required.
    Senator Lankford. Okay. Thank you.
    Senator Alexander [presiding]. Thank you, Senator Lankford.
    Senator Baldwin, I do not know whether Senator Blunt 
envisioned a second round of questions, but since you're here, 
we don't want to waste the time. So why don't you go ahead, and 
if Senators come back who have not asked questions on the 
Democratic side, we'll let them go ahead. Is that all right?
    Senator Baldwin. That sounds good.
    Senator Alexander. So why don't you go ahead with a 5-
minute round.
    Senator Baldwin. Thank you.

                     BETTER CARE RECONCILIATION ACT

    Secretary Price, in your testimony, you claimed that the 
President's budget, ``Commits to working with Congress to 
transition from the failures of Obamacare.'' But neither I nor 
the American people have had an opportunity to see you take 
action on this, and the Republicans in the United States Senate 
are still operating in secret to craft their plan.
    We both served in the House together. We held a very 
transparent and bipartisan process to craft the health reform 
bill. We had 79 bipartisan hearings and markups, and considered 
almost 240 bipartisan amendments. In fact, I think one of your 
amendments offered in the Education and Workforce Committee was 
ultimately included during the consideration of the committee's 
bill, and I think maybe one other that you cosponsored with our 
former colleague Congresswoman Biggert.
    Do you agree that this secret and closed-door process on 
this partisan bill is unfair to the American people, who so 
desperately seek to find out its details and its impact on 
them?
    Secretary Price. Well, again I won't--I'm not going to 
comment on the process here. I will comment, though, on your 
characterization that the American people haven't seen any 
action on the ACA.
    Senator Baldwin. On the promise to work with Congress to 
transition.
    Secretary Price. And we solicited input on a market 
stabilization rule that was put forward earlier this year that 
provided for greater flexibility in the area of special 
enrollment periods and grace periods as well as greater 
flexibility for States to be able to define what constitutes a 
qualified health plan so that individuals across this country 
are able to have greater access to the kind of coverage that 
they want.
    Senator Baldwin. I'd like to know if you would join me and 
my colleagues in calling on the Republicans to hold hearings 
here in the United States Senate like we did in the House those 
years ago so that we can hear from our families who are 
struggling with prescription drug abuse issues or the many, 
many others who will be impacted by this plan, to hear from 
experts, to hear from those in industry, to hear from those who 
practice medicine on the front lines. Will you join me in 
calling for that sort of process here in the Senate?
    Secretary Price. What I have control over is what we do at 
the Department and in the administration. Yesterday, we met 
with over a dozen physicians from across the land who have been 
harmed, their practices have been harmed, by the Affordable 
Care Act. We met with stakeholders from A to Z on the current 
situation at the Department, and we put out information 
regarding each and every one of those meetings to document 
where we believe the challenges exist in the current system and 
why we believe that reforms are absolutely vital so that 
individuals can gain access to quality coverage at a price that 
they can afford.
    Senator Baldwin. The fact remains that nobody has had the 
opportunity to see what's being drafted by the Senate 
Republicans right now. I go home every weekend, and people are 
rightly concerned about the fact that there has been no public 
sharing of this legislation, extremely consequential 
legislation. And rumors are out there that we could see this 
brought to the Senate floor and passed with no hearings in any 
committee. And I call on you to call that out and have a much 
more transparent process, as you got a chance to participate in 
along with me on our respective committees in the House, where 
we took the time it required to get that sort of input.
    Secretary Price. Well, with respect, our recollections of 
what happened in 2009 and 2010 are significantly different.
    Senator Baldwin. The record is in the record.

                          U.S. OPIOID EPIDEMIC

    I want to return to the issue of the opioids. I still 
continue to be perplexed that your budget claims to fight the 
opioid epidemic while simultaneously proposing really drastic 
cuts to critical behavioral programs. Almost no substance use 
disorder programs received an increase, and in fact, the budget 
radically cuts the Medicaid program, cuts opioid prevention 
programs in particular, and we can't--prevention has to be an 
element of this. It eliminates CDC programs to support research 
on opioid overdoses and eliminates behavioral health workforce 
training programs that help----
    Senator Alexander. Five minutes is----
    Senator Baldwin. Oh.
    Senator Alexander. Senator Blunt was trying to stick to the 
5-minute rule, but go ahead and finish your question.
    Senator Baldwin. Okay. Please explain how you plan to 
combat the growing epidemic with these cuts, specifically the 
ones that I just outlined.
    Secretary Price. Yes. We put forward from the Department we 
have a five-point strategy that addresses and focuses on the 
needs for appropriate recovery and treatment of addiction that 
is an attempt to try to get the amount of resources necessary 
into communities large and small across this land for overdose-
reversing drugs. That takes a public health aspect to 
surveillance to figure out what's going on out there.
    As we mentioned before in our conversation, we're moving in 
the wrong direction. The numbers are not improving. And you 
highlighted that with just that tragedy that occurred in your 
State just within the last week, to make it so that the NIH has 
the resources necessary so that they're able to continue their 
incredible work on a non-euphoric pain medication, a non-
addictive pain medication, on the potential, the exciting 
potential, for a vaccine for addiction, which your head almost 
explodes when you think about that, but what an exciting 
prospect that is.
    And then finally, as I mentioned to Senator--I believe 
Senator Lankford on the issue, or Senator Capito on the issue 
of pain management. How do we treat pain in this country? What 
have we done as a Federal Government that has exacerbated the 
problem of opioid addiction and the addiction concerns that 
exist?
    So we believe that the resources that exist in the budget 
are sufficient to be able to put in place that strategy and to 
try to move us in a direction where we're actually turning the 
cost--or the curve in the right direction.
    In addition to that, as you know, the President has 
appointed a commission to address the opioid crisis headed by 
Governor Christie, from New Jersey, and we look forward to 
seeing what they have to say as well on the recommendations 
that they will make. I know they're working diligently on it.
    Senator Alexander. Thank you, Senator Baldwin.

                       ELECTRONIC MEDICAL RECORDS

    I'm going to try my 5 minutes now, and I'd like to get back 
to electronic medical records. But I've been listening for the 
last couple of days to the Democratic talking points on the 
Republican efforts to fix the collapsing markets in the 
Affordable Care Act.
    I have a pretty vivid memory of how the Affordable Care Act 
was enacted. The Democratic majority leader brought in a bill 
on a Saturday in December, no one had seen it except a few 
people in a back room. We voted on it Christmas Eve, 5 days 
later, and it passed in the middle of a snowstorm. So the bill 
that Republican Senators are working on will, of course, have 
to go to the Senate floor, be considered, and a process of 
almost unlimited amendments, which we call ``vote-a-rama.'' And 
then if it should pass, then it would have to go through a 
process. Before we voted on it we would have to know what it 
costs because those are our rules in the Senate.
    So it would be exposed to the public before we voted. It 
then would have to be combined with the House bill. That would 
all be very public. So we're going through the same kind of 
reconciliation procedure that the Democrats used to finish 
passing the Affordable Care Act in the first place.
    Senator Blunt, I think everybody has had their 5 minutes, 
Senator Baldwin got 5 minutes in a second round. I want to ask 
a question about electronic medical records, if that's all 
right, before I go back and vote.
    Senator Blunt. Absolutely.
    [Laughter.]
    Senator Alexander. I'll be brief.
    All I wanted to say was I know that Dr. Price, because as a 
practicing physician, understands that issue much better than 
any of us, and I just want to emphasize that in the Health, 
Education, Labor, and Pensions Committee, you've got a 
bipartisan group of people, Senators, who want to work on that 
and who want to, of course, get interoperability, but we also 
want to reduce the burdens on practicing physicians in the 
country so they can go back to practicing medicine.
    I tried to get the last administration to not move on to 
Meaningful Use 3 because it was going too fast. I mean, at 
Vanderbilt University, which uses electronic medical records, 
they said phase 1 was helpful, phase 2 was tolerable, and phase 
3 was terrifying. But they went ahead with the stage 3 rules 
anyway. Yet we did some good work with the Obama administration 
in trying to get back on track.
    I would just pledge to you, on behalf of a bipartisan group 
of Senators, we'd like to work with you, both on 
interoperability and on a national effort that would say to 
physicians in this country, ``If you're spending 40 or 50 
percent of your time filling out records instead of talking to 
patients, either you're not doing your job or we're not doing 
our job, and we want to work with you, and see if we can get 
whatever that number is today down to a tolerable level.''
    So I look forward to that, and some of that could come 
before Senator Blunt's committee here, but a lot of it would be 
before our committee in the HELP Committee.
    Secretary Price. Major problem, and I appreciate you 
highlighting it. In so many ways, we've turned physicians of 
this land into data entry clerks, and it is literally driving 
physicians out of practice, and we've got our focus on it and 
are going to do all that we can to relieve that burden.
    Senator Alexander. Well, I thank you for being here. And 
I'll now relinquish the gavel, and I'll let Senator Blunt know 
that while in his absence we just made a few minor changes to 
the budget that the President submitted, and we've increased by 
10 percent the appropriations for the National Institutes of 
Health.
    [Laughter.]
    Senator Blunt [presiding]. Not to mention the money 
available now for the labs and the--and I would say--I didn't 
have a chance to follow up on Senator Alexander's comments 
about our visit to the labs, but I do think that's something 
worth looking at. We talked to Seema Verma about it as soon as 
we got back. And so she's been thinking about it. I think you 
have, too. But if there is a way to do that, certainly 
everybody would benefit from doing that except those people who 
are unfairly taking advantage of the system now, and we don't 
want them to benefit, we want the system to work better for 
more people. So I think it's really worth looking at. It would 
be one of the big ideas that I think you could bring to how we 
look at Medicare and Medicaid and other government payments.

               LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

    LIHEAP, have you had a chance to talk about LIHEAP while I 
was gone?
    Secretary Price. No.
    Senator Blunt. Missouri is far enough north that we use 
substantial LIHEAP money. It's not a big benefit, but about 
150,000 households take advantage of that, up to $450 benefit 
to help pay heating and cooling costs. They also use that, in 
our State at least, as a leverage tool to raise private money 
as part of an overall LIHEAP fund to go along with that. I 
think the budget eliminates LIHEAP. Do you have anything you 
want to add to that?
    Secretary Price. Yes. I think that it's obviously an 
important program. In the past, it has been primarily a State 
program along with private partners. Most States require that 
energy can't be cut off at a difficult time from a weather 
standpoint. So we believe that returning this to the States is 
probably the most appropriate venue for it.
    Senator Blunt. Well, I think it may be like--some of these 
programs like the victims of child abuse program is a pretty 
small amount of money for the whole country, but it does 
somehow leverage lots of local contributors as well as State 
money. And so that's maybe one of the ways we ought to talk 
about this as we talk further through this.
    Secretary Price. Sure.
    Senator Blunt. Is there a leveraging component there that 
encourages legislatures to do things they might not otherwise 
do and private sector donors to do things that they might not 
otherwise do?

                   EXCELLENCE IN MENTAL HEALTH PILOT

    I would also like to talk for a minute about excellence in 
mental health. There are eight pilot States right now, 
including Missouri, that were part of the 24 States that 
applied to be part of this 2-year pilot. Qualified facilities, 
usually on the community mental health center model, as long as 
they had staff and access hours that allowed them to be part of 
a State program, qualified facilities would for 2 years treat 
mental health just like any other health essentially on the 
Federally Qualified Health Center model--they have various ways 
to pay for the mental health services, but at the end of year, 
in this case, the Federal Government will come in over 2 years 
and help even that out.
    I talked again to our mental health community yesterday. 
They are convinced, like I am, that in the overall healthcare 
problems of the behavioral health community, that if you're 
seeing your doctor to deal with your behavioral health issue, 
you're taking your medicine, you're eating better, you're 
sleeping better, you're feeling better about yourself, that 
whatever other problem you have is so much more easily dealt 
with, that I think, Dr. Price, what we're likely to find, 
certainly whatever big county study has found up till now, is 
you actually save money if you do that. And I know behavioral 
health has been one of the issues you've been interested in 
over the years. I hope that you will carefully watch that, as I 
am, as the Congress is, and be sure we're properly documenting 
what's happening there, but I think it's likely we'll find out 
what we always knew, that this is the right thing to do, but 
actually it's a very cost effective way to look at overall 
health.
    Secretary Price. Absolutely. The mental health issues are 
incredibly important, and we put significant resources toward 
them, have a new program for children's mental health, and 
actually increased resources in the Indian Health Service for 
mental health, which is a major, major challenge.
    Senator Blunt. Right.
    Senator Murray.
    Senator Murray. Thank you, Mr. Chairman, and thank you for 
accommodating a second round. I think we have a few members 
coming back, we'll double-check for you while we're doing this.
    Senator Blunt. Okay.

                             WOMEN'S HEALTH

    Senator Murray. Secretary Price, I'm not asking a question, 
I'm just going to tell you that I really believe that your 
budget is an assault on women's health. There's a net cut to 
the Maternal and Child Health Bureau. There's proposed 
eliminations of programs that expand universal newborn 
screening, support for children with autism, preventing teen 
pregnancy. This is just a bad bill for women, and choosing to 
eliminate Planned Parenthood, which you repeatedly have 
supported, is widely unpopular. I hope you know that. Under 
your proposal in Washington State alone over 100,000 women are 
going to lose access to critical care, and I know that's true 
for many other States.
    So deep cuts to Medicaid, losing preventive services, such 
as the contraception coverage, this is a bill that women across 
the country are standing up to take notice.
    But let me ask you a specific question on this. In your 
opening statement, you say that the Trump administration does 
not confuse government spending with government success, but 
your budget eliminates some Federal programs that have very 
strong evidence that prove that they work, like the Teen 
Pregnancy Prevention Fund, which actually funds local programs 
that have been shown through very rigorous evaluations to have 
an effect on outcomes that relate to teen pregnancy.
    Your budget does preserve the Sexual Risk-Avoidance 
program, formerly known as Abstinence-Only Education. There 
have been multiple evaluations that have shown that federally 
funded abstinence-only programs have no impact in teen sexual 
activity or pregnancy, and worse, some of these programs have 
been shown harmful.
    So I just want to ask you, how do you justify eliminating 
the teen pregnancy program, which is based on evidence, and 
instead funding ineffectively and frankly, potentially harmful 
abstinence programs?
    Secretary Price. I think the important point is the amount 
of resources that we bring to women's health. And the whole 
issue again, as I mentioned before, $125 billion across the 
entire Department. We increase funding for health centers, for 
increase funding for Maternal and Child Block Grants, we 
maintain funding for Ryan White, and we increase funding for 
pregnancy and postpartum care.
    Senator Murray. Well, we have a disagreement on your 
characterization of those, quote, increases, and I just have to 
say that I am deeply disturbed by this budget in terms of its 
impact on women.
    I have one more question, Mr. Chairman. Let me ask, are 
there any other members coming back that we know of? Okay.

                        CONGRESSIONAL INQUIRIES

    Well, I'll just say, Secretary Price, recent news reports 
indicate that Federal agencies have been told now by the White 
House to ignore information requests from the minority. In 
fact, on May 1st, the Justice Department's Office of Legal 
Counsel released a memo which stated that individual members of 
Congress, including ranking minority members, do not have the 
authority to conduct oversight in the absence of a specific 
delegation by a full House committee or subcommittee. As a 
result, the Trump administration believes it has no legal 
obligation to respond to information requests from the 
minority.
    That is really disturbing to me because performing 
oversight of the executive branch, whether you disagree or 
agree, is something that all of us in Congress know is an 
important responsibility, it's a longstanding responsibility of 
this committee, and one that actually Senators of both sides 
take very seriously.
    So I just wanted to ask you while you're here, will you 
commit to responding to minority--my questions, written 
questions, for information, and to do so in a timely fashion?
    Secretary Price. Yes. Having sat on that side of the dais, 
one of the frustrating things is making a request of a 
department and not getting a response. I've instructed 
everybody in our Department to respond to any requests from 
Members of Congress.
    Senator Murray. I really appreciate that. Thanks so much 
for clarifying that.
    Thank you, Mr. Chairman.
    Senator Blunt. Let me ask one final question while I'm--
likely to be final, depending on whether any other Members are 
returning. We're trying to determine that right now.

                         EMERGENCY PREPAREDNESS

    One of your priorities that I wasn't here to hear about at 
least during the part of the hearing you were asked while I was 
voting was emergency preparedness and response. There is a 
substantial increase here for pandemic influenza. I do know, by 
the way, from our visit at NIH that Senator Durbin mentioned, 
that they're working to get to the point where we can develop 
one flu shot to where every year we wouldn't be trying to 
adjust, and often, as it turns out, adjusting not quite right 
to what we think is going to be that year's flu. So clearly if 
we could get that research done that would save a lot of money 
every year in the pandemic area. But I notice that's a place 
where you've increased funding in BARDA, in Bioshield, in the 
Strategic National Stockpile. I'm going to let you respond to 
that one priority I don't think you've had much of a chance to 
talk about.
    Secretary Price. Yes, no, absolutely. And it's really 
exciting, the opportunities that exist out there. And you 
mentioned NIH working on a single vaccine for flu, the annual 
flu, which would just revolutionize what goes on and also save 
significant, significant resources.
    But we believe strongly in preparedness and response. It's 
something that we have to work on. It was part of the ongoing 
conversation when I was in Berlin with the G20 Health Summit 
and at the World Health Assembly in Geneva.
    The United States is a leader in global health security and 
has tried to encourage all nations to participate to make 
certain that all nations have the capacity to respond to an 
epidemic when it breaks out so that we don't end up with the 
pandemic challenges that we've had in the past.
    The resources that we put forward go through both the 
preparedness and response, but also through CDC. And we are 
intent on making certain that we are prepared and that we're 
able to respond in a way should or when the next challenge 
arises.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Blunt. Well, thank you, Mr. Secretary. The record 
will stay open for 1 week for additional questions.
    Secretary Price. Thank you, Chairman. Thank you.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
                Questions Submitted by Senator Roy Blunt
                     indirect costs proposal at nih
    Question. The proposal to cap indirect costs at NIH at 10 percent 
is controversial. I understand that many nonprofits have similar caps, 
but they are likely able to do that because: (1) they are only a small 
part of the research community; and (2) NIH's indirect costs offset the 
cost of their research. While I encourage you to look into 
inefficiencies and inequalities in the program, and especially review 
the burdensome red tape for the research community, I do not think that 
characterizing this funding as ``something other than research'' is 
fair or accurate. Further, indirect costs are not cut to put towards 
more ``direct'' research activities, but just cut from the NIH budget. 
What type of reviews of the program did the Department do to come up 
with the 10 percent cap?
    Answer. The fiscal year 2018 Budget presents an opportunity for HHS 
and NIH to reexamine how to optimize Federal investment in a way that 
best serves the American people. This policy will enhance the 
stewardship of taxpayer dollars by focusing our limited resources on 
innovative scientific research rather than administrative and overhead 
costs. The Department assessed opportunities within the NIH to 
determine where greater efficiencies may be possible within the 
research project grant mechanism. In addition, HHS also assessed 
strategies used by other non- Federal entities such as foundations and 
private sector organizations to understand how funds for direct and 
indirect research costs are allocated.
    Question. How will the 10 percent cap affect current grantees and 
new grantees?
    Answer. The effect on grantees will vary by institution, depending 
on the current indirect cost rate and a variety of other factors. The 
impact will likely be greater on institutions that have a higher 
percentage of NIH funding compared to total funding, or a lower ability 
to cover indirect costs from other sources (e.g., donations, endowment 
income, state government, tuition). The Department continues to work on 
specific details of the NIH indirect cost policy for fiscal year 2018 
and will assess the impact on grantees once the policy is finalized.
    Question. All HHS grant programs are affected by the indirect cost 
rate negotiated by the Department, yet NIH is the only agency to have 
their indirect costs capped. Is it your plan to cap all HHS indirect 
costs in the future?
    Answer. The fiscal year 2018 Budget indirect cost policy is focused 
on NIH. The Department will continue to assess and monitor current 
indirect cost policies and implement necessary policies that create 
more efficient and effective programs.
    Question. What discussions did you have while developing the 10 
percent cap with the extramural NIH research community?
    Answer. The Department considered the impact the 10 percent cap 
would have on the NIH extramural research community when it was 
developed. The extramural NIH research community has provided feedback 
since the Budget release. Increasing efficiencies within NIH remains a 
priority of the Administration. NIH is working with the Department to 
identify strategies to streamline process and increase efficiencies 
within NIH. This includes efforts to address the costly and time-
consuming indirect rate setting process and reporting requirements. 
These strategies to reduce grantee administrative burden are informed 
by direct feedback from grant recipients.
    On May 8, 2017, Secretary Price participated in an event at the 
White House on the scientific opportunities in biomedicine. Key leaders 
from government, the private sector and academia discussed the United 
States' comprehensive biomedical landscape. The meeting was organized 
by the National Institutes of Health and was led by its director, Dr. 
Francis Collins. Leaders in the medical, education and research 
community joined executives from companies who invest in biotech to 
provide analysis and real-life examples of how America's sustained 
leadership in the biomedical industry has resulted in immeasurable 
benefits to both our country's economic and physical well-being.
                             mental health
    Question. The budget eliminates Mental Health First Aid that funds 
programs for community members and potentially first responders to 
assist someone experiencing a mental health episode. Given the success 
of this program and the Administrations priority of severe mental 
illness, how will HHS work to make sure these types of efforts 
continue?
    Answer. This program is duplicative of other school-based programs, 
such as Youth Violence Prevention, which will continue to promote 
healthy childhood development and prevent violence and alcohol and drug 
use. SAMHSA has developed lessons learned and technical assistance 
strategies from Mental Health First Aid that will be shared with other 
communities interested in exploring such efforts.
                       public health preparedness
    Question. I understand that the budget places a priority on public 
health preparedness and response activities. This includes requesting a 
$135 million increase for pandemic flu activities. Why is this increase 
necessary and how will the Department manage ongoing pandemic influenza 
needs within current funding levels?
    Answer. The fiscal year 2018 President's Budget increases funding 
for pandemic influenza activities to sustain ongoing investments in 
domestic influenza vaccine and adjuvant manufacturing facilities and in 
pre-pandemic vaccine and adjuvant stockpiles that enable the Department 
to quickly produce and deliver vaccines in response to evolving and 
emerging influenza viruses with pandemic potential. The Budget also 
continues to support the advanced research and development of improved 
influenza countermeasures and novel vaccine platform technologies 
through key public-private partnerships. Additional funding is 
necessary due to the exhaustion of the Department's pandemic influenza 
balances from prior year supplemental appropriations, which have 
supported pandemic influenza activities across the Department over the 
last decade. Using remaining pandemic influenza balances from prior 
year supplemental appropriations, the Department is currently working 
to manufacture and stockpile a new vaccine to match the currently 
circulating highly pathogenic H7N9 influenza virus in China. Should the 
H7N9 virus continue to evolve and shift to a pandemic scenario, the 
Department would require supplemental resources beyond the requested 
increase in the fiscal year 2018 Budget to support the activities 
appropriate for a pandemic response. In addition, the Budget proposes a 
new emergency response fund with Department-wide transfer authority in 
order to enable a swift response to emerging public health threats.
    In addition to these activities, the Department recently issued the 
Pandemic Influenza Plan 2017 Update, the first since January 2009.
    Question. The budget cuts 15 percent from preparedness resources 
that are targeted to local governments and hospitals. Under your 
proposal, some States will receive no funding for these preparedness 
activities. How will HHS make sure States are adequately prepared for 
emergencies with these funding reductions?
    Please provide a table with the proposed state allocation for the 
reductions in CDC's Public Health Emergency Preparedness program.
    Answer. As the Federal Government, we must make the health and 
safety of Americans the driving force behind all that we do. To deliver 
the needed change to protect Americans from disasters that impact 
people's health, the Department proposes to disrupt the status quo and 
reform the preparedness grant programs in fiscal year 2018, driving 
strategic advancements in healthcare delivery system readiness, and 
enhancing government efficiency and accountability. The fiscal year 
2018 President's Budget request restructures HHS preparedness grants to 
direct resources to States with the greatest need and supports the most 
innovative approaches.
    ASPR intends to create a lean, yet effective Hospital Preparedness 
Program in fiscal year 2018 by focusing Federal funding on those states 
and jurisdictions with the greatest need. For healthcare preparedness, 
need is defined as those most at risk.
    In fiscal year 2018, the CDC's Public Health Emergency Preparedness 
Cooperative Agreement will gain efficiencies, address capacity gaps, 
and incentivize innovation by incorporating a competitive and risk-
based component, and linking awards with performance.
    Through its fiscal year 2018 proposals, and given the reduced 
funding level, the Department will target funds to those jurisdictions 
with the greatest need and continue to provide all jurisdictions with 
technical assistance to inform their preparedness and response efforts.
    [The charts follow:]
    
    
    
    
                            medicare appeals
    Question. HHS has been working for years to reduce the backlog of 
Medicare appeals, but continues to project a backlog of over 650,000 
appeals in 2017. What new steps is HHS taking to reduce the incoming 
number of appeals?
    Answer. HHS continues to address the backlog of pending Medicare 
appeals and address resolving appeals earlier in the process. To that 
end, HHS has undertaken several administrative actions at the first and 
second appeal levels to reduce the number of appeals at the third level 
(OMHA) where the backlog exists. Through revisions to the Recovery 
Audit Program, implementation of a prior authorization regulation for 
durable medical equipment, prosthetics and orthotics, and supplies, as 
well as a continuation of the Qualified Independent Contractor (QIC) 
formal discussion demonstration, HHS seeks to reduce the number of 
incoming appeals at OMHA.
    To ensure that no stone remains unturned and all workable ideas are 
given due consideration, the Department has also actively engaged in 
outreach and listening sessions with appellants and provider 
organizations to solicit suggestions on actions that can be taken to 
address the backlog of pending appeals and resolve appeals earlier in 
the appeals process.
    The fiscal year 2018 President's Budget is an important component 
of the comprehensive strategy the Department has developed to eliminate 
the backlog of Medicare appeals. Taken together, the additional 
funding, administrative initiatives, and legislative proposals included 
in the President's Budget will help ensure beneficiaries and providers 
have timely resolution of appeals. The Department is committed to 
working with Congress to achieve enactment of a comprehensive and 
common sense reform package to improve the Medicare appeals process and 
address the pending backlog.
    Question. Has HHS created a more consistent redeterminations 
process at the Centers for Medicare and Medicaid Services and the 
Office of Medicare Hearings and Appeals to discourage continued 
appeals?
    Answer. The Department continues to pursue and implement 
administrative initiatives to improve efficiency within the Medicare 
appeals process and to address and resolve appeals as early as 
possible. In March 2017, the Department began implementing an appeals 
final regulation which will expand the pool of available Office of 
Medicare Hearings and Appeals (OMHA) adjudicators, increase 
decisionmaking consistency among the levels of appeal, and streamline 
the appeals process so less time is spent by adjudicators and parties 
on repetitive issues and procedural matters. Furthermore, several 
changes are being implemented to the statistical sampling program to 
expand the administrative option to additional appellants and respond 
to feedback received from the pilot program. This effort, coupled with 
administrative actions HHS has undertaken at the first and second 
appeal levels, is expected to have an appreciable impact on creating 
efficiency within the Medicare appeals process and limit the number of 
appeals to the third appeal (OMHA) level.
    In addition to the administrative initiatives, the Department is 
committed to working with Congress to achieve enactment of a 
comprehensive and common sense reform package to improve the Medicare 
appeals process and address the pending backlog.
                                 ______
                                 
              Questions Submitted by Senator Thad Cochran
                               telehealth
    Question. Telehealth has demonstrated the ability to deliver needed 
healthcare to patients where and when they need care. As a rural state 
with healthcare provider shortages, Mississippi has built a statewide 
telehealth system to reach patients with healthcare in their local 
communities. The University of Mississippi Medical Center is leading 
this effort and has seen tremendous outcomes for patients who use this 
system. While states across the country have implemented policies to 
enable telehealth reimbursement by private payers and state Medicaid 
departments, Medicare currently limits telehealth reimbursement, 
keeping these healthcare services from reaching many patients. In 
response to Senator James Lankford's question during the hearing, you 
indicated that the Department of Health and Human Services has 
authority to make adjustments to Medicare reimbursement for telehealth. 
However, it is my understanding that existing geographic and 
originating site limitations for telehealth reimbursement are statutory 
restrictions from Section 1834(m) of the Social Security Act. For 
example, a federally qualified health center (FQHC) located in a non-
rural area would not qualify for Medicare telehealth reimbursement 
because, although FQHCs are approved originating sites of service for 
Medicare telehealth reimbursement, the facility is not located in a 
rural area. Telehealth, however, could deliver specialty services and 
expanded options to patients that otherwise might not be available at 
the FQHC.
    Do you have administrative authority to make changes to Section 
1834(m) or other existing telehealth reimbursement policy in the 
Medicare program, including rural or urban, or originating site 
considerations for reimbursement?
    What assistance do you need from Congress to be able to make these 
changes?
    Answer. We recognize the importance of telehealth in the healthcare 
delivery system and its critical role in providing access to care. We 
are currently reviewing our programs to find ways to promote the use of 
telehealth for Medicare beneficiaries.
    Through our annual Medicare Physician Fee Schedule rulemaking, the 
Centers for Medicare & Medicaid Services (CMS) has a process for adding 
services to the list of Medicare telehealth services for which payment 
can be made. This process provides the public with an ongoing 
opportunity to submit requests for adding services to the Medicare 
telehealth list. We carefully consider all requests to determine if 
additional services should be added to the telehealth list.
    It is correct that the statute only allows Medicare payment for 
telehealth services if beneficiaries are furnished the services while 
present in certain healthcare settings (i.e., originating sites) that 
are located in certain geographic areas. However, with respect to 
certain demonstrations and Center for Medicare and Medicaid Innovation 
(CMMI) payment and service delivery models, such as the Next Generation 
Accountable Care Organization model, the Social Security Act statute 
permits HHS/CMS to waive the restrictions applicable to telehealth 
reimbursement requirements for purposes of conducting those 
initiatives. Some waivers have been made based on the needs of a 
particular initiative. We anticipate learning from the evaluations of 
these models, and we will continue to evaluate opportunities to test 
adjustments to Medicare policy for telehealth. However, in order for 
any changes to be made to the current law originating site and 
geographic limitations for Medicare payments for telehealth services, 
Congress would need to act and change the statute at section 1834(m) of 
the Social Security Act.
                   complex rehabilitation technology
    Question. The Medicare Improvements for Patients and Providers Act 
of 2008 specifically excluded CRT power wheelchairs and related 
accessories from the Medicare competitive bidding program. However, the 
Centers for Medicare and Medicaid Services (CMS) published a document 
that announced plans to apply competitive bidding to CRT accessories. 
As a temporary measure, Congress has twice passed legislation to delay 
this process, but the current delay will expire on June 30, 2017, and 
CRT accessories will be subject to competitive bidding pricing. Will 
CMS review this document and issue a written clarification excluding 
CRT from competitive bidding prior to June 30?
    Answer. Addendum--occurred after date of the hearing: On June 23, 
2017, CMS issued new policy guidance on how adjustments to the fee 
schedule based on information from competitive bidding programs apply 
to wheelchair accessories and back and seat cushions used with group 3 
complex rehabilitative power wheelchairs. As a result, effective July 
1, 2017, payment for these items will continue to be based on the 
standard unadjusted fee schedule amounts, which will help to protect 
access to complex rehabilitative power wheelchair accessories on which 
people with significant disabilities depend.
                         intrathecal pain pumps
    Question. For almost 20 years, pharmacies could bill Medicare 
directly for the patient-specific prescribed compounded pain medication 
used in intrathecal pain pumps. However, in 2013, CMS issued CR 7397, 
which now requires doctors to buy these medications on behalf of the 
patient and then bill Medicare for these drugs as incident to the 
physician's services. Intrathecal pumps deliver a fraction of the dose 
of pain medication directly into the spine, allowing patients to 
experience greater pain relief with more appropriate and less dosage 
than oral medications. In addition, because these pumps are surgically 
implanted, the pain medication cannot be diverted like oral medication 
can be. With prescription opioid abuse in America rising to epidemic 
levels, it is imperative that Medicare beneficiaries retain access to 
this treatment option.
    Are you aware that many state boards of pharmacy, including 
Mississippi's, do not allow pharmacies to sell compounded solutions to 
physicians or other third parties for resale to patients?
    Since many pharmacies across the country are legally prohibited 
from selling these compounded medication to physicians, Medicare 
beneficiaries in places like Mississippi have lost access to this 
treatment option. Based on a response from CBO, I understand that 
reversing this policy would be budget neutral. Would you be willing to 
reconsider this misguided policy and ensure Mississippi seniors have 
access to the pain medication prescribed by their doctors?
    Answer. HHS is committed to ensuring that the many Medicare 
beneficiaries across the country that suffer from chronic pain have 
access to the medications and treatments they need.
    Depending on the circumstances, drugs used to refill an implanted 
intrathecal pump can be paid under either ``incident to'' a physician's 
services under Part B, under the DME benefit category, or under 
Medicare Part D. In the Calendar Year 2013 Medicare Physician Fee 
Schedule final rule, CMS clarified longstanding policy that drugs used 
by a physician to refill an implanted item of DME were considered to be 
``incident to'' a physician's services and not in the DME benefit 
category. Therefore, for the drug to be paid under Part B, the 
physician must buy and bill for the drug, and a non-physician supplier 
that has shipped the drug to the physician's office may not bill CMS 
separately. We note that payment to pharmacies (or suppliers) for drugs 
used to refill an implanted pump can be made under the DME benefit 
category where the drug is directly dispensed to a patient and the 
implanted pump is refilled without a physician's service. However, it 
is our understanding that implanted pumps are rarely refilled without 
utilizing the service of a physician.
    It was our understanding at the time the rule was written, that the 
majority of pharmacies in the country were in compliance with the 
physicians' ``buy and bill'' approach. We have not received reports 
that the situation has changed, nor have we received reports of 
significant access problems. CMS will continue to monitor this 
situation. In that regard, we would welcome any further information 
about any issues or problems that Medicare beneficiaries may be 
experiencing as a result of this policy.
                     low-volume payment adjustments
    Question. I was pleased to find that the CMS Inpatient Prospective 
Payment System (IPPS) proposed rule clarified that Indian Health 
Services (IHS) hospitals should not be considered Subsection (d) 
hospitals for purposes of determining eligibility for Medicare 
inpatient hospital low-volume payment adjustment for non-IHS hospitals. 
However, the IPPS proposed rule would only affect discharges beginning 
in fiscal year 2018. It does not affect non-IHS hospitals that have 
already returned low-volume payments to CMS due to proximity to an IHS 
hospital.
    Will your Department clarify that the policy stated in the IPPS 
proposed rule has been the CMS policy all along?
    Given the proposed IPPS rule, what can your Department do 
retroactively to address payments the affected hospitals already have 
returned to CMS?
    As you know, the CMS appeals process is lengthy and quite 
expensive. Many hospitals small enough to qualify for the low-volume 
payment adjustments cannot bear the significant expense of mounting a 
years-long appeal to recover payments returned to CMS related to this 
issue. What will your Department do to expedite a solution for affected 
hospitals?
    Answer. As you note, the Inpatient Prospective Payment System 
fiscal year 2018 proposed rule, which was displayed by the Office of 
the Federal Register on April 14, 2017, included a prospective, 
parallel adjustment equal to the applicable low-volume hospital payment 
adjustment for certain hospitals that would otherwise not meet the 
distance requirement for the statutory low-volume hospital payment 
adjustment, including (1) those IHS or Tribal hospitals whose sole 
disqualifier for the low-volume hospital payment adjustment is 
proximity to a non-IHS or Tribal hospital, and (2) those non-IHS or 
Tribal hospitals whose sole disqualifier is proximity to an IHS or 
Tribal hospital. Such an adjustment would provide that, practically 
speaking, an IHS or Tribal hospital would be able to receive a low-
volume hospital payment adjustment based on its distance to the nearest 
IHS or Tribal hospital, and a non-IHS hospital would be able to qualify 
to receive a low- volume hospital payment adjustment based on its 
distance to the nearest non-IHS hospital. The rule's 60-day comment 
period ended on June 13, 2017. We will carefully consider all comments 
received during the comment period before a final policy decision is 
made and the final rule is published. CMS's ultimate determination will 
be included in the final regulation, along with a summary of the 
comments and our responses.
    We recognize the challenges that small hospitals face in the 
appeals process, including the expenses involved to appeal a 
determination. We are committed to ensuring the appeals process works 
effectively and efficiently for hospitals seeking to appeal any 
contractor determination. The fiscal year 2018 President's Budget is an 
important component of the comprehensive strategy the Department has 
developed to eliminate the backlog of Medicare appeals. Taken together, 
the additional funding, administrative initiatives, and legislative 
proposals included in the President's Budget will help ensure 
beneficiaries and providers have timely resolution of appeals. The 
Department is committed to working with Congress to achieve enactment 
of a comprehensive and common sense reform package to improve the 
Medicare appeals process and address the pending backlog.
                            liver transplant
    Question. The United Network for Organ Sharing (UNOS) is the entity 
designated by the Federal Government to manage the Organ Procurement 
and Transplantation Network. In 2016, UNOS's Liver and Intestinal Organ 
Transplantation Committee offered a new plan for allocating livers for 
transplantation nationally. Many in the liver transplant community 
expressed concern that this plan would have had a disproportionately 
negative effect on rural, underserved states. UNOS reviewed public 
comments on the plan, a vast majority of which opposed the proposed 
redistribution plan. Therefore, UNOS determined that it would 
reevaluate the proposal in 2017. It is my understanding that process is 
underway and a revised proposal could be released this year.
    Please provide an update on this process.
    What is the process by which UNOS is engaging hospitals, 
physicians, and patients in rural, underserved states like Mississippi 
as it reevaluates its proposal?
    If UNOS follows through with previous proposal, what will HHS do to 
address resulting access issues in many parts of the country?
    Answer. The National Organ Transplant Act of 1984, as amended 
(NOTA), authorizes the Organ Procurement and Transplantation Network 
(OPTN) to develop policies on the allocation of donor organs and on 
other issues necessary for the functioning of the OPTN. The 
implementing Federal regulation, the OPTN ``final rule'' (42 CFR Part 
121), governs the structure and operation of the OPTN, and establishes 
other requirements regarding organ allocation and other policies. Per 
the OPTN Final Rule, OPTN allocation policies must, among other 
factors, be based on sound medical judgment, seek to achieve the best 
use of donated organs, and shall not be based on a candidate's place of 
residence or listing except to the extent required to satisfy other 
factors. Often, these factors must be balanced, and HRSA relies on the 
expertise of the OPTN and transplant community to balance these factors 
as organ allocation policies are created and changed. The OPTN policy-
making process takes into account changing medical technology and 
advances, includes the examination of the potential consequences of 
policy changes, reviews of simulation modeling predictions, and 
opportunities for the public, including those who may be affected, to 
express their views.
    In 2012, the OPTN Board of Directors took the position that 
existing geographic disparity in the allocation of livers for 
transplant is unacceptably high. The Board instructed the Liver and 
Intestinal Organ Transplantation Committee to propose methods of 
reducing that disparity. In some regions of the United States, patients 
must reach a very high disease severity in order to get a transplant. 
In other areas, patients are more often transplanted with lower disease 
severity. The current effort to address disparities in liver allocation 
is part of the OPTN's responsibility to promote equitable allocation of 
organs. The transplant community is also encouraging organ donation to 
increase the supply.
    The Liver and Intestinal Organ Transplantation Committee has 
developed a new proposal that, based on available statistical modeling, 
addresses measures of geographic disparity while not significantly 
increasing travel time or flight travel for livers. The new proposal 
would not redraw existing donor service area or regional boundaries. 
However, it would provide greater allocation priority to candidates 
listed at hospitals within 150 nautical miles of the donor hospital, 
regardless of the donor service area or region where these nearby 
candidates are located. In this way, it would provide earlier access to 
available livers for urgent liver candidates who are outside, but 
nearby to, existing regional boundaries. The Committee anticipates 
releasing a revised proposal for public comment on July 31, 2017, for a 
period through October 2, 2017, and finalizing a proposal for 
consideration by the OPTN Board of Directors in December 2017.
    HHS will continue to monitor developments regarding proposed 
changes to the OPTN liver allocation policy for compliance with the 
requirements set forth in the OPTN final rule (42 CFR 121).
                         transitional policies
    Question. On February 23, 2017, CMS issued guidance to allow states 
to continue to issue certain health insurance policies known as 
transitional policies through December 31, 2018. Unless another 
extension is issued, Mississippians will face substantial premium 
increases in both the individual and small group health insurance 
markets beginning in 2019. Will your Department consider extending this 
transitional policy relief into 2019 and beyond?
    Answer. The Administration recognizes that states are the primary 
regulators of health insurance, and it remains imperative for the 
Executive Branch to empower states with more flexibility and control.
    Consistent with this belief, as you note, on February 23, 2017, HHS 
announced that people will continue to be allowed to keep their 
transitional plans if they like them,\1\ ensuring lower premiums and 
real choices for millions of Americans. (Since Obamacare went into 
effect, HHS permitted renewal of noncompliant individual and small-
group plans under certain conditions, but that policy was set to expire 
this year.)
---------------------------------------------------------------------------
    \1\ See: https://www.cms.gov/CCIIO/Resources/Regulations-and-
Guidance/Downloads/Extension-Transitional-Policy-CY2018.pdf.
---------------------------------------------------------------------------
    We will continue to ensure that policies empower states to make 
decisions that work best for their markets, understanding that there 
are differences in markets from state to state. We will support state 
flexibility and control to create a free and open healthcare market in 
accordance with current statute.
                 mississippi delta health collaborative
    Question. For many years, the Centers for Disease Control has 
provided funding for the Mississippi Delta Health Collaborative. This 
Collaborative provides leadership in the Delta region to implement 
heart disease and stroke prevention interventions in order to reduce 
morbidity, mortality, and related health disparities.
    What important outcomes or findings have resulted from the work of 
this Collaborative?
    Answer. Since 2008, CDC has provided funding to the Mississippi 
Delta Health Collaborative (MDHC) to prevent and control heart disease 
and stroke in the Mississippi Delta Region. Major accomplishments 
resulting from this funding include:
  --Infrastructure and Capacity: MDHC established and maintains 
        expertise in key areas, including: epidemiology/surveillance, 
        nursing, health education, project management, and healthcare 
        extension (i.e., community health workers, congregational 
        nurses).
  --Epidemiology/Surveillance: Implementation of the Cardiovascular 
        Health Examination Survey (CHES) is a population-based, cross-
        sectional survey that enables the Mississippi Delta Region to 
        accurately document baseline prevalence and distribution of 
        primary risk factors for cardiovascular disease, and examine 
        existing environmental supports for healthy choices.
  --Community-Clinical Linkages:
    --Community Health Workers (CHWs): MDHC has engaged 21 healthcare 
            clinics, including rural clinics, and all 5 Mississippi 
            Delta Region federally qualified health centers (FQHCs) to 
            use their electronic health records (EHR) to identify, 
            classify, and treat eligible hypertension patients for 
            disease self-management and make community referrals. To 
            date, five of the six healthcare systems are utilizing an 
            EHR to generate a list of all eligible patients. CHWs visit 
            such patients or call them to recruit into the program.
    --Pharmacists--Medication Therapy Management (MTM) Initiative: The 
            University of Mississippi, College of Pharmacy has 
            partnered with MDHC to implement a MTM initiative. These 
            activities help ensure people take medications as 
            prescribed and also discuss the importance of diet, 
            exercise, and other lifestyle choices that may eliminate 
            the need for certain medications.
    --Congregational Health Nurses and Barbers: MDHC is partnering with 
            congregational health nurses and barbers to promote blood 
            pressure screening and awareness.
    Question. What does the CDC plan to do to expand this good work in 
future years?
    Answer. In the fiscal year 2018 President's Budget, CDC proposes 
creating the $500 million America's Health block grant. With funding 
from this block grant, Mississippi may choose to continue to support 
activities related to prevention and control heart disease and stroke 
in the Mississippi Delta Region.
                              rural health
    Question. Rural hospitals are closing at an alarming rate, leaving 
many rural Americans uncertain about where they will receive their 
healthcare. Each year, this Committee seeks to find innovative ways to 
help rural Americans maintain access to care in their local 
communities.
    What policies will your Department put in place to address rural 
healthcare challenges?
    Answer. The Federal Office of Rural Health (FORHP) within HRSA 
serves as the HHS lead on all activities to address rural health 
matters. HRSA collaborates with Federal partners in order to maximize 
support to rural areas for healthcare access and financing.
    HRSA works with Centers for Medicare & Medicaid Services to monitor 
potential effects of pending regulations, especially those related to 
Medicare, on rural providers and systems.
    FORHP also works closely with the Centers for Disease Control and 
Prevention to coordinate research efforts and promote the use of 
clinical guidelines by rural providers, and with the Department of 
Veterans Affairs's, Office of Rural Health to enhance care for rural 
Veterans.
    Question. What CMS reimbursement policies will your Department 
pursue to stabilize rural healthcare?
    How will CMS use regulations and rulemakings to ensure rural 
healthcare is strengthened and is not further weakened?
    Answer. We understand and take seriously our obligation to ensure 
the quality of and access to high-quality healthcare in rural America. 
Patients and healthcare providers in rural areas face special 
challenges in accessing and delivering services. Rural providers, 
including hospitals, struggle with thin operating margins and lower 
patient volumes. Healthcare employment issues, such as physician 
shortages, also make accessing and providing healthcare challenging. I 
recognize these challenges, and am committed to working with you to 
ensure regulations issued by the Department are not overly burdensome 
on patients' ability to access care, and providers' ability to deliver 
services. Open communication with Congress, providers, and the 
communities they serve are key for gauging, monitoring, and mitigating 
the impact of regulatory requirements.
    In 2016, CMS established the Rural Health Council to consider three 
strategic areas: first, ways to improve access to care for all 
Americans in rural settings; second, ways to support the unique 
economics of providing healthcare in rural America; and third, making 
sure a healthcare innovation agenda appropriately fits rural healthcare 
markets. There are Regional Rural Health Coordinators in each of the 
ten CMS regional offices who participate in regular outreach and 
education sessions with rural stakeholders and maintain partner 
relationships with state offices of rural health and various state 
rural provider associations and advocacy groups. CMS routinely hosts a 
dedicated Rural Health Open Door Forum call to provide information and 
learn about emerging rural health issues.
       quality improvement center for infant toddler court teams
    Question. It is my understanding that the Administration for 
Children and Families failed to fund a continuation of the national 
technical assistance effort offered by the Quality Improvement Center 
for Infant-Toddler Court Teams in fiscal year 2016, despite 
continuation funds included in that year's appropriations bill. When 
this work ends in September 2017, newer infant- toddler court team 
sites, like the one in Rankin County, Mississippi, will be at risk of 
closure. How is your Department working to move quickly to award the 
fiscal year 2017 funding, as included in the Consolidated 
Appropriations Act , 2017, (PL 115-31), omnibus appropriations bill, to 
ensure that these sites can remain active?
    Answer. On June 21, 2017, ACF published a Funding Opportunity 
Announcement for a Quality Improvement Center that will support 
demonstration sites that establish or enhance collaborative community 
court teams. The demonstration sites must involve intensive 
collaboration among the child welfare agency, Court Improvement 
Program, local courts, legal community, substance abuse treatment 
providers, preventative service providers, mental health providers, 
medical providers, and other key stakeholders. Applications are due to 
ACF by July 21, 2017.
                                 ______
                                 
               Question Submitted by Senator Jerry Moran
                             clinical labs
    Question. The Protecting Access to Medicare Act of 2014 (PAMA) 
included a provision to reform the Medicare Clinical Laboratory Fee 
Schedule (CLFS) so that it becomes a ``market-based'' fee schedule. 
While a market-based fee schedule should ultimately provide certainty 
for clinical laboratories and patients, specific provisions in PAMA 
implementation created complex and burdensome data reporting 
requirements.
    While reviewing reported private market rates, did CMS considered 
the differences between hospital laboratories, physician office 
laboratories, and independent laboratories? Can you ensure that the new 
fee schedule reflects accurate rates across the market and that 
Medicare beneficiaries have adequate access to clinical laboratory 
services?
    Answer. CMS is committed to the successful implementation of the 
new private payor rate- based CLFS and looks forward to working with 
the laboratory industry to ensure accurate payment rates. Regarding the 
data reporting requirements, during notice and comment rulemaking, CMS 
finalized a low expenditure threshold to reduce the reporting burden on 
laboratories by reducing the number of laboratories that must report. 
Even though we have reduced the number of physician office and 
independent laboratories for which applicable information will be 
reported, we estimate those physician laboratories and independent 
laboratories for which applicable information must be reported accounts 
for nearly all of the laboratory HCPCS codes on the CLFS, which will 
help to ensure that the new fee schedule reflects accurate rates across 
the market. We will continue to review the operations of the program 
and look forward to industry feedback on how to improve the program.
                                 ______
                                 
               Questions Submitted by Senator Marco Rubio
                             cybersecurity
    Question. It's no secret that our nation is vulnerable to 
cybersecurity threats. This problem goes far beyond cyber threats to 
our national defense infrastructure, as we have recently seen hospitals 
being held at ransom by hackers aiming to exploit them for money.
    How does this budget demonstrate a commitment to increasing the 
security of our healthcare system?
    Are most hospitals and healthcare systems in the country aware of 
the cyber threats we face, and do they know how to protect themselves 
and their patients?
    What is the Administration doing to provide resources and guidance 
to healthcare systems that are not sure how to protect their network?
    Answer. The fiscal year 2018 President's Budget includes $72 
million for the HHS cybersecurity program, an investment of $22 million 
above the fiscal year 2017 Enacted level. The Budget will allow the 
program to continue mission-critical activities which address the 
evolving cyber threats and protect the Department's sensitive 
information. The investment will, in part, be directed to expand HHS's 
capability to share cybersecurity threat information and resources 
across the Federal and private healthcare and public health spaces, for 
better protection of personally identifiable information and personal 
health information.
    Hospitals and healthcare systems around the country are acutely 
aware of the evolving and continual cyber threats. Health records 
possess a wealth of critical information, and the ability of healthcare 
professionals to quickly access them can be vital to ensuring positive 
patient outcomes. However, these records also contain information that 
is valuable to cyber criminals. That is why HHS focused in two primary 
areas of cybersecurity during the recent global ransomware attack: 
protection of HHS systems and coordination with our public health and 
private sector partners to help protect their systems as well. In order 
to better support coordination within the healthcare system, the 
Department is realigning existing capabilities to create an enhanced 
cybersecurity capability. This capability is the Healthcare 
Cybersecurity Communications and Integration Center (HCCIC). The HCCIC 
is a central location for information sharing across HHS and Federal 
Government partners, and it will provide data and tools to support the 
healthcare and public health sector. HHS has led a strategy to enhance 
cybersecurity within the Department and in the healthcare and public 
health sector. This strategy strengthens relationships across the 
Federal Government, state, territorial, and local public health 
authorities, and private sector to facilitate information and resource 
sharing, provide guidance in response to cyber threats, and establish 
relationships which are essential to conduct an effective response to a 
cyber attack.
    HHS understands that healthcare facilities are facing cybersecurity 
challenges. The Assistant Secretary for Preparedness and Response has 
developed a collection of peer-reviewed resources on cybersecurity to 
help healthcare industry stakeholders better protect against, mitigate, 
respond to, and recover from cyber threats, in order to better defend 
patient safety and operational continuity. Additionally, the Department 
is supporting the healthcare sector by: establishing and sustaining 
valued cybersecurity industry partnerships; providing analysis of 
incidents, threats, and vulnerabilities; maintaining post-incident and 
risk-informed trending and analysis; sharing healthcare and public 
health specific lessons learned across the sector; and enabling 
healthcare and public health partners to make actionable risk-based 
decisions.
                           childhood obesity
    Question. I appreciate the budget's emphasis on the need to reduce 
childhood obesity. Reports show that one out of every five children in 
America is obese. This is a public health issue and a problem for our 
national security. In 2013, the DoD estimated more than 70 percent of 
17 to 24-year-olds in the U.S. would fail to qualify for military 
enlistment for various reasons, including obesity. At the end of last 
year, the Department of Defense announced a review of its recruiting 
standards which noted the high number of potential recruits that are 
ineligible for the U.S. Military.
    Could you please elaborate on how childhood obesity poses a risk to 
our nation's public health and national security?
    Answer. Improved nutrition and increased physical activity can 
build a strong nation. Obesity affects almost 1 in 5 children and 1 in 
3 adults, putting people at risk for diseases such as diabetes, heart 
disease, and certain cancers. Obesity also costs the U.S. healthcare 
system $147 billion a year.
    Obesity affects the military's ability to recruit and retain 
personnel in many ways. Nearly one in four young adults are too heavy 
to serve in our military; obesity is among the top three reasons why 
young adults are ineligible to serve; obesity among active duty service 
members rose 61 percent between 2002 and 2011. These individuals are 
less likely to be medically ready to deploy; and both obesity and low 
levels of physical fitness increase the risk for injury among active 
military personnel.
    The fiscal year 2018 President's Budget proposes the new $500 
million America's Health block grant, which will enable states and 
tribes to organize chronic disease prevention and control efforts, 
including obesity-related interventions, and deploy already-identified, 
evidence-based interventions in a manner that makes the most sense to 
their jurisdictions and circumstances.
    Question. Has HHS coordinated with the U.S. Military on how we can 
ensure that HHS' efforts to combat obesity complement the Military's 
recruitment requirements?
    Answer. In May of 2016, CDC established a Memorandum of 
Understanding (MOU) with the Department of Defense (DoD), which 
provides the opportunity for DoD personnel to have 1 year of post-
graduate training and skill-building experience at CDC. Each 
participating DoD staff member works closely with CDC public health 
nutrition researchers to broaden his/her knowledge and skills in 
implementing and evaluating food environment programs and 
interventions. To date, this partnership has resulted in increased 
opportunities and expertise to provide healthier foods and beverages at 
military bases and the surrounding communities. Since signing the MOU, 
CDC has hosted one DoD fellow from 2016--2017 and will host another 
fellow starting in the summer of 2017.
    In addition, CDC has a partnership with the non-profit organization 
Mission: Readiness to educate the general public about the risk obesity 
poses to maintaining national security. With a membership made up of 
more than 700 retired admirals, generals, and other top military 
leaders, Mission: Readiness supports evidence-based state and Federal 
activities that are proven to prepare youth to serve their nation in 
any way they choose. Recently, CDC partnered with Mission: Readiness to 
release a new infographic Unfit to Serve--Obesity is Impacting National 
Security. This infographic outlines how the obesity epidemic in the 
United States impacts our national security.
                               zika virus
    Question. With regard to Zika, two primary focal points within the 
CDC are pregnancy registry and surveillance. While these are laudable 
initiatives, they do not calm the fears of mothers and soon-to-be 
mothers in my home state of Florida. In the $1.1 billion Zika 
supplemental, a small portion of funding was given to states like 
Florida for vector control. While I appreciate the inclusion of funding 
for Zika research in the fiscal year 2018 budget, that will not help 
local communities as mosquitoes become more prevalent in the summer 
months.
    What is HHS doing immediately to help local communities prevent the 
spread of Zika in the coming months--not just track cases?
    Answer. CDC is working around the clock to respond to the Zika 
virus outbreak. CDC's work includes developing laboratory tests to 
diagnose Zika, conducting studies to learn more about Zika, publishing 
reports about Zika, monitoring and reporting cases of Zika, providing 
guidance to travelers and Americans living in areas with outbreaks, and 
providing on-the-ground support in countries and US territories with 
current Zika outbreaks.
    In addition to tracking the spread of Zika virus and other 
mosquito-borne viruses in the United States and around the world, CDC 
is helping communities prevent the spread of Zika by:
  --Teaching healthcare providers how to identify Zika;
  --Advising travelers how to protect themselves while traveling in 
        areas with risk of Zika;
  --Training disease detectives to find and report Zika cases;
  --Testing samples (https://www.cdc.gov/zika/hc-providers/
        diagnostic.html) for Zika and providing laboratories with 
        diagnostic tests; and
  --Educating the public about Zika virus.
    Additional details describing the ways in which CDC is helping 
communities now through Zika response activities can be found on CDC's 
Zika website at: https://www.cdc.gov/zika/about/whatcdcisdoing.html.
    For CDC activities in Florida, please see CDC's Zika website at: 
https://www.cdc.gov/zika/specific-groups/cdcactivities.html.
    Question. Some have raised concerns that couples have not been able 
to be tested for Zika before they try to get pregnant. Understandably, 
couples would like to know whether they have Zika before getting 
pregnant. What is the administration doing to enable couples to get 
tested before conceiving?
    Answer. Zika virus testing is performed at CDC, at several state 
and local health departments, and at some commercial laboratories. 
Several lab tests are available to help determine if a person is 
infected with Zika virus disease. Healthcare providers should contact 
their state and local health department to facilitate testing. See 
CDC's Testing for Zika Virus webpage for information on how to obtain 
Zika testing: (https://www.cdc.gov/zika/hc-providers/testing-for-
zikavirus.html).
Testing Recommendations for Non-Pregnant Women and Men
    Symptomatic Patients: Zika virus testing is indicated for non-
pregnant women and men who have possible exposure to Zika and who 
experience symptoms of Zika virus disease. (See CDC's Zika virus 
testing webpage https://www.cdc.gov/zika/hc-providers/testing-for-
zikavirus.html) Possible exposure is defined as living in, or having 
recently traveled to an area with risk of Zika, or sex without a condom 
with someone who lives in or has recently traveled to an area with risk 
of Zika. The most common symptoms of Zika virus disease are fever, 
rash, headache, joint pain, conjunctivitis (red eyes), and muscle pain.
    Asymptomatic Patients: Routine testing is not currently recommended 
for women who are not pregnant and men who have possible exposure to 
Zika virus, but have no clinical illness. However, Immunoglobulin M 
(IgM) testing can be considered for asymptomatic women who are planning 
to conceive in the near future among those who live in or frequently 
travel to areas with Travel Notices (see below).
    No test is 100 percent accurate. A test result can sometimes be 
negative in the setting of true infection, and the results could be 
falsely reassuring.
    For example:
  --If the IgM test is performed too early after infection when the 
        antibody levels are not yet high enough, the results could be 
        negative even though infection is present.
  --If the IgM test is performed after the IgM has waned, the results 
        could be negative. Similarly, if the serum or blood Polymerase 
        Chain Reaction (PCR) is performed after the virus is no longer 
        in the blood, Zika could still be present in other bodily 
        fluids (e.g., semen). In those situations, the blood test would 
        be negative but the person could still be infected and able to 
        infect others.
  --It is also possible for IgM test results to be positive in the 
        absence of infection because of, for example, extended IgM 
        persistence after infection has resolved or due to cross-
        reactivity of IgM test with another virus.
Preconception Testing Recommendations for Women
    Preconception Zika IgM testing can be considered for asymptomatic 
women planning to become pregnant in the near future who live in, or 
frequently travel to, areas with a CDC Zika travel notice. Testing 
shortly before pregnancy can provide information that may help 
interpret test results in the future if a woman is exposed to Zika 
subsequently, during pregnancy. Positive IgM test results before 
pregnancy should not be used to determine if it is safe for a woman to 
become pregnant because the test results could have multiple 
interpretations. Positive test results could mean a recent infection 
with Zika; recent infection with a similar type of virus such as 
dengue, a false positive result, or a past infection with Zika. 
Negative IgM test results before pregnancy and a subsequent positive 
IgM test result during pregnancy might reflect a new Zika infection 
that occurred between the first and the second test or a recent Zika 
virus infection. Again, the positive test result during pregnancy could 
also be reflecting a false positive result or a recent infection with a 
similar virus.
    Additional information can be found on CDC's Zika website at: 
https://www.cdc.gov/zika/hc-providers/reproductive-age/exposure-
testing-risks.html.
                               zika virus
    Question. Using funds from the Zika supplemental appropriations, 
the Federal Government funded multiple vaccine proposals, including one 
from the French pharmaceutical company, Sanofi. The U.S. Army and HHS 
provided Sanofi with about $43 million in research grants to develop a 
vaccine. Recent reports indicate that the Federal Government has 
granted Sanofi an exclusive license for this vaccine, but that Sanofi 
has denied the government's request for fair pricing guarantees.
    What were the factors used to determine the need to extend this 
exclusive license to Sanofi?
    Answer. Licensure negotiations are between Sanofi Pasteur and the 
Department of Defense (DoD)/Walter Reed Army Institute of Research 
(WRAIR). HHS is not involved in a decision to provide a license for use 
of the WRAIR vaccine technology to Sanofi. It should be noted that this 
is related to the intellectual property of the vaccine technology, and 
does not relate to the regulatory process of licensing vaccine for use 
based on safety and efficacy, conducted by the Food and Drug 
Administration.
    Question. To date, what percentage of the costs to develop this 
vaccine were funded by American taxpayers?
    Answer. As part of a portfolio approach to making an effective Zika 
vaccine available, HHS has obligated a total of $54 million for the 
development of the Zika vaccine being developed by Sanofi Pasteur. HHS 
is not aware of the total costs to date incurred by DoD/WRAIR.
    Question. It is my understanding that Sanofi declined the request 
for price assurances because it did not yet know the final costs of the 
drug's development and manufacturing. Has Sanofi expressed a 
willingness to reconsider the U.S. Army's request at a later date?
    Answer. HHS is not involved in licensure negotiations between 
Sanofi Pasteur and DoD/WRAIR.
    Question. Are there any plans for Sanofi to reimburse the Federal 
Government for its financial contributions, if the company chooses not 
to re-evaluate price guarantees?
    Answer. HHS is not aware of any plans for Sanofi to reimburse the 
Federal Government. While the United States Government (USG) is 
supporting the development of the vaccine, the manufacturer, Sanofi 
Pasteur, is utilizing its personnel and established infrastructure to 
expedite development of the vaccine. Large pharmaceutical companies 
have the expertise and infrastructure (manufacturing facilities and 
assay and release test validation) to quickly respond to emerging 
diseases that create an immediate public health concern. These efforts 
are not captured in the financial assistance that is provided by the 
USG. Many times, the companies will put aside other commercial 
interests in order to respond as part of their corporation's commitment 
to address public health concerns. These opportunity costs have value 
that are often not captured as part of the USG support and should be 
considered a cost sharing effort.
    Question. Did the request for pricing assurances only pertain to 
the vaccine's list price? If not, has Sanofi been asked to discount the 
vaccine to the CDC's national stockpile program? If not, will the CDC 
will be required to pay for the vaccine at its list-price?
    Answer. As the vaccine is in relative early stages of development, 
and HHS is not involved in discussions between Sanofi and DoD/WRAIR, 
HHS is not aware of discussions related to the vaccine list price or 
potential discounts that could be offered to CDC's Strategic National 
Stockpile program. Products in the Strategic National Stockpile are 
typically FDA licensed or approved, or in an advanced stage of 
development in which they are eligible for consideration for FDA 
Emergency Use Authorization.
    Question. Are there plans to offer exclusive licensing for the 
other taxpayer-funded Zika vaccines currently in development?
    Answer. HHS is not part of any license negotiations for the vaccine 
technology of Zika vaccines, which is separate from the regulatory 
process of licensing vaccines for use based on safety and efficacy, 
conducted by the Food and Drug Administration. BARDA is supporting the 
development of Zika vaccines with Takeda Pharmaceuticals and Moderna 
Therapeutics, and both companies are utilizing their established 
platforms that they already have licenses for or were developed by the 
companies. Zika vaccine candidates under development at NIH/NIAID may 
undergo discussions regarding licensing of the vaccine technology when 
these vaccines are ready to transition to a private sector partner.
    Question. When can we expect to see a Zika vaccine made available 
to Americans?
    Answer. Investigational Zika vaccines supported by HHS have entered 
preclinical and early clinical studies, with the most advanced in Phase 
2 trials, and with another starting Phase 2 trials in late 2017. The 
duration of these clinical trials will depend on factors such as the 
intensity of Zika virus transmission and the efficacy of the vaccine 
candidate. Based on the timelines provided by our development partners 
and assuming a traditional approval pathway that includes clinical 
efficacy studies, FDA-licensed Zika vaccines could be available in 
2020--2022. Vaccine availability under alternative, emergency 
regulatory pathways that can be exercised prior to FDA licensure may 
occur sooner.
                                 hcfac
    Question. There is a culture in South Florida that promotes 
healthcare fraud to take advantage of Medicare, Medicaid and other 
healthcare programs, costing taxpayer dollars. I appreciate the 
agency's request to increase funding for healthcare fraud and detection 
by more than $18 million through the HHS Inspector General and its 
partnership with the Department of Justice.
    Has the Department decided where these additional resources will be 
directed?
    Answer. Our law enforcement partners, including the HHS Inspector 
General, the Department of Justice, FBI, and CMS program integrity 
contractors, all supported by the Health Care Fraud and Abuse Control 
(HCFAC) Program Account, direct their resources based on their analysis 
of threats of healthcare fraud and abuse. South Florida has 
consistently been an area that has been identified as an area at high 
risk for fraud and abuse in Medicare and Medicaid. In 2007, as part of 
the South Florida Initiative, the interagency HCFAC teams launched the 
first Medicare Fraud Strike Force. The Strike Force model is a multi-
agency collaboration bringing together the prosecutorial, investigative 
and analytical resources of DOJ Criminal Division, U.S. Attorney's 
Offices, FBI, HHS-OIG, CMS, and state and local law enforcement 
partners to focus on the worst offenders engaged in fraud in the 
highest intensity regions--fraud ``hot spots'' identified using 
advanced data analysis techniques. Since inception in 2007, the Strike 
Force has expanded to 8 additional cities.
    As the risk in South Florida still exists, the Departments will 
continue to operate the Medicare Strike Forces in Miami and Tampa. 
Further, HCFAC law enforcement partners employ sophisticated data 
analysis to determine which types of services areas such as Durable 
Medical Equipment or Prescription drugs and/or geographic areas such as 
South Florida are at greatest risk for fraud and abuse in healthcare. 
Resources are then allocated towards those areas that have the greatest 
risk.
    Question. Would you be willing to consider using some of these 
funds to increase the agency's anti-fraud efforts in South Florida?
    Answer. South Florida has been identified as a high risk area for 
fraud and abuse, and as such has been subject to many interventions to 
address fraud and abuse, including implementation of a Medicare Strike 
Force and provider enrollment moratoria for home health providers in 
Medicare and Medicaid.
    The HCFAC Program partners, including HHS-OIG, DOJ, and the FBI, 
use data analysis to determine how to allocate their HCFAC resources to 
address healthcare fraud and abuse. Therefore, the determination on how 
to apply additional resources toward any specific geographic or health 
service area will be based on data analysis of the risk of fraud in 
that area.
    Addendum--occurred after date of the hearing: On July 13, 2017 
Attorney General Jeff Sessions and Department of Health and Human 
Services (HHS) Secretary Tom Price, M.D., announced the largest ever 
healthcare fraud enforcement action by the Medicare Fraud Strike Force, 
involving 412 charged defendants across 41 Federal districts, including 
115 doctors, nurses and other licensed medical professionals, for their 
alleged participation in healthcare fraud schemes involving 
approximately $1.3 billion in false billings. Of those charged, over 
120 defendants, including doctors, were charged for their roles in 
prescribing and distributing opioids and other dangerous narcotics. 
Thirty state Medicaid Fraud Control Units also participated in today's 
arrests. In addition, HHS has initiated suspension actions against 295 
providers, including doctors, nurses and pharmacists.
    For the Strike Force locations, in the Southern District of 
Florida, a total of 77 defendants were charged with offenses relating 
to their participation in various fraud schemes involving over $141 
million in false billings for services including home healthcare, 
mental health services and pharmacy fraud. In one case, the owner and 
operator of a purported addiction treatment center and home for 
recovering addicts and one other individual were charged in a scheme 
involving the submission of over $58 million in fraudulent medical 
insurance claims for purported drug treatment services. The allegations 
include actively recruiting addicted patients to move to South Florida 
so that the co-conspirators could bill insurance companies for 
fraudulent treatment and testing, in return for which, the co-
conspirators offered kickbacks to patients in the form of gift cards, 
free airline travel, trips to casinos and strip clubs, and drugs.
                                 opioid
    Question. The opioid issue cuts across multiple Federal, state and 
local government entities. To fully address this crisis, we must 
coordinate efforts in a multi-pronged approach.
    How does HHS plan to coordinate with states and other Federal 
agencies, such as USPS, DEA, DOJ, DHS and State?
    What may be preventing increased coordination and how can this 
Committee help break down some of those barriers
    Answer. The U.S. Department of Health and Human Services is keenly 
aware of the devastating impact that opioid addiction is having on our 
families and communities. Ending this public health crisis is among my 
top Departmental priorities, and your shared commitment to this fight 
is greatly appreciated. Coordination among Federal agencies and with 
our state and local partners is key to combatting opioid misuse, abuse, 
and overdose, and is reflected in the investments proposed in the 
fiscal year 2018 President's Budget. Within HHS, the Behavioral Health 
Coordinating Council works to share information and identify and 
facilitate collaborative, action- oriented approaches to address the 
HHS behavioral health agenda without duplication of effort across the 
Department. HHS coordinates this work with Federal agency partners 
through the Interagency Workgroup on Prescription Drug Abuse 
Prevention/Opioid Overdose Prevention, led by the White House's Office 
of National Drug Control Policy. In addition, in March 2017, the 
President announced a Commission on Combating Drug Addiction and the 
Opioid Crisis to map out the Administration's approach to combat this 
crisis. We look forward to working across the administration and with 
state and regional partners on the critical task of reducing opioid 
overdose deaths.
    Question. About 75 percent of patients receiving substance abuse 
treatment in South Florida are not Floridians--some of whom are preyed 
upon by bad actors promising substance abuse treatment that they fail 
to deliver. Drug dealers have also been known to conduct their 
activities next door to the poor performing treatment centers. In far 
too many cases, these patients relapse and it's up to Florida's local 
emergency services to respond. However, this is straining the financial 
resources and manpower of these emergency responders in South Florida.
    What is HHS going to do to account for areas like South Florida 
that have epidemics that are not reflected in the community's 
population when allocating substance abuse grants?
    What, if anything, can HHS do to work with private accreditation 
boards to identify bad actors that don't provide the substance abuse 
treatment they promise?
    How can HHS work with different states' private insurers to give 
the resources needed to steer patients towards quality substance abuse 
treatment centers that can actually help patients?
    Answer. On June 5 and 6, 2017, SAMHSA held a meeting that included 
representation from states (including Florida), accrediting bodies, 
payers and national provider associations to discuss the issue of 
potentially unethical and fraudulent practices by treatment providers 
in ``sunshine states.'' A report with recommendations from the meeting 
is under development. Once available, HHS is happy to share with your 
office. Thank you for your commitment to this issue. HHS looks forward 
to continuing our work with you and your staff as we work to end this 
public health crisis.
                          market stabilization
    Question. Because of the Affordable Care Act, a number of insurers 
have left the individual market entirely over the past few years. 
Federal law under HIPAA prevents insurers from re-entering the market 
for 5 years after they choose to withdraw. What can we do to increase 
competition amongst insurers in the next few years?
    Answer. Across the Nation, Obamacare is failing the American 
people, delivering high costs, few options, and broken promises. 
Americans across the Nation have seen their health insurance choices 
collapse under Obamacare, leaving an increasing number attempting to 
buy health insurance through the Obamacare Exchanges with only one 
insurer. The ever-narrowing set of choices Americans are facing means 
that there is a very real chance some counties will have no insurers 
selling ACA plans in 2018.
    The Administration is taking steps to increase patient choice and 
provide greater flexibility for issuers to help attract healthy 
consumers, with the aim of improving the risk pool and bringing 
stability to the individual and small group markets. We began this work 
in a rule finalized in April, which includes policies to ease issuer 
burden and encourage them to continue participation in the individual 
market in 2018.
    The Department continues to look for areas to reduce regulatory 
burden under the President's Executive Order, and is committed to 
returning to states their traditional authority to regulate health 
plans. We seek to ensure that policies empower states to make decisions 
that work best for their markets, understanding there are differences 
in markets from state to state. We will support state flexibility and 
control to create a free and open healthcare market in accordance with 
current statute.
                                 macra
    Question. Last Congress, legislation was enacted to overhaul the 
Medicare payment system to pay Medicare providers based more on health 
outcomes and performance than the traditional Fee-For-Service model. 
There is a disconnect between the new payment model known as MACRA that 
encourages providers to innovate to improve health outcomes and current 
CMS Medicare rules that restrict providers and prevent them from 
developing new ways to care for patients.
    Has HHS considered how we can better align Medicare payments and 
Medicare rules to encourage providers to innovate?
    When do you expect HHS to begin the process of soliciting public 
comments to reform some of these regulations
    Answer. The Center for Medicare & Medicaid Services (CMS) has 
already proceeded with the implementation of the Medicare Access and 
CHIP Reauthorization Act (MACRA), through the creation of the Quality 
Payment Program. The Quality Payment Program, meant to promote greater 
value within the healthcare system, includes two tracks: the Merit-
based Incentive Payment System and Advanced Alternative Payment Models. 
The Quality Payment Program started in 2017, and CMS is currently 
evaluating the program and using stakeholder feedback to find ways to 
streamline and reduce clinician burden, and to make it easier for 
clinicians to participate and put their patients first. CMS recently 
released a proposed rule for the second year of the Quality Payment 
Program (82 FR 30010). This proposed rule will further advance the 
agency's goals of regulatory relief, program simplification, and state 
and local flexibility in the creation of innovative approaches to 
healthcare delivery. Once the public comment period for this proposed 
rule is closed, CMS will review and consider public comments.
                        assets for independence
    Question. Assets for Independence, otherwise known as AFI, fund 
Individual Development Account (IDA) programs which successfully 
combine financial education with matched savings accounts, empowering 
low-income families to build assets. IDA participants combine their own 
savings with matches from private and public funds to purchase a home, 
capitalize a business, or pay for postsecondary education or training.
    What factors led the Administration's proposal to cut funding for 
this program?
    Answer. In a constrained budget environment, difficult funding 
decisions were made to ensure that Federal funds are being spent as 
effectively as possible. Historically, the Assets for Independence 
Program has failed to use all of the funds appropriated for the 
program. Congress chose to discontinue this program in the fiscal year 
2017 final appropriation.
    Question. Does the Administration anticipate that states will 
provide the funding to enable IDA to continue to operate?
    Answer. There are already a range of non-Federal funding sources 
that support individual development accounts.
                    average manufacturer price rule
    Question. There are concerns that the recent Average Manufacturer 
Price rule and requirement to use acquisition based pricing models have 
some flaws and/or could cause increased costs in the Medicaid program. 
Does the current Administration plan to revisit this proposal given 
that most states still do not have their State Plan Amendments approved 
when the rule took effect on April 1, 2017?
    Answer. This Administration believes that states should have the 
flexibility they need to manage their Medicaid programs in the way that 
best meets the unique needs of the people they serve. The 
Administration is still in the process of reviewing a variety of 
regulations to maximize efficiency, accountability, and state 
flexibility.
                      medicaid drug rebate program
    Question. Some regulations like Federal anti-kickback statutes and 
the Medicaid drug rebate program prevent more innovative approaches to 
controlling drug costs through value-based purchasing or pay for 
performance programs--delivery system reforms in which CMS has 
previously expressed interest. Does the current Administration have any 
plans to revisit these regulations and/or the Medicaid drug rebate 
program and consider revisions to help enable these types of payment 
reforms used in commercial and non-regulated market plans?
    Answer. This Administration believes that states should have the 
flexibility they need to manage their Medicaid programs in the way that 
best meets the unique needs of the people they serve. HHS is committed 
to supporting innovative solutions that help lower the cost of 
prescription drugs. This Administration is still in the process of 
reviewing a variety of regulations to maximize efficiency, 
accountability, and state flexibility.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray
                                medicaid
    Question. Secretary Price, you have denied that your budget 
includes severe cuts to Medicaid for millions of children, pregnant 
women, veterans, people with disabilities, and low-income seniors. Not 
only does your budget cut the program by as much as $1.3 trillion, 
repeal the Medicaid expansion, and end the traditional Medicaid program 
as we know it, you claim that these are ``reforms'' to a broken 
program. We know that Medicaid is already a lean program, with costs 
per beneficiary that are substantially lower than those for private 
insurance or Medicare. Most studies show that Medicaid has helped 
millions of people access preventive and primary care, protecting 
against serious diseases. Can you please provide the justification for 
President Trump's decision to break his promise not to cut Medicaid and 
choose instead to jeopardize the healthcare of 75 million Americans?
    Answer. Under the Budget, nobody will fall through the cracks, and 
in fact, Medicaid spending will be higher over the next decade than the 
last decade by a significant margin. However, current growth in 
Medicaid spending is unsustainable, with growth outpacing gross 
domestic product and national health spending and accounting for an 
increasing share of Federal and State budgets. The current open-ended 
structure of Federal Medicaid funding encourages States to shift costs 
to the Federal Government and does not encourage States to focus on 
preventing waste, fraud, and abuse. At the State level, Medicaid crowds 
out important State priorities such as investments in education, public 
safety, and infrastructure. Medicaid's outdated rules are restrictive 
and complex, tying States' hands and preventing States from designing 
innovative approaches that address the specific needs of their 
populations. The Budget would help set Medicaid on a sustainable path 
and ensure the program can continue to provide care to those who are 
most vulnerable, the elderly, individuals with disabilities, children 
and pregnant women.
                             general budget
    Question. Secretary Price, the Center on Budget and Policy 
Priorities found that President Trump's budget gets three-fifths of its 
savings from programs for low- and moderate-income people. The safety 
net programs that your Department proposes to reduce includes 
eliminating the Social Services Block Grant, more than half of which 
goes to services like child welfare and protecting adults from abuse 
and neglect, as well as Community Action Agencies, which provide 
critical services to every county in my home of state of Washington. In 
previous hearings, you have spoken about identifying redundancies and 
potential partnerships that might be able to provide those services. 
Many state budgets are already struggling with scarce resources, and 
according to a letter from the National Governors Association, Federal 
funds make up an average of 31 percent of state budgets. Can you please 
provide specifics on what services will replace those currently 
provided by the Low Income Housing Energy Assistance Program, Social 
Services Block Grant, Community Services Block Grant, Community 
Economic Development program and the Rural Community Facilities 
program? And if you propose that state budgets will provide some of 
those services, how will states be able to do so given their current 
fiscal challenges?
    Answer. Both the Social Services Block Grant (SSBG) and the 
Community Services Block Grant (CSBG) provide funding that is 
duplicative of resources available through other programs. For example, 
the Community Services Block Grant accounts for only 5 percent of total 
funding received by the local agencies that benefit from these funds. 
Similarly, the SSBG constitutes only 10 percent (in fiscal year 2014, 
the most recent data available) of the total funding local 
organizations use to provide services. In neither program is receipt of 
Federal funding tied to strong performance outcomes. Funding for 
Community Economic Development and Rural Community Facilities is also 
duplicative of other Federal programs.
    For the Low Income Home Energy Assistance Program (LIHEAP), a 
difficult funding decision was made in a constrained budget environment 
to ensure that Federal funds are being spent as effectively as 
possible. LIHEAP is unable to demonstrate strong performance outcomes 
and is not the only source of assistance for low income households. As 
HHS looks for ways to improve the effectiveness and efficiency of the 
Federal Government, energy assistance programs are one area where we 
may look to States and private entities to play a larger role. Utility 
companies and state and local governments already provide significant 
heating and cooling assistance to low income households and the 
majority of states also prohibit utilities from discontinuing a 
household's energy in periods of severe weather or in certain other 
circumstances.
                     office of refugee resettlement
    Question. Your budget proposes to combine the Social Services and 
Targeted Assistance Programs at the Office of Refugee Resettlement 
(ORR). The combined funding level requested in your budget is $43 
million below the fiscal year 2017 level. Do envision this cut will 
come entirely from ``achieving greater efficiencies'', and if so, can 
you please provide more specifics about how these improvements will be 
realized? Will the level of services remain the same?
    Answer. The Budget proposes to combine these two programs to 
achieve greater efficiencies and reduce the administrative burden on 
States. Most Social Services and Targeted Assistance funding is used to 
help new arrivals to become self-sufficient, integrated members of 
American society. Funding can be reduced for these programs because new 
policies have resulted in a reduced number of refugees and other 
populations entering the country.
                           human trafficking
    Question. Victims of modern-day slavery include both sex and labor 
trafficking victims and are both foreign nationals and United States 
citizens. They are vulnerable to exploitation for a variety of reasons, 
but every vulnerable community is at risk for human trafficking. In a 
budget seeking cuts to protective HHS services, how will HHS ensure 
that more individuals do not become victims of human trafficking and 
have the support and resources they need to avoid exploitation?
    Answer. HHS assists foreign national and domestic (U.S. citizen and 
lawful permanent resident) victims of human trafficking and improves 
the national response to human trafficking through a number of efforts 
including: screening and identifying victims, providing victims 
benefits and services, conducting research, and raising awareness and 
preventing human trafficking. To keep more individuals from becoming 
victims of human trafficking and providing them the support they need 
to avoid exploitation, the Budget maintains the funding level that was 
current at the time for anti-trafficking in persons programs. The 
Budget also maintains funding that was current at the time for programs 
serving at risk populations including Runaway and Homeless Youth, Child 
Abuse Prevention, and Child Welfare Services.
                     community services block grant
    Question. The Community Services Block Grant (CSBG) is the sole 
Federal funding stream dedicated to Community Action Agencies (CAAs). 
CAAs utilize the CSBG local needs assessment and their tripartite 
boards to target the causes of poverty in their community. If CSBG 
funding were eliminated as your budget proposes, what would take the 
place of the unique local needs assessment that CAAs currently provide?
    Answer. The Community Services Block Grant accounts for only 5 
percent of total funding received by the local agencies that benefit 
from these funds.Therefore, communities that find the CAA needs 
assessment process useful are free to continue this activity using 
state, local, and private funds.
                         adoption opportunities
    Question. Why does the President's budget include a cut of $9 
million to the Adoption Opportunities Grant Program, from $39 million 
to $30 million, at a time when the number of children waiting to be 
adopted from foster care has increased to 112,000 over the past 3 
years?
    Answer. The Budget prioritizes maintaining direct services programs 
in child welfare and child abuse prevention and makes a targeted 
reduction to Adoption Opportunities, which primarily provides technical 
assistance.
                             homeless youth
    Question. Studies have shown that homeless youth exhibit 
psychiatric disorders at a rate four to six times greater than the 
general youth population. With an estimated 1.3 to 1.7 million youth 
experiencing homelessness each year across the country, the need for 
mental health services is staggering. In Washington State, 48 percent 
of youth exiting mental health facilities experience homelessness 
within 12 months. Our homeless service providers are struggling to 
address their behavioral health needs because of the lack of available 
intervention, counseling, and mental health services. How will HHS 
support Washington and other states across the country to ensure youth 
experiencing or at risk of homelessness have access to the mental 
health treatment they need to prevent or exit homelessness?
    Answer. The Budget continues to invest in programs that address 
homelessness, providing a total, for example, of $139 million in 
SAMHSA, an increase of $4.7 million above the fiscal year 2017 Enacted, 
and maintaining the funding level that was current at the time for the 
Runaway and Homeless Youth Programs in ACF.
    In addition, the Budget proposes new, innovative demonstrations 
within longstanding programs to translate recent research by the 
National Institute of Mental Health into action. This includes allowing 
for the first time up to 10 percent of the Children's Mental Health 
Services program to serve youth at the highest clinical risk of a first 
episode of psychosis.
                  preschool development grants program
    Question. In 2015, Congress demonstrated bipartisan support for 
prioritizing investments in early learning with the authorization of 
the Preschool Development Grants program in the Every Student Succeeds 
Act (ESSA). The program as currently authorized builds on the previous 
bipartisan support for expanding high-quality preschool opportunities 
for children, while emphasizing coordination and expansion of early 
learning services across programs. Given the support in Congress for 
this newly authorized program and your claim that your budget funds the 
``highest priorities, such as . . . early care and education'', how can 
we work together to ensure funding for these critical programs that 
have bipartisan support?
    Answer. Although the President's fiscal year 2018 Budget Request 
does not include funding for PDGs, in HHS alone, the Budget request 
includes over $15 billion for direct early care and education programs 
as well as funding for programs that states can use for early care and 
education, such as the Temporary Assistance for Needy Families program. 
We note that, in fiscal year 2017, Congress did not fund the newly 
authorized Preschool Development Grant program and instead only funded 
the final year of the current grants. The Administration looks forward 
to working with Congress to support important priorities such as early 
care and education.
                 child care and development block grant
    Question. In 2014, Congress came together to pass a bipartisan 
reauthorization of the Child Care and Development Block Grant (CCDBG) 
Act that is aimed at improving health and safety requirements for child 
care providers, increasing quality, and enhancing transparency for 
families so they are equipped to make the best choice. Can you please 
provide to this Subcommittee an update on the efforts that the 
Department is taking to support states and communities as they 
implement these reforms? Will the President's fiscal year 2018 budget 
proposal ensure that implementation of the law continues while 
maintaining the current caseload of 1.4 million families, which the 
Department itself estimated would require an increase of approximately 
$700 million for the CCDBG program?
    Answer. ACF has worked closely with states, territories, and tribes 
in the two and a half years since the CCDBG Act was reauthorized. This 
includes:
  --Approving temporary waivers submitted by states and territories to 
        give them the time they needed to meet the new requirements in 
        an effective manner, such as longer implementation timelines to 
        provide a minimum of 12 months of eligibility for services.
  --Providing training and technical assistance to states, territories, 
        and tribes through the funding of 12 different projects. 
        Federal staff and technical assistance partners have hosted 
        trainings, both in person and through webinars, covering a wide 
        range of topics related to reauthorization. These trainings 
        have been designed to help state administrators and other state 
        agencies playing a role in implementing reauthorization. The 
        technical assistance centers have also provided support to 
        states, territories, and tribes through one- on-one projects, 
        peer learning groups, and general guidance. These resources are 
        shared widely and made available either on the ACF 
        Reauthorization webpage or through the TA system website.
  --Working across agencies to implement comprehensive background check 
        requirements. States and territories have expressed significant 
        concerns about implementing the required background check 
        components, particularly regarding the National Crime 
        Information Center (NCIC). ACF has worked closely with the FBI 
        on how states may use this system, and recently the FBI issued 
        guidance for state criminal justice offices on how to work with 
        CCDF agencies on the NCIC. ACF has also been looking into 
        existing systems that may help states by reducing duplication 
        in the background check components and complications inherent 
        in sharing criminal records across states, as well as exploring 
        new collaborations with other programs that have similar 
        background check requirements.
  --Issuing policy guidance and clarifications through regulations, 
        information memoranda, program instructions, and frequently 
        asked questions. All of these documents were shared widely and 
        posted on the ACF Reauthorization webpage.
  --Providing funding for evaluations. Funding from the child care 
        research set-aside is being used to support cooperative 
        agreements that will help states plan and then complete an 
        evaluation of changes made in response to the 2014 
        reauthorization.
    The fiscal year 2018 President's Budget maintains the funding level 
that was current at the time the Budget was prepared while continuing 
to support the implementation of the CCDBG Act.

                            early education
    Question. Secretary Price, the budget proposal released in March 
stated that ``in fiscal year 2018, HHS funds the highest priorities, 
such as . . . early care and education . . . ''. However, the 
Congressional Research Service estimates that Federal child care 
funding would decrease by as much as $438 million between fiscal years 
2017 and 2018 as a result of the President's budget proposal. That 
figure does not include the President's request to eliminate the 
Preschool Development Grants, or fund Head Start at a level that is $85 
million less than the fiscal year 2017 Omnibus. As the President's 
proposal states that it prioritizes early care and education, please 
provide additional information on how you to plan to ensure that early 
childhood education services and investments are prioritized within HHS 
and align with Congressional support for early childhood education as 
in the final fiscal year 2017 Omnibus bill? Please describe how you 
plan to work with Congress to ensure these programs provide access to 
affordable, quality child care for working families?
    Answer. The President's fiscal year 2018 Budget Request for ACF 
includes nearly $15 billion for the Child Care and Development Fund and 
Head Start, the two largest Federal early care and education programs. 
This investment represents a 25 percent increase from just 10 years 
ago. The budget also continues existing tax credits that help working 
families afford child care and includes new provisions to support paid 
family leave.
                                 ______
                                 
                Questions Submitted by Senator Jack Reed
                                medicaid
    Question. Your budget proposes cutting over $1 trillion from 
Medicaid, which ensures that the most vulnerable citizens, such as 
seniors, children, and people with disabilities, have access to care. 
Can you provide estimates for how many people you expect to lose 
coverage because of this cut?
    Approximately half of all Medicaid spending goes towards nursing 
home care for seniors and 60 percent of nursing home residents have 
their care paid for by Medicaid. How much of this cut do you anticipate 
will be shouldered by seniors and nursing home care?
    Almost half of all Medicaid beneficiaries are children. How many 
children do you expect will lose coverage because of this cut?
    One in two Rhode Islanders with disabilities gets care through 
Medicaid. Will they also lose coverage because of this cut?
    How do you expect states to make up the difference from this 
trillion dollar cut? I am concerned that states will be left with the 
bill, and left with the choice to fund either Medicaid or higher 
education or transportation. I suspect that with the size of this cut, 
states will have to make severe cuts in all of these areas.
    Answer. Current growth in Medicaid spending is unsustainable, with 
growth outpacing gross domestic product and national health spending 
and accounting for an increase share of Federal and State budgets. The 
current open-ended structure of Federal Medicaid funding encourages 
States to shift costs to the Federal Government and does not encourage 
States to focus on preventing waste, fraud, and abuse. At the State 
level, Medicaid crowds out important State priorities such as 
investments in education, public safety, and infrastructure. Medicaid's 
outdated rules are restrictive and complex, tying States' hands and 
preventing States from designing innovative approaches that address the 
specific needs of their populations. The Budget would help set Medicaid 
on a sustainable path and ensure the program can continue to provide 
care to those who are most vulnerable, the elderly, individuals with 
disabilities, children and pregnant women.
                                 liheap
    Question. Preserving LIHEAP funding has been a perennial bipartisan 
priority for me and my colleague from Maine, Senator Susan Collins. How 
does HHS plan to continue its longstanding commitment to providing our 
most vulnerable populations with home energy assistance--which is vital 
to ensuring the health and safety of many low-income households, 
children, and seniors? How can HHS ensure our most vulnerable do not 
have to choose between paying for needed prescriptions and heating 
their homes?
    Answer. In a constrained budget environment, difficult funding 
decisions were made to ensure that Federal funds are being spent as 
effectively as possible. LIHEAP is unable to demonstrate strong 
performance outcomes and is not the only source of assistance for low 
income households. As HHS looks for ways to improve the effectiveness 
and efficiency of the Federal Government, energy assistance programs 
are one area where we may look to States and private entities to play a 
larger role. Utility companies and state and local governments already 
provide significant heating and cooling assistance to low income 
households, and the majority of states also prohibit utilities from 
disconnecting a household's energy in periods of severe weather or in 
certain other circumstances.
                         emergency preparedness
    Question. You have proposed across the board cuts to CDC, including 
$662 million from programs that combat bioterrorism and mass illness. 
Can you explain how you intend to keep Americans safe from these public 
health threats, while making hundreds of millions of dollars in cuts to 
the very programs that do this work?
    Answer. Supporting state and local health departments through 
grants and cooperative agreements remains a core priority of CDC's work 
in the fiscal year 2018 President's Budget.
    For example, since 9/11, CDC's Public Health Emergency Preparedness 
(PHEP) program has partnered with 62 states, local, and territorial 
public health departments to prepare for, withstand, respond to, and 
recover from, potentially devastating public health emergencies. The 
PHEP program supports the development and maintenance of capable, 
flexible, and adaptable public health systems ready to respond rapidly 
to ensure Americans are protected.
    CDC will build on the preparedness investments made to date, and 
continue to support state and local public health operations in order 
to detect, and respond to, life threatening diseases and threats at 
levels requested in the President's Budget.
    Question. In addition, can you explain the rationale for 
eliminating the Fogarty International Center under the National 
Institutes of Health? The Fogarty Center trains healthcare 
professionals and provides critical expertise across the globe to help 
prevent public health epidemics before they start. We know--and we saw 
this in practice with Ebola--the best way to prevent Americans from 
global health threats is to prevent them or stop them before they come 
to the U.S.
    Answer. The fiscal year 2018 Budget eliminates the Fogarty 
International Center, while retaining certain mission-critical 
international research and research-related activities. Approximately 
$25 million within the Office of the Director will be dedicated to 
coordinating global health research across the NIH, including issues 
regarding workforce development and engagement with NIH's international 
biomedical research partners. This restructuring will allow NIH to more 
efficiently support intramural and extramural international research 
activities and training. NIH will preserve key Fogarty Center 
activities and redistribute Federal personnel within other NIH 
Institutes and Centers. Key activities include services within NIH and 
the extramural community, such as service within NIH and extramural 
training, awards and career development activities for fellows and 
scholars.
                        cdc immunization program
    Question. Your budget proposal calls for an $89.5 million cut in 
direct discretionary funding for the CDC Immunization Program. In 
addition, the proposed reduction of the Prevention and Public Health 
Fund this year would eliminate another $120.8 million from immunization 
activities. As you know, a number of states rely exclusively on Federal 
funding support. At the same time, a number of communities across this 
country are facing recurrent outbreaks of vaccine-preventable 
conditions such as measles, pertussis and mumps. How are states and 
local health departments going to effectively protect the public health 
and maintain immunization coverage rates in the midst of these growing 
challenges with the funding levels proposed in this budget request?
    Answer. The CDC Immunization Program provides funding to all 50 
states, the District of Columbia, five major cities, and eight 
territories. At the funding level proposed in fiscal year 2018, CDC 
will continue to provide funding to the 64 awardees for state 
infrastructure awards and vaccine direct assistance, but at a reduced 
level. CDC will continue providing technical assistance and laboratory 
support to states and local communities responding to vaccine- 
preventable disease investigations, including outbreaks, but at a 
reduced level.
    The discretionary Immunization Program plays a fundamental role in 
achieving national immunization goals and sustaining high vaccination 
coverage rates to prevent death and disability from vaccine-preventable 
disease. It acts as the backbone of our nation's public health system 
by supporting the science that informs our national immunization 
policy, providing a safety net to uninsured, poor adults for vaccine 
purchases, monitoring the safety of vaccines, educating providers and 
performing community outreach, and conducting surveillance, laboratory 
testing, and epidemiology to respond to disease outbreaks.
                                 ______
                                 
             Questions Submitted by Senator Jeanne Shaheen
                                opioids
    Question. The President's budget for SAMHSA cuts programs to 
prevent substance misuse at the state and regional levels. How will we 
continue to make progress with fighting the opioid epidemic with these 
drastic cuts to programs that fund education, prevention, and 
treatment?
    Answer. The U.S. Department of Health and Human Services is keenly 
aware of the devastating impact that opioid addiction is having on our 
families and communities. Ending this public health crisis is among my 
top Departmental priorities, and your shared commitment to this fight 
is greatly appreciated. That is why the Budget protects substance abuse 
treatment efforts in SAMHSA from reductions. However, in a constrained 
budget environment, difficult funding decisions must be made and not 
every activity can be protected from reductions.
    The Budget provided $811 million in HHS to address the opioid 
crisis. Congress has demonstrated its willingness to substantially 
support opioid prevention and treatment activities. HHS looks forward 
to working with Congress to fight substance abuse.
                      america's health block grant
    Question. Please explain how the newly created America's Health 
Block Grant will fill the research and provider education gap that will 
be left with the elimination of the Prevention Research Centers or the 
Epilepsy Program at the CDC.
    Answer. The new America's Health Block Grant builds on CDC's 
successful chronic disease prevention expertise while allowing states 
greater flexibility in addressing their jurisdiction's leading causes 
of death and disability, such as: diabetes, heart disease and stroke, 
tobacco use, obesity and lack of physical activity, and arthritis. This 
block grant provides states and tribes the ability to organize 
prevention and control efforts and deploy already-identified evidence-
based interventions in a manner that makes the most sense to their 
jurisdictions and circumstances.
    Question. How will America's Health Block Grant address programs 
that are national initiatives, such as the Prevention Research Centers 
or the Epilepsy Program?
    Answer. The America's Health Block Grant will enable states and 
tribes to organize prevention and control efforts and deploy already-
identified, evidence-based interventions in a manner that makes the 
most sense to their jurisdictions and circumstances. CDC's chronic 
disease prevention portfolio will continue to focus more narrowly on 
leading causes of death and disability, and implementation of the most 
effective interventions.
                              cdc funding
    Question. Moving forward, how does the CDC plan to work with 
academic research and medical centers to promote healthy lifestyles, 
including opiate addiction, obesity and prevention for avoidable high-
cost events in a rapidly aging population?
    Answer. CDC values its long record of funding academic research 
institutions and medical centers to protect the health of Americans by 
discovering new ways to prevent diseases more effectively. CDC will 
continue to collaborate with academic research and medical centers.
            prevention research centers and epilepsy program
    Question. Without programs like the Prevention Research Centers and 
Epilepsy Program, who will fulfil function of national surveillance for 
epidemiologic and population health data?
    Answer. CDC's fiscal year 2018 President's Budget request includes 
funding at a reduced level for its surveillance, epidemiology, and 
public health informatics activities. At this funding level, CDC will 
focus its support on core public health surveillance.
                  managing epilepsy well (mew) network
    Question. The Managing Epilepsy Well (MEW) Network was established 
in 2007 with support from the Prevention Research Centers. The 
Coordinating Center for the network is located in New Hampshire and is 
creating evidence-based programs to help individuals with the disease 
and the families and caregivers that support them. What is your 
rationale for eliminating this program? How do you anticipate the 
continuation of the ten active research projects in the MEW Network?
    Answer. The fiscal year 2018 President's Budget proposed 
elimination of the Prevention Research Centers and the Epilepsy program 
supports the transition of CDC's chronic disease prevention portfolio 
to focus limited resources on the leading causes of death and 
disability. CDC's chronic disease prevention portfolio will continue to 
focus on implementation of the most effective existing interventions.
                                 ______
                                 
              Questions Submitted by Senator Brian Schatz
                               telehealth
    Question. Telehealth improves outcomes and saves costs in our 
healthcare system. Along with Senators Wicker, Cochran, Cardin, Thune, 
and Warner, I introduced the CONNECT for Health Act to lift outdated 
restrictions on Medicare's reimbursement of telehealth.
    In February, you testified to the Finance Committee that you 
believe that ``Telehealth can provide innovative means of making 
healthcare more flexible and patient-centric.'' However, I was 
disappointed to see that your budget cuts the Office for the 
Advancement of Telehealth from $17 million to $10 million. Funding for 
this office has been one of my top priorities.
    Secretary Price, how do you think that cutting this office will 
expand the use of telehealth? Do you no longer believe that telehealth 
should be integrated into our healthcare system? What is your view on 
telehealth?
    Answer. With the proposed funding level, the fiscal year 2018 
Budget provides $10 million for HRSA's Telehealth program grantees to 
allow base-level support for the Telehealth Network Grants and 
Telehealth Resource Centers. Telehealth grants support telehealth 
technologies, including the Telehealth Network Grant Program, which 
through the use of telehealth networks improves healthcare services for 
medically underserved populations in urban, rural, and frontier 
communities. Additionally, in support of telehealth activities, HRSA 
allocated $750,000 this year to fund a Telehealth-Focused Rural Health 
Research Center, which will further develop the evidence base for 
telehealth services in rural areas.
                     hospital preparedness program
    Question. The Hospital Preparedness Program is the only source of 
Federal funding for healthcare delivery system readiness, intended to 
improve patient outcomes and enable rapid recovery in the case of 
emergencies and disaster events. I repeat: it is the only source of 
Federal funding. In the fiscal year 2018 budget, you defunded 19 
states, including Hawaii. This is unacceptable.
    These dollars are used to prepare for and respond to natural 
disasters, disease pandemic, bioterrorism, and public health 
emergencies. Hawaii is particularly at risk for hurricanes, tsunamis, 
Zika, or a military attack--and just last year we had a significant 
dengue outbreak.
    Please explain the rationale for defunding Hawaii and 18 other 
states. How will you assist these states in the event of an emergency 
or disaster, especially when states like Hawaii are so at risk?
    Answer. As the Federal Government, we must make the health and 
safety of Americans the driving force behind all that we do. To deliver 
the change needed to protect Americans from disasters that impact 
people's health, ASPR proposes to reform the Hospital Preparedness 
Program (HPP), driving strategic advancements in healthcare delivery 
system readiness, and enhancing government efficiency and 
accountability. In fiscal year 2018, HPP intends to focus Federal 
financing on those states and jurisdictions with the greatest need.
    For healthcare preparedness, need is defined as those most at risk. 
HPP currently funds 62 awardees, which include all 50 states, the 
District of Columbia, Los Angeles County, Chicago, New York City, and 
all U.S. territories and freely-associated states. However, 
distributing limited tax dollars to every state and U.S. territory 
dilutes HPP's mission effectiveness. Moreover, while HPP has 
incorporated risk into its funding distribution formula since fiscal 
year 2014, much more must be done. In fiscal year 2018, HPP proposes to 
target awards to those states and jurisdictions with the highest risk 
and will use evidence- and science-based tools to clearly define risk.
    ASPR strives to assist all jurisdictions--including jurisdictions 
that would no longer receive HPP dollars--with preparing for, 
responding to, and recovering from emergencies and disasters. When 
disaster strikes, ASPR provides critical services to protect public 
health and help communities recover faster. ASPR's Technical Resources 
Assistance Center and Information Exchange (TRACIE) provides technical 
assistance to help communities connect with the right resources and 
experts; HHS' emPOWER map provides deidentified data on populations 
reliant on lifesaving electricity-dependent medical equipment and 
healthcare services to inform disaster response; the Division of 
Recovery enhances pre-disaster and post-disaster recovery knowledge, 
skills, and networks; and the Division of Partner Readiness and 
Emergency Programs (PREP) supports both Federal partners and partners 
at the state, local, tribal, and territorial levels in preparing for, 
mitigating, and responding to emergencies and disasters.
    With TRACIE, emPOWER, the Division of Recovery, and PREP, ASPR will 
continue to provide all jurisdictions with technical assistance and 
support to prepare for and respond to emergencies and disasters; and, 
due to its reduced funding level, HPP strives to apply its fiscal year 
2018 proposals to target Federal funds to those jurisdictions with the 
greatest need.
                              cuts to hrsa
    Question. Your budget completely eliminates at least nine programs 
from HRSA. You eliminate the Emergency Medical Services for Children 
program, universal newborn hearing screening, and grants for rural 
hospitals, to name a few.
    The Emergency Medical Services for Children program serves a 
critical role in our emergency response system. It makes sure that 
emergency responders are trained to appropriately treat children in an 
emergency situation. It also ensures that ambulances and ERs are 
prepared to treat children as well as adults. This program has provided 
grants to all 50 states, D.C., and five territories.
    Why was this cut made?
    Answer. The fiscal year 2018 Budget prioritizes programs that 
support direct healthcare services, while giving states and communities 
flexibility to meet their local needs.
    Question. Do children not warrant up-to-date and well-prepared 
emergency services?
    Answer. Children are a vulnerable population, and their needs for 
emergency medical services require special consideration. While 
dedicated funding for the Emergency Medical Services for Children 
Program was eliminated, the fiscal year 2018 Budget request included 
increased funding for the Maternal and Child Health Block grant 
program. We anticipate that some of these activities could be continued 
by states by redirecting a portion of their Maternal and Child Health 
Block Grant funds to cover these services.
    Question. What if your child had an emergency--would you feel 
comfortable allowing him or her to be treated in an ambulance or ER 
that is not prepared for children?
    Answer. Children are best served in an emergency medical services 
system prepared to address unique pediatric health needs. The proposed 
funding increase to the Maternal and Child Health Block Grant program 
allows states an opportunity to continue work currently implemented 
through the Emergency Medical Services for Children Program, based on 
the individual priority needs identified by the state and its existing 
resources.
                                 ______
                                 
              Questions Submitted by Senator Tammy Baldwin
                     acl paralysis resource center
    Question. Your Budget request states that the Administration for 
Community Living ``is dedicated to ensuring that individuals with 
disabilities and their families are able to fully participate in and 
contribute to all aspects of community life.'' Despite this stated 
commitment, you propose to eliminate funding for the Paralysis Resource 
Center (PRC), which is the only federally funded program specifically 
tailored for mobility impaired Americans.
    The PRC features information specialists, a national peer-to-peer 
network that has provided help to more than 5,400 people, and a 
military and veterans program designed to support the unique needs of 
current service members and veterans affected by paralysis and other 
mobility impairments. I have strong concerns with this elimination, as 
these essential services improve the quality of life for disabled and 
older Americans and their families, and are not provided by any other 
Federal agency.
    Can you explain this funding cut and how you plan to ensure that 
this population continues to get the help they need if the Paralysis 
Resource Center is eliminated?
    Answer. The Department will continue to fund a range of resources 
that are available to people with all types of disabilities. For 
example, Aging and Disability Resource Centers support State efforts to 
create ``No Wrong Door'' points of entry making it easier for people to 
get objective information and one-on-one, person-centered counseling 
about public programs assessing their health and long-term service and 
support options. Centers for Independent Living offer services 
assisting those with disabilities including people who are aging as 
well as who are mobility impaired, with information and referrals, 
independent living skills training, peer counseling, individual and 
systems advocacy, assistance in avoiding institutionalization and 
returning to communities for those who are institutionalized. In 
addition, the National Institute on Disability, Independent Living, and 
Rehabilitation Research will continue to focus on improving health and 
function, employment, and community participation, including spinal 
injury research conducted through the Spinal Cord Injury Model Systems 
Program.
                              rural health
    Question. You are proposing a nearly 50 percent funding cut to 
rural health, including zeroing out funding for programs that support 
rural hospitals and the State Offices of Rural Health. This proposal 
would eliminate almost all of Wisconsin's Federal rural health funding. 
Together, these programs bring over $1.3 million into Wisconsin every 
year for rural healthcare activities and support--which might not be a 
lot in the Federal budget, but makes a real difference in my rural 
state.
    The Rural Hospital Flexibility Program and the Small Rural hospital 
Improvement Programs fund quality improvement projects that save lives 
in my state. Through these programs, rural hospitals without the 
capacity of urban tertiary centers are learning how to quickly treat 
strokes and other emergencies where timing is everything. These 
programs also help our vulnerable rural hospitals with critical 
technical support. These funds help them conduct in- depth financial 
analysis to plan for long term financial sustainability. We cannot 
afford to lose the rural safety net in Wisconsin or in any rural part 
of America. These funds are small investments that have major impact.
    Without these critical infrastructure programs, how will you ensure 
that rural Americans have access to high quality care when they need it 
most?
    Answer. The fiscal year 2018 Budget provides $74 million for 
critical rural health activities such as Rural Health Outreach Network 
and Quality Improvement Grants, Rural Health Policy Development, Black 
Lung Clinics, and Telehealth. These investments will improve access to 
quality healthcare services in rural and underserved areas. The Budget 
also continues to support health services in rural communities through 
the Community Health Centers Program and the National Health Service 
Corps. In 2015, Community Health Centers served approximately one in 
five rural Americans and, as of September 30, 2016, nearly one quarter 
(24 percent) of National Health Service Corps clinicians served at 
rural sites.
    The Budget discontinues Rural Hospital Flexibility Grants and State 
Offices of Rural Health to prioritize programs that provide direct 
healthcare services.
                         emergency preparedness
    Question. I was encouraged to see increased funding for pandemic 
influenza preparedness in the President's fiscal year 18 Budget 
Request. H7N9 bird flu remains an ongoing concern in China as the 
deadly virus continues to spread in the poultry population and 
occasionally to humans. However, the concern is not just limited to 
China; any deadly virus may be just a plane ride away from our 
homeland, which we saw with Ebola and SARS, that could have dangerous 
implications for the US. For one, in 2004, we saw a dangerous shortage 
of influenza vaccine in the US due in part to disruptions in vaccine 
production overseas. I am concerned that, according to BARDA Director 
Rick Bright, the US stockpile of the H7N9 vaccine would not provide 
adequate protection, and a new vaccine is needed.
    How will you ensure that the US is positioned to respond to outside 
threats like this bird flu circulating in China? What are you doing to 
prioritize and address this gap in preparedness, including efforts to 
ensure sufficient domestic production of needed vaccines?
    Answer. On May 19th, a delegation from the Department, including 
Secretary Price, represented the United States at the first-ever G20 
Health Ministerial Meeting in Berlin, Germany. Health officials from 
around the world discussed how to harness knowledge, capabilities, and 
expertise to reinforce and strengthen our global health security and 
also participated in a public health emergency simulation exercise to 
aid in improving mutual understanding of countries' preparedness and 
response needs, communication related to emerging and active threats, 
and capabilities through research, development, and innovation.
    Additionally, the Delegation participated in productive global 
health discussions including preparations to combat influenza and 
viruses with pandemic potential, antimicrobial resistance (AMR), the 
work of the World Health Organization (WHO), and the World Health 
Assembly (WHA) and held bilateral meetings with Indonesia, China, Saudi 
Arabia, and the United Kingdom.
    The fiscal year 2018 President's Budget requests a total of $207 
million for pandemic influenza activities within the Public Health and 
Social Services Emergency Fund, including a $135 million increase for 
the Assistant Secretary for Preparedness and Response, to sustain 
ongoing investments in domestic influenza vaccine and adjuvant 
manufacturing facilities and in pre- pandemic vaccine and adjuvant 
stockpiles. These infrastructures enable the Department to quickly 
produce and deliver vaccines in response to evolving and emerging 
influenza viruses with pandemic potential. The Budget also proposes a 
new emergency response fund with Department-wide transfer authority in 
order to enable a swift response to emerging public health threats. In 
addition, since the Biomedical Advanced Research and Development 
Authority (BARDA) was established by the 2006 Pandemic and All Hazards 
Preparedness Act, one of our core missions has been to address pandemic 
influenza medical countermeasure preparedness. This includes 
significantly expanding the domestic influenza vaccine and adjuvant 
manufacturing capacity, developing new types of influenza vaccines for 
a more rapid response, and maintaining and continually evaluating a 
national stockpile of pre-pandemic vaccines and adjuvants that will be 
effective against influenza virus strains with pandemic potential. In 
the past, this approach included stockpiling antiviral drugs in the 
Strategic National Stockpile, in collaboration with the Centers for 
Disease Control and Prevention.
    To prepare the United States to respond to H7N9 and other similar 
threats, HHS must sustain domestic readiness capabilities and capacity, 
including critical infrastructure, needed to produce vaccine and 
adjuvant. Using remaining pandemic influenza balances from prior year 
supplemental appropriations, the Department is currently investing up 
to $149 million to manufacture and stockpile a new vaccine to match the 
currently circulating highly pathogenic H7N9 influenza virus in China. 
In addition to these measures, BARDA must continue to shape the 
landscape and support the advanced development of more effective 
influenza vaccines, more robust therapeutics that are effective in 
severely ill and hospitalized patients, and make a strategic move to 
push diagnostics out of laboratories and into homes to more rapidly 
identify influenza, make all interventions more effective and empower 
patients to assist in reducing the transmission of the virus. BARDA is 
also supporting the development of new vaccine platform technologies 
that can be used to rapidly produce a variety of vaccines that are 
needed to respond to an emerging threat. These vaccine platforms will 
utilize common components, facilities and processes to produce 
vaccines. This approach could have the potential to reduce the overall 
development time of a vaccine for a newly emerging pathogen.
    In addition to these activities, the Department recently issued the 
Pandemic Influenza Plan 2017 Update, the first since January 2009.
                        medical countermeasures
    Question. The 21st Century Cures Act included several important 
provisions related to medical countermeasure (MCM) development at HHS. 
Section 3082 granted authority over all BARDA contracts to the BARDA 
Director to help reduce delays and improve administrative efficiency in 
contracting for time-sensitive MCM development programs. Immediate 
implementation of this provision is essential to ensure that BARDA has 
the flexibility it needs to deliver MCMs to the Strategic National 
Stockpile and protect the American people.
    Can you please provide an update on HHS' implementation of this 
critical provision?
    Answer. The 21st Century Cures Act clearly communicates Congress's 
intent that the Secretary, acting through the BARDA director, shall 
have authority over all BARDA programmatic activities and specifically 
the execution of procurement contracts, grants, and cooperative 
agreements. The Department is considering how best to implement section 
3082 in accordance with the statutory text and congressional intent.
    The Department recognizes the importance of implementing the 21st 
Century Cures Act. Provisions which substantially modify the way ASPR--
or any other HHS component--conducts business must be given 
considerable attention.
                          indirect cost policy
    Question. The proposed 10 percent cap for facilities and 
administrative costs for NIH grants will result in a $50 million loss 
of recovery per year at the University of Wisconsin-Madison. There 
would be comparable losses at every American research university. How 
do you plan to ensure that the impact of those cuts will not lead to 
loss of faculty and students, greatly reduced research efforts, and a 
deterioration in U.S. innovation and economic strength?
    Answer. While NIH provides funding to many universities and 
institutions, and guidance on grant administration, it generally does 
not dictate what personnel will be supported by that funding; thus, the 
effect on university faculty and students would largely be governed by 
decisions and policies at each institution. The Administration also 
will propose a package of reforms to streamline Federal compliance 
requirements and reduce burden on NIH grantees. It is expected that 
these targeted policies will reduce the time and expenses that grantees 
must currently spend to comply with overly burdensome Federal grant 
requirements, thus lowering grantees' administrative costs and 
mitigating some of the impact of lower reimbursements.
                     office of refugee resettlement
    Question. The Office of Refugee Resettlement (ORR) Matching Grant 
Program, a 40-year public-private partnership established by Congress 
in 1979, assists recently resettled refugees, asylees, Cuban and 
Haitian Entrants, Iraqi and Afghan Special Immigrant Visa (SIV) holders 
and Certified Victims of Human Trafficking in achieving self-
sufficiency through early and sustained employment. Harnessing the 
significant public support and local community participation in 
assisting in the resettlement process, the Matching Grant (MG) Program 
offers an essential alternative to public cash assistance. In fiscal 
year 2016, the most recent data available, over 82 percent of MG 
clients were successful in reaching self-sufficiency by the end of the 
180-day service period. Leveraging private in-kind and cash 
contributions with Federal dollars is both good stewardship and smart 
policy, and ultimately it is local community members matching 
government dollars with their own contributions that make this program 
the success it is.
    In 2017, the significant disruption to the U.S. Refugee Admissions 
Program (USRAP) these past months, coupled with the uncertainty around 
the Federal budget, has created program instability, negatively 
impacting those populations that would benefit from this successful 
program. On June 22, 2017, over a month and a half after the 
Consolidated Appropriations Act of 2017 (Public Law No. 115-31) was 
passed by Congress, the national refugee resettlement agencies received 
a significant reduction in funding with no explanation as to the 
rational for the delay or decrease in funds.
    Can you please explain the overall reduction in fiscal year 2017 
Matching Grant funds that will be obligated to the national refugee 
resettlement agencies? Why did ORR reduce funding for this program, 
especially when the population in need has not decreased and the 
funding appropriated by Congress did not decrease from fiscal year 2016 
to fiscal year 2017?
    Answer. The eligible population decreased substantially from fiscal 
year 2016 to fiscal year 2017. This reduction in the eligible 
population relates to changes in the policy to parole Cubans into the 
U.S. and a reduction in the number of refugee admissions. The funding 
level for the Matching Grant program was reduced because of the 
reduction in eligible arrivals. HHS anticipates that the eligible 
population will further decrease in fiscal year 2018. The number of 
Matching Grant slots are based on anticipated eligible population 
levels. The chart below illustrates the funding and number of slots for 
program enrollments.

------------------------------------------------------------------------
                Fiscal year                     Slots         Budget
------------------------------------------------------------------------
2016.......................................       34,700      76,340,000
2017.......................................       31,000      68,200,000
2018 *.....................................       22,000      55,000,000
------------------------------------------------------------------------
* The fiscal year 2018 President's Budget assumes an increase in the per
  capita rate for each slot.

    Question. Does ORR intend to make any further changes to the MG 
program in fiscal year 2017 or fiscal year 2018?
    Answer. HHS anticipates a decrease in eligible arrivals in fiscal 
year 2018. The number of Matching Grant slots is based on anticipated 
eligible population levels.
    Question. How many refugees and other eligible populations does ORR 
intend to serve through the MG program this fiscal year?
    Answer. The chart above depicts the planned service level through 
the Matching Grant program for fiscal years 2017 and 2018.
    Question. Will ORR provide an exemption to the 31-day enrollment 
period, changing the enrollment period to 90 days, in order to allow 
refugees and other eligible populations to access the MG program?
    Answer. ACF evaluates the need to change the enrollment period on a 
case-by-case basis and plans on continuing this policy. In certain 
cases, ACF does extend this policy.
    Question. The arrival of fiscal year 2018 will mean the beginning 
of a new grant cycle for the MG program. Can you please provide clarity 
for the timeline of the application process in order to allow 
resettlement agencies to adequately plan and receive input from their 
networks and other community stakeholders?
    Answer. ACF has not yet announced the application timeline, pending 
finalization of an administrative change in the way funding will be 
provided, beginning in fiscal year 2018. This administrative change 
will expedite and streamline the annual application process. ACF 
expects to notify grantees about this change in the near future.
                                 ______
                                 
           Questions Submitted by Senator Christopher Murphy
                             mental health
    Question. During your confirmation process, we spoke about the 
importance of the mental health section of the 21st Century Cures Act 
and you committed to work together to ensure the law's implementation. 
Among these are provisions designed to improve enforcement and 
compliance with the Mental Health Parity and Addiction Equity Act. 
Specifically, Sections 13001-13004 of the 21st Century Cures Act 
requires the Departments of Health and Human Services (HHS), Labor and 
Treasury to issue:
  --compliance guidance on disclosure of plan documents and non-
        quantitative treatment limitations by December of 2017;
  --Convene a public meeting by June of 2017 and a report on the 
        meeting by December of 2017;
  --A report on all investigations summarizing the results of all 
        closed Federal parity investigations;
  --A GAO study on parity compliance.
    Can you describe the progress the Department of Health and Human 
Services (HHS) has made in implementing this new mental health law, 
especially the parity provisions, since you were sworn in? How has HHS 
worked with the Department of Labor to ensure that parity compliance 
improves significantly from where it is now?
    Can you please describe the Departments' workplan for the public 
stakeholder meeting required under the 21st Century Cures Act to be 
convened by June of 2017? Please include date and time, invitees, 
witnesses and other relevant information that would allow those most 
affected by lack of parity compliance to attend? The Congressional 
intent of this provision was for this meeting to be a transparent and 
widely attended meeting.
    Answer. SAMHSA, CMS, and Departments of Labor and Treasury have 
collaborated extensively to provide states and stakeholders with 
education, resources, and technical assistance to support their efforts 
to implement parity protections.
    In 2017, SAMHSA hosted two Parity Policy Academies (PPAs). One of 
the PPAs focused on implementation of the Mental Health Parity and 
Addiction Equity Act in the commercial insurance market and the other 
focused on parity as required by Medicaid and CHIP. The PPAs were 
designed as a continuum of technical assistance activities spanning 
from February through August 2017, with in-person meetings held in 
March and April, to address states' needs related to parity. Twenty-
nine states, the U.S. Virgin Islands ,and Puerto Rico participated in 
the PPAs, represented by state teams comprising state officials from 
state insurance departments, Medicaid agencies, state mental health 
authorities, and single state agencies for substance abuse services.
    In addition, on June 26, 2017, the Departments issued Affordable 
Care Act Implementation FAQs Part 38, which again solicited comments on 
FAQs Part 34 as required by the Cures Act. The Departments also 
solicited comments on a draft model form that participants, enrollees, 
or their authorized representatives could use to request information 
from their health plan or issuer regarding Non-Quantitative Treatment 
Limits that may affect their Mental Health/Substance Use Disorder (MH/
SUD) benefits, or to obtain documentation after an adverse benefit 
determination involving MH/SUD benefits to support an appeal. The model 
form and instructions are available at https://www.dol.gov/agencies/
ebsa and the Federal Register notice is available at https://
www.Federalregister.gov/documents/2017/06/26/2017-13224/proposed-
revision-of-information-collection-request-submitted-for-public-
comment-draft-model.
    Question. Additionally, the White House Task Force on Parity, after 
investigation and input from all stakeholders, issued a report in 
October 2016 making several recommendations to improve enforcement of 
the Mental Health Parity and Addiction Equity Act and its implementing 
regulations.
    Which of the recommendations are you prepared to support and which 
are you not prepared to support, and what is the reason for your 
answers?
    Answer. Several actions and recommendations from the White House 
Task Force report have already been supported or acted upon by this 
Administration. For example, the SAMHSA's Parity Policy Academies were 
executed, HHS created the one-stop web portal for consumers, simplified 
disclosure tools are being created and released, and additional 
educational materials for families and caregivers are being developed 
by SAMHSA and the Department of Labor.
    Question. It is no secret that there is considerable disagreement 
between the plans and consumer and provider groups on specific details 
of what constitutes parity compliance. Does the Department intend to 
issue a Request for Information (RFI) regarding the compliance program 
document? If not, why not? If so, will the responses be made public?
    Answer. As mentioned previously, on June 26, 2017, the Departments 
issued ACA Implementation FAQs Part 38, which again solicited comments 
on the questions and issues relating to disclosures with respect to 
mental health/substance use disorder (MH/SUD) benefits under MHPAEA and 
other laws that were previously raised in FAQs Part 34 as required by 
the Cures Act. The Departments also solicited comments on a draft model 
form that participants, enrollees, or their authorized representatives 
could use to request information from their health plan or issuer 
regarding nonquantitative treatment limits that may affect their MH/SUD 
benefits, or to obtain documentation after an adverse benefit 
determination involving MH/SUD benefits to support an appeal. The model 
form and instructions are available at https://www.dol.gov/agencies/
ebsa and the Federal Register notice is available at https://
www.Federalregister.gov/documents/2017/06/26/2017-13224/proposed-
revision-of-information-collection-request-submitted-for-public-
comment-draft-model.
    Question. Secretary Price, given your testimony highlighting the 
department's focus on people with severe mental illnesses, I was 
genuinely surprised that the administration proposed nearly $400 
million in overall SAMHSA funding cuts. Specifically, the budget 
requests $147 million less for the Community Mental Health Services 
Block Grant and requests scant funding to implement the recently passed 
mental health provisions from the 21st Century Cures Act.
    Do you believe that we are spending too much on mental healthcare 
in America?
    Answer. As Secretary, I am committed to leading HHS to address the 
crisis of serious mental illness. The Budget right sizes some 
investments because programs can be streamlined, have accomplished part 
of their original purpose, or are more appropriately addressed at the 
state level.
    The Budget invests in high-priority mental health initiatives to 
deliver hope and healing to the 43.1 million adults with mental 
illness,\2\ including nearly 10 million Americans suffering from a 
serious mental illness,\3\ as well as the 19.6 million adults with both 
mental and substance use disorders,\4\ the 3 million adolescents who 
have experienced a major depressive episode,\5\ and 350,000 adolescents 
with both a major depressive episode and substance use disorders.\6\ 
These initiatives will target resources for psychiatric care, suicide 
prevention, homelessness prevention, and children's mental health. For 
example, the Budget proposes $5 million in new funding authorized by 
the 21st Century Cures Act for Assertive Community Treatment for 
Individuals with Serious Mental Illness. The Budget also includes a 
demonstration within the Children's Mental Health Services program to 
test the applicability of new research from the National Institute of 
Mental Health on preventing or delaying the first episode of psychosis.
---------------------------------------------------------------------------
    \2\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16-4984, NSDUH Series H-51). Pg. 27 Retrieved from 
http://www.samhsa.gov/data/
    \3\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16-4984, NSDUH Series H-51). Pg 27 Retrieved from 
http://www.samhsa.gov/data/.
    \4\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://
www.samhsa.gov/data/.
    \5\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16-4984, NSDUH Series H-51). Pg 38 Retrieved from 
http://www.samhsa.gov/data/.
    \6\ Center for Behavioral Health Statistics and Quality. (2016). 
Key substance use and mental health indicators in the United States: 
Results from the 2015 National Survey on Drug Use and Health (HHS 
Publication No. SMA 16-4984, NSDUH Series H-51). Page 40 Retrieved from 
http://www.samhsa.gov/data/.
---------------------------------------------------------------------------
    Question. Studies have shown that despite overall gains in life 
expectancy, individuals with serious mental illness die between 13 to 
31 years earlier. Most of this early mortality is attributable to acute 
and chronic co-morbid physical conditions, such as heart disease. The 
Promoting Integration of Behavioral Health and Primary Care within the 
Substance Abuse and Mental Health Services Administration is one of the 
few programs in the entire department that is dedicated to integrating 
physical and behavioral healthcare for this highly vulnerable patient 
population.
    Can you please describe why the administration chose to eliminate 
funding for this program?
    Answer. This program was proposed to be discontinued because other 
sources of funding are available to implement this evidence-based 
practice, such as for the eight states participating in a Medicaid 
demonstration in fiscal year 2018 to operate Certified Community 
Behavioral Health Centers. SAMHSA will continue to disseminate the 
lessons learned from this program.
                     medication assisted treatment
    Question. Medication Assisted Treatments are a critical tool in our 
battle against the opioid epidemic. They have a very high success rate, 
with one study indicating they can cut overdose rates by close to 37 
percent. Yet recently, you criticized the approach of MAT, with a false 
claim of ``if we're just substituting one opioid for another, we're not 
moving the dial much.'' In my opinion, reducing overdose deaths by 37 
percent, or potentially more, is a very significant moving of the dial. 
What is the administration doing in order to expand access to this life 
saving treatment?
    Answer. The Budget provides a total of $811 million in support of 
the five-pronged strategy guiding our Department's efforts to fight 
this scourge:

      1.  Improving access to prevention, treatment, and recovery 
        services, including the full range of MAT;
      2.  Targeting availability and distribution of overdose-reversing 
        drugs;
      3.  Strengthening our understanding of the crisis through better 
        public health data and reporting;
      4.  Providing support for cutting edge research on pain and 
        addiction; and
      5.  Advancing better practices for pain management.
    Within these priorities, one of the key pillars of HHS's approach 
is improving access to prevention, treatment and recovery services, 
including the full range of medication-assisted treatments (MAT). 
Through the State Targeted Response to the Opioid Crisis grants 
authorized in the 21st Century Cures Act, HHS is expanding access to 
opioid addiction treatment through evidence-based interventions, 
including the full range of MAT. We are targeting the barriers to 
seeking and successfully completing treatment and achieving and 
sustaining recovery. This funding and these efforts are a critical 
piece to reversing the opioid crisis.
                       substance abuse prevention
    Question. Substance Abuse Prevention, especially when evidence 
based, is incredibly effective. Studies prove that $1 spent on evidence 
based prevention in a classroom setting can save as much as $18 in 
future costs. Yet your budget recommends a reduction to the Center for 
Substance Abuse Prevention at SAMHSA. How can your administration end 
opioid and drug abuse by decreasing the budget for such a critical 
endeavor?
    Answer. The U.S. Department of Health and Human Services is keenly 
aware of the devastating impact that opioid addiction is having on our 
families and communities. Ending this public health crisis is among my 
top Departmental priorities, and your shared commitment to this fight 
is greatly appreciated. That is why the Budget protects substance abuse 
treatment efforts in SAMHSA from reductions.The Budget continues also 
continues to support priority substance abuse prevention activities.
                            health workforce
    Question. While the Trump Administration claims to be continuing 
the fight against the opioid crisis, your HHS fiscal year 2018 budget 
tells a different story. Almost no programs aimed at treatment and 
prevention receive an increase, and many receive decreases. Of 
particular interest is the Behavioral Health Workforce Education and 
Training program at HRSA, which your administration has proposed for 
elimination. In reality, we have a dire workforce shortage in this 
field, and the Bureau of Labor Statistics says we will need 20,000 more 
professionals over the next 8 years. How do you propose to increase 
workforce with such a reduction?
    Answer. The Budget prioritizes funding for health workforce 
activities that provide scholarships and loan repayment to clinicians 
in exchange for their service in areas of the United States where there 
is a shortage of health professionals. To that end, the Budget provides 
continued support to the National Health Service Corps. As of September 
30, 2016, approximately 35 percent (3,662) of the National Health 
Service Corps field strength are mental and behavioral health 
providers. The National Health Service Corps supports the following 
mental and behavioral health disciplines: Psychiatrists, Psychiatric 
Physician Assistants, Psychiatric Nurse Practitioners, Health Service 
Psychologists, Licensed Clinical Social Workers, Licensed Professional 
Counselors, Marriage and Family Therapists, and Psychiatric Nurse 
Specialists.
    The Budget also funds the Teaching Health Center Graduate Medical 
Education program to support the primary care workforce through primary 
care and dental residency programs in community-based ambulatory 
settings, and improves the distribution of this workforce into needed 
areas through emphasis on underserved communities and populations. In 
Academic Year 2015-2016, the Teaching Health Center Graduate Medical 
Education program supported four psychiatry residency programs, which 
trained 43 residents.
                         mental health research
    Question. We saw the urgent need for renewed investment in mental 
health research four and a half years ago at Sandy Hook Elementary 
School in my home state of Connecticut. As you know, the 21st Century 
Cures Act we passed last year included major mental health reform 
legislation. Can you tell us what the Department of Health and Human 
Services, National Institutes of Health (NIH) and Congress should be 
doing next to advance mental health research to help Americans who are 
suffering from mental illness? How does the President's fiscal year 
2018 budget fit into that vision when it cuts NIH funding by over $7 
billion and cuts the National Institutes of Mental Health by 
approximately $360 million?
    Answer. NIH's National Institute of Mental Health (NIMH) is the 
lead Federal agency for research on mental illnesses, with a mission to 
transform the understanding and treatment of mental illnesses through 
basic and clinical research, paving the way for prevention, recovery, 
and cure. Within available fiscal year 2018 funding, NIMH will 
prioritize highly promising mental health research. For example, 
scientists and collaborators recently uncovered the mechanisms behind 
the rapid antidepressant effects of ketamine, an anesthetic drug, in 
individuals with treatment- resistant depression. Results revealed that 
a byproduct of ketamine's chemical breakdown, and not ketamine itself, 
produces the antidepressant effects. Identifying this mechanism is a 
crucial step in the drug development process, and highlights the 
importance of basic science in getting treatments to patients. Another 
example is NIMH support for efforts to identify genetic and 
environmental risk factors for suicide, and develop strategies to 
reduce suicide. NIMH recently funded three Zero Suicide studies focused 
on adult and youth based suicide prevention practices in healthcare 
settings. These efforts include improving the quality of behavioral 
healthcare to reduce suicide risk, testing the efficacy of a suicide 
prevention approach, and identifying youth at risk for suicidal 
behavior.
    NIMH plays a leading role in the NIH Brain Research through 
Advancing Innovative Neurotechnologies (BRAIN) Initiative, which aims 
to revolutionize our understanding of the human brain by accelerating 
the development and application of innovative technologies. NIH 
recently announced its third round of BRAIN Initiative grants; NIMH 
will support a variety of projects including novel methods to better 
understand brain cells and circuits, and new approaches to noninvasive 
brain-based treatments for mental illnesses. The BRAIN Initiative also 
supports studies that demonstrate novel methods and findings that may 
prove important for uncovering neuronal dysfunction in mental 
illnesses. The fiscal year 2018 Budget requests the full $86 million 
authorized in the 21st Century Cures Act for the BRAIN Initiative.
                     office of refugee resettlement
    Question. The Department of Health and Human Services' Office of 
Refugee Resettlement (ORR) provides crucial services to refugees 
seeking a safe haven in the United States, including asylees, 
trafficking and torture survivors, unaccompanied children, and Special 
Immigrant Visa recipients who worked alongside U.S. troops. ORR funding 
is critical to helping these individuals and families rebuild their 
lives in the United States, and ensure local communities have the 
resources they need to provide adequate support.
    Even though ORR's budget has not kept pace with its growing 
mandate, nor the cost of living and inflation, your budget proposes 
dramatic cuts in refugee programs. How do you plan to meet current 
mandates and program requirements with these dramatic cuts?
    Answer. Most refugee funding is used to help new arrivals become 
self-sufficient integrated members of American society. Funding can be 
reduced because new policies have resulted in a reduced number of 
refugees and other populations entering the country. The Budget 
includes sufficient funding to continue to provide 8 months of cash and 
medical assistance for an estimated 98,000 new arrivals, including 
refugees, asylees, Cuban and Haitian entrants, and other humanitarian 
entrants, in fiscal year 2018. The Presidential Determination on 
Refugee Admissions for fiscal year 2018 will be released later this 
year.
                                 ______
                                 
            Questions Submitted by Senator Joe Manchin, III
                              jessie's law
    Question. Secretary Price, in 2016, we lost a young woman with 
great potential named Jessica Grubb. Jessie was a great student, a 
loving daughter and sister, and an avid runner. She was also recovering 
from an opioid addiction.
    When she had surgery for an infection related to a running injury, 
her parents were there to take care of her and both Jessie and her 
parents told her doctors and hospital personnel that she was a 
recovering addict and not to be prescribed opioids. Unfortunately, 
Jessie's discharging physician did not know that she was a recovering 
addict and sent her home with a prescription for 50 oxycodone pills. 
That night, she overdosed and passed away in her sleep.
    That is why I introduced Jessie's Law. This bill would require your 
agency to establish standards for hospitals and medical professionals 
for prominently displaying substance use disorder history in a person's 
medical record when that information is provided by the patient.
    This bill is a commonsense step that would help save the lives of 
people like Jessie.
    Secretary Price, can you promise to work with me on this issue--
either through my legislation or through your administrative powers--to 
ensure that hospitals and medical professionals have a set of best 
practices that they can adopt to keep us from losing more people like 
we lost Jessie Grubb?
    Answer. Thank you for your shared commitment to this fight. Our 
country is losing too many young people like Jessie in the prime of 
their lives to the crisis. We agree this crisis knows no bounds. We 
will need to continue to work across HHS, with our partner agencies and 
other stakeholders, and with Congress to identify and dismantle 
barriers that hinder our response to this crisis, as well as leverage 
our resources in order to effectively implement these strategies. We 
look forward to continuing our work with you and your staff as we work 
to end this public health crisis.
                    the opioid epidemic and the ahca
    Question. Secretary Price, I am glad to see that the President's 
budget includes a significant amount of funding to combat the opioid 
epidemic though I strongly believe that even more is needed.
    We lost more than 33,000 people to an opioid overdose in 2015. And 
my state of West Virginia has been hit harder by the opioid epidemic 
than any other state. We lost more than 700 people last year.
    That is why I am concerned that the budget also assumes that the 
House Republican bill to repeal the ACA, the American Healthcare Act, 
becomes law.
  --Estimates from the Center on Budget and Policy Priorities found 
        that as many as 2.8 million Americans with a substance use 
        disorder, including 220,000 with an opioid use disorder, would 
        lose some or all of their insurance if the ACA's consumer 
        protections and Medicaid expansion are eliminated.
  --And the CBO estimates that under the American Healthcare Act, out-
        of-pocket spending on mental health and substance abuse 
        services could increase by thousands of dollars a year for 
        individuals who use those services.
    West Virginians who are suffering from opioid addiction don't have 
an extra few thousand dollars to spend on treatment.
    Secretary Price, if this budget assumes that the AHCA becomes law, 
then that means that it includes a net decrease in Federal support for 
people who need help getting substance abuse treatment. What will 
happen to the people of West Virginia who lose their private insurance 
or their Medicaid coverage? How will they get the treatment that they 
need?
    Answer. The U.S. Department of Health and Human Services is keenly 
aware of the devastating impact that opioid addiction is having on our 
families and communities. Ending this public health crisis is among my 
top Departmental priorities, and your shared commitment to this fight 
is greatly appreciated. The Budget calls for $811 million in support of 
the five-pronged strategy guiding our Department's efforts to fight 
this scourge:

      1.  Improving access to prevention, treatment, and recovery 
        services, including the full range of medication-assisted 
        treatments;
      2.  Targeting availability and distribution of overdose-reversing 
        drugs;
      3.  Strengthening our understanding of the crisis through better 
        public health data and reporting;
      4.  Providing support for cutting edge research on pain and 
        addiction; and
      5.  Advancing better practices for pain management.
    This funding increase will expand grants to Health Resources 
Services Administration (HRSA) Community Health Centers targeting 
substance abuse treatment services from $94 million to $144 million. 
Also within this total is $500 million for State Targeted Response to 
the Opioid
    Crisis Grants that were authorized in the 21st Century Cures Act, 
which expand access to treatment for opioid addiction. Using evidence-
based interventions, these grants will help to address the primary 
barriers preventing individuals from seeking and successfully 
completing treatment and achieving and sustaining recovery.
                                lifeboat
    Question. Secretary Price, in 2015, more than 33,000 people died 
from heroin or prescription opioid overdose. That's 15 percent more 
people than died in 2014.
    Unfortunately, a major barrier that those suffering from opioid 
addiction face is insufficient access to substance abuse treatment. In 
fact, between 2009 and 2013, only 22 percent of Americans suffering 
from opioid addiction participated in any form of addiction treatment.
    That is why I introduced the LifeBOAT Act. This bill would require 
pharma companies to pay a small fee--1 cent per milligram--on their 
opioid products. It would then direct this funding to Substance Abuse 
Prevention and Treatment Block Grant.
    Secretary Price, will you support this commonsense proposal?
    We must increase funding for the many West Virginians and Americans 
who are struggling to recover. How do you propose we pay for treatment 
facilities to keep people from dying?
    Answer. Thank you again for your shared commitment to this fight. 
We agree this public health crisis knows no bounds. We will need to 
continue to work across HHS, with our partner agencies and other 
stakeholders, and with Congress to identify and dismantle barriers that 
hinder our response to this crisis, as well as leverage our resources 
in order to effectively implement these strategies. We look forward to 
continuing our work with you and your staff as we work to end this 
public health crisis.
    The Budget provided $811 million in HHS to address the opioid 
crisis. Congress has demonstrated its willingness to substantially 
support opioid prevention and treatment activities. HHS looks forward 
to working with Congress to fight the opioid crisis.
                     community services block grant
    Question. Secretary Price, I was very disappointed to see that the 
President's Budget completely eliminated funding for the Community 
Services Block Grant.
    Last year, this block grant provided $7.9 million dollars to West 
Virginia to serve more than 100,000 low-income West Virginians. And 
this funding helped my state leverage $3.88 from state, local, and 
private sources for every $1 in Federal funding.
    This funding is used to provide meals for seniors, fund early-
childhood education, strengthen career training, and provide services 
for our veterans. The flexibility in this grant gives West Virginia to 
target the resources to those who need it the most.
    Secretary Price, West Virginia has--at last count--a $500 billion 
deficit. We cannot replace these Federal dollars with state funding. 
What do you propose telling the children, veterans, and seniors who 
rely on the services that this block grant helps us provide?
    Answer. In a constrained budget environment, difficult funding 
decisions were made to ensure that Federal funds are being spent as 
effectively as possible. The Community Services Block Grant accounts 
for only 5 percent of total funding received by the local agencies that 
benefit from these funds. In addition, grantees can continue receiving 
funds even if they have not demonstrated strong performance because the 
formula for distribution is not directly tied to local agency 
performance. For these reasons, the fiscal year 2018 President's Budget 
proposes to discontinue the Community Services Block Grant to 
prioritize funding for other programs, such as early childhood care and 
education programs as well as services for older Americans.
                       black lung clinics program
    Question. Secretary Price, the President's budget proposes cutting 
$500,000 from the Black Lung Clinics program.
    That may seem like a small amount when we're talking about this 
huge budget, but for a $7.2 million program that serves some of the 
hardest working people the country, that's a lot of money.
    That is why I have joined with Senators Kaine, Warner, and Casey to 
push for the fully authorized level of funding for this program: $10 
million.
    The black lung clinics provide health screenings, medical care, and 
assistance in securing black lung benefits for miners.
    In West Virginia, more than 4500 miners with black lung benefited 
from this program in 2016.
    These are the people who worked their whole lives to bring energy 
to our country. The least we can do is see that they have the treatment 
that they need.
    Secretary Price, we made a promise to our miners and cutting this 
critical funding undermines that promise. Will you commit to working 
with me to protect funding for our coal miners and ensure that they 
have access to the healthcare that they need?
    Answer. The fiscal year 2018 President's Budget of $6.7 million 
continues the Black Lung Program's historical funding level and ensures 
improved access to quality care for miners living in rural and 
underserved areas. HRSA will continue to support the clinics to provide 
services to coal miners and their families.
                     federal funding for the opioid
    Question. Secretary Price, in your testimony, you note that the 
budget includes about $50 million more than fiscal year 2017 to combat 
the opioid epidemic. I applaud you for the funding that you did 
include, but this is nowhere near enough to solve this problem, and I 
have concerns about many of the programs that have seen even small 
cuts. To name a few:
  --The budget cuts the Substance Abuse Prevention and Treatment block 
        grant by $4 million. This block grants gives states flexible 
        funding to meet their substance abuse treatment needs.
    In West Virginia, more than 40,000 people sought treatment for 
illicit drug use, but were not able to receive it. We have too few 
options for people who need help and every penny counts.
  --The budget cuts the Drug-Free Communities Program and the High-
        Intensity Drug by a collective $6.5 million. Again, a 
        relatively small amount, but this funding is critical to 
        prevention and law enforcement efforts in West Virginia.
  --And the budget ends the Medicaid expansion and dramatically cuts 
        Medicaid, which paid for a quarter of public and private 
        spending for drug treatment in 2014. That's $7.9 billion of the 
        $31.3 billion total. These cuts are significant and will reduce 
        access to substance abuse treatment for thousands of West 
        Virginians.
    Secretary Price, with 91 people dying every day, we cannot short-
change our efforts to combat this crisis. We must provide dramatically 
more Federal support for treatment, prevention, and research than we've 
ever provided. What will happen to the 129,000 West Virginians and 21.6 
million Americans with a substance use disorder if we do not do more to 
fund prevention and treatment?
    Answer. The U.S. Department of Health and Human Services is keenly 
aware of the devastating impact that opioid addiction is having on our 
families and communities. Ending this public health crisis is among my 
top Departmental priorities, and your shared commitment to this fight 
is greatly appreciated. At HHS, we have identified five specific 
strategies that we can bring to the fight: improving access to 
prevention, treatment, and recovery services, including the full range 
of medication-assisted treatments; targeting availability and 
distribution of overdose- reversing drugs; strengthening timely public 
health data and reporting; supporting cutting-edge research; and 
advancing the practice of pain management.
    The Budget provided $811 million in HHS to address the opioid 
crisis. Congress has demonstrated its willingness to substantially 
support opioid prevention and treatment activities. HHS looks forward 
to working with Congress to fight the opioid crisis.
              state councils on developmental disabilities
    Question. Secretary Price, I was disappointed to see that the 
President's budget completely eliminates funding for the State Councils 
on Development Disabilities.
    West Virginia has approximately 33,000 people with a developmental 
disability, and we have the 3rd highest rate in the country of children 
needing special education.
    This funding is critically important to my constituents and to our 
efforts to ensure that every West Virginian is able to achieve 
independence, economic self-sufficiency, and inclusion in the 
community.
    Secretary Price, with our state budget deficit at around half a 
billion dollars, the state of West Virginia cannot fill in where 
Federal funding goes away. Won't cutting these resources actually lead 
to greater costs in the future because without these supports 
individuals with developmental disabilities will have a harder time 
becoming independent and contributing to our economy?
    Answer. We share your concerns that every American have the tools 
that would help to be able to achieve independence, economic self-
sufficiency, and inclusion in their communities. State Councils on 
Developmental Disabilities are part of the Administration for Community 
Living's network of programs that currently operate three separate 
State councils and boards focused on supporting individuals with 
disabilities and their families. The proposed Partnership for 
Innovation, Inclusion and Independence would merge each State's 
separate, legislatively mandated councils into a single State-wide body 
focused on capacity building, advocacy, and systems change to enhance 
the availability, quality, and coordination of services and supports 
needed for individuals with significant disabilities to live in the 
community. This proposal will allow limited resources to be targeted 
where most needed to benefit persons with any type of significant 
disability living in the community. HHS recognizes that creating a new 
cross- disability State Council that serves the needs of individuals 
with disabilities and their families would raise questions, which is 
why we will be reaching out to stakeholders this summer to get their 
input, and we look forward to working with Congress on the development 
of authorization language for the new program.
                     rural healthcare and the ahca
    Question. Secretary Price, I am concerned about the impact that the 
President's budget request would have on access to healthcare in rural 
communities.
    In particular, I am concerned about changes to Medicaid. The budget 
assumes that the Republican healthcare bill--the AHCA--becomes law. The 
CBO has said that that bill cuts $834 billion in Federal funding for 
Medicaid and it would eventually eliminate the Medicaid expansion. This 
budget claims another $610 billion in reducing Federal funding for 
Medicaid.
    Let me share some numbers with you:
  --In my state of West Virginia, uncompensated care reached $692.27 
        million in 2013.The following year, after Medicaid expansion 
        was enacted, the state's uncompensated care dropped 38.3 
        percent to $427.44 million.
  --That's because almost 200,000 West Virginians gained insurance 
        coverage either on the exchanges or through the Medicaid 
        expansion--suddenly these rural healthcare providers were being 
        reimbursed for services instead of absorbing the cost.
    I have heard from rural hospital CEOs, physicians, and other 
healthcare providers in West Virginia that these cuts would be 
devastating to rural hospitals and clinics in my state.
    Many of them would have to close leaving my constituents hours away 
from the closest emergency room.
    Secretary Price, what is your plan to ensure that rural healthcare 
providers are able to continue to serve my constituents in rural West 
Virginia if those West Virginians lose their Medicaid coverage or 
private health insurance?
    Answer. By strengthening the Federal and state Medicaid 
partnership, we will empower states to develop innovative solutions to 
challenges like high drug costs or providing healthcare in rural areas, 
rather than telling states how they should run their programs. Every 
state has different demographic, budgetary, and policy concerns that 
shape their approach to Medicaid. That is one of the reasons I believe 
a one-size-fits-all approach is not workable for a country as diverse 
as the United States. We will work with states to use the tools and 
authorities we have to provide regulatory relief, and make the Medicaid 
program more flexible and efficient for the people it serves, 
particularly those in rural areas.
               a bipartisan approach to healthcare reform
    Question. Secretary Price, I am very concerned about the approach 
that my Republican colleagues are taking right now to repeal the ACA.
    I have said many times that I will be first in line to help repair 
the ACA because we all know that there are things that need to be 
fixed. But this must be done in an open, bipartisan process.
    I was not here when the ACA was passed, and I disagreed with the 
decision then to pass a partisan bill, but the bill did go through an 
extensive vetting process with input from stakeholders and members on 
both sides of the aisle. In fact:
  --The HELP Committee held 47 bipartisan hearings, meetings, 
        roundtables and walkthroughs. There were more than 300 HELP 
        Committee amendments and the Committee adopted more than 160 
        Republican amendments.
  --The Finance Committee held 53 hearings, meetings, negotiations and 
        walkthroughs. During the 7-day Finance Committee markup, they 
        adopted 11 Republican amendments.
  --Finally, the bill was debated in the Senate for 25 consecutive 
        days--a total of 160 hours of debate on the Senate floor.
    This is, frankly, not what we're seeing today. There have been zero 
public hearings, the text of the bill in the Senate has been kept 
secret, and not one Democrat has been asked for their input.
    Secretary Price, as a leader in healthcare policy in your party, 
will you commit to fighting for an open, bipartisan process to repair 
the ACA?
    Answer. As a representative of the Executive branch, I defer to 
Congress in terms of its process. I am committed to restoring, 
protecting, and preserving the doctor-patient relationship, while 
developing a healthcare system that's patient-centered, affordable, 
accessible, and of the highest quality.
                               ahca taxes
    Question. Secretary Price, the President's budget assumes that the 
House Republican bill to repeal the ACA becomes law.
    According to the CBO, this bill offers a $661 billion tax cut, 
primarily for industry and wealthy individuals.
    Breaking that down further, the Center on Budget and Policy 
Priorities has found that the AHCA would:
  --Offer millionaires an average tax cut $40 billion--an average of 
        $50,000 per household and offer the 400 wealthiest households 
        an average tax cut of $7 million per year each.
  --But it would take $38 billion from the 32 million households living 
        in poverty who will lose valuable tax credits to help them 
        purchase insurance or access to Medicaid.
    Secretary Price, some have called the AHCA a tax cut bill with a 
healthcare pay for. How can we justify giving the wealthy a tax cut 
while we take healthcare away from 23 million people?
    Answer. Under Obamacare, premiums in the individual market have 
skyrocketed across the country--on average doubling what Americans are 
paying for health insurance coverage. Because of these rising costs, 
some Americans have dropped their unaffordable coverage and others have 
been forced to pay a tax penalty just for the right to go without. 
Patients, doctors, job creators, and Americans from all walks of life 
are being harmed and losing access to the affordable coverage and care 
they need.
    The Administration supports a patient-centered reforms repeal and 
replace approach that improves Medicaid's sustainability and targets 
resources to those most in need, eliminates Obamacare's onerous taxes 
and mandates, provides funding for States to stabilize markets and to 
ensure a smooth transition, and helps Americans purchase the coverage 
they want through the use of tax credits and expanded Health Savings 
Accounts.
                       groups opposed to the ahca
    Question. Secretary Price, dozens of medical and patient groups are 
opposed to the House Republican bill to repeal the ACA.
    This list includes the American Medical Association, the American 
Hospital Association, the American College of Physicians, the American 
Academy of Pediatrics, the American Cancer Society, the American 
Diabetes Association, and the list goes on.
    Secretary Price, given the number of experts and patient advocates 
who are opposed to this bill because of the harm that it will cause to 
the people that they serve, would it make sense to stop this partisan 
process and work with stakeholders on a bipartisan effort to repair the 
ACA?
    Answer. Obamacare is failing the American people, delivering high 
costs, few options, and broken promises. The Administration is 
committed to working with Congress to repeal and replace 
Obamacare.While Congress works to pass legislation, the Administration 
remains committed to providing needed flexibility to issuers to help 
attract healthy consumers to enroll in health insurance coverage, 
improve the risk pool and bring stability and certainty to the 
individual and small group markets, while increasing the options for 
patients and providers.
                           smokeless tobacco
    Question. Secretary Price, I have heard from West Virginia 
businesses who are concerned about the effects a proposed rule (21 CFR 
Part 1132) would have on their business. Specifically, they are 
concerned that the proposed standard for N-nitrosonornicotine (NNN) of 
1 part per million is technically unachievable.
    Secretary Price, is this an achievable standard and, if so, what 
data do you have to support that claim? What is the FDA doing to review 
and address these concerns?
    Answer. The proposed rule would establish a limit of N-
nitrosonomicotine (NNN) in finished smokeless tobacco products sold in 
the United States. The Department's regulation of tobacco is of 
particular interest and an issue on which many have strong feelings.
    The Administrative Procedure Act includes a comprehensive set of 
requirements agencies must follow before issuing regulations. As with 
any rulemaking, it is important for the agency to hear from the public 
regarding their thoughts on the proposed rule. To ensure an even more 
robust opportunity for public participation in the rulemaking process, 
the comment period for this proposed rule was extended by an additional 
90 days. It closed on July 10, 2017, giving interested parties nearly 6 
months to submit any information to FDA.
    Thus far we have received comments from smokeless tobacco 
manufacturers and farmers addressing issues of technical achievability 
and implementation. We have also received comments from public health 
groups addressing the potential impact of this rulemaking on reducing 
tobacco related morbidity and mortality. We are, and will continue to, 
carefully review all comments to ensure that if this rulemaking is 
finalized we have considered both the public health impacts and effects 
on farmers and industry.
                         cost sharing reduction
    Question. Secretary Price, the Trump Administration has refused to 
commit to paying the Cost Sharing Reduction payments (CSRs) over the 
long term. These subsidies help keep copays and deductibles low for the 
most vulnerable enrollees. Insurers have argued that without these 
subsidies, they will have to raise rates or withdraw from the market, 
leaving millions without health insurance.
    Secretary Price, as the Administration's health representative, 
does HHS plan to honor agreements set forth in the Affordable Care Act 
to these insurance companies so that Americans, especially those in 
rural and underserved areas, remain unharmed while Congress debates the 
future of healthcare?
    Answer. As you know, there is pending litigation on the issue of 
cost-sharing reductions, and as a named defendant in that litigation, I 
am limited in what I can say. The Administration has emphasized the 
importance of reforming our healthcare system to one that works better 
for patients and their providers. For any additional information, I 
would refer you to the Department of Justice.
                                 ______
                                 
            Questions Submitted by Senator Patrick J. Leahy
                       health workforce programs
    Question. Health workforce programs administered through the Health 
Resources and Services Administration (HRSA) have long expanded 
education and training opportunities available to our nation's most 
critical healthcare providers. From the Nursing Workforce Development 
Program, which not only supports education and training for advanced 
nurses, but also provides loan reimbursement for nursing students who 
practice in underserved areas; to the Training in Primary Care Medicine 
program, which strengthens primary care physician training on patient 
interaction and care, HRSA's health workforce programs ensure our 
nation's providers receive the training and education possible to 
continue serving patients in need.
    According to the Association of American Medical Colleges, the 
shortfall of primary care physicians is expected to range from 14,900 
to 35,600 by 2025. Non-primary care specialties are also expected to 
experience a shortfall of between 37,400 and 60,300 physicians within 
in the next decade. And nurse vacancies are expected to reach 1.2 
million by 2022, with a shortfall expected of more than twice as large 
as any nurse shortage experienced since the introduction of Medicare 
and Medicaid, by 2025.
    Clearly, the U.S. health workforce will fail to adequately provide 
for millions of patients in the coming years if shortfalls are not 
addressed. Yet the proposed budget for HRSA in fiscal year 2018 
includes $377 million in cuts to health workforce programs, including 
$146 million from the Nurse Workforce Development Program. It also 
completely eliminates funding for the Training in Primary Care Medicine 
Program. Without these programs, patients within our most vulnerable 
communities will undoubtedly face reductions in care.
    What is the justification for cutting funding for vital health 
workforce programs that support our nation's highest-need patients, 
especially given the projected physician and nurse shortages in coming 
years?
    Answer. The fiscal year 2018 Budget provides $771 million in 
mandatory and discretionary resources for HRSA health workforce 
programs. At this level, funding is maintained for activities that 
directly increase the number of primary healthcare professionals 
working in communities facing a shortage of such providers by providing 
scholarships and loan repayments and by requiring a service commitment. 
Priority is given to health workforce programs that support more 
targeted efforts to provide direct healthcare services to patients in 
primary care settings and in health profession shortage areas, such as 
the NURSE Corps and National Health Service Corps Loan Repayment and 
Scholarship Programs.
    Question. Without funding for health workforce programs, what plan 
does the administration suggest to tackle projected physician and nurse 
shortages?
    Answer. Projections published by HRSA indicate a projected shortage 
of primary care physicians through 2025. In addition, geographic mal-
distribution also contributes to the shortage of primary care providers 
in many communities. For example, rural areas have less than half the 
number of physicians to population compared to urban areas. Although 
HRSA's nursing projections indicate that the supply of nurses will 
outpace demand at a national level in 2020 and beyond, the 
maldistribution of nurses will be a continued problem in some areas of 
the country, including rural areas.\7\
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    \7\ Https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-
analysis/research/projections/primary-care-national-projections2013-
2025.pdf and https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/
projections/nursingprojections.pdf.
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    The Budget provides $771 million in mandatory and discretionary 
resources for HRSA health workforce programs. This funding level 
supports workforce activities, including programs that directly 
increase the number of healthcare professionals through scholarships 
and loan repayments in exchange for service commitments in communities 
facing shortages of healthcare professionals. For example, the Budget 
maintains funding for:
  --National Health Service Corps Program ($310 million), to support 
        qualified healthcare providers dedicated to working in areas of 
        every U.S. state and territory in exchange for repayment of 
        educational loans. As of September 30, 2016, the National 
        Health Service Corps has a field strength of nearly 10,500 
        primary care medical, dental, and mental and behavioral health 
        practitioners providing service nationwide at NHSC-approved 
        sites in rural, urban, and frontier areas.
  --NURSE Corps Programs ($83 million), to support nursing services in 
        areas of the nation facing critical nurse shortages in exchange 
        for scholarships and the repayment of educational loans. As of 
        September 30, 2016, the NURSE Corps program has a field 
        strength of over 2,000 nurses serving in critical shortage 
        facilities across the country.
  --Children's Hospitals Graduate Medical Education program ($295 
        million), to support graduate training for pediatricians and 
        pediatric subspecialists. In Academic Year 2015- 2016, the 
        CHGME program supported 6,877 resident FTE providing services 
        to children in children's hospitals across the county. 
        Children's hospitals receiving CHGME funding train about 48 
        percent of the nation's pediatricians and over half of all 
        pediatric sub- specialists, making the program a significant 
        contributor to the pediatric workforce.\8\
---------------------------------------------------------------------------
    \8\ Data based on AY 2014-2015 CHGME Program data on number of 
residents trained at CHGME hospitals and ACGME Data Resource Book 2015-
2016 file.
---------------------------------------------------------------------------
  --Teaching Health Center Graduate Medical Education program ($60 
        million), to support the primary care workforce through new and 
        expanded primary care and dental residency programs in 
        community-based, ambulatory settings, and improves the 
        distribution of this workforce into needed areas through 
        emphasis on underserved communities and populations. In 
        Academic Year 2015-2016, the program supported 690 enrolled 
        full time equivalent resident slots.\9\
---------------------------------------------------------------------------
    \9\ Updated June 28, 2017.
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  --Health Care Workforce Assessment ($5 million): The National Center 
        for Health Workforce Analysis (NCHWA) collects and analyzes 
        health workforce data and information in order to provide 
        national and state policy makers, researchers, and the public 
        with information on health workforce supply and demand. NCHWA 
        also evaluates the effectiveness of HRSA's workforce 
        investments.
                       mental health block grant
    Question. Mental health services are essential to our nation's 
communities, especially as the substance abuse epidemic continues. Just 
last year, Congress made the commitment to strengthening Federal mental 
health parity laws through the passage of the 21st Century Cures Act, 
which ensures victims of mental illness have the resources necessary to 
thrive.
    The Community Mental Health Services Block Grant (MHBG), 
administered through the Substance Abuse and Mental Health Services 
Administration (SAMHSA), is vital in efforts to strengthening mental 
health parity. By providing states with funding to expand community 
mental health services, MHBG ensures that adults and children with 
serious mental illness have the means necessary to participate in 
family, school, and workplace settings, while also receiving the care 
they need to live comfortably and independently. SAMHA's mental health 
programs of Regional and National Significance also strengthen mental 
health resources for vulnerable populations, including through suicide 
prevention grants and mental health first aid for veterans and their 
families.
    The proposed budget for SAMHSA in fiscal year 2018 cuts MHBG by 
$116 million and programs of Regional and National Significance by $136 
million. Additionally, the budget eliminates funding for the Behavioral 
Health Workforce Education and Training program, which supports 
enhanced resources for specialists to care for individuals with mental 
illness.
    With substance abuse disorders often directly connected to mental 
illness, how will the administration's commitment to combatting the 
opioid abuse epidemic work without strong mental health resources for 
our nation's most vulnerable communities?
    Answer. Mental health services and treatment for individuals with 
mental illness is of importance in improving the lives of the nation's 
most vulnerable communities--including those impacted by the opioid 
crisis. The President's 2018 budget provides support for the Mental 
Health Block Grant program as well as the majority of SAMHSA's Programs 
of Regional and National Significance for mental health service needs. 
SAMHSA will work closely with states and others to improve efficiencies 
in these programs and to focus the use of funds on evidence- based 
practices to maximize reach and impact. This effort also includes 
providing assistance to leverage other public and private funding 
streams to increase access to needed care.
              national institutes of health indirect costs
    Question. Biomedical research is critical to saving lives. Through 
clinical trials and scientific discoveries, biomedical research has 
long led to discoveries, including the development of vaccines, the 
eradication of serious diseases, and innovative cures for cancer. 
Biomedical research is not only made possible through strong Federal 
resources, but also through the commitment of our nation's researchers 
and institutions.
    Currently, institutions that receive Federal grants from the NIH 
enter into an agreement with the agency to receive additional funding 
for indirect costs, such as the cost of labs and equipment, 
researchers, facility maintenance, and utilities. These funds are 
critical to ``keeping the lights on,'' and ensure that biomedical 
research can actually be carried out. In my home state of Vermont, our 
largest research institution, the University of Vermont (UVM), received 
more than $137 million in Federal grants funding last year, $26.3 
million of which was used for indirect costs. Under the 
administration's proposed budget, UVM would lose more than half of what 
it is currently allotted for indirect costs, meaning biomedical 
research would ultimately cease to function at UVM, costing jobs and 
future medical breakthroughs.
    To date, UVM has contributed to the globe's most cutting edge 
medical knowledge on combatting lung and heart disease. Without the 
ability to use biomedical research dollars to hire researchers and run 
labs using updated facilities, equipment, and resources, this 
incredible work will ultimately come to a halt.
    How will research institutions maintain and advance biomedical 
research programs if they are no longer able to support the 
infrastructure needed for research?
    Answer. While NIH provides funding to many universities and 
institutions, and guidance on grant administration, it generally does 
not dictate what personnel, facilities, or equipment will be supported 
by that funding; thus, the way institutions manage their programs would 
largely be governed by decisions and policies at each institution. The 
Administration also will propose a package of reforms to streamline 
Federal compliance requirements and reduce burden on NIH grantees. 
These targeted policies are expected to reduce the time and expenses 
that grantees must currently spend to comply with overly burdensome 
Federal grant requirements, thus lowering grantees' administrative 
costs and mitigating some of the impact of lower indirect cost rate. 
Additionally, institutions may also apply for funding from private 
organizations.
    Question. The administration's proposal to cap indirect costs at 10 
percent will result in the loss of thousands of jobs, not to mention 
important biomedical research that directly saves lives. How does this 
proposal fit with the President's ``jobs'' agenda?
    Answer. The Department supports the Administration's agenda of 
creating a more effective and efficient government and to support 
economic growth. The fiscal year 2018 Budget presents an opportunity 
for HHS and NIH to reexamine how to optimize Federal investment in a 
way that best serves the American people. This policy will enhance the 
stewardship of taxpayer dollars by focusing our limited resources on 
innovative scientific research rather than administrative and overhead 
costs.
                        public health prevention
    Question. Public health prevention resources are critical to 
ensuring states have the means necessary to combat significant health 
epidemics. Public health resources provide state governments, community 
stakeholders, and providers with tools to both educate the public on 
how to prevent and treat serious diseases, and ensure the safety of 
patients and providers in the event a serious epidemic hits home soil. 
State budgets more and more constrained in today's fiscal environment, 
especially with regards to promoting the health and wellbeing of 
patients. Without strong public health prevention funding, our 
communities will lack the capacity to fight and prevent disease.
    The Administration's proposed budget for fiscal year 2018 includes 
cuts to public health preventative medicine in several capacities. 
First, it eliminates funding for the Public Health and Preventive 
Medicine Programs through the Health Resources and Services 
Administration (HRSA). Next, it reduces public health prevention 
funding from the Centers for Disease Control and Prevention (CDC) in 
the following programs: Immunization and Respiratory Disease, 
Environmental Health, Public Health Preparedness and Response, and 
Chronic Disease Prevention and Health Promotion. Additionally, the 
budget proposal reduces funding for the Hospital Preparedness Program 
in the Public Health and Social Services Emergency Fund.
    Given the significant cuts to these resources in the 
administration's proposed budget for fiscal year 2018, how can states 
possibly prepare for similar resources in the event of a serious 
epidemic such as Zika or Ebola?
    Answer. As the Federal Government, we must make the health and 
safety of Americans the driving force behind all that we do. The fiscal 
year 2018 President's Budget request supports HHS's preparedness 
efforts.
    ASPR intends to create a lean, yet effective Hospital Preparedness 
Program in fiscal year 2018 by focusing Federal funding on those states 
and jurisdictions with the greatest need. For healthcare preparedness, 
need is defined as those most at risk.
    Through its fiscal year 2018 proposals, the Department will target 
Federal funds to those jurisdictions with the greatest need, and will 
continue to provide all jurisdictions with technical assistance to 
inform their preparedness and response efforts. Supporting state, 
local, and territorial health departments through grants and 
cooperative agreements remains a core priority of CDC's work in the 
fiscal year 2018 President's Budget.
    For example, since 9/11, CDC's Public Health Emergency Preparedness 
(PHEP) program has partnered with 62 state, local, and territorial 
public health departments to prepare for, withstand, respond to, and 
recover from, potentially devastating public health emergencies. The 
PHEP program supports the development and maintenance of capable, 
flexible, and adaptable public health systems ready to respond rapidly 
to ensure Americans are protected.
    CDC will build on the preparedness investments made to date and 
continue to support state, local, and territorial public health 
operations, preparedness, and our collective ability to detect and 
respond to life threatening diseases and threats at the levels 
requested in the President's Budget.
    NIH has made significant progress in the development of vaccines, 
diagnostics, and therapeutics for Zika and Ebola. The emergency 
supplemental appropriations to the National Institute of Allergy and 
Infectious Diseases (NIAID) were $152 million in fiscal year 2016 for 
Zika research, and $238 million in fiscal year 2015 for Ebola research. 
In addition, $81 million was transferred from HHS and other NIH 
Institutes and Centers to NIAID in fiscal year 2016 for Zika research.
    In March, the NIH-developed Zika vaccine candidate entered a two 
part Phase 2/2b clinical trial testing. Sites will include two U.S. 
States (Texas and Florida) and one US territory (Puerto Rico) at high 
risk for Zika transmission. The study is currently expected to be 
completed by 2019.
    NIH also maintains a research portfolio on Ebola. NIH is conducting 
and supporting the development of multiple candidate vaccines, in 
partnership with industry and the US Army. In addition, NIH is working 
on novel therapeutics and continuing to study the long-term effects of 
Ebola on the health of survivors. Within available fiscal year 2018 
funding, NIH expects to continue to treat these activities as a high 
priority.
    In addition, the President's Budget proposes a new emergency 
response fund with Department- wide transfer authority in order to 
enable a swift response to emerging public health threats. Such a fund 
will help bridge the Department's response in situations that exceed 
the planned scope of preparedness and response activities or where the 
emergency occurs late in the fiscal year.
                   women's health/planned parenthood
    Question. This budget is devastating for women's health and 
offensive to American women and their families. Not only does it 
eliminate funding for Planned Parenthood, which provides important 
preventative care, including cancer screenings, annual checkups, and 
contraception, but it also precludes Planned Parenthood from 
participating in any Health and Human Services program, including 
Medicaid. It would also bar Planned Parenthood funding for HIV/AIDS 
testing and prevention, programs funded by the CDC, and grants 
authorized by the Violence Against Women Act (VAWA). More than 50 
percent of Planned Parenthood health centers are located in health 
professional shortage, rural, or medically underserved areas, meaning 
this budget would disproportionately affect vulnerable American 
families. Additionally, the budget eliminates the Teen Pregnancy 
Prevention program, which supports evidence-based approaches to reduce 
teen pregnancy.
    Millions of women depend on Planned Parenthood for regular 
preventative healthcare and cancer screenings. If they are otherwise 
unable to afford health insurance or private care, where would you 
suggest they go?
    Answer. The mission of our department is to protect the health and 
well-being of all Americans. We take our commitment to that mission 
seriously, and will do everything within our power to support access to 
quality, affordable healthcare for all Americans. Part of that effort 
has been support for community health centers that provide critical 
health services. We need to do all we can to strengthen them, ensuring 
they are staffed with the highest quality providers and providing the 
highest quality care.
    Question. In Vermont, Planned Parenthoods are the only Title X 
recipient. Our Community Health Centers have already said that they do 
not have the capacity to accept patients turned away from Planned 
Parenthood services, even with the increase in community health center 
funding in your budget.
    If community health centers cannot fill the need of this 
population, do you expect women will forgo care?
    Answer. No women will have to forgo care. Over the last several 
years, a significant number of Planned Parenthood clinics have closed, 
and its number of contraceptive clients has dropped. At the same time, 
federally qualified health centers have grown both in number of clinics 
opened and contraceptive clients served. If Planned Parenthood clinics 
are no longer participating in Title X, other entities will provide 
these services in the Title X program. In addition, the Budget includes 
$5 billion for Community Health Centers, which provide a broad range of 
primary healthcare to nearly 26 million patients nationwide.
    Question. How many more unplanned pregnancies does the Department 
estimate if this budget were enacted?
    Answer. While we don't have an estimate of unplanned pregnancies, 
the Budget supports women having access to services and funds many 
women's health programs at current levels or higher.
    Question. Why does the Trump administration believe--as evidenced 
by the budget for your Department--that low-income women do not deserve 
access to specialists for annual visits rather than seeing a primary 
care doctor for reproductive health services?
    Answer. The President's Budget prioritizes women's health programs 
through investing in research to improve health outcomes, maintaining 
support for women's health services, empowering women and families, and 
emphasizing prevention. The Maternal and Child Health Block Grant is 
increased to improve the health of mothers, children, and adolescents, 
particularly those in low-income families. In addition, funding is 
maintained for a variety of vital programs serving women across HHS, 
including,community health centers, domestic violence programs, Healthy 
Start, women's cancer screenings and support, mother and infant 
programs, and the Office on Women's Health.
                                 liheap
    Question. I am particularly concerned that the budget would 
eliminate funding for the Low-Income Energy Assistance Program 
(LIHEAP). Last year, LIHEAP helped keep 21,000 Vermonters and their 
families warm during a very harsh winter, not to mention 6 million 
additional families nationwide, most of whom are elderly, disabled, or 
have children under the age of five. Vermonters and Americans across 
the nation count on LIHEAP when they would not otherwise be able to 
afford to heat or cool their homes.
    LIHEAP saves lives and supports low-income families during bitterly 
cold winters and severe heat waves. How does the Department justify 
eliminating funding for a program that saves lives?
    Answer. In a constrained budget environment, difficult funding 
decisions were made to ensure that Federal funds are being spent as 
effectively as possible. LIHEAP is unable to demonstrate strong 
performance outcomes and is not the only source of assistance for low 
income households. As HHS looks for ways to improve the effectiveness 
and efficiency of the Federal Government, energy assistance programs 
are one area where we may look to States and private entities to play a 
larger role. Utility companies and state and local governments already 
provide significant heating and cooling assistance to low income 
households, and the majority of states also prohibit utilities from 
discontinuing a household's energy in periods of severe weather or in 
certain other circumstances.
                          refugee resettlement
    Question. I am concerned that this budget cuts the Office of 
Refugee Resettlement (ORR) by 13 percent or $218 million compared to 
the fiscal year 2017 enacted level. The budget also cuts refugee 
transitional and medical services by $169 million. These programs serve 
and protect refugees, and are critical to ensuring refugee families 
have the means necessary to survive in their new communities.
    I want to know your justification as to why and how the $169 
million reduction to refugee transitional and medical services was 
calculated. Many refugee families will undoubtedly lose coverage as a 
result of these cuts. What services would you prescribe they access in 
lieu of those currently offered by the Office of Refugee Resettlement?
    Answer. Funding can be reduced for refugee programs because new 
policies have resulted in a reduced number of refugees and other 
populations entering the country. The Budget includes $320 million for 
Transitional and Medical Services, which is sufficient to continue to 
provide 8 months of cash and medical assistance for an estimated 98,000 
new arrivals, including refugees, asylees, Cuban and Haitian entrants, 
and other humanitarian entrants, in fiscal year 2018. The Presidential 
Determination on Refugee Admissions for fiscal year 2018 will be 
released later this year.
                       health insurance coverage
    Question. When discussing the House version of the Trumpcare bill, 
Secretary Price stated that `` . . . the plan in its entirety is the 
one that the President has ensured the American people every single 
American will have access to affordable coverage that works for them.'' 
That is an extraordinary statement that conflicts with virtually every 
objective analysis of the bill. For example, the Congressional Budget 
Office disagrees with Secretary Price's assessment and estimates that 
the markets will become unstable for those with preexisting health 
conditions by 2020.
    How can the Trump administration stand by Secretary Price's 
statement that everyone will have affordable access to coverage, 
especially when the President himself referred to the House-passed 
healthcare bill as ``mean''? What does the Department define as health 
insurance ``coverage''?
    Answer. Across the Nation, Obamacare is failing the American 
people, delivering high costs, few options, and broken promises. 
Americans across the Nation have seen their health insurance choices 
collapse under Obamacare, leaving an increasing number attempting to 
buy health insurance through the Obamacare Exchanges in which only one 
insurer may be participating. The ever-narrowing set of choices 
Americans are facing means that there is a very real chance some 
counties will have no insurers selling ACA plans in 2018.
    Without competition among insurers, Americans have been forced to 
buy increasingly unaffordable coverage, with premiums spiraling out of 
control. Obamacare premiums in some States have increased by double and 
triple digits. Mandating that every American buy Government-approved 
health insurance was never the right solution for our country. 
Americans should have the freedom to make the decisions that are right 
for them and their families, and should have more choices and access to 
the healthcare they want and deserve.
    The Budget supports a repeal and replace approach that improves 
Medicaid's sustainability and targets resources to those most in need, 
eliminates Obamacare's onerous taxes and mandates, provides funding for 
States to stabilize markets, and ensure a smooth transition away from 
Obamacare, and helps Americans purchase the coverage they want through 
the use of tax credits and expanded Health Savings Accounts. This 
approach sets a foundation for a patient-centered healthcare system 
where Americans will have more choices, lower premiums, and greater 
access to different insurance options.
                           rural health care
    Question. Vermont is a predominately rural state, and rural areas 
experience certain challenges related to healthcare. In rural areas, 
providers are often few and far between, causing patients to travel 
long distances to get to the doctor. This also means rural areas have 
trouble recruiting and retaining physicians and nurses. The Office of 
Rural Health Policy within the Health Resources Services Administration 
is charged with supporting the healthcare challenges rural areas face. 
President Trump's budget cuts this program in half, and discontinues 
resources that help rural areas test ways to better serve patients. 
Combined with the cuts to Medicaid, this budget makes the challenges 
rural patients face even worse.
    How can you ensure patients in rural areas have access to high-
quality care when the Department is slashing programs that help small 
hospitals and communities deliver better care, especially to those who 
rely on Medicare?
    Answer. The fiscal year 2018 President's Budget provides $74 
million for critical rural health activities such as Rural Health 
Outreach Network and Quality Improvement Grants, Rural Health Policy 
Development, Black Lung Clinics, and Telehealth. These investments will 
improve access to quality healthcare services in rural and underserved 
areas. The Budget also continues to support health services in rural 
communities through Community Health Centers and the National Health 
Service Corps. In 2015, Community Health Centers served approximately 1 
in 5 rural Americans, and as of September 30, 2016, nearly one quarter 
(24 percent) of National Health Service Corps clinicians served at 
rural sites.
    The Budget discontinues Rural Hospital Flexibility Grants and State 
Offices of Rural Health to prioritize programs that provide direct 
healthcare services. The Budget does not include any direct cuts to 
Medicare.

                          SUBCOMMITTEE RECESS

    Senator Blunt. The subcommittee will stand in recess until 
10 a.m. on Thursday, June the 22.
    [Whereupon, at 11:54 a.m., Thursday, June 15, the 
subcommittee was recessed, to reconvene at 10 a.m. Thursday, 
June 22.]