[Senate Hearing 117-]
[From the U.S. Government Publishing Office]



 
  DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND 
          RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2022

                              ----------                              


                        WEDNESDAY, JUNE 9, 2021

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:02 a.m., in room SD-124, Dirksen 
Senate Office Building, Hon. Patty Murray (chairwoman) 
presiding.
    Present: Senators Murray, Reed, Shaheen, Schatz, Baldwin, 
Murphy, Manchin, Blunt, Capito, Hyde-Smith, Braun, and Leahy.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

                        Office of the Secretary

STATEMENT OF HON. XAVIER BECERRA, SECRETARY


               opening statement of senator patty murray


    Senator Murray. Good morning. The Senate Appropriations 
Subcommittee on Labor, Health and Human Services, Education, 
and Related Agencies will come to order. Today, we are having a 
hearing on the Biden administration's fiscal year 2022 budget 
request for the Department of Health and Human Services. 
Senator Blunt and I will each have an opening statement, then I 
will introduce our witness, Secretary Becerra. After his 
testimony, Senators will each have 5 minutes for a round of 
questions, and before we begin, I do want to walk through the 
COVID-19 safety protocols in place today, and I want to thank 
all of our clerks and everyone who has worked really hard to 
get this set up and help everyone stay safe and healthy.
    As I mentioned before the break, with the change in 
guidance from the Office of the Attending Physician, the 
committee is now returning to requiring in-person attendance by 
witnesses and members who wish to make statements or ask 
questions. However, social distancing remains in effect, and 
those who have not been fully vaccinated are strongly 
encouraged to wear masks.
    While we are unable to have the hearing fully open to the 
public or media for in-person attendance, live video is 
available on our committee website, and if you are in need of 
accommodations, including closed captioning, you can reach out 
to the committee or the Office of Congressional Accessibility 
Services.
    Secretary Becerra, I am pleased to say this budget 
represents a world of change from the past few years on 
healthcare, and a road map on progress for years to come. It 
proposes increasing the Centers for Disease Control and 
Prevention's budget by nearly a quarter, which, as we discussed 
in our hearings with Director Walensky, will not only help see 
our Nation through this pandemic, but help us rebuild our 
public health system, and better prepare for the next one.
    It also proposes serious investments to tackle other 
ongoing public health crises. Healthcare providers across my 
State have reported a sharp uptick in youth mental health 
emergencies during this pandemic, and the national suicide rate 
has been climbing for years. This budget builds on the 
resources we've provided for mental health and substance use 
services in our COVID-19 bills with an additional $9.7 billion 
for the Substance Abuse and Mental Health Services 
Administration, and an increase of $3.7 billion over fiscal 
year 2021 levels.
    Washington State also saw drug overdoses increase by 38 
percent over the first half of 2020, and our Nation saw a 
record-breaking number of overdose deaths last year. President 
Biden is proposing an historic investment of $10.7 billion 
across HHS (Department of Health and Human Services) programs 
to end the opioid epidemic, and he is proposing we continue the 
progress we've seen towards ending another epidemic by 
investing $670 million in the HIV/AIDS elimination initiative.
    And to aid the fight against cancer, Alzheimer's, long-term 
COVID-19, and countless other diseases, President Biden is 
calling for the largest budget increase for the National 
Institutes of Health in the agency's history.
    In the fight against systemic racism, he has proposed new 
investments across the department to reduce health disparities, 
and after years of relentless attacks on women's healthcare and 
reproductive rights, President Biden is charting a clear path 
in a new direction, one that puts women's health first, and 
puts patients, not politicians, in charge of their own 
healthcare decisions.
    I am pleased to see this budget call for $340 million for 
the Title X Family Planning Program, which helps so many 
patients, particularly women of color, get birth control, 
cancer screening, STD screenings, and other essential care. 
This funding will build on the administration's recent progress 
to restore the Title X Family Planning Program with a new 
proposed rule.
    The budget would also eliminate the Hyde Amendment, which 
is a critical step towards ensuring every person is trusted to 
make their own individual choices about their life and future, 
based on their own values, no matter who they are, where they 
live, or how much money they make. I do recognize that is an 
area of strong disagreement among members of this committee, 
but for too long, Hyde has made abortion accessible only to 
those with means, while women of color and women who are paid 
low incomes struggle to get care.
    This budget also takes other important steps to prioritize 
women's health. Our maternal death rate is the highest in the 
developed world, and two in three of those deaths is 
preventable. The death rate for rural mothers is 50 percent 
higher, and black and native women are two to three times more 
likely to die from a pregnancy-related cause than white women. 
This budget will invest $220 million to combat our maternal 
mortality crisis.
    Domestic violence is another longstanding and urgent 
problem, and one made more challenging by a pandemic that makes 
it even harder for people to get away from their abusers. This 
budget proposes doubling Federal funding for programs that 
provide shelter and support for survivors of domestic violence.
    We've also seen throughout this pandemic how the childcare 
crisis has grown worse, and been particularly hard on women, 
and hardest of all on women of color, and women who are paid 
low wages. This budget acknowledges the importance of investing 
in a bright future for every child in our Nation, and proposes 
to increase funding for childcare and development block grants 
by $1.5 billion in addition to the bold investments proposed in 
the American Families Plan, and provide an increase of over $1 
billion for Head Start and pre-school development grants.
    It also acknowledges our moral obligation to provide relief 
to some of the world's most vulnerable populations, including 
making sure the children in our Nation's custody are treated 
with decency, humanity, and kindness by calling for $1 billion 
in funding for refugee programs, and $3.3 billion for the 
unaccompanied children program, which has been stretched thin 
by this pandemic. These funds will help ensure children in HHS 
custody are quickly and safely placed in appropriate homes, 
provide care and services for them while they are in HHS 
custody, and provide social and legal services after they leave 
HHS custody.
    Secretary Becerra, I look forward to hearing more from you 
on how the department is prioritizing the health and well-being 
of these children, and how this funding will help that work.
    I always say a budget is a reflection of your values, and 
all-in-all, this budget paints a clear, encouraging picture of 
President Biden's values on healthcare. It shows he values 
public health, science, equity, women, children, families, and 
critically, the health and well-being of every single American, 
and that he believes healthcare must truly be a right in this 
country, not a privilege. I look forward to working with him 
and Secretary Becerra and my Senate colleagues to pass 
investments like those outlined in this budget into law to take 
bold steps to lower healthcare costs, and expand coverage, and 
apply lessons learned from the COVID-19 pandemic. With that, I 
will turn it over to Senator Blunt for his remarks.


                     statement of senator roy blunt


    Senator Blunt. Thank you, Senator Murray. Appreciate 
Secretary Becerra being here today. We spent several years 
working together in the House before I came to the Senate, and 
you went home to become the Attorney General of California, and 
I look forward to what we can do together over the next couple 
of years.
    Certainly, over the past year, we've faced a global 
pandemic that nobody would have anticipated, and nobody was 
trained for. You said in the House hearing in May that the 
fight against COVID-19 isn't over yet, and certainly, I agree 
with that. While the vaccination rates are going up, and the 
cases are going down, we still have a lot to finish to win this 
fight.
    Many public experts have stated, and that includes those 
within the administration, that we really do have to achieve a 
certain vaccination level necessary to reach the kind of 
immunity where the virus ceases to spread, and we would hope, 
when it had no opportunity to spread, it would then cease to be 
something we need to be concerned about right now.
    But we also are going to be looking carefully to see if a 
booster is going to be required, and, of course, if a booster 
is required to maintain that level of immunity, it's going to 
be a great obligation on you, and the administration, and the 
Congress to see that we have a plan that makes that work.
    We also really need to have a clear strategy to provide 
vaccines to developing nations. We've seen in the past that 
outbreaks like Ebola, the one thing we know is that the next 
sick patient is only a plane ride away from here, and so, what 
we can do to help there ultimately protects us, as well.
    I'm particularly concerned about what we're doing and the 
strategy we have for unaccompanied alien children. You and I 
have talked about that even yesterday, and I look forward to 
chances to talk about that more. Many people think that this 
unaccompanied children issue has nothing to do with COVID, but, 
of course, how you deal with individuals coming in from another 
country does have something to do with COVID, and it also has 
something to do with COVID when you're taking money from our 
COVID-19 funds to deal with this problem that has to be dealt 
with.
    So far, the department's transferred $2.98 billion to the 
unaccompanied children account to deal with the fallout of 
border policies that just simply aren't working. This includes 
funding specifically that came out of COVID-19 relief, out of 
the American Rescue Plan. I want to remind the committee than 
only a few short months ago, President Biden felt it was so 
imperative to pass a COVID-19 supplemental bill that the 
administration pushed a $1.9 trillion bill through on a totally 
partisan vote, with no real input from my side of the aisle, 
and then, immediately, almost immediately, transferred $850 
million of that funding that was going to go for COVID-19 
relief to this fund for unaccompanied children.
    Just last week, the administration transferred another $846 
million to the unaccompanied children program from COVID-19 
funding. That money in the bill was intended to fund community 
health centers, behavioral health centers, workforce training, 
public health workforce, and other programs. Well, you know, $3 
billion of that money won't be allowed to do that because we're 
having to deal with a policy at the border that has to be dealt 
with, with even the vice president, in the last week, trying to 
do things to tell people to stop coming to the border. We have 
to have a policy that works better there.
    The supplemental passed in December that was written by 
this committee included, and it was a bipartisan vote, included 
critical resources for the Strategic National Stockpile. We saw 
the problems during the pandemic of what happened if the 
Stockpile wasn't there. The department already has taken $850 
million from the Stockpile fund to, again, the unaccompanied 
children program. I will remind all of us that we've all had 
questions over the last year of why didn't we do a better job 
having the Stockpile money being used for the Stockpile. We 
don't want to see the Stockpile again become a fund that is 
easily transferred.
    Finally, the department transferred $426 million from 
fiscal year Labor/HHS funds for programs like--children's 
hospitals, graduate medical education, the Ryan White HIV/AIDS 
Program, medical research, childcare. One of the problems in 
this last bill that was passed--I hope we don't repeat this in 
a bill that comes through our committee.--I don't believe we 
will, but unlike language we had normally had, there was no 
real restraint on transfers, no restriction on those transfers, 
no requirement to justify to the committee the transfers, no 
notification of the transfers.
    Those things were in every other bill we passed last year. 
They were not in the first bill that was passed this year, and 
so, the department hasn't given us notice on all of those 
transfers in a timely way, but the bill didn't require them to 
give us notice in a timely way. The members on my side of the 
aisle want to have discussions about how we deal with this 
ongoing in a better way.
    Without a dialogue with this committee, I would hope again 
that we don't have the flexibility next year that we have 
insisted on, like reporting and things, in the past. While we 
may disagree, and I may disagree with the Department's 
transfers, or even the way the Unaccompanied Children Program 
has been managed, there are certainly significant areas where I 
do agree.
    I support the National Institutes of Health increases. I 
think the new research institute at NIH (National Institutes of 
Health), ARPA-H (Advanced Research Projects Agency for Health), 
is in the right place at the right time with the right focus, 
and I announced in our hearing last week, you remember, Chair, 
that I intend to be supportive of that, and I believe we can 
make it work in a way we wouldn't have envisioned before the 
last couple of years, and the new things we did to step up to 
the pandemic.
    I certainly agree with the expansion of the Certified 
Community Behavioral Health Clinics to help address the mental 
health crisis. I agree with efforts to end the HIV pandemic and 
bring additional resources to bear on the opioid epidemic. The 
devil's always in the details, but I hope we can move forward 
on those things and others, but the administration is obviously 
requesting a huge increase in nondefense discretionary funding. 
In the Department of Health and Human Services alone, a 23 
percent increase, or an increase of $23 billion. That's 
compared to a defense department budget that the increase of 
1.6 percent doesn't even keep up with inflation.
    For the last several years, our friends on the other side 
of this dais have pushed for parity between defense and 
nondefense when Republicans were in charge and were advocating 
defense spending. I hope we can have, and I expect, frankly, 
will have a similar discussion this year.
    Finally, I wholeheartedly disagree with the 
administration's removal of the longstanding Hyde Amendment. 
One of things I've had a chance to do in both House and Senate 
is count, and I don't believe we can get a bill out of this 
committee without having the Hyde Amendment in that bill. It's 
been in the Appropriations Bill for 40 years. Every person on 
this committee who has ever voted for a final Labor/HHS bill 
has voted for Hyde since it first appeared in 1976. I don't 
think this year should be or, frankly, at the end of the day, 
will be different, but it is clearly, as the chair's already 
pointed out, going to be an issue we're going to vigorously 
discuss.
    This committee, Mr. Secretary and Chair, have been 
successful over the past 6 years with passing the bill, because 
we've really done things that, while they move things in a 
great direction, in the right direction, I think, didn't do it 
in a way that made drastic policy changes. I look forward to 
that same kind of incremental approach, and look forward to 
working with you, Mr. Secretary, as we move forward to continue 
to head your critically important department in the right 
direction, because it serves the American people, and in many 
ways, serves people all over the world. Thank you, Chairman.
    [The statement follows:]
                Prepared Statement of Senator Roy Blunt
    Thank you, Chair Murray. I appreciate Secretary Becerra 
(pronounced: ba-serra) for being here today to discuss the 
Administration's fiscal year 2022 budget request.
    Over the past year, we have faced the challenges of a global 
pandemic. At a hearing in the House in May, you testified that, ``The 
fight against COVID-19 is not yet over.'' I agree. While vaccination 
rates are going up and cases are going down, we're still not finished 
with the fight. First, as many public health experts have stated, even 
those within the Administration, there is a certain vaccination level 
necessary to reach herd immunity and we're not there quite yet. Second, 
we may or may not need COVID-19 boosters at some point in the future 
and if we do, that will require further outreach and vaccination 
campaigns. Finally, we need to have a clear strategy to provide 
vaccines to developing nations. As we have seen with past infectious 
disease outbreaks like Ebola, the next sick patient is only a plane 
ride away.
    That is why I have been particularly concerned with the 
Administration's strategy on Unaccompanied Alien Children. Many may 
think that one issue has nothing to do with the other. But when the 
Administration is robbing Peter to pay Paul, they become inextricably 
linked.
    Mr. Secretary, over the past three months the Department has 
transferred $2.98 billion to the Unaccompanied Children account to deal 
with the fallout of the Administration's failed border policies. This 
includes funding specifically for COVID-19 relief from the American 
Rescue Plan. I want to remind the Committee that only a few short 
months ago, President Biden felt it was so imperative to pass a COVID-
19 supplemental bill that the Administration pushed through a $1.9 
trillion partisan bill, with no input from Republicans, and then almost 
immediately transferred $850 million from funding that should have gone 
to additional COVID-19 testing to fund additional unlicensed shelter 
beds for Unaccompanied Alien Children. And just last week, the 
Administration transferred an additional $846.5 million to the 
Unaccompanied Children program from their partisan COVID-19 bill 
intended to fund Community Health Centers, behavioral health workforce 
training, public health workforce, among other programs.
    Second, the bipartisan COVID-19 supplemental passed in December 
that was written by this Committee included critical resources for the 
Strategic National Stockpile--which has proven essential during this 
pandemic, and for future crises. The Department took $850 million from 
this vital stockpile under the guise that the Unaccompanied Children 
program needed money due to COVID-19 and not failed border policies.
    Finally, the Department transferred $426 million from fiscal year 
2021 Labor/HHS funds, from programs like Children's Hospitals Graduate 
Medical Education, Ryan White HIV/AIDS, medical research, and child 
care. Prior to making these choices, none of these decisions were 
discussed with this Committee. In fact, Members on my side of the aisle 
have had no substantive discussions with you about the crisis at the 
border, even though the Administration has transferred or reprogrammed 
almost $3 billion of funding to address it.
    I understand that the Department is not in charge of our 
immigration laws and that the Department has to care for unaccompanied 
children that cross the border, regardless of where they come from or 
how they arrive. But without a dialogue with this Committee on how to 
do so, I suspect you will not have the flexibility to run this program 
next year as you have had this year. The Appropriations Committee 
appropriates funding based on the budget request, through arduous 
negotiations between the Senate and House, between Republicans and 
Democrats. I do not think the Administration should simply ignore that.
    While we may disagree on the Department's management of the 
Unaccompanied Children program, there are significant places where we 
agree. I support the increase to the National Institutes of Health and 
think that the new research Institute at NIH is coming at the right 
time with the right focus. I agree with expansion of Certified 
Community Behavioral Health Clinics to help address the mental health 
crisis, efforts to end the HIV epidemic, and bringing additional 
resources to bear to end the opioid epidemic.
    However, this is going to be a difficult year and the devil is 
always in the details. For example, the Administration is requesting a 
15.9% increase for non-defense discretionary funding, and the 
Department of Health and Human Services is requesting a 23% increase or 
an increase of $23 billion. That is significant, especially when 
compared to the Defense Department's budget request doesn't even keep 
up with inflation. Over the last several years, the other side of the 
aisle has pushed for parity between defense and non-defense funding and 
that is where we have ended up. I would expect a similar outcome this 
year.
    Finally, I wholeheartedly disagree with the Administration's 
removal of the longstanding Hyde Amendment. The Hyde Amendment prevents 
the Department from using federal taxpayer dollars to fund elective 
abortions. Hyde has been included in every government funding bill for 
more than 40 years. Every person on this Committee who has ever voted 
for a final Labor/HHS bill has voted for Hyde since its first 
appearance in 1976. And I do not think this year should be any 
different.
    Mr. Secretary, this Committee has been successful over the last six 
years with passing a bill because we haven't made fundamental, drastic 
policy changes. That is the position I took as Chairman and it will 
continue to be my position this year. I hope the Department will set 
aside its partisan policies to support programs that benefit all 
Americans instead.
    Thank you, again, for being here today.

    Senator Murray. Thank you very much, Senator Blunt. I will 
now introduce our witness today. It's Xavier Becerra, the 
Secretary of the Department of Health and Human Services. Thank 
you for joining us today. And at this point, I'm going to turn 
the gavel over to Senator Reed. Thank you for being here. I 
have to go introduce three constituents at another committee 
meeting. I will return, but until that time, Senator Reed will 
hold the gavel, and Secretary Becerra, you can begin your 
testimony. Thank you.

                SUMMARY STATEMENT OF HON. XAVIER BECERRA

    Secretary Becerra. Madam Chair, thank you. Ranking member 
Blunt, members of the committee, thank you again. The 
Department of Health and Human Services is at the center of 
many challenges facing our country today. The COVID-19 pandemic 
has shed light on how inequities and inefficient Federal 
funding can leave communities vulnerable to crisis. Now, more 
than ever, we must ensure that the Department has the resources 
to achieve its mission, and to build a strong public health 
system, and a healthier America.
    For HHS, the budget proposes $131 billion in discretionary 
budget authority, and $1.5 trillion in mandatory funding. This 
budget underscores the administration's commitment to prepare 
the Nation for the next public health crisis, to expand access 
to affordable healthcare, to address health disparities, to 
tackle the opioid and other drug crises, and to invest in other 
priority areas, like maternal health, Tribal health, and early 
childhood education.
    We know the fight against COVID-19 is not yet over, but 
even as HHS works to beat the pandemic, we must also prepare 
for the next public health challenge. To start, the budget 
makes significant investments in our preparedness and response 
capabilities, including by investing in the Strategic National 
Stockpile, and the public health workforce. It provides a new 
mandatory funding stream for the manufacture of medical 
countermeasures here at home, to protect Americans from future 
pandemics, and create U.S. jobs.
    The budget includes the largest fiscal year investment in 
the CDC (Centers for Disease Control and Prevention) in almost 
two decades. The budget reflects the president's commitment to 
expand access to quality, affordable healthcare for all 
Americans. It builds on the groundbreaking reforms introduced 
in the American Rescue Plan by permanently extending the 
enhanced premium subsidies that put affordable healthcare 
coverage within reach for millions more Americans.
    The budget also expands access to home and community-based 
services under Medicaid, critical services that allow older 
Americans and our loved ones with disabilities to live 
independently in their homes and communities. And the budget 
calls for Congress to take additional steps this year to lower 
the costs of prescription drugs, and further expand and improve 
health coverage through additional benefits and public coverage 
options.
    Healthcare must be a right, not a privilege, and I will 
work hard to ensure that families across the Nation are able to 
secure the healthcare that they need. And as we work to expand 
access to affordable healthcare and address the challenges of 
COVID-19 and future pandemics, we need to address public health 
crises that are already here. Like violence in our communities 
and climate change.
    The President's budget increases funding to support 
domestic violence survivors. It addresses gun violence by 
doubling funding for firearm violence prevention research and 
allows HHS to play a major role in the administration's 
government-wide effort to tackle the climate crisis, by 
supporting research and programs identifying the human health 
impacts of the climate change and establishing an Office of 
Climate Change and Health Equity.
    To ensure that HHS is equitably serving all Americans, the 
budget invests in reducing maternal mortality and morbidity 
that disproportionately impacts women of color. It builds on 
the American Rescue Plan's State option to extend Medicaid 
postpartum coverage, it funds a range of rural healthcare 
programs, and expands the pipeline for rural health providers. 
It includes a dramatic funding increase in advance 
appropriations for the Indian Health Services, and it invests 
in improving access to vital reproductive and preventative care 
services through Title X.
    To support families and build the best possible future for 
our children, the budget makes major investments to ensure high 
quality childcare is affordable for low- and middle-income 
families, and to provide high-quality pre-K for all 3- and 4-
year-olds. We know our experiences as children shape the adults 
we become. Support in childhood leads to success in the future.
    To address COVID-19's unprecedented acceleration of 
substance use and mental health disorders, the budget makes 
historic investments in SAMHSA (Substance Abuse and Mental 
Health Services Administration) to support research, 
prevention, treatment, and recovery services. To support 
innovation in research, the budget increases funding for NIH by 
$9 billion, $6.5 billion of which will go to establish the 
advanced research project agency for health, ARPA-H, with an 
initial focus on cancer and other diseases such as diabetes and 
Alzheimer's.
    This major investment in Federal research and development 
will leverage ambitious ideas to build transformational 
innovation through health research and the application and 
implementation of health breakthroughs.
    Finally, to ensure our funds are used appropriately, the 
budget invests in program integrity, including efforts to 
combat fraud, waste and abuse in Medicare, Medicaid, and 
private insurance.
    Madam Chair, I'd like--and Mr. Chairman, I'd like to close 
by recognizing the women and men at HHS for their outstanding 
and tireless work fighting COVID-19 to protect the health of 
their fellow Americans. To build back a prosperous America, we 
need a healthy America. We've taken important steps over the 
past few months to expand access to quality, affordable 
healthcare, to lower healthcare premiums, and to protect 
women's health at home and abroad. President Biden's budget 
request builds on that progress. Thank you.
    [The statement follows:]
               Prepared Statement of Hon. Xavier Becerra
    Chair Murray, Ranking Member Blunt, and Members of the Committee, 
thank you for the opportunity to discuss the President's Fiscal Year 
(FY) 2022 Budget for the Department of Health and Human Services (HHS). 
I am pleased to appear before you, and I look forward to continuing to 
work with you.
    HHS is at the center of many challenges facing our country today--
the COVID-19 pandemic, safely caring for unaccompanied children at our 
southern border, the overdose and the addiction epidemic gun violence, 
racial inequality, and more--and we are rising to meet those 
challenges. I am honored to be given the responsibility to lead HHS at 
this time.
    COVID-19 has shed light on how health inequities and insufficient 
Federal funding can leave communities vulnerable to crises. The 
President's Budget invests in America, demonstrates a conscious effort 
to address racial disparities in health care, tackles the opioid and 
other drug crises, and puts us on a better footing to take on the next 
public health crisis.
    Now more than ever, we must ensure that HHS has the resources to 
achieve its mission and tackle these challenges after years of 
underfunding. The President has put forward a budget that does just 
that. The FY 2022 budget proposes $131.8 billion in discretionary 
budget authority and $1.5 trillion in mandatory funding. The Labor-HHS 
total is $119.5 billion, an increase of $23 billion. Investments in the 
budget support families in areas such as behavioral health (mental 
health and substance use), maternal health, emerging health threats, 
science, data and research, tribal health, early child care and 
learning, and child welfare.
    To build back a prosperous America, we need a healthy America, and 
President Biden's budget builds on that vision while investing in the 
many programs housed at HHS to save lives.
          preparing for and responding to public health crises
    The fight against COVID-19 is not yet over. Even as HHS works to 
beat this pandemic, we are also preparing for the next public health 
crisis. The FY 2022 budget makes significant investments in our 
preparedness and response capabilities.
    The Strategic National Stockpile, within the HHS Office of the 
Assistant Secretary for Preparedness and Response, has served a 
critical role in the COVID-19 response, permitting rapid deployment of 
personal protective equipment, ventilators, and medical supplies to 
states, cities, tribes, and territories across the country. The budget 
provides $905 million for the stockpile, $200 million above FY 2021, to 
ensure that the stockpile is ready to respond to future pandemic events 
and any other public health threats while maintaining a robust 
inventory of critical medical supplies, enhancing visibility of the 
domestic supply chain, and modernizing the stockpile's distribution 
model. In addition, the budget provides $823 million, $227 million 
above FY 2021, for the Biomedical Advanced Research and Development 
Authority, which has supported the development of new vaccines, 
therapeutics, and diagnostics for the COVID-19 response. Additional 
resources will support improved medical countermeasure platforms that 
will enable quicker, more effective detection and public health and 
medical responses to health security threats. The budget also supports 
a strong public health workforce, and addresses gaps in the existing 
public health infrastructure, including at the state and local levels. 
In addition to discretionary investments, the budget includes $30 
billion over four years in mandatory funding for HHS, the Department of 
Defense, and the Department of Energy to protect Americans from future 
pandemics and create U.S. jobs through major new investments in medical 
countermeasures manufacturing; research and development; and related 
biopreparedness and biosecurity investments.
    During this pandemic, we have seen the critical role of the Centers 
for Disease Control and Prevention (CDC). To ensure that CDC is well 
positioned to address current and emerging public health threats, the 
budget restores capacity to the world's preeminent public health agency 
by investing an additional $1.6 billion over the FY 2021 level for a 
discretionary funding total of $8.7 billion. This is the largest budget 
authority increase for CDC in almost two decades. A core function of 
CDC is partnering with state, tribal, local, and territorial entities, 
and this funding will enhance those partnerships. The budget will also 
provide CDC with additional resources to further develop and expand 
teams of highly trained and deployable public health experts to support 
preparedness at the local level.
    The COVID-19 pandemic has also shown the importance of producing 
reliable data. Bad inputs lead to bad outputs, and without good data, 
CDC cannot effectively prepare for, or respond to, public health 
threats and make well-informed decisions to protect the American 
people. With funding provided in the FY 2022 budget, CDC will build 
upon previous investments in the data infrastructure to date and 
continue efforts to modernize public health data collection and 
analysis nationwide.
    Public health threats know no borders, and CDC is working to 
prevent, detect, and respond to epidemic threats at home and abroad. 
With CDC experts embedded in countries around the world, CDC is 
supporting global COVID-19 response by leveraging core public health 
capacities and relationships built through decades of CDC global health 
activities. As we continue to confront new and emerging COVID-19 
variants, as well as a surge of cases in India, support for CDC's work 
is even more important. CDC is working closely with U.S. government 
agencies, ministries of health, and other partners to assist countries 
in responding to COVID-19, while simultaneously developing and 
implementing adaptations to interventions for malaria, HIV, and 
vaccine-preventable diseases. With the President's proposed FY 2022 
investments, CDC will not only address preparedness within the United 
States, but will also support core public health capacity improvements 
overseas and strengthen global health security by improving our ability 
to deploy experts internationally and support efforts to prevent, 
detect, and respond to emerging global biological threats. CDC will 
invest in global health security and continue to fight health threats 
worldwide while simultaneously enhancing domestic preparedness to 
address threats here at home. Domestic health is increasingly impacted 
by global factors and CDC's global health security efforts include 
conducting research to ensure efficient disease response.
    The Assistant Secretary for Preparedness and Response (ASPR) and 
CDC investments complement preparedness activities across HHS including 
basic and clinical research within National Institutes of Health (NIH) 
and activities within the Food and Drug Administration (FDA) to advance 
regulatory science and mitigate potential supply or drug shortages.
    While we prepare for future pandemic threats, we are also facing a 
public health crisis that is already here: violence in our communities. 
The current public health emergency has shone a light on the issue of 
domestic and gender-based violence. More than 1 in 4 women and more 
than 1 in 10 men have experienced contact sexual violence, physical 
violence, or stalking by an intimate partner and reported significant 
impacts. The budget provides $489 million for the Administration for 
Children and Families (ACF) to support and protect domestic violence 
survivors, which is more than double the FY 2021 enacted levels. The 
budget also provides $66 million for victims of human trafficking and 
survivors of torture, more than 45 percent above FY 2021 enacted 
levels.
    We have also seen the devastating impact of gun violence in 
communities across the country. Almost 40,000 people die as a result of 
firearm injuries in the United States every year, while homicide is the 
third leading cause of death for people ages 10-24. This is a public 
health issue, and one that disproportionately impacts communities of 
color. The budget addresses this crisis by doubling CDC and NIH funding 
for firearm violence prevention research. The budget provides $100 
million in discretionary funding to CDC to start a new Community 
Violence Intervention initiative, in collaboration with the Department 
of Justice, to implement evidence- based community violence 
interventions at the local level. In addition to the discretionary 
investment for the Community Violence Intervention initiative, the 
budget includes a total of $5 billion in mandatory funding for CDC and 
the Department of Justice, beginning in FY 2023 and continuing through 
FY 2029.
    The climate crisis has real public health impacts, and the HHS' 
mission depends on healthy and sustainable environments. HHS thus has a 
major role to play in the Administration's government-wide effort to 
tackle this crisis. HHS' investments to combat climate change in the FY 
2022 Budget will advance health equity, lay the foundations for 
economic growth, and ensure that benefits from tackling the climate 
crisis accrue to tribal communities, communities of color, low-income 
households, and disadvantaged communities that have been marginalized 
or overburdened. The budget includes a $100 million increase in NIH 
funding to support research aimed at understanding the health impacts 
of climate change, as well as an additional $100 million investment in 
CDC's Climate and Health program to support efforts to understand and 
identify potential health effects, including children's environmental 
health considerations associated with climate change and implement 
plans to adapt to a changing environment. The American Jobs Plan also 
would invest $1.5 billion to increase the resilience of hospitals and 
critical infrastructure, fund health emergency preparedness cooperative 
agreements, and build resilience including in relation to the effects 
of a changing climate.
       caring for all americans through health and human services
    Central to the HHS mission is the charge to enhance the health and 
well-being of all Americans. The budget invests in areas across HHS to 
ensure that we are equitably serving the American people. As Secretary, 
I will ensure that this focus is fundamental to all of our work.
    A critical part of this is investing in civil rights enforcement to 
ensure that all people receiving services from HHS-conducted or HHS-
funded programs, no matter who they are, or where they live, can 
receive health care free from discrimination.
    The FY 2022 Budget makes expanding affordable health care access a 
priority across Centers for Medicare & Medicaid Services programs. A 
recently released report titled ``Health Coverage Under the Affordable 
Care Act: Enrollment Trends and State Estimates'' shows that the 
Affordable Care Act (ACA) has expanded health insurance coverage to 
millions of Americans, and the budget goes even further. It builds on 
the groundbreaking reforms introduced in the American Rescue Plan Act 
by extending the enhanced premium subsidies that put affordable health 
care coverage within reach of millions more Americans. These 
improvements in the American Rescue Plan Act are lowering premiums for 
more than nine million current enrollees by an average of $50 per 
person per month. In addition, due to the COVID-19 pandemic, an ongoing 
opportunity to apply for enrollment in Marketplace health care coverage 
is available on HealthCare.gov through August 15. This extension 
provides individuals and families a desperately needed opportunity to 
get quality, affordable health insurance coverage. As of May 10, over 1 
million additional Americans have signed up for health insurance 
through the Marketplace, and an additional 2 million obtained improved 
benefits through the Marketplace, benefitting from both reduced 
premiums and more affordable cost sharing.
    The FY 2022 Budget also expands access to critical home- and 
community-based services (HCBS) under Medicaid, critical health care 
services that allow older people and people with disabilities to live 
independently in their homes and communities. The budget builds on the 
additional Medicaid funding included in the American Rescue Plan that 
not only expands access to these important services but also 
strengthens state HCBS programs by allowing states to use the 
additional money to, for example, provide additional benefits, like 
mental health and substance use services, to beneficiaries, as well as 
to raise wages and provide paid leave for home care workers.
    I look forward to working with the Congress to achieve the 
Administration's goal of lower costs and expanded and improved coverage 
for all Americans. This includes reforms to lower the costs of 
prescription drugs, such as allowing Medicare to negotiate payment for 
certain high-cost drugs, and requiring manufacturers to pay rebates 
when drug prices rise faster than inflation. We will also work to 
improve Medicare, Medicaid, CHIP, and private insurance coverage, by 
pursuing changes such as improving access to dental, hearing, and 
vision coverage in Medicare, making it easier for eligible people to 
get and stay covered in Medicaid, promoting Early and Periodic 
Screening, Diagnostic and Treatment (EPSDT) requirements for eligible 
youth, and reducing out-of-pocket costs for individuals in private 
insurance coverage obtained through the Marketplace. The Administration 
also supports additional public coverage options, including a public 
option that would be available through the insurance marketplaces. 
Health care is a right, not a privilege, and I will work to ensure that 
families across the nation are able to secure this right.
    The United States has the highest maternal mortality rate among 
developed nations, with an unacceptably high mortality rate for Black 
and American Indian/Alaska Native women. Addressing this critical 
public health issue is a major priority of this Administration, as 
evidenced by the American Rescue Plan's state option to extend Medicaid 
postpartum coverage. Building on HHS's longstanding efforts to improve 
maternal health, including the Department's recent Medicaid postpartum 
waiver approvals, the budget provides more than $220 million in 
discretionary funding to reduce maternal mortality and morbidity by 
implementing evidence-based interventions to address critical gaps in 
maternity care service delivery and improve maternal health outcomes. 
This includes increased funding to CDC's Maternal Mortality Review 
Committees and the Health Resources and Services Administration's 
(HRSA) Rural Maternity and Obstetrics Management Strategies program. 
HRSA also prioritizes maternal health through its Title V Maternal and 
Child Health Block Grant and Alliance for Innovation on Maternal Health 
programs. As with all our public health work, collecting good data will 
be critical. In addition to these discretionary resources, the budget 
includes $3 billion in mandatory funding over five years, to invest in 
maternal health and reduce the maternal mortality rate and end race-
based disparities in maternal mortality.
    HRSA's work is central to our focus on serving all Americans, given 
their mission to improve health outcomes and address health 
disparities. HRSA-funded Health Centers provide access to care for low-
income and marginalized populations, and they serve 1 in 11 people in 
the nation. The President's Budget increase to workforce diversity 
programs, highlights HRSA's commitment to supporting health care 
providers dedicated to working in underserved areas and building toward 
a workforce that reflects the communities it serves and is able to 
provide culturally relevant care.
    The budget provides $670 million across HHS to continue efforts to 
end the HIV epidemic in the United States by working closely with 
communities that have high rates of HIV transmission to implement 
effective prevention, diagnosis, and treatment strategies, including 
ones that address the disproportionate impact of HIV and Hepatitis C 
infections in Tribal communities. HHS programs have already made major 
progress in combating the HIV epidemic. HRSA ensures equitable access 
to services and supports for low-income people with HIV through Health 
Centers as well as the Ryan White HIV/AIDS Program. In 2019, 88.1 
percent of those served under the Ryan White HIV/AIDS Program had 
achieved viral suppression, a record level that exceeds the national 
average of 64.7 percent. HHS will build on this work to end the 
epidemic once and for all.
    Also, directly connected to the HHS mission is the need to provide 
access to high-quality care, no matter where you live. HHS will 
continue to focus on the unique needs of rural communities. HHS 
administers a range of programs that address rural health, from those 
that serve large populations such as Health Centers, to those serving 
targeted populations such as the Black Lung Clinics Program. The FY 
2022 budget serves active, inactive, retired, and disabled coal miners 
and their families through high-quality medical, outreach, educational, 
and benefits counseling services. It also provides funding to increase 
the number of individuals receiving training and serving in health 
professions in rural communities, as research has shown that providers 
are likely to remain in the communities where they train as residents.
    HHS will also address the stark health disparities that persist in 
Tribal communities by investing in the Indian Health Service (IHS), 
which serves over 2.6 million American Indians and Alaska Natives. The 
COVID-19 pandemic's devastating impact on Tribal communities has 
demonstrated the real human toll of these disparities. The budget 
provides a $2.2 billion, or 36 percent, increase for IHS in order to 
take a historic step to address chronic underfunding, expand access to 
high-quality health care, and address critical facilities and 
information technology infrastructure deficiencies across Indian 
Country. For the first time, the budget also proposes advance 
appropriations for IHS to provide stability for the Indian Health 
system and parity with how other Federal health agencies are funded. I 
am committed to strengthening the Nation-to-Nation relationship between 
the United States and Indian Tribes. To this end, the budget supports 
self-determination through a consultative process to consider long-term 
solutions, including mandatory funding, to ensure adequate and stable 
funding for IHS.
    The budget also provides an 18.7 percent increase to the Title X 
Family Planning program to improve access to vital reproductive and 
preventive care and to advance gender equity. Over the last two years, 
nearly half of the programs supported by Title X lost providers as a 
result of the 2019 regulation which added burdensome restrictions 
inconsistent with quality care guidelines and ultimately resulted in 
many highly qualified, longstanding healthcare entities to exit Title 
X. The budget allows Title X to not only restore highly qualified 
providers, but also to expand its essential services to meet increased 
demand as a result of the global pandemic and resulting recession. In 
2019, Title X-funded clinics served almost 3.1 million Americans, 66 
percent of whom had incomes at or below the federal poverty level and 
41 percent of whom were uninsured. This is nearly 1 million fewer 
people served than in 2018.
                    investing in children's futures
    Our experiences as children shape the adults we become, and support 
in childhood can mean success in the future. As Frederick Douglass 
wrote, ``It is easier to build strong children than to repair broken 
men.'' High-quality early care and education lay a strong foundation so 
that children can take full advantage of education and training 
opportunities later in life. The American Jobs Plan and the American 
Families Plan invest in school and child care infrastructure and 
workforce training, and ensure that low and middle-income families pay 
no more than 7 percent of their income on high-quality child care. 
These investments include $200 billion over ten years for a national 
partnership with states to offer free, high-quality, accessible, and 
inclusive preschool to all three- and four-year-olds, benefitting five 
million children. The budget also invests $250 billion over ten years 
to make child care affordable.
    The budget also provides $19.8 billion in discretionary funding for 
the Department's early care and education programs in ACF, $2.8 billion 
over FY 2021 enacted. This includes $11.9 billion for Head Start, which 
helps young children enter kindergarten ready to learn. Head Start 
programs deliver services through 1,600 agencies in local communities, 
and they provide services to more than a million children and pregnant 
women every year, in every U.S. state and territory. In addition, the 
budget provides $7.4 billion for the Child Care and Development Block 
Grant, $1.5 billion over FY 2021 enacted, to expand access to high-
quality child care for families in all corners of the country. Over a 
million children receive child care subsidies every month funded by the 
Child Care and Development Fund, and nearly half of the families 
receiving child care subsidies reported income below the Federal 
Poverty Level. These investments will improve outcomes for children 
across the country.
    The budget also invests in improvements to the child welfare 
system, particularly to address its racial inequity. The budget 
provides $100 million in new competitive grants for states and 
localities to advance reforms that would reduce the overrepresentation 
of children and families of color in the child welfare system and 
address the disparate experiences and outcomes of these families. This 
funding will also give more families the support they need to remain 
safely together. The budget also provides $200 million for states and 
community-based organizations to respond to, and prevent, child abuse, 
over 30 percent above FY 2021 enacted.
            combating mental health and substance use crises
    HHS must address the public health crises associated with mental 
health and substance use disorders. This need is especially urgent 
given that both crises have accelerated during the COVID-19 pandemic. 
Calls to mental health helplines have increased across the country as 
Americans struggle with increased anxiety, depression, risk of suicide, 
and trauma-related disorders resulting from the pandemic. Younger 
adults, racial minorities, essential workers, and unpaid adult 
caregivers are particularly impacted. Similarly, preliminary data from 
2020 suggests that overdose deaths, which were already increasing, 
accelerated at an unprecedented rate during the pandemic. Provisional 
data suggest that over 90,000 drug overdose deaths occurred in the 
United States in the 12 months ending in September 2020. That 
represents a year-over-year increase of close to 29 percent.\1\ This 
crisis is also evolving--overdose deaths involving substances other 
than opioids are also increasing. HHS will ensure that our work is 
responsive to the needs of communities across the country.
---------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention. (2021). Vital 
Statistics Rapid Release: Provisional Drug Overdose Death Counts. 
Retrieved May 6, 2021 at https://www.cdc.gov/nchs/nvss/vsrr/drug-
overdose-data.htm.
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    The budget addresses these crises through investments in the 
Substance Abuse and Mental Health Services Administration.
    In a historic investment, the budget provides $1.6 billion to the 
Community Mental Health Services Block Grant to respond to the systemic 
strain on our country's mental health care system--more than double the 
FY 2021 level. To address the undeniable connection between the 
criminal justice system and mental health, the discretionary request 
will also invest in programs for people involved in the criminal 
justice system. HHS will also focus on the behavioral impact of COVID-
19, including on children. When children and young people face Adverse 
Childhood Experiences (ACEs) such as trauma, it can continue to affect 
them across their lifespan, so it is critical we intervene now to 
support their social, emotional, and mental well-being.
    The budget also takes action to address addiction and the overdose 
epidemic, investing $11.2 billion across HHS, $3.9 billion more than in 
FY 2021, including $3.5 billion for the Substance Abuse Prevention and 
Treatment Block Grant, which has historically failed to keep up with 
increases in the cost of providing substance use care to America's 
neediest citizens. For the first time, the budget includes a 10 percent 
set aside for recovery support services, a critical step for building 
and sustaining the nation's recovery support services infrastructure. 
The Block Grant remains a critical source of funding for states, 
tribes, and territories to provide prevention, treatment, and recovery 
support services to their citizens. The impact of this epidemic is felt 
in our communities, and the budget will direct funding to states and 
Tribes to increase community-level response. The budget will also 
increase access to medications for opioid use disorder and expand the 
behavioral health provider workforce, particularly in underserved 
areas. I greatly appreciate the investments the American Rescue Plan 
Act provided to the Substance Abuse Prevention and Treatment Block 
Grant, Mental Health Block Grant, and Certified Community Behavioral 
Health Centers, and HHS will continue to build on these efforts.
                     promoting biomedical research
    HHS' work is responsible for major scientific breakthroughs, and we 
are committed to supporting innovative science and research in order to 
advance the health and well-being of our nation. As the world's premier 
biomedical research agency, NIH will continue to be at the forefront of 
scientific advancements. The budget includes $52 billion for NIH, a $9 
billion increase or 21 percent increase over FY 2021 enacted. Included 
in this increase is $6.5 billion to establish the Advanced Research 
Projects Agency for Health (ARPA-H). With an initial focus on cancer 
and other diseases such as diabetes and Alzheimer's, this major 
investment in Federal research and development will leverage ambitious 
ideas to build transformational platforms, capabilities, and resources 
to speed the application and implementation of health breakthroughs and 
shape the future of health and medicine in the U.S.
    This bold new approach will complement NIH's existing research 
portfolio, which is a vital contributor to longer and healthier lives, 
supports and trains world-class scientists, and drives economic growth. 
Outside of ARPA-H, the remaining $2.5 billion increase will allow NIH 
to continue investing in basic research and translating research into 
clinical practice to address the most urgent challenges, such as HIV/
AIDS and ending the opioid crisis.
                restoring america's promise to refugees
    HHS plays a critical role in promoting the wellbeing of those 
seeking refuge or relief in the U.S. The FY 2022 budget provides over 
$4.4 billion to the Office of Refugee Resettlement (ORR)--an increase 
of over $2.5 billion above FY 2021 enacted. This funding would allow 
ORR to support an increase in the refugee admissions ceiling to 62,500 
this fiscal year and to continue to rebuild the resettlement 
infrastructure in order to resettle up to 125,000 refugees in FY 2022.
    This funding increase also reflects a commitment to ensuring that 
unaccompanied children are provided with care and services that align 
with child welfare best practices while they are in ORR's custody, and 
unified with relatives and sponsors as safely and quickly as possible. 
Despite significant challenges posed by COVID-19 and policies from the 
previous administration, HHS is humanely caring for unaccompanied 
children while working to unite them with a vetted sponsor. Working 
across government and in close partnership with the Department of 
Homeland Security, we have substantially increased our ability to 
quickly facilitate the transfer of children out of U.S. Customs and 
Border Patrol custody and into child-appropriate settings, including 
with fully vetted sponsors.
                    funding core program operations
    It is simply not possible to meet the HHS mission and address all 
these key changes without sufficient funding to cover our operational 
needs. The FY 2022 budget invests to bolster operations. It strengthens 
administrative and operational resources throughout the Department 
needed to ensure proper stewardship of resources entrusted to HHS by 
Congress.
               providing oversight and program integrity
    Given the magnitude of HHS's work-and the taxpayer dollars used to 
fund it-it is critical that we ensure that our funds are used 
appropriately. The budget invests in program integrity, including 
efforts to combat fraud, waste, and abuse in Medicare, Medicaid, and 
Private Insurance.
                               conclusion
    I want to thank the Committee again for inviting me to discuss the 
President's FY 2022 Budget for HHS, which offers a comprehensive fiscal 
vision for the nation that reinvests in America's health, supports 
future growth and prosperity, and meets U.S. commitments in a fiscally 
sustainable way. I look forward to continuing to show how HHS helps 
fulfill that vision.

    Senator Reed [presiding]. Thank you very much, Mr. 
Secretary. Chairwoman Murray has allowed me to go first, and 
then I'll recognize Senator Blunt. Like Senator Blunt, one of 
the privileges of my life in public service is having served 
with you in the House of Representatives, and congratulations, 
Mr. Secretary, on your well-deserved position.

                  NATIONAL SUICIDE PREVENTION LIFELINE

    One of the legislative initiatives that I was involved with 
was the National Suicide Prevention Lifeline. I worked together 
with Senators Gardner, Baldwin, and Moran. We've changed the 
ten-digit number to a three-digit number, and several States 
have already adopted the number. Everyone has to adopt it by 
next year, but the reality is we'll need more funding, because, 
as more people use this number, we'll need more counselors and 
more capacity.
    We asked that SAMHSA provide a cost estimate to Congress on 
Lifeline in early April. Could you give us an update on the 
cost estimate, Mr. Secretary?
    Secretary Becerra. Senator, thank you for the question, 
because this one is important. Even though it's not one of the 
bigger items, it is crucial for a lot of people. Just as 911 
has become indispensable, 988, I believe, will become 
indispensable for those who need some help in crisis.
    And where we are right now, Senator, is we have had some 
briefings with members on the Hill. We're trying to follow up 
with those. We're hoping to move as quickly as possible. You 
may have seen in the budget, the President has quadrupled the 
amount of money that he would allocate for this particular 988 
program and so, we would hope to receive funding for--about a 
year's worth of funding of about $102 million over the 24 or so 
million that there was before.
    We're hoping to move quickly, but I think you're right. To 
do this well, and to do it throughout the country, we may need 
to come back to you.
    Senator Reed. Well, thank you, Mr. Secretary, but I think 
we all recognize there's been an incredible increase in 
suicides, and particularly disturbing, among young people, also 
among service members, and so, I appreciate your efforts to get 
this thing done.

               LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

    Turning to another issue, LIHEAP (Low Income Home Energy 
Assistance Program). It's a critical program, long supportive 
of it. The resources in the budget are impressive, and I 
appreciate it, but one of the issues we have is getting the 
word out, if you will. There are many individuals who could 
participate, but they're not aware of the program. Can you 
share the steps the agency is taking to conduct outreach and 
make sure that eligible individuals get their LIHEAP?
    Secretary Becerra. Senator, on top of increasing the budget 
for the LIHEAP program, because, like you, I have been a 
fighter for this program for quite some time, and we're also 
reaching out. We're reaching out to the utility companies, 
we're reaching out to local governments, we're trying to have 
them help us reach out to people who qualify for these 
services, and so, we don't want to just wait and believe that 
people will hear that we're increasing the funding for LIHEAP.
    We're going to try to work with our local partners, private 
sector and public, to try to reach those families that really 
need this funding to help them survive, and make sure, monthly-
wise they're covered.
    Senator Reed. Well, thank you, Mr. Secretary. One of the 
agencies that has been very effective are the community action 
agencies. They have roots in the community, so, I'm sure 
they're on your list, but I just wanted to mention that for the 
record.

              PERSONAL PROTECTIVE EQUIPMENT MANUFACTURERS

    We all are concerned about PPE (Personal Protective 
Equipment). We had a wake-up call during the pandemic, and we 
are concerned about how you're stockpiling it in terms of 
prioritizing U.S. manufacturers, or at least manufacturers that 
are consistent allies of the United States, and not potential 
competitors. But can you comment?
    Secretary Becerra. Here I have to thank you all for the 
work you did to help us stand up a sizeable pot of money, $10 
billion, that will help us make sure that we're doing all we 
can to increase domestic manufacturing of that. Not just the 
PPE, but the types of material, and the types of product that 
we need in the event of a future pandemic, or a future crisis.
    And so, we're trying to adapt. The stockpile has to enter 
the 21st century. We have to make sure that what we do have 
stored actually will work once we need it, and we have to make 
sure that what we are storing is what we need to be equipped 
for the crises of the 21st century. But thank you for that 
support.
    Senator Reed. Well, thank you very much, Mr. Secretary, and 
again, thank you for your service, and I'm extremely pleased 
that you're the Secretary. Thank you.
    Secretary Becerra. Thank you, Senator.
    Senator Reed. Senator Blunt, please.
    Senator Blunt. Thank you, Senator. Secretary, the Congress 
has provided $178 billion over the course of the last year for 
the Provider Relief Fund. There's another $8.5 billion in 
addition to that for rural hospitals in the American Rescue 
Plan that passed in January. I think most of that money has to 
be spent by June 30.
    You answered some questions on that at the Ways and Means 
Hearing yesterday. You said we're trying to make sure we don't 
make the mistakes of the past. What are a couple of those 
mistakes, and how are you trying to move forward without 
continuing what you think was a mistake?
    Secretary Becerra. Senator, I think we would all agree that 
we want to know where and why taxpayer dollars are going to 
particular item or cause, and I think most people will tell 
you--at least the comments that we're seeing are that there 
wasn't enough transparency in the process. How the money was 
allocated. Why was one provider provided dollars, in some 
cases, quite a bit of money, and in other cases, other 
providers who were also in need, didn't?
    And so, what we want to do is provide that transparency. At 
the same time, we understand that there were a number of 
providers who were left behind because of the formula that was 
used to disperse the dollars, based on Medicare claims.
    And in many cases, if you happened to be a provider that 
relied a lot on, say, Medicaid or other sources, or you 
provided a lot of charity care, you might not have had the same 
level of claims. That doesn't mean you didn't have the COVID 
patients. So, we're trying to provide the transparency, make 
sure we direct the money where it's needed, and with the money 
that's still left, we want to make sure that you all can look 
at this and say, we get it.
    Senator Blunt. So, I think there's approximately $50 
billion left. I also believe that money, most of it, needs to 
be spent by June 30. What are you doing to get that money out, 
and when you do get it out, what are you doing to make it more 
likely that the hospitals will be able to spend that money 
before the deadline?
    Secretary Becerra. Senator, there's a tranche of money that 
has not yet been allocated, and so the deadline for spending 
that has not yet been determined, but there is money that did 
go out that does have a deadline, and what we're trying to do 
is, over the next few weeks, make sure we provide some guidance 
so people understand how we can make sure that everyone 
fulfills their commitments in getting these dollars.
    We want to make sure we provide some flexibility. We also 
want accountability. We want to make sure folks understand that 
when they got these taxpayers dollars to help Americans in 
need, that taxpayers expect that it went to help those families 
in need. And so, what we'll try to do is--understand that we 
can't change the process that began before, but what we can try 
to do is make sure we get the accountability while trying to 
provide some flexibility.
    Senator Blunt. So, advice I gave the previous 
administration on this in a letter I wrote last fall was, don't 
make it needlessly difficult by continuing to change the 
guidelines that you've giving hospitals on how they can spend 
the money. So, I hope as you allocate this last amount of 
money, or put out whatever guidance you need, that it doesn't 
suddenly restrict what they were earlier told they could do, 
but more importantly, it does let them know that you're going 
to have guidelines out there that they can rely on if they 
spend the money that way, that it meets the guidelines.

                         UNACCOMPANIED CHILDREN

    On the unaccompanied children issue, Secretary, I think you 
have an average of about 400 children coming in every day. You 
can verify that, if you know, and how many children do you have 
leaving the program every day?
    Secretary Becerra. It's a number, Senator, as you know, 
that fluctuates. A couple months ago, the average was probably 
closer to 600, maybe above that. Today, you're probably right. 
It hovers somewhere between 3 to 5 hundred a day, but we can't 
predict it.
    Senator Blunt. Well, the average is kind of what I'm 
wondering about, both on children coming in and then children 
leaving the program.
    Secretary Becerra. Yes, again, right now, and what we do at 
the department, my team, we try to use a week average. We go 
week by week to see the trends, but I'd say you're probably 
accurate. Somewhere between 3 to 5 hundred a day, over the last 
week, two weeks coming in.
    Those that we are discharging to a responsible sponsor, 
after checking the background of those individuals, somewhere 
between, probably between 4 to 6 hundred, probably closer to 
the higher range of 600 than 400.
    Senator Blunt. And who checks the background on the 
individuals that these children are given responsibility for?
    Secretary Becerra. We have a dedicated team of people 
who've been trained to do background checks.
    Senator Blunt. And they work for you? HHS team, or a----
    Secretary Becerra. It's an HHS team. We pay for all the 
services that are provided. In many cases, we've been 
fortunate, the Department of Homeland Security has been very 
generous in providing us with some of their personnel who have 
been trained in doing intake work and processing. We have 
others within the Federal Government who have volunteered, and 
certainly we have folks from within HHS who are doing this.
    We had to substantially increase the number of caseworkers 
that we use so we could make sure we process in a timely 
fashion those children's record to see if they could be 
discharged to a responsible custodian.
    Senator Blunt. Well, when 400 are coming in, or 500 or 
coming in, but more importantly, when say, 500-600 are going 
out, I know you don't want, and I don't want any of those 
children to go to a place where they're less safe, where 
they're going to be exploited or taken advantage of, and I 
would hope you're doing everything you can dealing with those 
big numbers to be sure that that does not happen.
    Secretary Becerra. Senator, I can assure you, the reason 
back in March and April we were looking at this and really 
seeing it as a major challenge in CBP, that's Customs and 
Border Protection, was having these large number of children in 
their adult detention facilities, where they should not be, is 
because we wanted to make sure before we took that child, we 
could provide exactly what you just said.
    The safety, the health requirements, wherever we are going 
to place that child. We ran out of the licensed care facilities 
that we typically would send these kids to a substantial time 
ago. We've had to stand up a number of emergency shelters to be 
able to properly house these children, and where possible, we 
try to move them as quickly as we can to a safe home once we've 
gone through the vetting process.
    It is tough, it's challenging, and it's expensive, but 
we're going to do it right.
    Senator Blunt. Thank you, Mr. Secretary, thanks.
    Senator Reed. Thank you very much, Senator Blunt. And now, 
on behalf of Chairwoman Murray, let me recognize Senator 
Schatz.

                               TELEHEALTH

    Senator Schatz. Thank you Mr. Chairman, Ranking Member. 
Thank you, Secretary. Last month, Mr. Secretary, you said that 
telehealth can be a godsend. I agree. 55 senators on a 
bipartisan basis who cosponsored my telehealth bill agree, but 
we're facing a telehealth cliff, because your current authority 
to expand Medicare's coverage of telehealth expires when the 
public health emergency ends.
    Unless Congress acts, we will go back to the Dark Ages, 
with very limited access to telehealth. So, Secretary, do you 
believe that Medicare beneficiaries should have access to 
telehealth, no matter whether they live in rural or urban 
areas?
    Secretary Becerra. Absolutely. Telehealth is something that 
we have to move towards. We learned lessons from COVID, and I 
hope that you all are able to agree on legislation that gives 
us more authority.
    Senator Schatz. Do you think that it's important that 
Medicare beneficiaries are able to use telehealth in their 
homes?
    Secretary Becerra. We want to make sure telehealth reaches 
every part of the beneficiaries' surroundings. I want to be 
careful here, because we want to make sure there's 
accountability, and there are some proposals that would show 
that accountability. But we want to make sure that, in fact, if 
we're going to provide reimbursement for that service, that 
those beneficiaries are receiving real service.
    Senator Schatz. Are you satisfied that the current law that 
we're utilizing under this public health emergency is working, 
and that there's sufficient accountability?
    Secretary Becerra. Thank you for asking it that way. I 
think we need better authority.
    Senator Schatz. Thank you. Do you believe that federally 
qualified health centers and rural health clinics should be 
able to provide telehealth services to their patients?
    Secretary Becerra. Again, with accountability, yes.
    Senator Schatz. Do I have your commitment to work with 
Congress to provide the necessary data and technical assistance 
that we need to enact these telehealth policies this year?
    Secretary Becerra. You have me at hello on that one.

                         NATIVE HAWAIIAN HEALTH

    Senator Schatz. All right. Great. Let me just talk to you a 
little bit about issues of native Hawaiian health. The U.S. 
shares a unique political relationship with the native Hawaiian 
community. Different Federal agencies within HHS are 
responsible for the administration of native healthcare 
programs, but the same Federal trust responsibility requires 
the provision of comprehensive, quality healthcare to native 
Hawaiians, Alaska natives, and American Indians.
    But native Hawaiians are often overlooked or left out of 
HHS initiatives, and it does not always seem that HHS staff 
understand the Federal trust responsibility to native 
Hawaiians, and I don't think this is anybody's fault. We do 
oftentimes fall under a different statutory architecture 
because there's not a treaty relationship, there's a trust 
relationship, and so, what I'm really asking is if you would 
lay eyes on this particular relationship.
    The way the statutory architecture works is sort of, in my 
view, immaterial to whether or not we're going to recognize 
this trust responsibility, and then in its implementation as we 
do native Hawaiian health programs, and other dollars that flow 
through HHS, we want to make sure that we are on equal footing 
with all native people. Do I have your commitment for that?
    Secretary Becerra. Absolutely.

                      PUBLIC HEALTH EMERGENCY FUND

    Senator Schatz. Thank you very much. We have seen a--I want 
to talk to you about one final thing, and this is the Public 
Health Emergency Fund. We've seen a pattern where every few 
years, when an infectious disease outbreak or public health 
emergency occurs, we're taken by surprise, totally flat-footed. 
The Federal Government cobbles together funding, and then 
Congress appropriates.
    But often, these are delayed, and they're delayed for 
idiosyncratic reasons, whether the particular disease resonates 
with the public, whether or not Congress is in session, and so, 
you know, the idea here is to establish a reserve fund so that 
you don't have to come back to Congress in order to respond to 
a public health emergency.
    Do you think it would be helpful for Federal response 
agencies such as CDC, FDA (Food and Drug Administration), and 
NIH to be able to respond proactively and get ahead of these 
public health emergencies before they get out of control, and 
then you have to come to Congress and ask for not a few 
billion, but a few hundred billion?
    Secretary Becerra. Senator, I think I have to hire you, but 
yes, the answer is yes.
    Senator Schatz. Well, I'm often told if this doesn't work 
out, I'd be an okay staffer.
    [Laughter.]
    Senator Schatz. Thanks very much.
    Secretary Becerra. Thank you.
    Senator Murray [presiding]. Senator Manchin is next, I 
believe. He is not down there? Okay, we'll turn to Senator 
Baldwin.

                            SHORT TERM PLANS

    Senator Baldwin. Thank you, Madam Chair. A record 31 
million Americans have obtained coverage through the Affordable 
Care Act, and that's in part thanks to this administration's 
efforts to stand up a special enrollment period, and increase 
funding for the Navigator Program, which assists people in 
searching for a plan that's right for them. These are two of my 
top priorities that I called for at the very beginning of the 
pandemic, but obviously didn't occur until this year.
    I know that these actions have made a huge difference in 
people's lives. Unfortunately, under the previous 
administration, there were rules changes that allowed the 
proliferation of plans that I would refer to as junk insurance 
plans, that don't have to provide the same protections based on 
pre-existing conditions, et cetera.
    Secretary Becerra, does the administration have any way of 
knowing how many Americans have signed up for these junk 
insurance plans?
    Secretary Becerra. Senator, I don't know if we can give a 
precise number, but we do know that the number of people who've 
signed up for these plans has increased, and it is very 
troublesome, because now we see the consequences when you think 
you have insurance, and you go and use services, and lo and 
behold, you're going to pay out-of-pocket a whole lot of money.
    Senator Baldwin. Yes. We also know that many of these plans 
engage in deceptive or misleading marketing practices kind of 
aimed at confusing customers during both special enrollment 
periods and open enrollment. At a time when comprehensive 
coverage is more affordable than ever, and the administration 
is working to get more Americans covered, why hasn't there been 
any sort of action taken to combat these junk plans and their 
practices?
    Secretary Becerra. Probably the best answer there, Senator, 
is stay tuned. We are looking to do some things. We want to 
make sure whatever we do withstands any legal challenge, but we 
are taking a close look at these plans that are really offering 
no real benefit or service to the people who are paying money. 
And so, I'd look forward to working with you on that, because 
it is a development that is alarming, especially during this 
time of pandemic when everyone needs to know what they actually 
have access to.

                          MEDICAID REENTRY ACT

    Senator Baldwin. Exactly. I look forward to working with 
you on that. Incarcerated and newly released individuals who 
have substance use disorder are at significant risk of overdose 
and death, as well as recidivism. And during the pandemic, 
these individuals have been at a substantially higher risk of 
contracting and dying from COVID-19. I was proud to introduce a 
bipartisan measure called the Medicaid Reentry Act, which would 
allow States to restart Medicaid coverage for eligible 
individuals 30 days prior to their release from a jail or 
prison. This coverage is really vital to facilitating what we 
might call a warm hand-off to addiction treatment and other 
healthcare services. Mr. Secretary, can you speak to the 
importance of providing comprehensive care for reentering 
individuals, and will you commit to working with me to pass and 
implement the Medicaid Reentry Act?
    Secretary Becerra. Senator, not only do I want to be 
supportive, we want to help get this through quicker than you 
think, because so many people are falling through the cracks, 
and we know that there is a way to help many of these folks.
    We just put out, about 2 or 3 weeks ago, we announced $3 
billion that we were putting out as a result of your good work 
on the American Rescue Plan. $3 billion, half of which is going 
to go towards substance use disorder services, and the other 
half for mental health issues, and so, we want to get out there 
quickly, and so, we look forward to working with you on this, 
because this is a major endeavor.
    We have money in the budget to help us deal with folks who 
are reintegrating back into the community, and so, very much 
prepared to do that work with you.

                      STRATEGIC NATIONAL STOCKPILE

    Senator Baldwin. Yes. I believe you've been asked some 
questions, significant questions, on the Strategic National 
Stockpile already in this hearing. I just wanted to note that I 
spent much of last year writing letters to the previous 
administration to ensure that my State, the State of Wisconsin, 
received the supplies that it needed from the Strategic 
National Stockpile to combat COVID-19. And unfortunately, it 
often took you know, public pleas from governors and Senators, 
and letters from congressional delegations as a whole for 
States to obtain the supplies that they needed during this 
crisis in its early days.
    And that's unacceptable. The President's fiscal year 2022 
budget calls for an increase of $200 million for the Strategic 
National Stockpile, including for modernizing the Stockpile's 
distribution model, and increasing visibility of the domestic 
supply chain to improve our response capabilities.
    So, can you describe how HHS has worked to increase the 
supplies available in the Stockpile? And why it's important for 
us to prioritize this funding for distribution and oversight 
improvements.
    Secretary Becerra. Senator, first I want to thank you for 
the good work that you've done here. This probably looks very 
familiar, what you see in the budget, because it really follows 
much of what you were proposing and calling for. And so, we do 
want to increase the transport of supplies, the capabilities. 
We want to refine and modernize our inventory. We want to be 
able to track our supplies better. We want to be able to expand 
domestic manufacturing. The $10 billion that was made available 
for us to really focus on domestic manufacturing will be 
critical.
    All that's going to get underway. More will be done if we 
get a budget that reflects those priorities. If we can move the 
budget from $900 million to $1.1 billion, that's significant. 
And if that is included, then we can really launch in ways that 
really let us make sure that we tell the American people we're 
stockpiling for what you need to get ready for in the future, 
and not say, ``Oops, we didn't realize we'd need that,'' when 
it finally hits us.
    Senator Baldwin. Thank you.
    Senator Murray. Thank you. Senator Shaheen.
    Senator Shaheen. Thank you, Madam Chairman. Mr. Secretary, 
we're delighted to have you in front of us this morning, and 
congratulations on your new role. You are in a position that 
touches the lives of the majority of Americans, and so, we 
appreciate your good work.

                            EXCESS VACCINES

    I wanted to first ask you about a news report I heard this 
morning on the number of States that have excess vaccines, 
coronavirus vaccines that are going to expire if we don't 
figure out some way to use them. Estimates I've seen say that 
as many as 500 million excess vaccines could be available by 
fall.
    I just came back from a trip to Eastern Europe, where they 
are desperate for vaccines. While I was there, we were able to 
announce the decision to provide vaccines to the country of 
Georgia, and they were very pleased to hear that.
    Are we considering doing more to make those excess vaccines 
available to countries that are really in need?
    Secretary Becerra. Senator, thank you for the question. 
Obviously troubling if we do see vaccines expire, but we are 
working with our state partners. The difficulty is we have to 
make sure there's a process that's orderly, that we could 
ensure the utility of the vaccine, and that people can have 
confidence that it is still a viable vaccine.
    And so, there are a number of things that we have to do if 
we're going to move that vaccine, because you need to have that 
chain of custody in place. And so, we're absolutely working 
with our state partners on this.
    We want to make sure our state partners understand that, as 
much as they may want to just get out there and help somebody, 
we have to do it the right way, because we have to have the 
confidence that the vaccines still work.
    Senator Shaheen. Well, I appreciate that. I agree that's 
very important, but we know that China is doing this very well. 
In fact, when I was at a dinner in Georgia, I sat next to a 
woman who had just had her second vaccine from China. And so, 
if they can do it, we ought to be able to do it, and we should 
make this a priority. So, I hope you will agree to do your part 
to help make that happen.
    Secretary Becerra. We'll make it a priority, but we'll do 
it our way, not China's way.

                      STATE OPIOID RESPONSE GRANTS

    Senator Shaheen. That's appropriate. New Hampshire's one of 
those States that's been very hard hit by the substance misuse, 
and the opioid epidemic has hit us very hard. The decision by 
the previous administration to provide set-aside funding to 
help the hardest hit States was very helpful to us, those State 
opioid response grants that came to us, and the support in so 
many other ways.
    We have gotten much better at saving people's lives through 
Narcan and other means, but we're seeing people migrate to 
other substances, methamphetamines, cocaine, heroin, and I hope 
that you will commit to work with our office and some of those 
other States that have been so hard hit so that even though our 
overdose death rate may be flat, we don't see a dramatic drop 
in funding because of that.
    Secretary Becerra. Senator, as you probably saw in our 
budget, we actually try to increase the amount of money there 
is----
    Senator Shaheen. Which I appreciate.
    Secretary Becerra. Yes, the State opioid response grants 
that are out there. And so, we hope to work with New Hampshire 
and all the States. Quite honestly, there's not a State in the 
country that isn't being impacted by opioids. Some, however, 
like your State, more impacted than others.
    And so, definitely looking forward to working with you. 
This is one issue where I did a lot of work as State AG 
(Attorney General). I would have thought by now we might have 
heard, but I know there is a settlement in the making that will 
help supplement what the Federal Government is doing, and I 
hope together, with what the States acquire through a 
settlement, and what we're able to do working with you, we can 
actually tackle this in a meaningful way.
    Senator Shaheen. Well, now that we are seeing COVID in our 
rear-view mirror, it will really be important to get back to 
some of those programs so that we can reach people, so that we 
can make progress, and I appreciate the commitment that you 
have.

                          CHILDCARE PROVIDERS

    One of the other areas that has been heavily impacted 
because of the coronavirus has been childcare. We've seen the 
reports of what's happened to women because they can't get 
childcare anymore. In meeting with childcare providers in New 
Hampshire, they have had a very difficult time, and continue to 
have, as people try and come back, and they try and provide 
coverage for families. But one challenge has been expediting 
the funds that are going out to States, and it's an issue for 
us at the State level, as well, because of the challenge of 
making sure people understand the guidance and are very clear.
    What I heard from childcare providers is that they don't 
want to spend money and then find out later that they haven't 
complied with the rules and have to give it back. So, will you 
work with New Hampshire and other States to make sure that that 
guidance and assistance is there for our childcare providers, 
who are really struggling at this time?
    Secretary Becerra. Absolutely. Absolutely, and I look for 
your guidance, and any member who wishes to make sure that we 
are working closely with your state partners.

                       HEALTH INSURANCE SUBSIDIES

    Senator Shaheen. Thank you. Finally, I've only got a few 
seconds left, but if I could, Madam Chair, just ask a final 
question about health insurance, because we have a chart here 
that shows what would happen if we are able to address 
deductibles in a way that does what the American Rescue Plan 
did to help expand coverage. And what this shows is--I have 
legislation that would tie the plans and deductibles to the 
Gold plan rather than the Silver plan. And so, this shows what 
happens for a family making $25,000 or less, in terms of the 
impact of expanding the help so that they could get additional 
assistance with their deductibles if we peg it to the Gold plan 
rather than the Silver plan.
    And you can see the numbers behind me for medium cost-
sharing assistance is $800. For the highest cost-sharing 
assistance right now, it's $177. So, it would be really helpful 
to families to be able to expand, thus, to help with those 
deductible costs, and I hope we can work with you to do that.
    Secretary Becerra. Senator, I'd only add--I know time has 
expired--I'd only add that President Biden made a very strong 
commitment here, and the fact that we are trying to extend 
permanently the increase in subsidies that families get would 
be tremendously important, because all those families who 
you're pointing to who fall off that cliff, that fiscal cliff, 
when they hit that point in their income, where they no longer 
get the subsidies.
    Senator Shaheen. Right.
    Secretary Becerra. Wow. All of a sudden, they can't afford 
the care, and President Biden wants to extend the good work 
that you all did to provide additional subsidies for those 
middle-class families. So, we want to work with you.
    Senator Shaheen. Thank you, I appreciate it. Thank you, 
Madam Chair.
    Senator Murray. Thank you. Thank you. We have been honored 
to be joined by the Chair of the full committee, Senator Leahy. 
Thank you for being here. Turn to you.
    Senator Leahy. Thank you very, very much. Thank you and 
Senator Blunt for having this hearing. I appreciate having the 
Secretary here. I should note for the record, the Secretary and 
I have known each other for years. We've worked together at the 
Smithsonian as regents, and he knows that I'm a huge fan of 
his, and I look forward to working with him on this.
    I was glad to see a large increase in funding to support 
research and prevention treatment. Recovery support services, 
as you can tell from Senator Shaheen's question and others, and 
your own experience, really concerns all of us. We see the 
fatalities in opioid overdoses going up. We tried a lot of 
innovative, community-based approaches in my State of Vermont, 
and with your own experience in the Congress, you know that 
it's not unusual for local issues to come up among the members 
of the Appropriations Committee.

         ALTERNATIVES TO OPIOIDS FOR TREATMENT OF CHRONIC PAIN

    But I think that research to addiction alternatives has 
lagged at the Federal level. I think we have to have more 
research on chronic pain management and treatment, other than 
through the use of opioid painkillers, and I think that is 
extremely important, because we're going to need to help people 
with the chronic pains. Will your budget support funding for 
alternatives to opioids for treatment of chronic pain?
    Secretary Becerra. Mr. Chairman, first, great to see you, 
and thank you for your concern and the work that you've done. 
We're going to try to be as flexible as we can, because the 
solutions to opioids will not come from Washington, D.C., the 
support will, and we can provide some resources, so there are 
any number of ways to tackle substance abuse disorders, and, 
quite honestly, and one of the things I found when I was the 
attorney general of California is that even the medications 
differ in their utility State by State.
    And so, we have to be able to provide our state partners, 
local partners the flexibility. They're the ones that are going 
to do the work. They're the ones who have the know-how. We want 
to provide the support and be a partner.
    Senator Leahy. I know that the University of Vermont, their 
Center of Rural Addiction helps rural counties, and the budget 
includes a request increase of $55 million for rural 
communities' opioid response programs. And I hope we can use 
that to train, recruit, retain addiction specialists to serve 
in rural areas, because obviously, a State like mine, and 
actually every State here, has rural areas, and I would hope 
that you could look at what they're doing in the Center of 
Rural Addiction that we have. There could be similar ones in 
other States, and I just want you to think about how we can 
most effectively use that funding.
    Secretary Becerra. And Senator, again, having come from a 
position as a leader in my State of California, I want to now, 
as Secretary at the Federal level, make sure that I'm listening 
as closely as I can to the local leaders. And so, what we try 
to do should be to try to support the innovation, the best 
practices locally.
    Opioids is going to be very difficult, and even with all 
the resources that we're providing, and that this future 
settlement may provide with the attorneys general, it's still a 
bear. And we've learned many things about how to deal with 
opioids, but it's still going to be a bear, and so, whether 
it's rural or inner city urban, there are people doing this on 
the ground, and we should go with the most effective best 
practices that are out there.

                               TELEHEALTH

    Senator Leahy. Well, and I will make sure I get to you some 
of the things that we're doing, because the rural health 
programs are much needed. Telehealth is very needed, but then 
you have the problem that many of us find in rural areas, 
broadband connectivity and all these others, it's not the 
medication, it's getting the telehealth there in the first 
place. So, I hope your budget will address some of these 
issues.
    Secretary Becerra. Yes. And Senator, we spoke a little 
earlier about telehealth, and one of the things you want to do 
with telehealth as you learn from what COVID has taught us is 
to make sure that we expand access to that Internet service, to 
that technology. And it would be a shame, especially in rural 
communities that you just mentioned, and its poor rural and 
urban communities, if we expand telehealth but forget them 
because they can't get it because they lack good broadband.
    Senator Leahy. Thank you. Thank you, Madam Chairman.
    Senator Murray. Thank you, Mr. Chairman. Senator Capito.
    Senator Capito. Thank you, Chair Murray. I appreciate the 
hearing, and thank you, Secretary Becerra, who we served 
together, and congratulations on your new position. Before I 
begin to ask questions, I just wanted to echo the theme that I 
know Ranking Member Blunt had conveyed, and I share.
    I am the ranking member on Homeland Security, and so I have 
a particular interest in this, and I am, Mr. Secretary, I can't 
decide if I'm frustrated or grateful, but you have overseen the 
transfer and reprogramming of almost $3 billion within your 
department from COVID-related purposes. I believe testing and 
strategic reserve is where those dollars came from, to address 
the migrant crisis at the border.
    So, I'm frustrated you ignored the intent of the funds, but 
I appreciate that your action signals to your own 
administration something that we have been calling for months, 
and that is that billions of unspent COVID funds can and should 
be used for a more pressing need.
    My question is--I'm very interested, obviously, as a 
citizen and a representative from West Virginia, on the opioid 
and overdose issue, but I think you've answered that, and we 
certainly want to be a partner. When you mentioned that the 
answers are local, can be found locally, I think our State in 
many sections of our State, and Senator Manchin I think would 
agree here, have come forth with some tremendous ideas to be 
solutions to the problem that are community based, that are 
widespread within the community, and that lift those 
communities.
    Unfortunately, the pandemic--there's a lot of backsliding, 
as you know, so we've got to get this right back on the screen. 
And we also have along with that an increase in my own home 
county of HIV, which is very concerning to me, and I'm hoping 
that the CDC, while they're in our State right now on this 
issue, can be a bit more aggressive there.

                          ALZHEIMER'S DISEASE

    What I wanted to ask, then, I'll move to another area of 
passion for me, and that's the Alzheimer's disease. We saw most 
recently that a new treatment that emerged and was approved, 
tentatively, I think, is targeted for people at early stages of 
Alzheimer's disease. And it is the only drug on the market that 
aims to slow the brain's deterioration instead of just treating 
the symptoms.
    But along with this comes an effort that we've had, 
bipartisan here in the Senate, which is this new--not new, but 
the existing welcome to Medicare initial exam, where we are 
empowering and trying to empower our medical professionals to 
begin asking questions early to try to meet the challenges that 
not just that particular Medicare patient could have, but also 
the family. As you know, caring for the folks afflicted with 
Alzheimer's is very intense, and very, very difficult for 
families. And expensive.
    But in those visits, we encourage screen detection, 
diagnosis, and other things of related dementia. I think what 
we have here is, if we have this progression of a possibility 
of a drug that can help, we need to merge this with the welcome 
to Medicare exam so that we are expanding the possibilities 
that a welcome to Medicare exam could do, and sort of heading 
off what could be the later ravages of Alzheimer's.
    I don't know if you all have thought about that, in terms 
of Medicare, what your perspectives might be there.
    Secretary Becerra. Senator, you've hit on something that's 
crucial as we continue to see innovation in new medicines, and 
that is how do we incorporate them, because these are not 
inexpensive medicines.
    Senator Capito. Right.
    Secretary Becerra. And so, to your point, the earlier we 
start in the process of trying to detect conditions that a 
person might present with, the sooner we'll know if we have to 
provide these types of medicines. And it's going to save us a 
lot of money if we get them upfront versus later stages when 
it's extremely expensive to treat some of these very difficult, 
devastating diseases.
    So, I think you're absolutely right. It's the preventative 
model. It's approaching folks early. It's trying to do the 
intervention while you can, and maybe have a chance to either 
slow, or maybe in some cases cure the condition. But certainly, 
we should not be waiting until it's at its worst point.
    Senator Capito. Right. I agree with that. This one is a 
particular challenge, as you know, because it's not something 
that maybe is apparent in your blood count, or you know, you 
can physically see it. It's something that those of us who have 
experienced, and comes on very gradually in some cases, and 
before you know it, you can't ask that last question. So, I 
thank you for your dedication here. I want to work with your 
department to see if we can enhance that welcome to Medicare 
wellness check so we can prevent on the front end. Thank you.
    Secretary Becerra. Thank you.
    Senator Murray. Senator Manchin.

                         DOMESTIC MANUFACTURING

    Senator Manchin. Thank you, Madam Chairman. Secretary, the 
Food and Drug Administration reports that nearly 40 percent of 
finished drugs, and roughly 80 percent of active pharmaceutical 
ingredients are manufactured abroad. Widespread shortages of 
personal protective equipment, the PPEs as we know, and other 
medical equipment at the beginning of the COVID-19 had a 
disastrous impact on all of us, in hospitals and consumers 
especially.
    While global shortages of semiconductors in recent months 
forced U.S. manufacturers to slow or halt production lines. 
Just yesterday, President Biden directed Federal agencies to 
institute whole of government efforts to strengthen domestic 
competitiveness, and supply chain resilience, important to 
supporting domestic manufacturing of generic essential 
medicines.
    So, how is HHS responding to this directive to strengthen 
our domestic supply chain?
    Secretary Becerra. Senator, we've had conversations on 
this. And thank you, first, for providing us with some 
resources. The American Rescue Plan does provide us several 
billion dollars to try to move towards more domestic 
manufacturing. We've also seen as a result of COVID and the 
Strategic Stockpile how we lack the kinds of product and 
medicines that we needed.
    And so, what we're trying to do is, working within ASPR, 
(Assistant Secretary for Preparedness and Response) the agency 
within HHS that would deal with this, we're trying to move as 
quickly as we can to start having a stockpile that really will 
have us ready for the 21st century. We know COVID's not the 
last pandemic, and so we want to be ready. This report that was 
just issued yesterday that speaks to these issues on domestic 
manufacturing will go a long way in directing all of us in how 
we do this. But, no doubt, when it comes to anything related to 
health, HHS has to be on top of it.
    Senator Manchin. Has HHS done any type of an inventory, 
looking at what manufacturing facilities might be able to be 
restarted if or if not, or basically put into production for 
the needs of our country?
    Secretary Becerra. I'd say that's underway----
    Senator Manchin. Okay.
    Secretary Becerra [continuing]. Nowhere near completion.
    Senator Manchin. If you can, whenever you can have your 
people working on that, or we can work with them or something--
--
    Secretary Becerra. Yes.
    Senator Manchin [continuing]. Identifying those facilities.
    Secretary Becerra. Absolutely.

                                OPIOIDS

    Senator Manchin. Sir, also, we had 90,000 Americans die 
from overdose last year. My State's been hit the hardest. We 
have an average of about 70 to 75 thousand every year. We had a 
spike because of the COVID. The problem that I have seen is 
that basically they're putting more and more products on the 
market. Manufacturers are producing larger and larger volumes. 
It just doesn't stop, and I've never seen any of us being able 
to stop that or thwart that, so, if we know that these opioids 
are causing the problem, we need treatment centers, and we have 
not enough.
    I look at domestic shelters we have. When we identified 
domestic violence as really an epidemic in our country, we put 
domestic shelters in about every neighborhood. This is an 
epidemic. Overdose. So, I've had a piece of legislation called 
Lifeboat, and all we're doing is saying you will pay one penny 
per milligram production fee if you're going to make opioids.
    We never had opioids when you and I were growing up in it, 
okay? So, if this is what they think that they need, and that's 
their model business model, then you're going to pay for one 
penny per milligram, and every penny of that goes into 
treatment centers. So, every part of our Nation, any part of 
our Nation will have treatment centers to help people. Is it 
something you all think you could support, or have you heard 
much about it, or can we set with yours?
    Secretary Becerra. We look forward to working with you on 
that because we agree. In fact, just two or three weeks ago--I 
already mentioned this earlier--we put out grant funding of $3 
billion, half of which----
    Senator Manchin. You went $3.7. I applaud you all on the 
three and a half billion.
    Secretary Becerra. Yes. We're still----
    Senator Manchin. But still yet, it kind of goes you know, 
we hit these ebbs. This would be consistent. $2 billion a year. 
One penny is $2 billion a year.
    Secretary Becerra. Yes.
    Senator Manchin. Unbelievable. It doesn't hurt anybody.
    Secretary Becerra. Go to it. We'll offer you whatever 
technical assistance and whatever else we can, because what 
we're putting in our budget and we've already done through the 
American Rescue Plan, what you all have been working on, we're 
still not keeping pace with this epidemic.

                                  340B

    Senator Manchin. With the need. I agree with you. Thank 
you. And then also, my final question. The 340B program is 
essential for providing access to safe and affordable 
medications for low-income West Virginians, and low-income all 
over our country. Recently, HHS determined that six 
pharmaceutical companies have violated the program by 
restricting access to contract pharmacies.
    The undermining of the 340B program by pharmaceutical 
companies and pharmacies' benefit managers has taken its toll 
on my West Virginia hospitals, community health centers, and 
their contract pharmacy partners, and I'm sure in every State 
every one of us have been hit with this. What are the next 
steps that you will take as the head of HHS to ensure the 
integrity of the 340B program?
    Secretary Becerra. Well, Senator, as you just said, we just 
put out, in writing, we didn't just say it verbally, we put 
out, in writing, a clear message to these six manufacturers 
that we believe that they're violating the law. You violate the 
law, you pay the consequences, and so----
    Senator Manchin. Has it been turned over to DOJ (Department 
of Justice)?
    Secretary Becerra. We're waiting for responses.
    Senator Manchin. Okay.
    Secretary Becerra. Some have responded, but we're waiting 
for full responses. By the way, our budget also does increase 
funding in this area. I think we provide almost a doubling, not 
quite a doubling of the money that is available to make sure 
that we can do the grant rule-making that we need. I hope what 
you'll do is you'll give us more authority to actually give 
clear guidance on what can be done and can't be done on 340B 
because----
    Senator Manchin. And I really think we could do that in a 
bipartisan way, because I tell you, we're all being affected. 
Every one of us.
    Secretary Becerra. That would be helpful, because this way 
the manufacturers can't sort of play this shell game with us.
    Senator Manchin. Okay.
    Secretary Becerra. They'd know what their responsibility 
is.
    Senator Manchin. Well, I look forward to working with you, 
and thank you for your service, Secretary.
    Secretary Becerra. Thank you.
    Senator Manchin. Thank you, Madam Chairman.
    Senator Murray. Thank you. Senator Hyde-Smith.
    Senator Hyde-Smith. Thank you, Madam Chairman. Mr. 
Secretary, I recently visited the border with several of my 
colleagues a few months ago, and we just saw how many children 
were down there. The issue that's going on. The possibility of 
thousands of illegal immigrants crossing the Southern border 
and being transported to our State and housed in facilities in 
Mississippi is what the concern is.

                         UNACCOMPANIED CHILDREN

    But I understand that your department reached out to many 
States, including Mississippi, to identify potential housing 
locations for these unaccompanied migrant children, and when 
Mississippi declined to participate, your office sidestepped 
State and local governments by asking private organizations and 
nonprofits to house the immigrant children.
    And I've been getting several calls on this. I mean, from a 
friend who said the local caterer just had a called asking, 
``can you put in a bid of feeding 200 seven days a week, three 
times a day?'' Where is this coming from, Mr. Secretary? What 
do you know about this? Do we need to get our local resources 
ramped up for these children coming in? And I said, I know 
nothing about this.
    But this action, you know, just ignored the elected 
officials, who said that they were not going to participate, 
and they're not being notified or given up-to-date information. 
We just have to rely on these calls that we get. But you know, 
there's just no transparency whatsoever in the last few weeks, 
other than calls from my local sheriff saying, ``I heard this 
is happening,'' because of the inquiries being made in the 
community.
    It is of great concern to me and my constituents that HHS 
would send distressed children to States without the 
involvement or approval of those States and communities and 
without the resources and security that we would need to care 
for such a large influx of migrants.
    But I firmly believe this administration's misguided 
actions have created a humanitarian crisis on the Southern 
border, and you know, they're looking for the States to pick up 
the pieces, to make this happen if those children get 
transported without our knowledge into our State.
    Does your department plan to continue on this path and to 
circumvent the will of the State governments? Do they plan to 
continue that if we know best what the capabilities of us 
serving those children are, and how do you plan to improve 
communications with the States and provide up-to-date 
transparent information on the UC (unaccompanied children) 
program?
    Secretary Becerra. Senator, thank you for the question. 
Very important. And by the way, I hope in the future you feel 
comfortable reaching out to me. I'd like to develop that 
relationship with you so that your team and my team can work 
together on some of these issues. On this particular matter, my 
sense is that some of the information that you've been given is 
not only incorrect, but it's disturbing.
    We never make any approach into a State without talking to 
the State's leadership, and local leadership. As you just 
mentioned yourself that some of the State officials said that 
they were approached and they rejected the opportunity to have 
some of these migrant kids go into their State.
    We have an obligation to provide a safe place for these 
children. We typically look for licensed care facilities, 
people who are licensed and trained to do this. They're 
children. And so, we go wherever we can. We do reach out to the 
State leadership to see if they will help us, but if the State 
leadership doesn't want to help us with children who are in 
distress, we still have an obligation to find a place for these 
kids.
    We do nothing behind anyone's back, because all these 
facilities are licensed by the very State. And so, whoever is 
telling you that they don't know anything about this is either 
being disingenuous or they're not interested in helping us make 
sure we take care of children. We don't offer them luxury, we 
try to provide them with the basics. And we look for licensed 
care facilities. We're not going to put them in a facility 
where we don't have people who are trained to care for kids, 
and we have to search far and wide throughout the United 
States, because we don't just use facilities that are near the 
borders where these kids cross.
    And so, I would hope to be able to work with you and your 
team to show you how we do this, because we're not hiding 
anything. What I can guarantee you is that we're going to 
provide a safe place for these kids while they're in our care. 
However temporary it is, while they're in our care, we're going 
to do this the right way. I suspect you have kids or grandkids. 
I have children. No grandkids yet. I would expect whoever has 
my child to take the best care they can with what they've got.
    Senator Hyde-Smith. But you do understand the concerns of 
the local medical facilities and law enforcement if we were to 
overnight get 200 children in a small area.
    Secretary Becerra. Certainly, if that were the case. But 
that never happens, because we don't do something overnight. 
You can't, not with 200 kids. There's nothing you can do with 
200 kids that is just done overnight. We have to go through the 
process of establishing the relationship. Remember, most of 
these licensed facilities can't accommodate more than just a 
handful of kids.
    The emergency intake sites that we have stood up, 
principally in places like Texas and in California, those are 
large. But those take months. In some cases, maybe weeks, but 
months to stand up. And there's no way to hide when you have a 
facility that's holding maybe three or 400 kids, or more from 
the sight of any official.
    But the licensed care facilities are typically 10, 12, 20 
kids, and the State knows about it because these folks, these 
facilities have to seek a license from the State in order to 
operate. These are facilities that operate for these migrant 
children, unaccompanied migrant children. We don't take money 
from the foster care program to do this. It is a separate 
stand-alone program, because there are special circumstances.
    These kids are here under temporary--not even status--they 
are requesting asylum, and so we have to process them. That's 
done by DOJ and DHS (Department of Homeland Security), but we 
have the responsibility, HHS, to provide them with the care, 
either under our custody, or if we're able to find a 
responsible custodian, temporarily in that custodian's care.
    And the only activity that might occur in your State is 
only the result of having worked with that licensed care 
facility to reach an arrangement to have some of these kids 
housed temporarily there.
    Senator Hyde-Smith. Well, we may be contacting you, because 
it was a large number of calls. It was a couple hundred all in 
one, and the locals--and, of course we called everybody we knew 
in Mississippi, and no one knew anything about it. So, we may 
be contacting you on that, because----
    Secretary Becerra. Please do so.
    Senator Hyde-Smith [continuing]. You know, we just 
definitely want to be prepared and know those things.
    Secretary Becerra. Please, I invite you to.

                         FETAL TISSUE RESEARCH

    Senator Hyde-Smith. Another concern I have is funding 
research that uses fetal tissue from unborn children who have 
been aborted, I believe that science is best when it's ethical 
and respects the dignity of life. I also believe that the 
Americans who object to abortion should not have their taxpayer 
dollars going toward purchasing fetal tissue from abortionists 
like Planned Parenthood.
    Furthermore, even the American Medical Association has 
raised concerns regarding the serious ethical problems created 
by the financial benefits to those involved in the sale of 
fetal tissue. And I'm over my time, but I just want to make a 
couple of points here. Is----
    Senator Murray. If the Senator could be concise, we've got 
another Senator waiting quite a bit of time, and you are way 
over time.
    Senator Hyde-Smith [continuing]. We are concerned about 
that, and that the justification rule from 1995 is still being 
used, and we know that science has changed a lot since 1995, 
and so we may want to have another discussion about that. Thank 
you, Madam Chairman.
    Secretary Becerra. Look forward to it.
    Senator Murray. Thank you. Senator Murphy.
    Senator Murphy. Thank you very much, Madam Chair. Let me 
just underscore the Secretary's remarks about these kids and 
the facilities they're in. These are State-licensed facilities, 
as the Secretary said repeatedly. These are not federally 
licensed facilities. And so every State knows where these kids 
are, and they all have the opportunity, if they want to, to 
pull the license, modify the license, do whatever they need to 
do.
    But, let's be honest, these kids are not security concerns. 
I mean, I understand there's a logistical effort necessary to 
care for these kids, and I would hope that notwithstanding 
folks' political opposition to the President, we would all 
agree that if these kids are here applying for asylum, we 
should you know, all be in the business of trying to you know, 
make sure that they have a roof over their head. But they're 
not a security concern. These are you know, 13-, 14-, 15-year-
old kids who you know, fled destitute poverty and violence to 
come to a better life, and are temporarily in our care until 
they get connected with a relative. So, I just don't want to 
overstate the danger or the impact that these young people 
have.
    Let me just, Mr. Secretary, associate myself with the 
remarks of Senator Baldwin on the short-term, limited duration 
plans. I wasn't here for your answer, but I heard that you said 
we should wait and stay put for additional announcements. I 
hope that that is coming shortly. These plans you know, they're 
just frauds. They're sold a bill of goods, these folks who pick 
them up, and then find out that they actually have no 
insurance, and I hope that we can get those out of the 
marketplace as quickly as possible.
    My question to you is around the proposal for additional 
ACA (Affordable Care Act) premium subsidies, about $60 billion 
in the President's budget over the next 4 years to continue the 
increased subsidies, and I thank Senator Shaheen for her 
advocacy and her leadership on this. I'm very supportive of 
that proposal, but I just want to point out that that is $60 
billion not necessarily going to consumers. That's $60 billion 
that's going to the for-profit healthcare industry. That's $60 
billion that's going to end up in the pockets of insurance 
companies, and drug companies, medical device companies, for-
profit hospitals. You know, all sorts of entities that are just 
making a king's ransom off of our healthcare system today.
    I'm very glad that Senator Murray and Chairman Pallone have 
kicked off a process by which we're going to, I gather, start 
to come up with a path forward on a public option. The ability 
to put a Medicare, Medicare-like plan on these exchanges that 
does not have the kind of profit motive that private insurance 
plans do, and, if done right, will provide some real price 
pressure on the private sector.

                             PUBLIC OPTION

    For instance, Senator Merkley and I have introduced what we 
believe to be the sort of most aggressive public option, and in 
it would be included bulk purchasing authority for you or for 
CMS (Centers for Medicare and Medicaid Services) that would 
result in a lower price for the Medicare-like plan. But it 
would also create pressure that would have benefits to private 
sector plans, as well.
    What do you think of the process that has been announced in 
the Senate and the House to begin conversations about public 
option legislation? Do you see this as part of the answer on 
price moving forward? Because my only worry about a strategy on 
affordability that is predicated mostly on subsidy for the 
exchanges is that that ends up just feeding the for-profit 
health insurance and medical industry machine, which you know, 
ends up doing very well for them, ends up in increased coverage 
for Americans, but doesn't get at the price question.
    Secretary Becerra. So, Senator, having served with you as 
we were going through the process of passing the Affordable 
Care Act, and having pushed for many of the things that you're 
discussing, what I can tell is now, in this position, I just 
want you all to get something done, because, give me some 
authority to do something to lower costs, give me the ability 
to try to drive down the cost of those services, and to expand 
coverage.
    Any number of good ideas, but I know that you all have to 
go through this process and figure out how to get to the right 
number to get something passed. The President has publicly 
stated he is supportive of the public option, we have dollars 
in this budget to try to support movement towards getting more 
Americans onto coverage, and I would simply tell you, we're 
ripe to get something done. The American public wants to see us 
do something, and so, it's almost--yes to all of the above. 
Just let's see something cross over the finish line.
    Senator Murphy. I appreciate that the administration and 
you have a lot on your plate right now, but at some point, some 
leadership to point us and others in the right direction on 
this question on how we construct a public option would 
probably be helpful, but I thank the Chair for her leadership 
on this. Thank you.
    Senator Murray. Thank you. Senator Braun.
    Senator Braun. Thank you, Madam Chair. Good to be talking 
to you again----
    Secretary Becerra. Thank you.

                        PARTIAL-BIRTH ABORTIONS

    Senator Braun. February 23, in your nomination hearing, I 
asked will you follow the law, and it was in reference to the 
Hyde Amendment back then and some other things. Recently, you 
were testifying in a House committee, and the subject of 
partial-birth abortions came up, and I think there was some 
confusion as to whether there was a law on the books or not, 
and I assume that you of course now know there is.
    I think what I'm interested in is not so much what you're 
going to do to enforce existing law, what you might be 
proposing or pushing when it comes to, you know, the issue of 
abortion, sanctity of life. So, is there any interest in your 
office pushing or trying to get legislation out there that 
would overturn the ban on partial-birth abortions?
    Secretary Becerra. Senator, thanks for the question, and 
thanks for following up from our previous discussion on this. I 
think the President has been fairly clear, and maybe if I 
wasn't so clear in my previous testimony, I could try to 
elaborate a bit. We're going to do what the law permits us to 
do. We're going to follow the law. This is a subject that, 
obviously, people differ on. These issues usually are premised 
on very deeply held beliefs. But what I can tell you is that if 
I'm doing my job, I'm following the law, and right now, Roe v. 
Wade is the law of the land.
    We're going to do everything we can to protect a woman's 
reproductive rights, to have healthcare. We want everyone to 
have access equitably to healthcare, and so, we're going to do 
everything we can to make sure that whether you're rich, poor, 
young, old, tall, short, you're going to have access to the 
care you need.

                             HYDE AMENDMENT

    Senator Braun. So, the current law incorporates the Hyde 
Amendment, and in the President's budget, that is a clear 
omission. So, does that mean that, and were you part of the 
formulation of the budget you know, that would have that not as 
part of it? And that's been around since 1977. So, when you 
hear statements that would be unclear about an existing law of 
partial-birth abortions, which you actually voted against that 
law, the one banning it, it would give many of us pause in 
terms of what might be done.
    You're clear that you're going to respect the law, but I 
think I'm more interested in what you might be interested in 
doing to change the law. And the fact that the Hyde Amendment 
is not part of the budget, is that something more ominous on 
the horizon that it would be incorporated into law, at least 
it's reflected in the proposed budget, and were you part of 
crafting that omission?
    Secretary Becerra. Remember, Senator that President Biden, 
before he became president, said that he would be against 
maintaining the Hyde Amendment, and so, the budget is a 
reflection of what the President has said in the past. I have 
thousands of votes in my 24 years in the House of 
Representatives. I think my record's pretty clear where I stand 
on this issue, as well.
    But, as you just said, my obligation is to respect the law, 
and the law is not established by the executive, it is 
established by Congress. And so, we will respect and follow 
whatever the law is that you all pass.
    Senator Braun. Well, I'm glad to hear you're going to 
respect the law. I think that would be the minimum that we'd 
require out of anyone here in any capacity, and I think that 
what you're saying is that you may be trying to change the law, 
and President Biden has been clear, according to you, that he 
does not want the Hyde Amendment to be part of what ideally 
would be part of law in that area.
    And then, what would worry some of us is that then the next 
step might be taken to where partial-birth abortions come into 
play, and I think it just good to be honest about what one's 
intentions are, and we're in a climate right now when it looks 
like there's a lot out there legislatively, and for any of us 
that are passionate about the sanctity of life, it is 
something--obviously, we would love to know clearly you know, 
what the intentions of the administration would be. Your 
intentions and lawmakers, as well. So, I think that we're not 
going to get any further on that topic here today, but I 
thought it was definitely worth mentioning.
    Secretary Becerra. Senator, I look forward to working with 
you. The art of compromise and the ability to come together is 
what makes this democracy work, and so, we don't have to have 
the exact same views to be able to get things done for the 
country.
    Senator Braun. Thank you.
    Secretary Becerra. Thank you.

                           MATERNAL MORTALITY

    Senator Murray. Thank you. Mr. Secretary, the U.S. is the 
only industrialized nation where the maternal death rate is 
rising. Each year, 700 women die due to pregnancy, childbirth, 
or subsequent complications, according to the CDC, and the vast 
majority of those deaths are preventable. Black, Tribal, and 
women who live in rural areas are at much greater risk, so we 
need to address the gaps in care for pregnant and postpartum 
women and root out bias and discrimination in maternity care 
settings.
    So, I was really pleased to see your budget build on some 
of our bipartisan investments that we've been making in recent 
years to combat this crisis with $220 million across several 
agencies within HHS. I want you to talk to us about how this 
new funding will address the problems driving these disparities 
for women of color and women who live in rural areas, and maybe 
what lessons you've learned from the committee's initial 
investments.
    Secretary Becerra. Senator, thank you. This one is 
important, not only because it's the right thing to do, but, as 
you said, we as a country, as a Nation, a leading Nation are 
doing something totally wrong when it comes to protecting 
women, women who are going to help us move the next generation 
of leaders. And so, it's time, and I'm thrilled that the 
President saw the need to make a substantial investment here.
    Not only is it the $3 billion to improve the maternal 
health programs that we have under the American Families Plan 
that he has proposed, but it's the $223 million that I hope we 
get in funding, that's in this budget for a program that he 
wants to start to help improve maternal health programs around 
the country.
    It is the challenge to States to say, under Medicaid, we 
right now provide a woman 60 days of postpartum care after 
she's delivered. We're saying, guess what? You join in, and 
we'll give you--we'll help you pay for a full year's, 12 
months' worth of care for that woman. Because it's not just the 
delivery and the recuperation from the delivery, it's making 
sure the woman is ready to move forward in that first year of 
life of that child.
    And so, this one's critical, and, as I've always mentioned, 
this is something my wife, as an OBGYN has always talked so 
much about. How we don't really care too much except for making 
sure that we see the delivery go well. There's so much that 
goes on before the delivery, and so much that has to go on 
after. And to have in our own country, pockets of America where 
women are still dying, or their children are dying at birth, 
it's just incredible.
    So, these are the investments that we need to make, and 
it's unacceptable to not do otherwise.
    Senator Murray. Well, thank you. I look forward to working 
with you on that. Mr. Secretary, the number of migrant children 
referred to HHS's care began steadily increasing last year, 
including after courts enjoined the prior administration's 
policy of applying Title 42 restrictions to unaccompanied 
children. And at the same time, as you well know, COVID-related 
limitations significantly reduced HHS's capacity in its entire 
network of State licensed shelters.

             UNACCOMPANIED CHILDREN EMERGENCY INTAKE SITES

    And as a result of that, this administration inherited a 
system already approaching a breaking point, and the use of 
emergency intake sites has, thankfully, gotten a lot of our 
kids out of CBP facilities, and the department has made some 
progress in a very short period of time, I know, to reduce the 
number of kids at these emergency sites.
    But those sites do not provide the same level of care or 
services that HHS's other facilities, and their extended use 
really raises concerns. I wanted to ask you what is HHS doing 
to phase out of these emergency sites as quickly as possible by 
placing more kids into these State licensed facilities, and 
with appropriate families and sponsors as soon and safely as 
possible?
    Secretary Becerra. Well, Senator, as you may have heard in 
my discussion with Senator Hyde-Smith, we reach out to every 
facility we can, in any part of the country. Because you're 
right, while these emergency intake sites have done the job of 
providing these kids with the care that you would expect, far 
more than the Custom and Border Protection Service could, we 
know that it's better to have them in a facility that is 
licensed to provide that care.
    There are any number of licensed facilities, but very few 
of them we haven't already approached, and so, we're going 
everywhere we can, and we have been able to expand the number 
of licensed beds that have been available. There was a point 
where we had more kids in emergency intake centers than we had 
in licensed care facilities, when our census numbers were 
really high. But we have now flipped that, and there are more 
kids today in licensed care facilities than we have in these 
emergency intake sites.
    Senator Murray. Okay, and are you addressing the emergency 
intake sites, and what are we doing there to improve the level 
of care? Because they still do exist and will for a time.
    Secretary Becerra. Substantial amount. Today, those intake 
sites offer behavioral health services to kids, which we know 
that is important for so many of these kids because they come--
--
    Senator Murray. At all of the emergency intake sites?
    Secretary Becerra. I think we have it at all of the sites 
now. We do have behavioral health specialists who are there to 
provide for their needs. We've always provided the medical 
care. We were never sure when we first started standing up 
these sites how long they would be around, and so, we made sure 
we had the medical services. But getting behavioral health 
specialists is obviously a little bit extra. It's a tougher 
thing. But now, we do, because we've seen how we've had to open 
a number of them.
    We also now do discharge work. We actually do the process 
of doing the intake, getting the information, doing the 
background checks on potential custodians, sponsors. And that 
wasn't done at the beginning either, because they were just 
emergency intake sites to help us deal with the overflow.
    But we've seen that so many of these kids would end up 
staying in these sites for weeks, and so, we decided, no, let's 
start doing the work now of finding a responsible sponsor that 
can hold them, versus keeping them in one of these sites.
    So, it's almost a full service--it is a full service. If 
you go to Long Beach, California, not only is it a full-service 
site, several hundred kids, but the community has so much 
gotten involved that they ended up getting, and this was about 
a month or so ago, 70,000 toys and books donated by the 
community. Several hundred kids, but they got 70,000 gifts from 
the community, which now is making it possible for us to send 
some of these things to some of the other kids in some of these 
other sites.
    And so, it's a whole of agency approach, because we want to 
make sure that we provide the right service. Again, I have to 
acknowledge, this is expensive stuff. It is not easy. And we 
are not going to let a child go to someone unless we feel 
confident that they're going to be responsible caregivers. And 
so, it's very difficult, but these are kids.
    Senator Murray. Yes. Okay, thank you. Senator Blunt.

                         COVID-19 VACCINE GOALS

    Senator Blunt. Thank you, Chair. Mr. Secretary, are we 
going to reach the White House goal of 70 percent of all U.S. 
adults with at least one shot by July 4, and for 160 million 
Americans to be fully vaccinated by that date?
    Secretary Becerra. I would not bet against this President, 
Senator, because he's so far done a pretty good job of hitting 
his marks, and I know he's determined, and we're working with 
him to get to that 70 percent. But, quite honestly, it 
shouldn't be just a goal of the President. It should be a goal 
of every American to try to help us get to that 70 percent 
threshold and beyond, because it's for the good of the people, 
not just for the President.
    Senator Blunt. Well, I agree with that. I guess we'll see 
if there are enough donuts, and enough cans of beer, and 
whatever else is being offered as the incentive to get people 
to take that vaccine. It's really important to get this done, 
and I hope we meet that goal. I'd be pleased if we exceeded it. 
Who's taking principal responsibility for that?
    Secretary Becerra. The President has thought it so 
important that he established, even before he came into office, 
this working group. Jeffrey Zients has been leading that group 
for some time, and over the course, it's gone mostly from 
trying to address to combat the pandemic and COVID-19, to now 
making sure folks are getting vaccinated.
    We're still doing all of the other things. But the major 
focus has been now getting that vaccine out as best we can, and 
I'm waiting for the invite, Senator, so that we can go to your 
State and see the pockets that still have to get vaccinated, 
and we'll do what we can.
    Senator Blunt. Well, good. We'd be glad to have you, and 
we're trying to do that. I think one of the lessons we learned 
early on in this is you don't want to make it too complicated. 
Hopefully, we won't face this situation again in a hurry, but 
we might with the booster shots and, you know, the more people 
that can, without wondering if they qualify, can line up and 
get their vaccination, the better off we are, I think.

                       GRADUATE MEDICAL EDUCATION

    I noticed in your budget submission that there is no 
increase in children's hospitals graduate medical education. As 
you know, that's the one part of medical education that's not 
funded out of Medicare. We've made an increase every year in 
the last 6 years. I hope you'll help us look at that again and 
find an increase. There are accounts really close to that that 
have increases. You know, if you don't have the opportunities 
to go into children's hospitals and get your specialty that 
way, you wind up going somewhere else, and I think we'd all 
agree that we don't benefit from having a lack of people 
focused on children's healthcare.
    Secretary Becerra. GME (graduate medical education) 
programs are critical. When I was in the House, I fought very 
hard. LA obviously has a number of facilities, and at one 
point, we almost lost MLK hospital in Los Angeles, which was 
one of the safety net providers, and we fought really hard to 
preserve the GME slots that we had for MLK, so that once it got 
back into business, we'd still be able to bring in graduate 
medical students, and so, I absolutely agree with you. We have 
to do everything we can to try to increase the number of, and 
supply of these doctors. Especially because, as you know, we 
lack those physicians and in those specialties for children.
    Senator Blunt. I'd like to figure out some way we could do 
with children's medical education what we've done with all 
other medical education for all other specialties. Maybe we can 
work together and figure out if there is a way in some other 
fund we could fund this like we fund everything else.

                          ACA/UNINSURED NUMBER

    How many people--I know it was mentioned earlier that I 
think 31 million people have insurance through the Affordable 
Care Act. How many people do we believe don't have insurance 
now?
    Secretary Becerra. There are still probably tens of 
millions. I don't want to give you a number off the top of my 
head.
    Senator Blunt. Will you get back to us with a number on 
that?
    Secretary Becerra. Absolutely.
    Senator Blunt. I think when we started down this road a 
decade ago, it was 30 million we thought didn't have insurance. 
I'm afraid it's still about 30 million, but I'll let you take 
that for the record.
    Secretary Becerra. Will do, Senator.
    Senator Blunt. Okay. Thank you, Chair.
    Secretary Becerra. Thank you.

                               CHILDCARE

    Senator Murray. Thank you. Mr. Secretary, the pandemic 
really exposed what many of us have known for a very long time 
that the childcare system in our country is really broken. And 
childcare is just such an essential of our infrastructure. It's 
really key to our economy, and during the pandemic, we saw four 
times as many women leave the labor force as men, in large part 
due to increased caregiving and distance learning 
responsibilities. And the problem was even worse for Black and 
Latina mothers.
    So, I'm really glad to see your budget propose large 
investments in childcare, including a $1.5 billion increase to 
the Child Care and Development Block Grant. Prior to the 
pandemic, CCDBG (Child Care and Development Block Grant) 
programs served just one in seven eligible children, and the 
need for the services is now expected to rise significantly 
given the economic turmoil that's been created by this 
pandemic.
    So, talk to us about how this funding will improve access 
to childcare.
    Secretary Becerra. Madam Chair, you've said it. I mean, our 
economy will not fully recover until we address the childcare 
needs, especially for women, single women. And so, it is 
important for us to make these kinds of investments. But it 
still doesn't take us where we need to go. As you just 
mentioned, just for those who were eligible, we were only 
providing services to one in seven.
    It's unfortunate that we look at it this way. Maybe it's 
our tradition that we think that we could take care of our kids 
ourselves, but today, that's not the reality. More often than 
not, even if it's a two-parent household, both parents have to 
work. And no one wants to see a scenario--I grew up being a 
latchkey kid. No one wants to see a scenario where we damage 
our future because we didn't think of investing in our kids.
    The President's proposals to provide full-time pre-K for 3- 
and 4-year-olds would be a tremendous help for a lot of 
families. Providing the childcare tax credit that I know is 
before you, a tremendous help. But investments in these block 
grants that help those families is critical, especially for 
middle and low-income families.
    Senator Murray. Well, you know, there's a recent report 
that showed nationwide the cost of childcare jumped, on 
average, 47 percent during the pandemic. We now have people 
trying to go back to work, and they're going, I couldn't afford 
this before, now what am I going to do?
    And another problem we're seeing is the wages for childcare 
providers and early educators is abysmal, and yet these 
operators are now trying to operate on extremely thin margins, 
like everyone else. They can accept fewer kids, they have to 
have all of the sanitation equipment. It is much harder to run 
these businesses. So, I wanted to ask you how the budget 
requests address the funding gap that now exists between what 
parents can afford to pay and what high-quality childcare 
providers need so they can operate?
    Secretary Becerra. Madam Chair, probably the best way to 
say it is this is what happens when you fail to invest for a 
long time. It all starts to come at you, it hits you in your 
face, and what we're finding is that the costs will continue to 
increase, families will have a harder time, but quite honestly, 
we should not be paying the dirt low wages that so many of 
these childcare workers have been receiving. They deserve to be 
paid for the work they do. They're taking care of our most 
precious assets.
    And so, we need to see them receive a decent wage and 
salary, which will cost more in terms of the service for the 
parents, but we have failed for so long to really invest in 
taking care of our kids and helping our brothers and sisters in 
America care for their kids that things are coming home to 
roost. We have to make the investments. Fortunately, President 
Biden wants to make those investments. I know that there's a 
great deal of support in the House and in the Senate to do 
something serious when it comes to childcare, whether it's the 
tax credit or major direct investments, we need to do it, 
because----
    Senator Murray. Well, this is a top priority for me, and I 
know it is for pretty much every working parent out there so, 
we will work with you on that.
    Secretary Becerra. Amen.

                           HEALTH DISPARITIES

    Senator Murray. I wanted to ask you one last question. The 
pandemic's deadly impact on communities of color really shows 
that we have a long way to go to address systemic racism and 
health inequities, and there's factors from housing to food 
deserts to access to health services that can really have an 
impact on somebody's health. So, I was really pleased to see 
the budget focus on addressing those problems, including an 
increase of $150 million for CDC's social determinates of 
health activities. Can you talk a little bit about what those 
initiatives will do to reduce health disparities?
    Secretary Becerra. Madam Chair, the most important things 
is that we're now recognizing--the fact that we're using the 
words social determinants of health show how far we've come as 
a Nation and as a policy-making body that we recognize that, in 
so many ways, your health is determined by your background, too 
often by your ZIP code, and we have to change those things, 
because there are people in America who are left out. There are 
places, the pockets in America where the services don't reach 
them, whether it's rural America or whether it's inner-city 
America.
    And the President has made equity one of the prominent 
features of his administration, and we will do the same at HHS.
    Senator Murray. Well, thank you very much, and that will 
end our hearing today. I do want to thank all of our fellow 
committee members and Secretary Becerra for a very thoughtful 
discussion today about the President's budget request and how 
we can work together to really address some of these really 
critical issues of lowering healthcare costs, and helping 
families across the country get covered, address inequities, 
respond to public health crisis, childcare. So much more that 
is within your jurisdiction. So, really appreciate your 
testimony today.
    Secretary Becerra. Thank you.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Murray. For any Senators who wish to ask additional 
questions, questions for the record will be due June 18 at 5 
p.m. The hearing record will also remain open until then for 
members who wish to submit additional material for the record.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
            Questions Submitted to Secretary Xavier Becerra
              Questions Submitted by Senator Patty Murray
    Question. The past year has been particularly devastating for 
children and young adults' mental health. The CDC found the proportion 
of emergency room mental health visits increased by a quarter from 
April to October last year for children ages 5 and 11, and by nearly a 
third for those between ages 12 and 17. Suicide attempts and 
psychiatric help calls for children are also on the rise. Seattle 
Children's Hospital in Washington is seeing 170 children with mental 
health emergencies a week--compared to 50 before the pandemic. Sacred 
Heart Children's Hospital in Spokane saw admissions to its adolescent 
psychiatric unit and its pediatric floor for behavioral health issues 
both rise by around 70 percent.
    How does the budget request target mental health services 
specifically to children and young adults?
    How does the request address the ability for children to access 
mental health services within their communities?
    Answer. HHS is committed to providing mental health services that 
address the needs of children and young adults. SAMHSA supports school-
based programming in part through Project AWARE (Advancing Wellness and 
Resilience in Education). The purpose of this program is to build or 
expand the capacity of State Educational Agencies, in partnership with 
State Mental Health Agencies (SMHAs), to increase awareness, provide 
training and promote connection to services for youth with behavioral 
health needs. From October, 2016 to September, 2020, Project AWARE 
trained over 56,000 providers and ensured that more than half a million 
school-aged youth had access to and were referred to mental health 
services.
    School-based health centers (SBHC) are typically funded by U.S 
DHHS-Health Resources and Services Administration (HRSA; https://
www.hrsa.gov/our-stories/school-health-centers/index.html) and/or by 
individual State Departments of Health. SBHCs provide students with a 
variety of age-appropriate health services, including, but not limited 
to, primary medical care, health education, and nutrition education. 
SBHCs are increasingly offering behavioral healthcare services such as 
mental health and substance use screening, counseling, and case 
management/referral services. SBHCs are often operated as a partnership 
between the school and a community health organization, such as a 
community health center (FQHC) or local health department; and for 
behavioral health services, SBHCs often partner with local community 
mental health centers.
    SAMHSA has continued to expand the Certified Community Behavioral 
Health Clinics (CCBHCs) through expansion grants, awarding 134 grants 
in early 2021 through recent emergency funding, with up to 74 
additional grants being awarded in summer of 2021 as part of the 
regular appropriations process. 166 CCBHC grantees were awarded in 
fiscal year 2020. SAMHSA is also planning a formal technical assistance 
arrangement to support organizations in implementation and 
sustainability. The CCBHC programs provide an array of critical, 
integrated services to meet the behavioral health needs of communities. 
CCBHCs provide a full continuum of timely, person and family-centered 
services, including access to crisis services 24/7, and are 
particularly focused on the needs of individuals with serious mental 
illness (SMI), serious emotional disturbance (SED) and/or substance use 
disorder (SUD). The program is designed to support individuals and 
families who are uninsured or underinsured and who may otherwise lack 
access to effective screening and treatment. The program encourages use 
of telehealth and other modalities to increase reach of services and to 
address barriers to care access.
    Question. The fiscal year 2021 Labor-HHS bill included a new, 5 
percent set aside in the Mental Health Block Grant for states to 
develop crisis systems to improve their ability to respond to 
individuals experiencing a mental health crisis. These systems are 
intended to connect people with appropriate services, rather than 
referring them to law enforcement or emergency rooms.
    How does the request build on the crisis response set aside created 
in the fiscal year 2021 bill and how does HHS plan to work with states 
to ensure these systems are fully accessible with adequate coordination 
between mental health and law enforcement?
    Answer. The Community Mental Health Services Block Grant received 
an increase of $825 million in the fiscal year 2022 President's Budget, 
for a total of $1.6 billion, to expand access to behavioral healthcare. 
Within the total, $75 million is directed to the crisis services set-
aside. This investment in crisis services will direct funding to states 
to build much needed crisis systems that will provide high quality, 
expeditious mental healthcare. This funding also will support the 
partnering of behavioral health providers with law enforcement.
    SAMHSA has been actively engaging with states on the use of MHBG 
funds, including this crisis set-aside ($75 million in fiscal year 2022 
President's Budget). This coordination has included technical 
assistance on the use of funds, requests for information on specific 
allocations of funding across the crisis continuum of care, and 
recommended changes to the data reporting system. States are at 
different stages in their implementation of core crisis services and 
currently use the funds to expand existing core services or develop new 
services. Funding regional or statewide crisis centers is an allowable, 
but not required, use of the funds. There is significant variation in 
the degree to which states are using MHBG funds to support activities 
such as the Lifeline crisis call centers. The fiscal year 2022 
President's Budget includes funds for SAMHSA to further expand the 
capacity of the call centers to ensure they can respond to the expected 
increase in call volume accompanying the transition to 988.
    Beyond the current Lifeline functionality, it is critical that 
individuals experiencing a behavioral health emergency have access to a 
coordinated crisis system of care. Effectively responding to people in 
crisis who are experiencing a behavioral health emergency has three 
main components as outlined in SAMHSA's National Guidelines for 
Behavioral Health Crisis Care: providing someone to talk to, providing 
in-person response, and providing a place to go. Implementing 988 
successfully will be a critical first step in the crisis response. 
Current research suggests that many crises can be effectively addressed 
through a call alone. In addition, call centers that have follow-along 
capacity and/or access to local outpatient treatment resources can 
provide enhanced crisis care. A robust crisis system, including 988 
access through the Lifeline network, will decrease suicides, reduce 
arrests and criminal justice involvement for individuals with 
behavioral health needs, and will facilitate linkages to care to reduce 
unnecessary emergency department boarding and hospitalization. 
Implementation of the Lifeline, partnered with the development of a 
coordinated and comprehensive behavioral health crisis services system 
across the United States, will save lives.
    The fiscal year 2022 President's Budget further supports local 
communities in meeting the mental health needs of people who are 
incarcerated by investing $45 million more in these programs for a 
total of $51 million to support the needs of those who are involved in 
the criminal and juvenile justice system(s) providing funding for 
partnerships between mental health providers and law enforcement. 
SAMHSA will award a new cohort of grants to community-based behavioral 
health providers that focus specifically on the delivery of mental 
disorder treatment while in jail and provide linkages to care post-
incarceration.
    Question. The President's budget request includes a $77.6 million 
increase for the National Suicide Prevention Lifeline in order to help 
build the infrastructure necessary to make a smooth transition to the 
new three-digit code (9-8-8) as required by the National Suicide 
Hotline Designation Act.
    Please describe how this funding will strengthen the existing 
infrastructure of the Lifeline and better prepare local centers to 
respond to the increase in calls expected once the transition to 9-8-8 
occurs.
    Answer. The creation of 988 is a once-in-a-lifetime opportunity to 
strengthen and expand the Lifeline and transform America's behavioral 
health crisis care system to one that saves lives by serving anyone, at 
any time, from anywhere across the nation. Preparing the Lifeline for 
full 988 operational readiness will require a bold vision for a system 
that provides direct, life-saving services to all in need and links to 
community-based providers uniquely positioned to deliver a full range 
of crisis care services. SAMHSA sees 988 as the linchpin and catalyst 
for a transformed behavioral health crisis system in much the same way 
that, over time, 911 spurred the growth of emergency medical services 
in the United States.
    SAMHSA envisions a multi-phase approach to making 988 operational 
and effective. SAMHSA is committed to using this investment to 
strengthen the existing infrastructure and prepare for the launch of 
988. The first phase is focused on increasing the capacity and 
operational readiness for the National Suicide Prevention Lifeline to 
accept 988 calls, chats, and texts by July of 2022. This includes 
support to ensure a national back-up system or safety net. SAMHSA has 
reviewed modeling estimates to anticipate the expected call volumes 
with 988 rollout. The President's Budget includes funds to support the 
resources needed for network and telephony infrastructure expansion, 
training to harmonize protocols across all local centers, and staffing 
to increase the capacity of the Lifeline to respond to the anticipated 
increase in calls expected with the 988 transition.
    An ideal crisis system would include state and regional crisis 
hubs, which can be fully integrated with mobile crisis response, crisis 
receiving facilities and follow up care. SAMHSA believes that the 
crisis system will be critical to make 988 optimally effective in 
addressing behavioral health crisis needs and reducing unnecessary 
hospitalizations and law enforcement involvement.
    Question. The budget request notes that this funding will be used 
to increase the capacity to respond to text messages and to those who 
need specialized services. Does the Department plan on leveraging 
existing infrastructure rather than recreating these capabilities?
    Answer. Yes, leveraging existing infrastructure will be 
instrumental in the success of 988. Initially established by Congress 
in 2005, the Lifeline is a national network of over 180 independently 
operated crisis call centers, three Spanish language centers, and the 
Veterans Crisis Line (VCL). The network is currently linked by the 
toll-free telephone number, 1-800-273-TALK, which is available 24 hours 
a day, 7 days a week. The Lifeline network also consists of 9 national 
backup and 38 chat/text centers. The backup and chat/text core network 
centers operate under contractual obligations through the Lifeline 
Administrator, who oversees the current Lifeline cooperative agreement 
from SAMHSA.
    Until recently, funding for the National Suicide Prevention 
Lifeline was only $7 million. This funding along with limited state 
investments has been insufficient to pay local centers to answer 
Lifeline calls. With the President's Budget request, as well current 
state investments in the answering of Lifeline calls, important 
progress is being made.
    It is critical to invest in strengthening Lifeline network 
operations. While further system transformation will require additional 
capacities (e.g., substance use integration, coordination across the 
crisis continuum, etc.), the immediate priority is ensuring the 
Lifeline has sufficient resources to address the scope of contacts 
addressed directly in the National Suicide Hotline Designation Act, 
including individuals in suicidal or mental health crisis. In the near 
term, efforts should be made to map available local resources so that 
facilitated transfers and referrals can be made to support individuals 
with additional needs.
    SAMHSA recognizes the need for a multi-pronged approach to address 
the needs of populations at higher risk of suicide. This includes both 
leveraging existing technologies as well as piloting and developing 
novel approaches to enhance access to crisis care.
    Question. When does the Department intend to provide the 
Subcommittee with the report on the costs associated with a transition 
to 9-8-8?
    Answer. SAMHSA has been working diligently on three important 
reports to Congress--the 988 Appropriations Report, the Report on 
Training and Access to 988 for High Risk Populations, and the Report on 
988 Resources. SAMHSA worked collaboratively with the VA to develop the 
Resources report to Congress. All three reports are in the final stages 
and will be submitted to the respective Committees and your 
Subcommittee shortly.
    Question. The pandemic's impact on child-care has been especially 
hard on communities of color, undermining parents' economic stability 
and children's school readiness. Virtually all child-care workers are 
women, disproportionately women of color and immigrant women who do not 
receive adequate wages or benefits. COVID has only made these 
inequities worse. Additionally, even before the pandemic, children of 
color were less likely to attend a high- quality early learning program 
than their white peers, and entered kindergarten 9 months behind their 
white non-Hispanic peers in math and almost 7 months behind in reading, 
on average. Furthermore, Center closures because of the pandemic have 
threatened an already limited supply of care for infants and toddlers 
and made it even harder for families of color to get quality, 
affordable child-care. I am concerned these closures will deepen racial 
and socioeconomic inequities in access to high-quality early learning 
opportunities that promote kindergarten readiness for children.
    What role is HHS playing in addressing the racial inequities in 
child-care for families and providers?
    Answer. The HHS Office of Child Care (OCC) is providing guidance, 
technical assistance, and oversight to assist states, tribes, and 
territories with administering the multiple rounds of COVID-19 child 
care supplemental funding, including the $39 billion in child care 
funding provided by the American Rescue Plan Act consisting of $24 
billion in child care stabilization funds and $15 billion in 
supplemental Child Care and Development Fund (CCDF) awards. This 
funding is helping to stabilize and improve the child care sector and 
improve access for all children and families, including addressing 
racial and ethnic inequities.
    The American Rescue Plan Act child care stabilization funds are 
providing immediate financial relief to child care providers facing 
increased costs and declining revenue. Our guidance on these funds 
(Information Memorandum CCDF-ACF-IM-2021-02) indicates that 
applications, technical assistance, and written resources should be 
available in multiple languages, and that states are encouraged to work 
with culturally relevant organizations to meet the ongoing needs of 
providers receiving grants. We are also collecting data on the race, 
ethnicity, and location of child care providers to track the equitable 
distribution of resources.
    The CCDF supplemental funds in the American Rescue Plan Act are an 
unprecedented opportunity to expand access to high-quality child care 
and move toward a more equitable child care system by assisting many 
families and providers who have not previously participated in the 
child care subsidy system--including families and providers from 
communities of color. Our guidance (Information Memorandum CCDF-ACF-IM-
2021-03) strongly recommends that states prioritize increasing provider 
payment rates and workforce compensation so that child care providers 
can retain a skilled workforce and deliver higher-quality care to 
children receiving subsidies. These steps will advance equity for 
women, particularly women of color, lift families out of poverty, boost 
the broader economy, increase women's labor force participation, and 
improve outcomes for children. Our guidance also encourages states to 
pursue opportunities to build the supply of child care--including the 
use of grants and contracts--for historically-underserved populations. 
The guidance also encourages states to use some of the funds for 
outreach activities to underserved populations, including to 
disseminate materials in multiple languages, and to fund partners and 
organizations trusted by families and child care providers--including 
culturally relevant organizations.
    OCC has developed a number of technical assistance (TA) resources 
to help state, territory, and tribal CCDF administrators and other 
systems-level professionals assess and ensure equitable child care 
service delivery to racially disadvantaged communities. These resources 
encompass all child care settings, e.g., center-based care, family 
child care, and family, friend, and neighbor care; as well as the range 
of age groups served by CCDF. Our TA system embeds racial equity 
considerations in the planning, development, and evaluation of new 
resources to ensure they are inclusive of diverse perspectives and 
responsive to disadvantaged community's needs.
  --The National Center on Early Childhood Quality Assurance (ECQA) has 
        developed resources on considerations for leadership in early 
        childhood systems development and for child care licensing 
        systems, as well as other health equity resources to help 
        grantees develop integrated strategies to support the social 
        and emotional wellness of children by highlighting promising 
        strategies used by CCDF grantees. See for example Kickoff: 
        Office of Child Care Initiative to Improve the Social-Emotional 
        Wellness of Children and A Resource Guide for Developing 
        Integrated Strategies to Support the Social and Emotional 
        Wellness of Children.
  --Our TA Center for the Preschool Development Grants, Birth to Five 
        (PDG B-5)--which supports early childhood systems development, 
        including child care--recently delivered a webinar on building 
        state capacity to consider equity in data collection, 
        specifically administrative data, to improve equitable access 
        and outcomes through data collection and analysis. The Center 
        also developed a research to practice brief that highlights 
        current research trends and implications for racial and ethnic 
        disparities related to early childhood, including policy 
        choices to reduce disparities and set children and families on 
        more favorable trajectories. TA website users have demonstrated 
        a strong interest in this equity content and it is among the 
        PDG B-5 TA Center's most popular links: https://
        childcareta.acf.hhs.gov/improving-equity-services.
  --In recognition of the disproportionate impact of the COVID-19 
        pandemic on indigenous communities, OCC has made a focused 
        effort over the last year to identify ways to support Tribal 
        CCDF programs' response and recovery. Understanding that 
        cultural connection is a strength and resiliency factor in 
        tribal children and families, the National Center on Tribal 
        Early Childhood Development (NCTECD) has developed a number of 
        resources to support grantees with culturally relevant quality 
        improvement activities, including resources focused on CCDF 
        quality requirements; ideas and innovations for quality 
        improvement activities that meet community needs; support with 
        planning, including prioritization and budgeting; and 
        developing clear and strong policies and procedures. See 
        https://childcareta.acf.hhs.gov/quality-improvement- resource-
        page.
    In addition, our TA providers regularly refer states and other TA 
recipients to resources published by national organizations (such as 
the Annie Casey Foundation and Child Trends) that center racial equity 
in the development and implementation of child care policies and 
practices. These resources are used in the provision of intensive/
individualized, targeted/group, and universal TA strategies depending 
on grantee need and readiness.
    Looking ahead, the Biden-Harris Administration's Build Back Better 
vision for early childhood would add substantial ongoing investments to 
early learning services and infrastructure and continue the momentum 
created by the American Rescue Plan Act--to benefit all children, 
families and providers--including in communities of color. The 
President's fiscal year 2022 Budget includes $250 billion over 10 years 
to make child care affordable and to modernize and expand child care 
facilities. High-quality early care and education opportunities lay a 
strong foundation so that children can take full advantage of education 
and training opportunities later in life. The President's Build Back 
Better invests in child care infrastructure and workforce training and 
ensures that low and middle-income families pay no more than 7 percent 
of their income on high-quality child care. The Build Back Better also 
proposes $200 billion for a national partnership with states to offer 
free, high-quality, accessible, and inclusive prekindergarten to all 
three- and four-year-olds. The proposed universal prekindergarten 
program is designed to give states incentives to build out their 
existing pre-k programs to reach more 3- and 4 -year-olds and to 
increase program quality by building on what has already been 
established in states. The Budget also proposes increased funding 
levels for existing early care and education programs, including nearly 
$11 billion for CCDF and a total of $11.9 billion for Head Start.
    Question. Title X is the only Federal program dedicated to 
providing family planning services for people who are paid low incomes. 
It disproportionately serves communities of color, where the pandemic 
has hit the hardest and exposed sharp disparities in access to care. 
Sadly, this critical program has been chronically underfunded for too 
long. The President's Budget proposes to increase the program by $54 
million, its first increase in nearly a decade. Yet, research shows 
Title X would need hundreds of millions more annually to provide family 
planning services to all women without insurance and who are paid low 
incomes in the United States.
    Please explain how HHS plans to use this increase to help increase 
access for women of color and women who are paid low incomes?
    Answer. HHS agrees the nation must take swift action to prevent and 
remedy stark racial and ethnic disparities in health and healthcare 
delivery in America, including advancing equity and reducing health 
disparities in all healthcare programs. As you noted, the budget 
provides a 19 percent increase to the Title X Family Planning program 
for a total of $340 million to support family planning services for 
approximately 3.5 million persons, with approximately 90 percent having 
family incomes at or below 200 percent of the Federal poverty level and 
a disproportionate number of clients served identify as a person of 
color. The Office of Population Affairs (OPA), part of the Office of 
the Assistant Secretary for Health (OASH), advises the HHS Secretary on 
a range of public health priorities including quality family planning 
and adolescent health and serves as a key stakeholder on HHS' effort to 
advance health equity.
    OPA administers the Title X family planning program, the only 
Federal program devoted solely to the provision of family planning and 
related preventive healthcare. By law, under the Title X program, 
priority is given to individuals from low-income families, which 
include many communities of color. On January 28, 2021, President Biden 
issued a ``Memorandum on Protecting Women's Health at Home and Abroad'' 
directing the Department to review the 2019 Title X Final Rule and 
``consider, as soon as practicable, whether to suspend, revise, or 
rescind, or publish for notice and comment proposed rules suspending, 
revising, or rescinding, those regulations, consistent with applicable 
law, including the Administrative Procedure Act.'' The memorandum 
specifically directed the Department to ensure that undue restrictions 
are not put on the use of Federal funds or on women's access to medical 
information. After reviewing the 2019 rule, the Department went through 
notice-and-comment rulemaking and finalized a regulation to revoke the 
2019 rules and restore the 2000s regulation that successfully guided 
the program for decades with several modifications needed to strengthen 
the program and ensure access to equitable, affordable, client-
centered, quality family planning services for all clients.
    Question. Chairman Pallone and I recently wrote a letter to 
interested parties requesting input on how best to write legislation 
establishing a public health insurance option. The objective is to 
create a strong Federal public option that makes healthcare more 
accessible, more affordable, and simpler for patients and families. In 
addition to policies like permanently extending the increased premium 
tax credits in the American Rescue Plan, a public option would go a 
long way towards ensuring every person has quality, affordable coverage 
regardless of income, age, race, disability, or zip code. We were 
pleased that the budget expressed the President's support for a public 
option available through the ACA marketplaces.
    How would a public option help expand coverage, bring down 
healthcare costs, and make healthcare easier to access for patients and 
families?
    Answer. The President supports providing Americans with additional, 
lower-cost coverage choices by creating a public option that would be 
available through the ACA marketplaces and giving people age 60 and 
older the option to enroll in the Medicare program with the same 
premiums and benefits as current beneficiaries, but with financing 
separate from the Medicare Trust Fund. . President Biden has been clear 
that his goals for improving the American healthcare system begin with 
building on the successes of the Affordable Care Act, and HHS is 
committed to working toward that goal.
    Question. The Affordable Care Act (ACA) authorized $30 million for 
Consumer Assistance Programs (CAPs) to provide a dedicated Federal 
funding stream to help health insurance consumers effectively steer 
their way through our nation's complex health insurance system and to 
avail themselves of new consumer protections in the ACA. In 2010, HHS 
awarded nearly $30 million in CAP grants to 40 states, territories, and 
the District of Columbia. Regrettably, efforts to overturn and then 
weaken the ACA resulted in blocking additional funding after the first 
year. Many states--including New York, Massachusetts, Maine, 
Connecticut, Rhode Island, Vermont, the District of Columbia, Maryland 
and more--maintained CAPs with limited state funds, but others closed 
altogether for lack of funding. These programs help consumers 
understand and use their insurance plans, resolve medical billing 
problems, and appeal insurance denials. As the Biden Administration 
joins Congress to provide support to individuals who are underinsured 
or who have lost their jobs and healthcare coverage due to the economic 
downturn caused by the COVID-19 pandemic, assistance is needed to help 
consumers navigate and understand their healthcare options.
    Does the Administration support the resumption of the ACA CAP 
programs to sufficiently meet the demand for such assistance?
    How does the Administration plan to prioritize the provision of 
services provided in the CAP programs to people across the nation?
    Answer. HHS is committed to using all available tools to strengthen 
the ACA Marketplaces, making it easier for people to get and keep 
health insurance, and making sure more Americans know about their 
options and are supported in their enrollment.
    Question. In December 2018, the bipartisan 21st Century IDEA (PL 
115-336) was signed into law. It requires agencies to modernize their 
websites, intranets and digitize their paper-based forms with the goal 
of improving the Federal Government's customer experience and digital 
service delivery. Since Congress passed the 21st Century IDEA, the 
nature of how individuals engage with the government has fundamentally 
changed--in large part because of the COVID- 19 pandemic. These changes 
underscore an even stronger need to implement the 21st Century IDEA and 
allow Federal agencies to deliver an excellent customer experience from 
anywhere, to anyone, on any device.
    Has CMS fully implemented the 21st Century IDEA Act (Public Law No: 
115-336)? What barriers has CMS faced in implementing this law and 
modernizing its digital services?
    The law required each executive agency to digitize and ensure any 
paper- based form was made available to the public in a fully usable 
mobile friendly option. Where does CMS stand in ensuring its forms can 
be filled out and submitted electronically on all digital devices?
    Who is responsible inside CMS for ensuring the agency fully 
implements PL 115-336?
    Answer. CMS is committed to making sure beneficiaries, enrollees, 
providers, and other stakeholders have access to the information they 
need to make important decisions about their healthcare. The 21st 
Century IDEA provided CMS with valuable resources and guidance that 
bolstered its ongoing efforts to modernize its websites. CMS has 
implemented the 21st Century IDEA for all of its public websites, and 
many CMS forms are available for beneficiaries, enrollees, providers, 
and other stakeholders to fill out and submit online. The CMS Office of 
Communications continues to make updates that make it easier to access 
and submit these forms from a mobile device.
    Question. HRSA's C.W. Bill Young Cell Transplantation Program, 
along with its nonprofit partner the National Marrow Donor Program 
(NMDP), provides support and access for patients who need lifesaving 
bone marrow transplants. The President's budget request proposes to 
combine the Cell Transplantation/National Registry Program with the 
National Cord Blood Inventory (NCBI) Program. It also appears to 
request an increase of $7 million for the Cell Transplantation/National 
Registry Program.
    Please provide greater detail than what was included in the HRSA 
Congressional Justification (CJ) on the proposed consolidation and how 
HHS plans to spend the proposed increase.
    Answer. In fiscal year 2022, HHS will use approximately $49.2 
million in consolidated funds from the C.W. Bill Young Cell 
Transplantation Program (CWBYCTP) and the National Cord Blood Inventory 
(NCBI) to support the common legislative and therapeutic functions of 
both programs (i.e. bone marrow functions, cord blood functions, single 
point of searching access, stem cell therapeutic outcomes database, and 
patient advocacy) outlined in the TRANSPLANT ACT of 2021.
    In fiscal year 2022, HHS expects to award approximately $10 million 
to licensed cord blood banks to continue banking high-quality, diverse 
cord blood units. HHS also plans to provide approximately $7 million to 
examine ways to optimize cord blood utilization. The remaining $32.2 
million will support the five legislative functions described above 
through one or more contracts. HHS will obligate these funds primarily 
for contract-supported initiatives (i.e. adult donor recruitment and 
tissue typing, searches for stem cell sources through a single point of 
electronic access, patient education, case management, donor advocacy, 
public outreach, professional development, and data collection). HHS 
will use a small portion for administrative costs.
    Question. In addition, this Committee provided increases for this 
program in both fiscal year 2200 and fiscal year 2021, yet the CJ 
includes little detail on how HRSA plans to use these resources. Please 
provide execution detail for each of these fiscal year increases and 
the total amount that was obligated and applied to HRSA's partners who 
run the program.
    Answer. In fiscal year 2020, HRSA provided an increase in funding 
to support new and existing activities under the Single Point of 
Access-Coordinating Center contract. The activities for the Office of 
Patient Advocacy and Stem Cell Therapeutic Outcomes Database contracts 
remained unchanged. The funding provided for each CWBYCTP contractor is 
outlined below:
  --National Marrow Donor Program--
    --Single Point of Access-Coordinating Center (SPA-CC)--$21.8 
            million used to support the SPA-CC contract, which carries 
            out three legislative functions (i.e., bone marrow, cord 
            blood, single point of access);
      -- This funding included an additional $5.4 million, which 
            increased existing support for adult donor recruitment and 
            tissue typing; high-resolution tissue typing of cord blood 
            units and collaboration with cord blood banks to enhance 
            cord blood operations. The funding also supported new 
            activities under the contract, including: cytomegalovirus 
            testing of adult donors; COVID-19 related increases 
            including donor and courier costs; and cryopreservation of 
            blood stem cell products.
    --Office of Patient Advocacy (OPA)--$877,000 used to support the 
            Office of Patient Advocacy; and
  --Medical College of Wisconsin's Center for International Blood and 
        Marrow Transplant Research--
    --Stem Cell Therapeutic Outcomes Database--$4.6 million used to 
            collect outcomes data on blood stem cell transplants using 
            bone marrow and cord blood.
    In fiscal year 2021, HRSA plans to fund existing and enhanced 
activities carried out by the following CWBYCTP contractors:
  --Single Point of Access-Coordinating Center (SPA-CC)--$29.8 million 
        used to support the SPA-CC contract.
  --HHS will fund many of the same activities, including adult donor 
        recruitment and tissue typing, high-resolution tissue typing of 
        cord blood units, and collaboration with cord blood banks. 
        Also, HHS will fund donor advocacy and contingency planning 
        activities.
    --The additional $7 million will support existing NCBI cord blood 
            banks; raise physician awareness of all cellular therapy 
            treatment options, including cord blood; and support 
            engagement with the cord blood community.
  --Office of Patient Advocacy (OPA)--$903,000 used to support the 
        patient advocacy and case management. The scope for this 
        contract has not increased in recent years.
  --Stem Cell Therapeutic Outcomes Database--$4.7 million used to 
        collect outcomes data on blood stem cell transplants using bone 
        marrow and cord blood. The scope for this contract has not 
        increased in recent years.
    Question. The Committee included language in the fiscal year 2021 
Conference Agreement that encouraged HHS to ``review the accreditation 
and eligibility requirements for the Public Health Service Corps and 
behavioral health workforce programs to allow access to the best 
qualified applicants, including those who graduate from Psychological 
Clinical Science Accreditation System (PCSAS) programs''. This review 
and these changes are necessary to update Department policy that was 
adopted prior to the establishment of PCSAS to permit the graduates of 
the current 44 PCSAS University accredited doctoral programs in 
psychological clinical science to be eligible to compete.
    Please provide an update on progress to update these Department 
policy and regulation.
    Answer. As of December 2020, the Public Health Service Commissioned 
Corps includes the Psychological Clinical Science Accreditation System 
programs in the Category Specific Appointment Standards. This means 
that individuals with such accreditation are permitted into the Corps.
    HRSA is currently exploring options to include PCSAS doctoral 
programs as eligible entities in the upcoming fiscal year 2022 Graduate 
Psychology Education competition. HRSA will continue to explore options 
to include such programs in other future competitions, including, but 
not limited to, the Behavioral Health Workforce Education and Training 
program, and the Geriatric Academic Career Awards. HRSA currently 
anticipates posting the Notice of Funding Opportunity for the Graduate 
Psychology Education program in November 2021.
    Question. The Centers for Medicare & Medicaid Services (CMS) posted 
a final rule for Medicare's radiation oncology alternative payment 
model (RO APM) on September 18, 2020. Implementation of the model has 
been delayed by Congress until January 2022.
    Is the Biden Administration reviewing and planning to issue an 
updated RO APM?
    Will HHS commit to working with both Congress and stakeholders to 
improve the RO APM and ensure that a transition to new value-based 
models does not result in reduced patient access to innovative cancer 
treatments?
    Answer. Since 2014, CMS has explored potential ways to test an 
episode-based payment model for radiotherapy (RT) services. In December 
2015, Congress passed the Patient Access and Medicare Protection Act, 
which required the Secretary of Health and Human Services to submit to 
Congress a report on ``the development of an episodic alternative 
payment model'' for RT services. The report was published in 2017 and 
identified three key reasons why RT is ready for payment and service 
delivery reform: the lack of site neutrality for payments; incentives 
that encourage volume of services over the value of services; and 
coding and payment challenges.
    The Radiation Oncology (RO) Model, implemented through the CMS 
Innovation Center, aims to improve the quality of care for cancer 
patients receiving RT and move toward a simplified and predictable 
payment system. The RO Model tests whether prospective, site neutral, 
modality agnostic, episode-based payments to physician group practices, 
hospital outpatient departments, and freestanding radiation therapy 
centers for RT episodes of care reduces Medicare expenditures while 
preserving or enhancing the quality of care for Medicare beneficiaries. 
I am happy to work with Congress and other stakeholders to address any 
concerns about this model.
    The Consolidated Appropriations Act, 2021 enacted on December 27, 
2020 included a provision that prohibits implementation of the 
Radiation Oncology Model prior to January 1, 2022, effectively delaying 
the start date by at least 6 months. CMS intends to address the delay 
and make other modifications to the RO Model through notice and comment 
rulemaking.
    Question. Analysis of CDC data and other reports indicate a 
reduction in routinely recommended vaccination of children and youth 
last year resulting from the disruption to routine healthcare caused by 
the COVID-19 pandemic. Lack of proper vaccinations could provide an 
additional challenge to the return to in-person learning in the fall.
    How is HHS working with the Department of Education to support the 
vaccination of children and youth needed for school enrollment for in-
person learning?
    Answer. CDC issued a Call to Action in April 2021 encouraging 
healthcare providers to identify and follow up with families whose 
children have missed doses, and to schedule appointments for those 
children. CDC encouraged schools and state and local government 
agencies to use the state's immunization information system's reminder-
recall capacity to notify families whose children have fallen behind on 
routine vaccines and encourage compliance with vaccination 
requirements. In June 2021, CDC issued an MMWR article describing the 
decrease in routine childhood and adolescent immunizations in 10 U.S. 
jurisdictions during March-September 2020 as compared with the same 
period in 2018 and in 2019.
                                 ______
                                 
            Questions Submitted by Senator Richard J. Durbin
    Question. Secretary Becerra, the budget proposes $767 billion for 
Medicare. One of the greatest drivers of outlays by the Medicare 
program is the cost of chronic conditions, including tobacco-related 
costs. By some estimates, 10 percent of Medicare spending is 
attributable to smoking and the health harms it causes. So it would 
seem that the Department would want to be doing everything it can to 
prevent tobacco use, especially among youth. As you know, youth e-
cigarette use has skyrocketed over the past decade. Four million kids 
are now vaping--one in every five high school students.
    And for years, the Federal Government failed to regulate these 
addictive, kid-friendly products. Nine months ago, e-cigarette 
companies were required to submit applications to the FDA in order to 
stay on the market. This is a momentous time for the FDA, as it will 
evaluate whether these e-cigarettes are ``appropriate for the 
protection of public health.'' That is a high bar. But the FDA's 
priority should be protecting our youth and preventing a lifetime of 
addiction. I am deeply concerned that the FDA will let a product such 
as JUUL--which has partnered with Marlboro-maker Altria and had a 
years-long documented campaign of hooking our kids on nicotine--to 
remain on the market. In particular, I am worried that FDA will allow 
flavored products--which we know are meant to target kids--to 
proliferate.
    Can you commit to me that HHS and FDA will not authorize any vaping 
products that will lead to more youth use, including flavored products?
    Answer. FDA has a very important responsibility to review new 
tobacco products before they can be legally marketed. FDA determines if 
a new tobacco product may be legally marketed by assessing whether the 
marketing of the product meets the applicable standard Congress set in 
the law to protect the public health.
    As required by statute, a key consideration in our review of 
premarket tobacco product applications submitted for products like e-
cigarettes is to determine whether permitting the marketing of the 
product would be ``appropriate for the protection of the public 
health,'' taking into account the risks and benefits to the population 
as a whole. This determination includes consideration of how the 
products may impact youth use of tobacco products and the potential for 
the products to completely move adult smokers away from use of 
combustible cigarettes. Importantly, we know that flavored tobacco 
products are very appealing to young people. Therefore, assessing the 
impact of potential or actual youth use is a critical factor in our 
determination as to whether the statutory standard for marketing is 
met.
    Looking forward, FDA continues to work expeditiously to complete 
review of the remaining pending applications. While the Agency cannot 
prejudge applications or categorically deny marketing authorization 
based on certain characteristics, such as flavors, be assured that HHS 
and FDA share your concern about youth initiation and use of tobacco 
products, and we will continue to keep you updated as reviews continue.
    Question. Two decades ago, a CDC study came out that changed the 
way we think about public health. It was called the Adverse Childhood 
Experiences or ``ACEs'' study, and it established the link between 
exposure to trauma--things like witnessing violence or an overdose--and 
our long-term health, education, and economic outlook. We now 
understand how trauma and ACEs harm brain development, and how these 
emotional scars can lead to lower life expectancy, and a higher 
likelihood of suicide or drug use.
    When you look at the public health crisis of gun violence--along 
with the mental health and addiction--it's clear we must focus on the 
root issue of trauma. So Senator Capito and I teamed up in 2018 to pass 
legislation that created an ACEs program at CDC, and I am pleased to 
have secured $10 million over the past 2 years for this work. We also 
passed provisions creating the Interagency Task Force on Trauma-
Informed Care that brings our Federal agencies around the table to 
promote this understanding of trauma in every Federal grant program, 
increasing the authorization for the National Child Traumatic Stress 
Network, and authorizing a $50 million trauma and mental health 
services grant program for schools, which we have not yet been able to 
fund. This grant program--Section 7134 of the SUPPORT for Families and 
Communities Act--would assist schools in adopting trauma-informed 
practices, training more staff, engaging families, and forging 
partnerships with clinical mental health professionals.
    Now, the 2022 budget proposes a $61 million increase to SAMHSA's 
Project AWARE mental health funding, and a $100 million investment at 
CDC in community-based violence interventions, working with 
neighborhood organizations and hospitals to deliver services. Chicago 
is home to many of these programs--including street outreach efforts, 
trauma programming in schools, and hospital programs that pair victims 
of violence with social workers to address their trauma and reduce the 
current 50 percent re-injury rate.
    Secretary Becerra, can you explain how this new CDC community-
violence proposal can support programs like those in Chicago, and how 
you envision this constellation of programs working together?
    Secretary Becerra, in addition to, or as part of, the proposed 
increase to Project AWARE, would you also support appropriations for 
this already-authorized Sec. 7132 program to address the breadth of 
trauma needs in schools--setting up comprehensive plans, trainings, and 
partnerships?
    Answer. The Community Violence Initiative (CVI) proposal would help 
CDC address the root causes of community violence and support systemic 
approaches to violence prevention. CDC would prioritize implementing 
evidence-based, community strategies to reduce rates of violence; 
expand our prevention data surveillance, conduct research to address 
critical gaps; and enhance what is known about what works to prevent 
community violence. This approach includes prevention strategies that 
address the structural determinants of health that contribute to 
violence inequities within and across communities, such as those 
currently implemented in Chicago. In addition, Hospital-Community 
Partnerships, such as HEAL, represent an important type of strategy to 
prevent and reduce community violence and could be supported under the 
proposed Community Violence Initiative.
    A comprehensive approach is critically important to achieving and 
sustaining long-term reductions in community violence. A strong and 
growing research base demonstrates that there are multiple prevention 
strategies that are scientifically proven to reduce violence 
victimization and perpetration. Many of these strategies are upstream 
approaches that have yielded community savings that far outweigh 
implementation costs. These upstream approaches, coupled with programs 
like hospital-community partnerships, can create safe, healthier, and 
more resilient communities.
    In addition to funding 25 cities with the highest overall number of 
homicides and the 25 cities with the highest number of homicides per 
capita, the CVI proposal would also fund up to five non-governmental 
organizations that have expertise in partnering with communities most 
impacted by community violence. Doing so will build a network of 
violence prevention efforts, from local health departments to community 
organizations. The CVI proposal will also help modernize data systems 
like the National Violent Death Reporting System (NVDRS) to provide 
more timely data on causes of violence in communities.
    SAMHSA is also committed to effective school based mental health 
services that address the needs of children and families. Project AWARE 
grantees have established mechanisms to provide tiered services in 
school settings. This tiered system has three main components. One pays 
attention to the overall school climate and promotes social and 
emotional learning opportunities and supports for all children. The 
next tier has special programming for children at risk for the 
development of behavioral health conditions. The third and final tier 
is comprehensive services for children and their family with serious 
emotional disturbance (SED). A comprehensive approach to behavioral 
healthcare in schools is critical to build resilience in our children 
and youth include building trauma-informed school systems and providing 
training and community partnerships in trauma-informed care. Building 
in trauma-informed care to AWARE projects and augment that work with 
additional partnerships to address the breadth of need in schools is 
critical to meet the mental health needs of our children and youth.
    Several programs funded by HRSA are focused on measuring and 
addressing the impact of ACEs, as well as providing trauma-informed 
care in schools.
      national coordinating committee on school health and safety
    HRSA in collaboration with CDC leads the National Coordinating 
Committee on School Health and Safety (NCCSHS) to support student well-
being and ensure school facilities are healthy and safe environments. 
Since its inception in 1996, NCCSHS aims to support communication among 
governmental agencies and national non-governmental organizations in 
order to share resources and disseminate information about school 
health and safety to local and state partners. NCCSHS members are 
working to coordinate communication and encourage uptake at the state/
local levels of school-based approaches that protect student's mental 
health and well-being through expanding comprehensive, trauma-informed 
mental health services in schools and the Whole School, Whole 
Community, Whole Child model (WSCC). NCCSHS includes 170 members 
including eight Federal agencies and non-governmental organizations 
such as the American Academy of Pediatrics, American Psychological 
Association, and Council of Chief State School Officers.
   collaborative improvement and innovation network for school-based 
                            health services
    The Collaborative Improvement and Innovation Network for School-
Based Health Services (CoIIN-SBHS) provides trauma-informed, behavioral 
health technical assistance to state partners (e.g., Title V Maternal 
and Child Health programs, state Medicaid programs, child mental health 
agencies, education agencies, state-level non-profit organizations), 
school districts, comprehensive school mental health systems and 
school- based health centers. This program is in its fifth of 5 years 
of funding and is administered by the School Based Health Alliance in 
partnership with the National Center for School Mental Health.
     adverse childhood experiences (aces) in primary care settings 
                         demonstration project
    The newly awarded Adverse Childhood Experiences (ACEs) in Primary 
Care Settings Demonstration Project will study how best to implement, 
in primary care settings, screening protocols and evidence-based 
interventions for children and adolescents who have experienced ACEs. 
The goal of this program is to yield a model for integrating ACEs 
screening and strength-based, trauma-informed services into primary 
care settings. This three-year demonstration project aims to:
  --Study how primary care settings can best screen and provide care to 
        children impacted by ACEs, including strengths, limitations, 
        and implementation challenges; and
  --Produce a scalable model that can help pediatric providers 
        effectively integrate screening with strength-based, trauma-
        informed care and services in primary care settings.
National Survey of Children's Health:
    The National Survey of Children's Health (NSCH), funded and 
directed by HRSA's Maternal and Child Health Bureau, is the nation's 
largest annual survey of children's health at the state and national 
levels.
    This parent-reported survey includes questions to assess a range of 
Adverse Childhood Experiences (ACEs) among U.S. children.
    Data from 2019-2020, show that 21.7 percent of U.S. children ages 
0-17 had experienced one ACE in their lifetime, while 18.1 percent had 
experienced two or more ACEs. Data from the 2021 NSCH will be released 
on October 3rd, 2022.
    Question. Secretary Becerra, the United States is world's largest 
importer of personal protective equipment. Three-quarters of N95 masks 
in the U.S. are produced overseas, the majority from China. And from 
2019 to 2020, American imports of PPE from China skyrocketed from $2 
billion to $14 billion. This created shortages and price spikes--
resulting in those horrific images of our health heroes wearing garbage 
bags to stay safe. 80 percent of nurses reported re-using masks meant 
for single use. When it came to our prized Federal backstop--the 
Strategic National Stockpile--the supply was inadequate. 5 million N95 
masks in the Stockpile were expired. Governors only got a fraction of 
the masks, gowns, and gloves they asked for.
    Senator Cassidy and I have introduced the PPE in America Act to 
boost domestic manufacturing of PPE and medical supplies so we no 
longer have to rely on China and others to keep our health workers 
safe. Our bill would use the purchasing power of the Stockpile as an 
engine to sustain domestic PPE manufacturers. And it would enable a 
replenishable, churning mechanism for the Stockpile to routinely sell 
supplies to other agencies, states, and the commercial market . . . and 
re-stock equipment from domestic producers. This arrangement will 
provide predictability that domestic PPE manufacturers can depend on . 
. . and will improve their coordination with the Stockpile to avoid 
expiration of supplies.
    Secretary Becerra, I'm pleased to see the budget proposes a $200 
million increase for the Stockpile. Do you support policies that boost 
domestic PPE production, mitigate risk for expiration, and provide 
sustainability for manufacturers, including through replenishing 
mechanisms for the SNS?
    Answer. The global pandemic has highlighted the vulnerabilities of 
the global supply chain. It is critical that steps are taken to invest 
in expansion of U.S. domestic manufacturing capacity. To that end, the 
Office of the Assistant Secretary for Preparedness and Response (ASPR) 
is leveraging the authorities delegated to the Secretary under the 
Defense Production Act (DPA) to ensure that private sector partners 
making life-saving products are able to acquire raw materials, retool 
their machinery, scale their production facilities, train their 
workforces, and ultimately deliver their product. Throughout the COVID-
19 response, ASPR has used the DPA authority to issue 46 priority 
ratings for United States Government (USG) contracts for health 
resources, eight priority ratings for USG contracts for industrial 
expansion, and 3 priority ratings for non-USG contracts to indirectly 
support COVID-19 and/or mitigate the potential stockout of critical 
lifesaving therapies. Going forward, ASPR will continue to build 
capacity and partnerships with private industry toward the shared goal 
of ending the COVID-19 pandemic and preparing for future pandemics.
    ASPR is also working to support efforts in expanding the domestic 
industrial base. These industrial base expansion (IBx) efforts seek to 
reduce supply chain vulnerabilities and generate a domestic ``warm-
base'' for manufacturing that can be leveraged in a crisis. During the 
COVID-19 pandemic, all contracts--competitive and sole-sourced--awarded 
by the Department of Health and Human Services for N95 respirators were 
for U.S.-produced supplies. A total of approximately 800 million 
domestically produced N95 respirators were procured for the Strategic 
National Stockpile. Contracting actions executed in March 2020 were 
intended to encourage manufacturers to immediately increase production 
of N95 respirators, and these manufacturers with domestic production 
capabilities stepped up to support the nation with quality products at 
the best prices for the USG. Furthermore, with $10 billion received for 
emergency medical supplies enhancement, ASPR has been establishing and 
maintaining domestic capacity for critical supplies.
    Lastly, ASPR's Hospital Preparedness Program (HPP) included two 
requirements in the fiscal year 2019-2023 funding opportunity 
announcement to help address supply chain vulnerabilities. First, HPP 
recipients and their healthcare coalitions must conduct a supply chain 
integrity assessment to evaluate equipment and supplies that will be in 
demand during emergencies and develop mitigation strategies to address 
potential shortfalls. Second, each healthcare coalition must update and 
maintain a regional resource inventory assessment.
    ASPR will continue to assess and monitor domestic manufacturing 
capabilities going forward. As the COVID-19 pandemic continues, we will 
modify and refine efforts, as needed, to ensure they do not interfere 
with the private sector but support efforts to maintain and build a 
robust domestic capability.
    Question. One of the major lessons learned from the pandemic was 
the need to bolster our healthcare workforce. But this is not a new 
problem. Even before COVID-19, our nation faced a shortfall of 120,000 
doctors and a quarter-million nurses, with many rural and urban areas 
facing recruitment challenges. Across Illinois, 5 million people live 
in shortage areas for mental health providers, 3 million with too few 
primary care doctors. The problem starts with medical education in 
America. We take promising students, put them through years of rigorous 
education and training, and license them on one condition: student loan 
debt that can average more than $200,000. The burden of paying off 
these loans steers our brightest minds into higher- paying specialties 
and more affluent communities. This is especially true for healthcare 
providers of color. You may be aware there are fewer Black men entering 
medical school today than there were in the 1970s. Black and Latinx 
Americans make up 31 percent of the nation's population, yet just 6 
percent of doctors. We know that this discrepancy leads to worse care 
and outcomes for patients of color.
    Thankfully, the National Health Service Corps helps to address 
these gaps by providing scholarship or loan repayment for healthcare 
workers who commit to serve in urban and rural areas with shortages. 
President Biden's American Rescue Plan included a provision I authored 
with Senator Rubio to provide $1 billion in loan repayment and new 
scholarship awards to the National Health Service and Nurse Corps. It 
will help surge tens of thousands of new clinicians into under-served 
areas, representing the largest single-year appropriation to our 
healthcare pipeline in history. We know that scholarship-based awards 
can make a particularly meaningful difference when it comes to 
emphasizing recruitment from under-represented populations.
    The pandemic has also magnified acute workforce shortages in 
communities facing natural disasters or other public health 
emergencies. The GAO has recently reported on how the National Disaster 
Medical Service--which activates health personnel from private 
practices for deployment intermittent Federal employees--does not have 
the planning in place to ensure a workforce capable of responding to 
nationwide or multiple concurrent health events, and that its workforce 
is only a fraction of its target level. I have introduced legislation 
with Senator Rubio (S.54, the Strengthening America's Health Care 
Readiness Act), to test a pilot program that provides supplemental loan 
repayment for NHSC alumni who continue to practice in a shortage area, 
and current NHSC clinicians, who concurrently serve in the NDMS and are 
available for rapid, short-term deployment for health emergencies. 
Under this pilot program, HRSA and ASPR would have the authorities and 
directive to coordinate to ensure adherence to their core missions and 
the appropriate application of NHSC contract requirements and covered 
benefits/protections of NDMS employment. I have also introduced 
legislation with Senator Blackburn (S.924, Rural America Health Corps 
Act), to increase recruitment and retention of NHSC clinicians in rural 
areas, given the fact that only 5 percent of incoming medical students 
hail from rural areas and one-third of placements are in rural 
communities. This legislation would test a pilot program to explore 
whether an elongated service commitment and increased loan repayment 
award--5 years and $200,000--could enhance recruitment and retention in 
rural America.
    Secretary Becerra, your budget proposes a $47 million increase to 
the National Health Service Corps. Do you support using appropriations 
for certain pilot program approaches that test and evaluate new 
strategies to address specific nuances and acute gaps in our country's 
health workforce needs, including in health preparedness, health 
disparities, and in rural America?
    Answer. HRSA will implement the programs that Congress enacts. The 
aim of National Health Service Corps (NHSC) is to address the primary 
care needs of underserved populations and to provide them with access 
to quality healthcare. The $47 million request for the NHSC will be 
dedicated to bolstering the health workforce in rural and underserved 
communities where there is an existing shortage of primary care 
providers. Similar, in part, to the goals of the Rural America Health 
Corps Act, the proposed funding will expand access to primary care 
services to vulnerable populations, specifically those areas facing 
barriers to obtaining evidence-based substance use disorder (SUD) 
treatment services. The NHSC Rural Community Loan Repayment Program 
(LRP), SUD Workforce LRP, and the traditional NHSC LRP will serve as 
the mechanisms for distributing this requested funding, as these 
programs have proven their effectiveness in mobilizing and retaining 
providers in the areas where they are needed most. A total of 28,405 
clinicians in the NHSC and Nurse Corps completed their service between 
2012 and 2019; of these, 80 percent continue to serve in Health 
Professional Shortage Areas (HPSAs) after their service obligation is 
completed. One out of three of those NHSC alumni work in rural 
communities. Over the same timeframe, 78 percent of the NHSC 
participants who completed their service obligation at a site in a 
rural area continue to work in a rural area, with over 50 percent 
continuing to work in a HPSA in the same county where they completed 
their NHSC service.
    The Hospital Preparedness Program (HPP) supports efforts to 
strengthen healthcare sector readiness to provide coordinated, life-
saving care in the face of emergencies and disasters. The HPP portfolio 
supports a comprehensive, national network for healthcare preparedness 
and response. The programs and activities within the HPP portfolio are 
coordinated to address the many, complex facets of the nation's 
healthcare system, creating mechanisms and infrastructure to improve 
coordination between localities, states, and regions, as well as 
developing new capabilities (e.g., telemedicine, specialty healthcare, 
etc.) specific to key challenges within the modern threat landscape 
(e.g., highly pathogenic disease; biological/chemical incidents, etc.).
    As the primary source of Federal funding for healthcare system 
preparedness and response, HPP promotes a consistent national focus to 
improve patient outcomes during emergencies and to enable rapid 
healthcare service resilience and recovery. Since 2002, investments 
administered through HPP have improved individual healthcare entities' 
preparedness and have built a system for coordinated healthcare system 
readiness and response through healthcare coalitions (HCCs) and other 
partnerships, such as the Regional Disaster Health Response System 
(RDHRS) demonstration project. With respect to infrastructure needs, 
recipients of funding are expected to consider how to provide and plan 
for uninterrupted care when faced with damaged or disabled healthcare 
infrastructure during an emergency response; however, the HPP 
cooperative agreement does not allow for construction or major 
renovation costs.
    HPP provides cooperative agreement funding to states to support 
healthcare system preparedness efforts. Specific to Colorado, if 
appropriated at the requested level in fiscal year 2022, it is 
estimated that Colorado will receive $3,584,461 via the HPP cooperative 
agreement. Colorado will delegate this funding within the state to 
support such efforts, including enhancing rural capabilities.
  --Additional ASPR Programs and Tools Concerning Colorado and Rural 
        Health:
    --The Denver Health and Hospital Authority was also recently 
            awarded the Partnership for Disaster Health Response System 
            Cooperative Agreement to establish the Region 8 Mountain 
            Plains RDHRS demonstration site. To address gaps in 
            regional healthcare delivery during disasters, ASPR 
            developed the RDHRS: a tiered system that builds upon and 
            unifies existing healthcare and ASPR assets within states 
            and across regions that supports a more coherent, 
            comprehensive, and capable healthcare disaster response 
            system able to respond to health security threats. The 
            RDHRS helps improve disaster readiness capabilities and 
            capacity, increase medical surge capacity, and extend 
            provision specialty care--including trauma, burn and 
            infectious disease, among others--during large-scale 
            disasters or public health emergencies.
    --Additionally, the Rural Health Care Surge Readiness Portal was 
            established in 2020 to provide the most up-to-date and 
            critical resources for rural healthcare systems preparing 
            for and responding to a COVID-19 surge. The resources span 
            a wide range of healthcare settings (including EMS, 
            inpatient and hospital care, ambulatory care, and long-term 
            care) and cover a broad array of topics ranging from 
            behavioral health to healthcare operations to telehealth. 
            This portal was developed by the COVID-19 Healthcare 
            Resilience Working Group, a partnership with the U.S. 
            Department of Health & Human Services, the U.S. Department 
            of Homeland Security, and other Federal agencies, to 
            provide support and guidance for healthcare delivery and 
            workforce capacity and protection.
                                 ______
                                 
                Questions Submitted by Senator Jack Reed
    Question. My colleague on the LHHS Subcommittee, Sen. Capito, and I 
authored the Childhood Cancer Survivorship, Treatment, Access, and 
Research (STAR) Act--the most comprehensive childhood cancer bill in 
history--which was signed into law on June 5, 2018 (Public Law No: 115-
180). Every year since becoming law, Congress has provided full funding 
($30 million) to support the programs created by the STAR Act. However, 
two provisions remain to be implemented: Title 2, Section 201(a), which 
requires the Secretary of Health and Human Services to make awards to 
establish pilot programs to develop, study, or evaluate model systems 
for monitoring and caring for childhood cancer survivors throughout 
their lifespan, including evaluation of models for transition to adult 
care and care coordination; and Title 2, Section 201(b), which requires 
the Secretary to conduct a review of HHS activities related to 
workforce development for healthcare providers who treat pediatric 
cancer patients and survivors and to report the findings within 2 years 
of the enactment of the STAR Act.
    Could you provide a status update on the implementation of these 
two key provisions of the STAR Act?
    Answer. Senator Reed, first, thank your sponsorship of the 
Childhood, Cancer Survivorship, Treatment, and Research Act (STAR Act). 
The STAR Act enhances the research on the late effects of childhood 
cancers and is a critical step toward improving the quality of life for 
survivors of childhood cancer. The Agency for Healthcare Research and 
Quality (AHRQ) has partnered with the National Cancer Institute (NCI) 
to commission three evidence reports as part of the Department's 
response to the two provisions of the Act that you reference: Section 
201(a) and 201(b).
  --Disparities and Barriers to Pediatric Cancer Survivorship Care 
        (https://effectivehealthcare.ahrq.gov/products/pediatric-
        cancer-survivorship/research). The report was posted on the 
        AHRQ for public comment in October 2020, with simultaneous peer 
        review and the final report was published March 1, 2021.
    --Findings from the report were presented on April 20, 2021 on a 
            free NCI- sponsored webinar. The recording can be found at 
            https://cancercontrol.cancer.gov/ocs/events/disparities-
            and-barriers.
    --A manuscript titled ``Interventions to address disparities and 
            barriers to pediatric cancer survivorship care: a scoping 
            review'' derived from the report was published in the 
            Journal of Cancer Survivorship on June 16, 2021.
    --Findings from the technical brief were presented at University of 
            Cincinnati Hematology-Oncology Grand Rounds (5/28/2021); MD 
            Anderson Cancer Survivorship Grand Rounds (6/18/2021); 
            Cancer Support Community Seminar (7/27/2021); and the 
            University of Kentucky Markey Cancer Center Affiliate 
            Network's 15th Annual Cancer Care Conference (9/30/2021).
    The NCI used the findings of the report to provide administrative 
supplements for the ``NCI P30 Cancer Center Support Grants'' to support 
research to understand and address organizational factors that 
contribute to disparities in outcomes among childhood cancer survivors. 
Additionally, this report has already begun to inform the broader 
cancer survivorship research community and survivorship care providers 
based on dissemination of the review findings.
  --Models of Care That Include Primary Care for Adult Survivors of 
        Childhood Cancer (https://effectivehealthcare.ahrq.gov/
        products/pediatric-adolescent-cancer-survivorship/protocol). 
        This report was posted on the AHRQ website for four weeks of 
        public comment in June 2021, with simultaneous peer review. The 
        report is now being finalized. The final report is expected to 
        be shared with NCI and publicly posted by the end of 2021.
    AHRQ and NCI expect to widely disseminate this report to the 
        research community and the general public once it can be 
        publicly posted to raise awareness of the role that primary 
        care providers can play in the care of adult survivors of 
        childhood cancer. The NCI also plans to use the findings of 
        this report to evaluate its current grant portfolio, to 
        identify and assess potential gaps and opportunities for 
        additional research on this topic.
    Transitions of Care from Pediatric to Adult Services for Children 
        with Special Healthcare Needs (https://
        effectivehealthcare.ahrq.gov/products/transitions-care-
        pediatric-adult/protocol). The draft report was posted on 
        AHRQ's website in September 2021 for four weeks of public 
        comment and simultaneously underwent peer review. A final 
        report will be shared with NCI and posted publicly in 2022.
    Similar to the Models of Care report, AHRQ and NCI expect to widely 
        disseminate this report to the research community and the 
        general public once it can be publicly posted to raise 
        awareness of challenges in transitioning care from pediatric to 
        adult services for children with special healthcare needs. This 
        report is expected to serve as a resource for those with 
        interests related to a number of serious healthcare diseases 
        and conditions including cancer. The NCI also plans to use the 
        findings of this report to evaluate its current grant 
        portfolio, to identify and assess potential gaps and 
        opportunities for additional research on this topic.
                                 ______
                                 
             Questions Submitted by Senator Jeanne Shaheen
    Question. While I am pleased that we've made so much progress on 
vaccinations and getting through this pandemic, I continue to hear from 
hospitals and nursing homes in New Hampshire that are running on tight 
budgets after significant financial losses due to the pandemic. In 
particular, many of these hospitals and nursing homes are located in 
southern New Hampshire counties that were left behind in previous 
rounds of the Provider Relief Fund. These providers did not qualify for 
previous rural-focused rounds of the grants, despite treating 
significant portions of patients from surrounding counties that are 
rural. To help address that, we worked to give HHS more flexibility to 
make these types of hospitals and nursing homes eligible for the $8.5 
billion in Provider Relief Fund grants from the American Rescue Plan 
Act of 2021.
    Do you have an update that you can share on the plans that HHS has 
for the remaining Provider Relief Fund grants that have not yet been 
awarded?
    Answer. HHS is committed to distributing the remaining provider 
relief payments as quickly, transparently, and equitably as possible 
while utilizing effective safeguards to protect taxpayer dollars. HHS 
is planning for future Provider Relief Fund (PRF) allocations, 
including the $8.5 billion from American Rescue Plan Act and Phase 4 of 
the General Distribution.
    HHS is actively considering feedback from stakeholders, as well as 
operational lessons learned from prior PRF payments, as part of the 
planning process. The feedback from Members of Congress and other 
stakeholders informs HHS' ability to administer the PRF in a manner 
that bolsters the healthcare system and helps providers experiencing 
COVID-related financial hardships during this crisis. HHS will publish 
additional information on future distributions on the Health Resources 
and Services Administration's PRF webpage, at www.hrsa.gov/provider- 
relief, as soon as it becomes available.
    Question. I am pleased that the President has announced his 
intention to resettle 62,500 refugees in the second half of this fiscal 
year. However, the enormous cuts to refugee resettlement over the past 
4 years under the previous Administration have severely decimated the 
U.S. Refugee Admissions Program's capacity to provide local support for 
newly arrived refugees. Local resettlement agencies face substantial 
challenges as they work to restore their staffing and the services they 
provide, and they need timely support in order to hire and train the 
new staff necessary to meet the needs of increased numbers of newly-
arrived refuges.
    What specific measures are you taking to help resettlement agencies 
bolster capacity and prepare for the increased rate of refugee arrivals 
in the second half of this fiscal year?
    Answer. The President's fiscal year 2022 budget request includes an 
increase of $515 million over the fiscal year 2021 enacted level for 
Refugee and Entrant Assistance programs to accommodate the expected 
increase in arrivals through the end of this calendar year and beyond. 
This request would support a total of up to approximately 214,000 
arrivals in fiscal year 2022, including up to 125,000 refugees as well 
as other entrants, such as asylees, Cuban and Haitian entrants, and 
Special Immigrant Visa holders.
    This includes more than doubling the Refugee Support Services 
program, from $207 million in fiscal year 2021 to $450 million in the 
fiscal year 2022 Budget. This is one of the major sources of funding 
for resettlement agencies to bolster their capacity.
    In addition to the potential budgetary support, ORR has taken 
several programmatic steps to ensure that the resettlement network is 
prepared for an increase in refugee and other ORR-eligible arrivals. 
ORR conducted listening sessions in the spring of 2021 to better 
understand current state and local capacity to resettle refugees, plans 
to increase resettlement capacity, and barriers to such growth. ORR and 
the Department of State/PRM conducted a joint training for State 
Refugee Coordinators to ensure understanding of their role in local 
capacity planning.
    ORR and PRM are exploring options to strengthen policy and practice 
for the required community consultations, as well as private 
sponsorship. ORR staff are conducting coordinated outreach with other 
Federal agencies to ensure access to mainstream benefits and services. 
We are also planning for enhancements to existing services such as 
mental health, employer engagement, youth and family literacy, 
Preferred Communities and Matching Grant in anticipation of increased 
arrivals.
    Question. Does ORR anticipate being able to provide forward funding 
to refugee resettlement agencies, so they have the advance funding 
necessary to build capacity in anticipation of the increased rate of 
refugee arrivals?
    Answer. ORR continues to provide support and guidance to its 
partners and anticipates being able to provide sufficient forward 
funding through the President's fiscal year 2022 budget request.
                                 ______
                                 
              Questions Submitted by Senator Brian Schatz
    Question. In the hearing, you agreed that Congress should move 
forward with legislation to expand telehealth coverage in Medicare and 
committed that you would work with Congress to provide the necessary 
data and technical assistance to enact telehealth legislation this 
year. You also stated that you need ``greater accountability'' and 
``better authority.''
    What authority to ensure accountability and put safeguards into 
place for telehealth services does HHS need that it does not already 
have?
    What measures to ensure accountability does HHS plan to put into 
place when Congress expands coverage of telehealth services?
    What has the HHS Office of Inspector General determined about 
concerns related to fraud, waste, and abuse associated with expanded 
utilization of telehealth during the COVID-19 pandemic?
    Last July, ASPE released early data on Medicare beneficiary use of 
telehealth. Is HHS planning to release additional data on the use of 
telehealth in Medicare during the pandemic?
    What is the expected timeframe on the study that CMS has 
commissioned on the telehealth flexibilities during the COVID-19 
pandemic?
    What Center for Medicare and Medicaid Innovation (CMMI) models 
include telehealth waivers, and what are those waivers for? For each 
waiver, please specify how many model participants have elected the 
waiver and how many beneficiaries have used telehealth services under 
the waiver.
    In which CMMI models have waivers enabled healthcare professionals 
other than physicians and practitioners to furnish telehealth services, 
and how many participants have used those waivers?
    A 2018 OIG report recommended that CMS offer education and training 
sessions to practitioners on Medicare telehealth requirements. How has 
CMS addressed this recommendation?
    Answer. Telehealth is an important tool to improve health equity 
and improve access to healthcare. Healthcare should be accessible, no 
matter where you live. HHS continues to examine the telehealth 
flexibilities developed for the current public health emergency and 
determine how we can build on this work to improve health equity and 
improve access to healthcare. An HHS study released by ASPE has shown 
that massive increases in the use of telehealth helped maintain some 
healthcare access for Medicare beneficiaries during the pandemic. CMS 
also released a data snapshot showing increases in Medicare 
telemedicine utilization during the pandemic. Lessons learned from CMS 
Innovation Center models also provide valuable insight into how 
providers furnish high-value care and innovate in care delivery, 
including the use of telehealth. In addition to looking at which 
flexibilities HHS can and should continue administratively, I look 
forward to working with Congress to address changes that may need to be 
done through legislation.
    HHS is also dedicated to making sure providers are aware of the 
telehealth options available to them as they treat their patients. CMS 
routinely educates practitioners through various channels, including 
the Medicare Learning Network, weekly electronic newsletters, and 
quarterly compliance newsletters. CMS will continue to use channels 
such as these to educate and provide training sessions for 
practitioners on Medicare telehealth requirements and related 
resources.
    ASPE/HHS is currently preparing a follow-up issue brief on Medicare 
FFS beneficiary use of telehealth compared with in-person visit trends 
in 2020 which will examine telehealth use by beneficiary 
characteristics including race/ethnicity, urban/rural geography, state, 
visit type (primary care, specialist, mental health. The brief will 
also examine various telehealth modalities, including audio-only 
visits, telecommunications in addition to two-way interactive video-
based telehealth visits and whether the beneficiary was located at home 
or in a health-care setting for the telehealth visit. This issue brief 
is anticipated to be published later this fall.
    OIG is conducting significant oversight work (8 ongoing audits and 
studies) assessing telehealth services during the public health 
emergency. Once complete, these reviews will provide objective, 
independent findings and recommendations to policymakers and other 
stakeholders regarding the effect that the public health emergency 
flexibilities had on telehealth. This work will help HHS ensure the 
potential benefits of telehealth are realized for patients, providers, 
and HHS programs without being compromised my fraud, abuse, or misuse. 
OIG anticipates the first telehealth work products to be published this 
fall.
    Question. The Bipartisan Budget Act of 2018 authorized Medicare 
Advantage plans to offer additional telehealth benefits in their annual 
bid amount beyond eligible telehealth services under Medicare fee-for-
service.
    What percentage of plans have offered additional telehealth 
benefits?
    What type of additional telehealth benefits have been offered 
(i.e., types of services, types of healthcare professionals, etc.)?
    Has HHS determined if there are any concerns related to fraud, 
waste, and abuse associated with additional telehealth benefits in 
Medicare Advantage plans?
    Answer. Beginning in plan year 2020, Medicare Advantage plans have 
been permitted, but not required, to offer additional telehealth 
benefits as part of the basic benefit package beyond what is allowable 
under the original Medicare telehealth benefit. These benefits can be 
available in a variety of places, and people with Medicare Advantage 
plans can use them at home instead of going to a healthcare facility. 
For plan year 2021, over 94 percent of Medicare Advantage plans offered 
additional telehealth benefits reaching 20.7 million beneficiaries.
    Medicare Advantage plans have the flexibility to determine which 
services are clinically appropriate to furnish through additional 
telehealth benefits on an annual basis, consistent with the limits in 
statute and regulations. For example, a Medicare Advantage plan may 
offer a dermatology exam using store-and-forward technology.
    All Medicare Advantage plans are required to have an effective 
program to prevent, detect, and correct Medicare Advantage 
noncompliance and fraud, waste, and abuse. HHS is committed to 
oversight of plan compliance with this requirement while ensuring 
access to care for Medicare Advantage enrollees through additional 
telehealth benefits.
    Question. In January, HHS said that the COVID-19 public health 
emergency declaration would likely be in place for all of 2021.
    As we are now halfway through 2021, does HHS have an updated 
expectation for how long the public health emergency will last?
    What are the factors you are considering for when the public health 
emergency could be declared over (i.e., vaccination rates, daily cases, 
etc.)?
    Answer. The Secretary of Health and Human Services may, under 
section 319 of the Public Health Service (PHS) Act, determine that: (a) 
a disease or disorder presents a public health emergency (PHE); or (b) 
that a public health emergency, including significant outbreaks of 
infectious disease or bioterrorist attacks, otherwise exists. If and 
when declared, a PHE lasts until the Secretary declares that the 
emergency no longer exists or for 90 days, whichever comes first, but 
it may be extended for additional 90-day periods as needed and as 
determined by the Secretary.
    HHS will continue to evaluate the infection rate of COVID-19 and 
will modify the PHE, as needed, when cases decrease and the authorities 
under a PHE are no longer needed to support response operations.
    Question. In the hearing, you agreed that it would be helpful for 
Federal response agencies, such as CDC, FDA, and NIH to be able to 
respond proactively to public health emergencies before they get out of 
control.
    Would automatic funding to the Public Health Emergency Fund upon 
the declaration of certain public health emergencies--including 
infectious disease outbreaks--modeled after FEMA's Disaster Relief 
Fund, be helpful to ensure a quick and effective response to public 
health emergencies?
    Answer. A key lesson learned during the ongoing COVID-19 pandemic 
is that having available funding in the Public Health Emergency Fund 
would ensure that HHS can immediately respond while working in 
partnership with Congress on broader supplemental needs. For example, 
during the initial days of the COVID-19 pandemic, the Biomedical 
Advanced Research and Development Authority (BARDA) shifted program 
funds and redirected contracts from some of its investments in emerging 
infectious diseases (Zika and Ebola contracts) and leveraged pandemic 
influenza preparedness contracts to support vaccine and therapeutic 
development efforts. The funds were used to start a few critical 
programs early on; however, there were insufficient funds available to 
start the multi-pronged approach that led to success in both the 
vaccine and therapeutic development efforts. Using funds planned for 
other programs impacted the long-term investments that were in place 
for other identified threats, and there is no guarantee in a future 
public health emergency, that it would be possible to similarly shift 
program funds.
    If funded, the Public Health Emergency Fund would ensure that HHS 
could take immediate action to respond to a public health emergency 
before Congress enacts supplemental funding legislation. Immediate 
action can reduce the overall societal and economic impact of the 
public health emergency, reduce the lead time for development of 
supporting resources (e.g., medical countermeasure development if 
needed), and ultimately result in less overall expenditures if 
potential threats are quickly contained.
    Question. The pandemic has illustrated that Native communities 
often do not have access to the same resources that other communities 
do. For example, IHS-funded Tribal epidemiology centers are public 
health authorities, but do not have access to CDC public health 
authority data. And HHS agencies do not often work with states and 
other public health authorities to improve data collection to allow for 
disaggregation of American Indian/Alaska Native/Native Hawaiian 
information.
    How will you ensure that Native health systems, especially Native 
public health systems, have parity access to HHS resources going 
forward?
    What steps is HHS taking to include Native Hawaiians, who are too 
often overlooked and left out, in HHS programs and initiatives?
    Answer. Regarding your question about Native health systems, the 
HRSA funding opportunities for which tribes and tribal organizations 
were eligible to compete, as well as awards to tribes and tribal 
organizations have expanded.
    HRSA's Office of Intergovernmental and External Affairs leads the 
agency's Tribal Affairs, participates in HHS Tribal Consultations, and 
collaborates with IHS and other Federal and community stakeholders to 
address tribal issues. In response to tribal requests, the HRSA Tribal 
Advisory Council is being established to provide advice on how HRSA 
programs can better address tribal needs. HRSA IEA regional offices 
regularly communicate with tribal leaders to respond to issues and 
ensure they are aware of HRSA funding opportunities, program updates, 
and technical assistance.
    In fiscal year 2020, tribes and tribal organizations were awarded 
more than $16 million from Rural Tribal COVID-19 Response Program. The 
awards were distributed to 57 recipients across 22 states.
    Additionally, in fiscal year 2020, the Health Center Program 
awarded grant funding as further described below for Tribal/Urban 
Indian health center organizations.
  --Awarded nearly $88 million in annual operational grant funding to 
        35 health center organizations operating over 250 service 
        delivery sites serving Native communities across the U.S.
  --Awarded over $2.3 million to Tribal/Urban Indian health centers to 
        support infrastructure needs related to disaster response and 
        recovery efforts.
  --Awarded $31 million in Health Center Program supplemental funding 
        to Tribal/Urban Indian health centers to support efforts to 
        address the impact of the COVID-19 pandemic.
    Below are fiscal year 2021 Health Center Program actions related to 
health centers that are tribes or tribal organizations providing health 
services within Native American communities:
  --Continued annual health center operating grants, totaling 
        approximately $88 million for 35 health center organizations.
  --Awarded $60 million to 35 Tribal/Urban Indian health centers, as 
        part of the American Rescue Plan Act awards. Health centers use 
        the funds to support and expand COVID-19 vaccination, testing, 
        and treatment for vulnerable populations; deliver needed 
        preventive and primary healthcare services to those at higher 
        risk for COVID-19; and expand health centers' operational 
        capacity during the pandemic and beyond, including modifying 
        and improving physical infrastructure and adding mobile units. 
        This investment will help increase access to vaccinations among 
        hard- hit populations, and increase confidence in the vaccine 
        by empowering local, trusted health professionals in their 
        efforts to expand vaccinations.
  --In fiscal year 2021, HRSA and the Centers for Disease Control and 
        Prevention launched the Health Center COVID-19 Vaccine Program 
        to allocate COVID-19 vaccines to HRSA-supported health centers 
        directly. The program ensures our nation's underserved 
        communities and those disproportionately affected by COVID-19 
        are equitably vaccinated against COVID-19. HRSA invited all 
        HRSA funded health centers to participate in the program, 
        including the 35 Tribal/Urban Indian health centers. Eight 
        tribal organizations have set up accounts to participate in the 
        Health Center COVID-19 Vaccine Program. Six of the eight tribal 
        organizations have placed at least one order through the 
        program.
  --In late September 2021, HRSA expects to announce approximately $1 
        billion in awards supporting health center construction, 
        expansion, alteration, renovation, and other capital 
        improvements to modify, enhance, and expand healthcare 
        infrastructure.
    HRSA projects that 32 grants totaling approximately $18 million 
will be awarded to Tribal/Urban Indian health centers through this 
funding opportunity.
                  native hawaiian health care systems
    In fiscal year 2021, HRSA provided $20.5 million in grants and 
scholarship awards to Native Hawaiian Health Care Systems to improve 
the provision of comprehensive disease prevention, health promotion, 
and primary care services to Native Hawaiians.
    Additionally, in fiscal year 2021, HRSA provided $20 million under 
the American Rescue Plan Act to Native Hawaiian Health Care Systems to 
aid their response to COVID-19. The awards provided six Native Hawaiian 
Health Care Improvement Act (NHHCIA) recipients resources to strengthen 
vaccination efforts, respond to and mitigate the spread of COVID-19, 
and enhance healthcare services and infrastructure in their 
communities.
         technical assistance--health centers located in hawaii
    HRSA continues to make technical assistance available for Hawaii 
health centers to identify and address the primary healthcare needs of 
their target communities and populations, and to aid in identifying 
Federal programs to support those efforts. HRSA IEA Region 9 Office can 
assist Hawaii stakeholders with technical assistance and other HRSA 
resources.
                                 ______
                                 
            Questions Submitted by Senator Joe Manchin, III
    Question. Secretary Becerra, as you may be aware, Federal data 
shows that more than 1.5 million students experienced homelessness in 
the 2017-2018 school year, and in my home state of West Virginia, we 
had well over 10,000 students identified as homeless during the 2019-
2020 school year alone. Unfortunately, identification and reporting 
challenges have existed for years, and when you couple those existing 
challenges with the COVID-19 pandemic- we can only expect these numbers 
will be far greater than pre-pandemic levels. The Administration of 
Children and Families (ACF) is tasked with promoting the economic and 
social well-being of families and children, including those 
experiencing homelessness. That is why, in the height of the pandemic, 
I worked alongside Senator Murkowski and others to introduce the 
Emergency Family Stabilization Act; that would have created a dedicated 
funding stream through ACF to assist children, youth, and families 
experiencing homelessness during the COVID-19 pandemic. While I was 
able to work with my colleagues to secure dedicated funding through the 
Department of Education for identifying and assisting children and 
youth experiencing homelessness, it is not a permanent solution and 
does not incorporate the all the needed resources to address the issue.
    In recognizing the pandemic has greatly increased the need for 
better access to services for children, youth, and families 
experiencing homelessness; how does the President's budget further 
improve resources for those charged with identifying and connecting our 
children and youth experiencing homelessness with the services provided 
by ACF?
    Answer. The Administration for Children and Families receives 
funding, through the Runaway and Homeless Youth Act (RHYA), to provide 
services and resources to youth experiencing homelessness. Through the 
Family and Youth Services Bureau (FYSB), ACF funds a National 
Communications System (NCS), which is a national, toll-free, runaway 
and homeless youth crisis hotline to assist runaway and homeless youth, 
and those at risk of running away, in communicating with their families 
and with service providers. The NCS includes telephone, Internet, 
mobile applications, and any technology-driven services used for 
runaway and homeless youth or youth who are at risk of running away. 
The NCS provides crisis intervention, referral services, information, 
and prevention resources to youth at risk of separation from their 
families, runaway and homeless youth, their families, legal guardians, 
and service providers.
    The RHYA also authorizes the Runaway and Homeless Youth Training & 
Technical Assistance Center (RHYTTAC) to provide training and technical 
assistance to RHY program-funded grantees and allied professionals. 
RHYTTAC assists these organizations in developing effective approaches 
for serving runaway and homeless youth, accessing new resources to 
enhance their ability to serve these youth, and establishing linkages 
with other programs with similar interests and concerns. RHYTTAC also 
helps to ensure that grantees have effective interventions in place to 
build skills and capacities that contribute to the healthy, positive, 
and productive functioning of children and their successful transition 
from youth into adulthood.
    The President's fiscal year 2022 Budget proposed to fund RHY 
programs at a level of $144,987,000, which would be an increase of 
$8.2M from the fiscal year 2021 appropriation level. With the proposed 
increase, ACF/FYSB will seek to increase the number of RHY grantees and 
continue to support training and technical assistance. ACF commits to 
working with other Federal youth-serving agencies to increase awareness 
of resources available through RHY Programs, and to further develop 
coordinated efforts to support prevention, outreach, engagement, and 
timely referral to ACF services as well as services available from 
other Federal agencies. Additionally, Head Start and Child Care 
Development Fund (CCDF) Block Grants also serve families with young 
children experiencing homelessness.
    Question. During the COVID-19 pandemic, rural health providers have 
been hit hard. Last year alone, West Virginia had three hospitals 
close, putting patients at risk of accessing care. In response Congress 
passed $8.5 billion in the American Rescue Plan aimed at supporting 
rural health providers. Since this was signed into law, HHS has made no 
announcements on the plan to distribute this funding, yet rural health 
providers remain at risk.
    When will this funding begin to be allocated to our rural 
communities?
    Answer. HHS is working to finalize the $8.5 billion in American 
Rescue Plan Act of 2021 funding for rural Medicare and Medicaid 
providers and suppliers. HHS is considering operational lessons learned 
from prior Provider Relief Fund (PRF) payments, as well as feedback 
from Members of Congress and other stakeholders.
    Question. During the previous Administration, determining the 
status of the Provider Relief Fund was nearly impossible to do. Will 
you commit to ensuring transparency when distributing this $8.5 billion 
for rural providers?
    Answer. HHS is committed to an equitable, transparent, and 
responsive approach when distributing future provider relief payments. 
HHS has listened to stakeholder input and feedback and is committed to 
ensuring equity in future PRF distributions, better support to 
providers applying for funds, and transparency in communication to 
providers. Furthermore, the Administration is committed to building a 
strong working relationship with Congress going forward and plans to 
provide periodic updates on the distribution of $8.5 billion for rural 
providers.
    Question. The COVID-19 pandemic had significant impacts on rural 
communities in West Virginia, who were already at a disadvantage when 
it comes to accessing healthcare services. We have seen exponential 
growth in telehealth adoption across Americans of all ages, locations, 
and conditions to help address these disparities. Telehealth is a 
lifeline to countless patients and their doctors in my state of West 
Virginia. Telehealth among Medicare beneficiaries has been made 
possible by temporary flexibilities in place for the duration of the 
public health emergency. You have previously committed to work to 
expand certain telehealth policies after the end of the public health 
emergency. And we have learned and seen in practice that telehealth has 
saved lives throughout this pandemic.
    Secretary Becerra, how do we ensure that there is equitable access 
to telehealth services, particularly for individuals who lack a 
connection to broadband and rely on audio-only methods to communicate 
with their doctors?
    Answer. Telehealth is an important tool to improve health equity 
and improve access to healthcare. Healthcare should be accessible, no 
matter where you live. HHS continues to examine the telehealth 
flexibilities developed for the current public health emergency and 
determine how we can build on this work to improve health equity and 
improve access to healthcare.
    There are a number of efforts underway to help underserved 
communities and individuals, particularly rural and tribal communities, 
utilize telehealth services through access to broadband Internet 
connections. HRSA's Office for the Advancement of Telehealth serves as 
HHS's focal point on telehealth, which includes the management of the 
Telehealth.HHS.gov website and improving collaboration across HHS and 
Federal agencies. For example, HRSA's Office for the Advancement of 
Telehealth leads a Rural Telehealth Initiative, established through a 
memorandum of understanding with HHS, the Federal Communications 
Commission, and the
    U.S. Department of Agriculture, to increase access to affordable 
broadband services, which is the foundation for improving access to 
telehealth services. HRSA's Office for the Advancement of Telehealth 
also supports grants such as a Telehealth Broadband Pilot Program to 
measure access to high speed Internet in rural and underserved 
communities as well as programs to support the provision of direct 
telehealth services, telementoring, research, licensure portability, 
and technical assistance to providers and patients through the 
Telehealth Resource Center Programs.
    Question. What steps is the Department of Health and Human Services 
taking to ensure that Americans who have come to rely on telehealth 
services don't lose access when the public health emergency ends?
    Answer. Telehealth services are an important tool to improve health 
equity and access to healthcare. Throughout the pandemic, telehealth 
services have filled an urgent need to maintain access to care while 
social distancing was necessary. For example, federally Qualified 
Health Centers and Rural Health Clinics were able to be paid by 
Medicare as distant site telehealth service providers, which had not 
been permitted outside of the COVID-19 public health emergency. After 
the pandemic, HHS will continue to support telehealth services. HHS is 
currently reviewing the telehealth flexibilities developed for the 
current public health emergency to determine which can and should 
continue after the public health emergency has ended. HHS plans to 
continue to support telehealth after the pandemic through resources 
like the Telehealth.HHS.gov website and the Telehealth Resource Centers 
so patients and providers have access to telehealth technical 
assistance.
    Question. The 340B program is essential for providing access to 
safe and affordable medications for low-income West Virginians. 
Recently HHS determined that six pharmaceutical companies have violated 
the program, by restricting access to contract pharmacies. The 
undermining of the 340B program by pharmaceutical companies and 
pharmacy benefit managers has taken its toll on West Virginia's 
hospitals, community health centers and their contract pharmacy 
partners.
    What are the next steps HHS will be doing to ensure the integrity 
of the 340B program?
    Answer. On May 17, 2021, HRSA sent letters to six pharmaceutical 
manufacturers stating that HRSA has determined that their policies 
placing restrictions on 340B Program pricing to covered entities that 
dispense medications through pharmacies under contract have resulted in 
overcharges and are in direct violation of the 340B statute. In 
addition, the letters explain that the 340B Program Ceiling Price and 
Civil Monetary Penalties final rule (CMP final rule) states that any 
manufacturer participating in the 340B Program that knowingly and 
intentionally charges a covered entity more than the ceiling price for 
a covered outpatient drug may be subject to a Civil Monetary Penalty 
(CMP) not to exceed $5,000 for each instance of overcharging. Any 
assessed CMPs would be in addition to repayment for each instance of 
overcharging.
    In its letters, HRSA informed the pharmaceutical manufacturers that 
continued failure to provide the 340B price to covered entities 
utilizing contract pharmacies, and the resultant charges to covered 
entities of more than the 340B ceiling price, may result in CMPs as 
described in the CMP final rule. While there is ongoing litigation on 
these matters, HRSA is actively reviewing each manufacturer's response 
to its May 17, 2021, letter to determine whether subsequent action, 
such as referral to the HHS Office of the Inspector General for the 
imposition of CMPs is warranted.
                                 ______
                                 
                Questions Submitted by Senator Roy Blunt
                           covid-19 boosters
    Question. Mr. Secretary, at our last two hearings--one with the CDC 
Director and one with the NIH Director--the issue of whether we need 
vaccine boosters was raised. Even from our own officials, there seems 
to be a divide as to whether they'll be necessary. In early May, BARDA 
notified the Subcommittee that they intend to purchase 400 million 
vaccine doses for boosters for $7.9 billion. Does that notification 
mean that you believe boosters are necessary? Even though neither the 
Directors of CDC or NIH have officially said the same? My concern is 
that it could be very dangerous if vaccine companies, rather than 
public health experts, are stetting the public's expectations around 
COVD-19 boosters.
    Answer. Throughout the COVID-19 pandemic, BARDA has worked to 
develop and ensure that once authorized and/or approved by the FDA 
medical countermeasures (including vaccines) would be available to the 
American public immediately or with minimal delay. This has meant, 
contracting with companies to purchase millions of doses of vaccines 
prior to FDA authorization based on the lead time for vaccine 
manufacturing to ensure doses are available. Further, many 
manufacturers require orders to be placed several months ahead of the 
expected delivery date. Placing the order after a need is identified 
would result in a lapse/gap in production and ultimate delivery.
    Supporting the early manufacturing of countermeasures ensures that 
once the FDA issues an EUA, vaccine doses are immediately available. It 
has also meant that, if a vaccine we invested in failed, the USG would 
have realized the financial risk associated with the aggressive 
development strategy underlying Operation Warp Speed which is now 
called the Countermeasures Acceleration Group or CAG. BARDA is taking 
the same approach to purchasing additional vaccine doses to be 
available immediately if/when the FDA authorizes/approves boosters.
               covid-19 vaccines donated internationally
    Question. Secretary Becerra, on June 3, 2021, the Administration 
announced it would donate 80 million vaccines to the international 
community by the end of June. Did the Department of Health and Human 
Services fund the vaccines that are being donated?
    Specifically, which vaccines are being donated? Please provide 
estimates based on vaccine producer and number of doses.
    Answer. All vaccine doses the Department of Health and Human 
Services has purchased to date were ordered for domestic use. However, 
international donations have been made available from amounts that have 
been in excess of demand once vaccines were available for use.
                          barda misused funds
    Question. In January, the Office of Special Counsel investigated 
the misuse of funds appropriated to BARDA. The Special Counsel found 
that at least since fiscal year 2010, the Office of Assistant Secretary 
for Preparedness and Response misused funds appropriated for BARDA and 
failed to accurately report this mismanagement to Congress. In fact, 
the practice of using BARDA funding by ASPR for non-BARDA purposes was 
so common that it was referred to in the agency as the ``Bank of 
BARDA.'' Mr. Secretary, has the Department determined whether these 
actions violated the Anti-deficiency Act and what steps has HHS taken 
to address this issue?
    Answer. HHS/ASPR is committed to ensuring taxpayers dollars are 
used in the most judicious manner and in accordance with statutory 
obligations. In response to the HHS Inspector General's report, HHS's 
Office of Finance is undertaking an internal review of the HHS 
Assistant
    Secretary for Preparedness and Response (ASPR)'s use of advanced 
research and development funding from the Public Health and Social 
Services Emergency Fund for fiscal years 2015 through 2019 to identify 
any potential Anti-deficiency Act violations. HHS also hired an outside 
accounting firm which is auditing ASPR's use of these funds. Both 
reviews are estimated to be completed in 2021.
                               disease x
    Question. The COVID-19 pandemic has highlighted the need for the 
Federal government to respond rapidly to the next fast-moving, novel 
infectious disease. The fiscal year 2021 LHHS bill included language 
that encouraged the Department of Health and Human Services to work 
with the Department of Defense to implement a program focused on 
developing flexible vaccines and antiviral treatments to address 
emerging and previously unidentified infectious disease threats, 
referred to as Disease X. Mr. Secretary, what progress has the 
Department made in implementing such a program and how is the 
Department planning to develop countermeasures for previously 
unidentified viral threats?
    Answer. While no specific Disease X program has been established, 
BARDA does have processes and capabilities to prepare to respond to 
various disease threats. While BARDA has a mandate to develop medical 
countermeasures against emerging infectious disease threats, these 
efforts cross over and could support a robust and effective response to 
any rapidly emerging infectious disease event, subsequent to funding 
availability. One example is BARDA's support of platform technologies 
to develop vaccines and therapeutics for Ebola Zaire virus (Merck, 
Janssen, Regeneron) and Zika (Moderna). When COVID-19 outbreaks began, 
BARDA was able to pivot these efforts to develop medical 
countermeasures to aid the response to the emerging threat.
                         unaccompanied children
    Question. Mr. Secretary, while your Department has no role in 
setting border policy or enforcing border security, HHS is responsible, 
by law, for the safety and well-being of the unaccompanied children 
referred to its care. And this fiscal year, HHS is on track to have the 
highest number of referrals of unaccompanied children on record, with 
almost 69,000 referrals already. Instead of working to open multiple 
Influx facilities that provide an equivalent standard of care for 
children as the shelters in the permanent network, HHS created a new 
concept of Emergency Intake Sites that do not have the same 
accountability requirements as Influx facilities and provide children 
with only a minimal level of care. Why, months after this crisis began, 
have you not opened additional Influx facilities or transitioned some 
of these Emergency Intake Sites into Influx facilities?
    Answer. ORR's preference is to place unaccompanied children into 
state-licensed care provider facilities, including transitional foster 
homes while their sponsorship suitability determinations or immigration 
cases are adjudicated (in cases when a child has no viable sponsor). 
ORR has prioritized increasing its network of state licensed beds by: 
(1) safely bringing back online beds that were impacted by COVID-19 
restrictions, (2) partnering with current providers to provide 
additional bed capacity through recipient-initiated supplements, and 
(3) engaging non-governmental organizations and governmental 
jurisdictions to identify ways to expand bed capacity. However, during 
a time of sustained high referrals, ORR activates and operates Influx 
Care Facilities and Emergency Intakes Facilities (EIS) to meet its 
statutory obligations to care for unaccompanied children (UC) 
transferred from the Department of Homeland Security (DHS) and ensure 
that children are not waiting in CBP custody for longer than 72 hours. 
Since March 2021, ORR has activated a total of 14 EISs, and to date, 
ORR operates only one ICF and three EIS. At a minimum, these EISs 
provide lifesaving services, consistent with best practices in 
humanitarian and disaster response efforts. In addition, ORR has been 
working diligently to ramp up services including wrap-around services, 
where possible, to ensure the safety and well-being of the children in 
ORR care and custody.
    Question. When do you expect to ensure that every unaccompanied 
child in the care of HHS receives the required standard of care?
    Answer. ORR recognizes that children who enter ORR care may have 
experienced significant trauma not only in their home countries but 
also during their journey to the United States, and ensures that ORR's 
continuum of care remains rooted in trauma-informed care, and 
prioritizes the best interest of each child across its network of care 
provider facilities, including Carrizo ICF and the EISs.
    Question. HHS has transferred or reprogramed almost $3 billion to 
cover the costs of the influx of unaccompanied children crossing at the 
southern border. Do you expect that the transferred amount will cover 
the costs of the UC program for the remainder of the fiscal year?
    Answer. Yes. HHS anticipates that the allocated amount will cover 
the costs of the UC program through the end of the fiscal year.
    Question. Do you anticipate that your request of $3.3 billion for 
the program in fiscal year 2022 accurately reflects the amount needed 
for the next fiscal year?
    Answer. HHS strongly supports the President's budget request. 
However, given the ever- evolving situation at the southern border, it 
can be challenging to predict medium-to-long term funding needs with 
any degree of certainty. HHS continues to gather data and employ 
rigorous evaluation methods to inform its budgetary requests and 
decisionmaking, and will continue to update the Office of Management 
and Budget (OMB) and both the House and Senate Appropriations 
Committees on the dynamic situation at the southern border and the 
resultant resource requirements. HHS remains committed to working with 
Congress to ensure all relevant funding needs are communicated in a 
timely manner.
    Question. What are the key assumptions behind both of those cost 
estimates?
    Answer. To arrive at its cost estimates, ORR considers a variety of 
factors such as external political events, natural disasters, and other 
issues that may impact the number of referrals from DHS.
    Additionally, cost estimates for fiscal year 2022 includes 
expanding the scope of post-release services and the number of children 
who receive them, as well as other critical programmatic reforms such 
as improving case management and implementing policies and procedures 
intended to reduce the time it takes to unify children with their 
sponsors.
                         organ transplantation
    Question. Mr. Secretary, I was pleased to see the Administration 
move forward with finalizing the Centers for Medicare and Medicaid 
Services' (CMS) rule to improve oversight and accountability of organ 
procurement organizations (OPOs) (CMS-3380-F2).
    Related, a government contractor, the United Network for Organ 
Sharing (UNOS), has great influence over the protocols and processes 
for organ procurement and allocation. UNOS has held the government 
contract to run the Organ Procurement and Transplantation Network 
(OPTN) for roughly 35 years and appears to operate with little to no 
oversight by HHS. Over the course of the last few years, UNOS policies 
have had the effect of redistributing donated organs from the Midwest 
and South to more urban and coastal areas. In addition to the CMS OPO 
accountability rule, what more can the Department do to bring 
accountability and oversight to the organ procurement process and to 
hold the OPTN contractor accountable to actually improve the organ 
transplantation system in the U.S.?
    Answer. HRSA provides oversight of the OPTN and the OPTN 
contractor. HRSA exercises its oversight according to statutory 
requirements, regulatory requirements, and through the OPTN contract. 
The OPTN Board of Directors develops organ allocation policies with the 
advice of the OPTN membership and other interested parties The OPTN 
contractor neither develops nor approves OPTN policies. HRSA staff are 
ex-officio members of OPTN committees and the OPTN Board of Directors 
and attend all OPTN business meetings.
    HRSA currently works closely with CMS on CMS' regulation of organ 
procurement and transplantation services. Additionally, HRSA and CMS 
collaborated to establish a new Affinity Group on Organ Procurement and 
Transplantation to improve oversight by the two agencies.
    Question. The fiscal year 2021 Appropriations Joint Explanatory 
Statement encouraged CMS to consider removing the disincentive for 
Medicare Certified Transplant Centers to transfer patients suffering 
from complete loss of brain function to organ recovery centers operated 
by organ procurement organizations. What is the status of this work at 
CMS?
    Answer. CMS published a final rule \1\ on December 2, 2020 that 
updates the OPO Conditions for Coverage to change the way OPOs are held 
accountable for their performance. The final rule improves the current 
measures by using objective and reliable data, incentivizes OPOs to 
ensure all viable organs are transplanted, and holds OPOs to greater 
oversight while driving higher OPO performance. Under new outcome 
measures introduced in this final rule, except for pancreas procured 
for research (which is required by law to be counted), an OPO will not 
receive credit for procuring an organ if the organ is not transplanted, 
creating greater incentive for OPOs to place all organs for transplant 
that they procure. Following review, the final rule went into effect 
March 30, 2021 (except for amendment 3).\2\
---------------------------------------------------------------------------
    \1\ https://www.Federalregister.gov/documents/2020/12/02/2020-
26329/medicare-and-medicaid-programs-organ-procurement-organizations-
conditions-for-coverage-revisions-to.
    \2\ The January 20, 2021 memorandum from the Assistant to the 
President and Chief of Staff, entitled ``Regulatory Freeze Pending 
Review,'' instructed Federal agencies to delay the effective date of 
rules published in the Federal Register, but which have not yet taken 
effect, for a period of 60 days. The effective date of the final rule, 
except for amendment number 3, which would have been February 1, 2021, 
became March 30, 2021. CMS also included a 30-day public comment period 
on the rule to allow interested parties to provide comments about 
issues of fact, law and policy raised by the rule. The 60-day delay in 
effective date was necessary to give Department officials the 
opportunity for further review of the issues of fact, law, and policy 
raised by this rule.
---------------------------------------------------------------------------
                             mental health
    Question. The pandemic has exacerbated the children's mental health 
crisis across the country and we are seeing alarming increases in 
children presenting in emergency rooms in severe crisis. Could you 
comment on how your budget addresses this crisis and ensures that 
children can get access to mental and behavioral health services 
earlier, closer to home, and in their communities?
    What are your thoughts on further efforts we should consider to 
direct funding to address this crisis, such as Children's Hospital 
Graduate Medical Education which helps train frontline professionals 
focused on treating children's mental and behavioral health?
    Answer. HHS is committed to improving access to mental and 
behavioral healthcare services for children and families. The fiscal 
year 2022 President's Budget requests includes an additional $756 
million for SAMHSA to increase access to children's behavioral health 
services, which includes $473 million for mental health, $281 million 
for substance use treatment, and $2 million for substance use 
prevention related services and activities.
    Within HRSA, the Budget provides $10 million for pediatric mental 
healthcare access to increase access to behavioral health. This 
investment promotes behavioral health integration in pediatric primary 
care by supporting the development of new, or the improvement of 
existing, statewide or regional pediatric mental healthcare telehealth 
access programs.
    The Children's Hospitals Graduate Medical Education (CHGME) Program 
is a formula based payment program that helps eligible hospitals 
maintain Graduate Medical Education (GME) programs to support graduate 
training for physicians to provide quality care to children. As such, 
the program supports the training of pediatric psychiatrists and other 
pediatric physician behavioral subspecialists. In Academic Year 2019-
2020, 199 Child and Adolescent Psychiatry fellows received training 
through the CHGME Program. In addition, CHGME-funded hospitals served 
as sponsoring institutions for 42 residency programs and 252 fellowship 
programs, and also served as major participating rotation sites for 628 
additional residency and fellowship programs. The CHGME Program also 
supported the training of 5,433 Pediatric residents that included 
General Pediatrics residents, as well as residents from seven types of 
combined pediatrics programs (e.g., Internal Medicine/Pediatrics). In 
total, 3,055 Pediatric Medical Subspecialists, including 199 Child and 
Adolescent Psychiatry fellows, received training.
                             hyde amendment
    Question. Mr. Secretary, for more than forty years, Democrat and 
Republican-led Administrations, as well as Democrat and Republican-led 
Congresses have supported the principle that taxpayer dollars should 
not fund elective abortions. As members of Congress, President Biden, 
Vice President Harris, and you, Mr. Secretary, all voted in favor of 
funding bills year after year that included this prohibition. It 
remains unclear why this radical change in public policy is suddenly an 
imperative for the Biden Administration to fund elective abortions with 
taxpayer dollars. Further, your request does not detail the cost this 
change will have on the U.Ss taxpayer. Can you please provide an 
estimate of how many abortions would receive Federal funding, and what 
amount of Federal expenditures would be incurred to pay for abortions, 
relative to current law for this fiscal year and the next ten?
    Answer. The Hyde Amendment disproportionately impacts the growing 
number of low- income, women of color who are enrolled in Medicaid, and 
is a barrier to expanding access to healthcare. That is why the 
President's first budget calls for Congress to remove the restriction 
from government spending bills.
    The Department of Health & Human Services implements the laws that 
Congress passes. Implementation of any changes in coverage related to 
the President's Budget would depend on the final language Congress 
passes. After passage of any legislation, agency staff and counsel 
review the language to determine the agency's authority and options for 
implementation action, such as initiating notice and comment rulemaking 
or issuing guidance documents.
    Question. HHS issued a proposed rule in April that would allow 
Title X grantees to promote abortion as a form of family planning. The 
preamble of the proposed rule cites ``that Planned Parenthood conducted 
a major fundraising campaign with the 2019 Title X regulatory changes 
as its key motivating message. If funds are more efficiently gathered 
and distributed via a program such as Title X than through such private 
campaigns, the efficiency would represent a cost savings attributable 
to the proposed rule.'' It is widely known that Planned Parenthood 
walked away from the Title X program in 2019, so I am troubled by the 
fact that HHS' proposal implies that Planned Parenthood is somehow 
entitled to taxpayer funding. This notion and the rush to finalize the 
proposed rule also raises questions about your agency's ability to be 
impartial in awarding of future Title X grants. How is this proposed 
rule not a kickback to Planned Parenthood?
    Answer. On January 28, 2021, President Biden issued a ``Memorandum 
on Protecting Women's Health at Home and Abroad'' directing the 
Department to review the 2019 Title X Final Rule and ``consider, as 
soon as practicable, whether to suspend, revise, or rescind, or publish 
for notice and comment proposed rules suspending, revising, or 
rescinding, those regulations, consistent with applicable law, 
including the Administrative Procedure Act.'' The memorandum stated 
that undue restrictions on the use of Federal funds have made it harder 
for women to access medical information.
    After conducting an extensive review and consideration of the 2019 
Title X Final Rule (84 Fed. Reg. 7714) pursuant to the Presidential 
memorandum, the Department published a Notice of Proposed Rulemaking 
(NPRM) entitled ``Ensuring access to equitable, affordable, client-
centered, quality family planning services'' in the Federal Register 
that was open for public comment from April 15, 2021 to May 17, 2021.
    As outlined by the Title X statute and reinforced in its 
regulations, ``None of the funds appropriated under this title shall be 
used in programs where abortion is a method of family planning.'' 
Consistent with the program's statute and regulations, any public or 
private nonprofit organizations, including faith-based organizations, 
state, county, local, and tribal governments, school districts, and 
public and state higher education institutions are eligible to apply 
for Title X grant funds. Title X's regulations, in the NPRM, also 
clearly define the criteria the Department uses to decide which family 
planning services projects to fund and in what amount.
          psychological clinical science accreditation system
    Question. The fiscal year 2021 Appropriations Joint Explanatory 
Statement encouraged HHS to ``review the accreditation and eligibility 
requirements for the Public Health Service Corps and behavioral health 
workforce programs to allow access to the best qualified applicants, 
including those who graduate from Psychological Clinical Science 
Accreditation System (PCSAS) programs.'' Currently, there are more than 
40 PCSAS University accredited doctoral programs in psychological 
clinical science, including Washington University in St. Louis, but the 
Department's guidance and regulations were adopted prior to the 
establishment of PCSAS and do not permit the graduates of PCSAS 
programs to be eligible to compete for these funding opportunities. 
What is the status of this review and updates at the Department and 
within the Health Resources and Services Administration, as it relates 
to the behavioral health workforce programs?
    If this process has not yet started, please provide an explanation, 
an estimated start date, and any additional information that may be 
necessary to proceed.
    Answer. HRSA is currently exploring options to include PCSAS 
doctoral programs as eligible entities in the upcoming fiscal year 2022 
Graduate Psychology Education competition. HRSA will continue to 
explore options to include such programs in other future competitions, 
including, but not limited to, the Behavioral Health Workforce 
Education and Training program, and the Geriatric Academic Career 
Awards. HRSA currently anticipates posting the Notice of Funding 
Opportunity for the Graduate Psychology Education program in November 
2021.
                       provider relief fund (prf)
    Question. Mr. Secretary, Congress provided $178 billion over the 
course of the last year for the Provider Relief Fund, and the American 
Rescue Plan included an additional $8.5 billion for rural providers. 
How is HHS planning to distribute the approximately $50 billion 
remaining, and when can we expect to see the distribution?
    Answer. HHS is committed to distributing the remaining provider 
relief payments as quickly, transparently, and equitably as possible 
while utilizing effective safeguards to protect taxpayer dollars.
    HHS is planning for future Provider Relief Fund (PRF) allocations, 
including the $8.5 billion from American Rescue Plan Act and Phase 4 of 
the General Distribution.
    HHS is actively considering feedback from stakeholders, as well as 
operational lessons learned from prior PRF payments, as part of the 
planning process. The feedback from Members of Congress and other 
stakeholders informs HHS' ability to administer the PRF in a manner 
that bolsters the healthcare system and helps providers experiencing 
COVID-related financial hardships during this crisis. HHS will publish 
additional information on future distributions on the Health Resources 
and Services Administration's PRF webpage, at www.hrsa.gov/provider-
relief, as soon as it becomes available.
    Question. How are you planning to account for the ongoing needs of 
rural hospitals and rural healthcare providers in the distribution of 
the $8.5 billion?
    Answer. HHS is working to finalize the $8.5 billion in American 
Rescue Plan Act of 2021 funding for rural Medicare and Medicaid 
providers and suppliers. HHS will publish additional information on 
future distributions on the Health Resources and Services 
Administration's PRF webpage, at www.hrsa.gov/provider-relief, as soon 
as it becomes available.
                                opioids
    Question. There is no question that the pandemic has been 
challenging for many people and the data shows an unprecedented rise in 
opioid overdose deaths in 2020. What can you say about the latest 
trends in opioid overdoses and what we need to do to build on the 
investments of the last 6 years to combat the opioid epidemic?
    Answer. The overdose crisis has certainly worsened in the face of 
the COVID-19 public health emergency. Estimates from the CDC find that 
more than 90,000 drug overdose deaths have occurred in the 12 months 
ending in September 2020. That represents a year-over-year increase of 
close to 29 percent. For the last few years, this increase in lives 
lost is principally driven by synthetic opioids like fentanyl, but 
increasingly, we are seeing stimulants, including methamphetamine and 
cocaine also involved. HHS is investing $11.2 billion in programs 
responding to the overdose crisis, an increase of $3.9 billion over 
fiscal year 2021 Enacted, with the goal of ending the crisis of opioids 
and other substance use by increasing funding for States and Tribes for 
medication-assisted treatment, and by expanding the behavioral health 
provider workforce. Of the $11.2 billion, $6.6 billion is from SAMHSA's 
prevention and treatment activities that address the substance use and 
opioid crisis, an increase of $2.6 billion over Fiscal year 2021 
enacted. HHS is committed to investments in the Substance Abuse 
Prevention and Treatment Block grant to expand implementation of 
evidence-based prevention, treatment and recovery support services for 
individuals, families, and communities across the nation. The budget 
includes a new 10 percent set-aside to direct funds to states for 
recovery support services, which can be provided prior to, during, 
after, and in lieu of treatment. This funding will allow SAMHSA to 
serve 2.1 million people in fiscal year 2022 and to significant 
strengthen the Nation's recovery support services infrastructure. The 
fiscal year 2022 President's Budget also makes significant investments 
in First Responder Training programs to train first responders to 
respond to and prevent opioid overdose deaths, as well as expanding 
treatment for SUD for pregnant and post-partum women.
    HHS is committed to continued support for efforts to increase 
access to SUD and broader behavioral healthcare services through the 
Rural Communities Opioid Response Program (RCORP). The budget includes 
a total of $165 million to support prevention, treatment, and recovery 
services for opioids and other SUDs in the highest-risk rural 
communities. Through RCORP, more than 23,000 individuals received 
medication-assisted treatment; and the number of DATA-waivered 
providers serving rural communities was increased. In fiscal year 2019 
and 2020, the National Health Service Corps Rural Community Loan 
Repayment Program (NHSC RC LRP) also served to further increase access 
to behavioral healthcare workforce services in rural communities with 
651 providers working in rural communities, and 118 of those working 
specifically at RCORP service sites.
    Other considerations to address the overdose epidemic include:
    Treatment Capacity: The SAMHSA-HRSA Workforce projections report 
indicates a shortage of over 10,000 full time equivalents for child 
psychiatrists and master's level mental and SUD counselors by the year 
2025. The report also highlights the need for peer specialists in a 
wide variety of integrated and specialty care settings. Peers, as 
members of integrated healthcare teams, support all team members in 
working at the top of their scope of practice, improving efficiency and 
maximizing skill utilization.
    Decreasing Barriers: Research reveals geographic and 
sociodemographic barriers to receiving treatment.\3\ Indeed, many 
treatment facilities are found in urban and suburban areas, and there 
is disparity in access to buprenorphine providers and Opioid Treatment 
Programs (OTPs).\4\ Recent policy changes, such as The Practice 
Guidelines for the Administration of Buprenorphine for Treating Opioid 
Use Disorder, remove perceived barriers to obtaining a DATA-2000 Waiver 
and expand access to this treatment.. New flexibilities enable more 
OTPs to establish mobile medication units (e.g., vans), which can 
improve geographic access and expand the provision of opioid use 
disorder treatment to disparate populations. Grants such as the State 
Opioid Response (SOR), Medicated Assisted Treatment for Prescription 
Drug and Opioid Addiction (MAT-PDOA), Targeted Capacity Expansion-
Special Projects (TCE-SP), and Screening, Brief Intervention and 
Referral to Treatment (SBIRT) will be used to address this need. The 
fiscal year 2022 President's Budget Request proposes increases for each 
of these programs.
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    \3\ Sharma RN, Casas RN, Crawford NM, Mills LN. Geographic 
distribution of California mental health professionals in relation to 
sociodemographic characteristics. Cultur Divers Ethnic Minor Psychol. 
2017 Oct;23(4):595-600.
    \4\ Goedel WC, Shapiro A, Cerda M, Tsai JW, Hadland SE, Marshall 
BDL. Association of Racial/Ethnic Segregation With Treatment Capacity 
for Opioid Use Disorder in Counties in the United States. JAMA Netw 
Open. 2020;3(4):e203711. Published 2020 Apr 1. doi:10.1001/
jamanetworkopen.2020.3711.
---------------------------------------------------------------------------
    Wrap Around Services Addressing Social Determinants of Health: 
These services not only improve the treatment experience, but also 
provide support to clients during their recovery. For example, research 
demonstrates that women's SUD treatment outcomes are improved when 
women-specific needs are addressed through wraparound services, such as 
the provision of childcare, employment assistance, or mental health 
counseling.\5\ Additionally, the receipt of basic needs, child care, 
educational, family, and medical services is associated with 
improvements in several outcomes.\6\ These services represent an 
important opportunity to support clients and to ameliorate many of 
those social determinants of health that precipitate substance misuse. 
That is why the fiscal year 2022 President's Budget Request proposes 
increase for programs such as the Pregnant & Postpartum Women, 
Treatment, Recovery, and Workforce Support, Adult and Family Treatment 
Drug Courts.
---------------------------------------------------------------------------
    \5\ Oser C, Knudsen H, Staton-Tindall M, Leukefeld C. The adoption 
of wraparound services among substance abuse treatment organizations 
serving criminal offenders: The role of a women-specific program. Drug 
Alcohol Depend. 2009;103 Suppl 1(Suppl 1):S82-S90. doi:10.1016/
j.drugalcdep.2008.12.008.
    \6\ Pringle, J, et al. The Role of Wrap Around Services in 
Retention and Outcome in Substance Abuse Treatment: Findings From the 
Wrap Around Services Impact Study. Addict Disord Their Treatment 
2002;1:109--118.
---------------------------------------------------------------------------
    Telehealth: The recent pandemic has demonstrated the utility of 
telehealth in reaching disparate populations. Telehealth is a mode of 
service delivery that has been used in clinical settings for over 60 
years and empirically studied in the mental health space for over 20 
years.\7\ Telehealth is not an intervention itself, but rather a mode 
of delivering services. This mode of service delivery increases access 
to screening, assessment, treatment, recovery supports, crisis support, 
and medication management \8\ across diverse behavioral health and 
primary care settings. Practitioners can offer telehealth through 
synchronous and asynchronous methods. The increase requested under 
SAMHSA's SOR grants can be used to address this need.
---------------------------------------------------------------------------
    \7\ Bashshur, R. L., Shannon, G. W., Bashshur, N., & Yellowlees, P. 
M. (2016). The empirical evidence for telemedicine interventions in 
mental disorders. Telemedicine and e-Health, 22(2), 87-113.
    \8\ Substance Abuse and Mental Health Services Administration. 
(2015). Using technology-based therapeutic tools in behavioral health 
services. Treatment Improvement Protocol (TIP) Series 60.
---------------------------------------------------------------------------
    Evidence Based Practice: There is a need for combining leadership 
development with organizational strategies to support a climate 
conducive to evidence based practice implementation.\9\ This represents 
an opportunity to promulgate the evidence and best practices through 
SAMHSA publications, reports, and announcements. Beyond this, SAMHSA 
will work with grantees to consider implementation science strategies 
that support program sustainability and fidelity to the evidence base. 
The Evidence-Based Practice Center and Technical Assistance Grants will 
be used to address this need. Additionally, the Prevention Technology 
Transfer Center Network and the Addiction Technology Transfer Network 
will continue to help states develop capacity through training, 
consultation, and technical assistance and SAMHSA's new Peer Recovery 
Center of Excellence, authorized under Section 7152 of the SUPPORT Act 
for Patients and Communities, will continue to provide training and 
technical assistance to support integration of peer support workers 
into non-traditional settings, build and strengthen recovery community 
organizations, a key component of recovery support services 
infrastructure. It will also enhance the professionalization of peers 
through workforce development, providing evidence-based and practice-
based toolkits and resources to diverse stakeholders.
---------------------------------------------------------------------------
    \9\ Aarons GA, Ehrhart MG, Moullin JC, Torres EM, Green AE. Testing 
the leadership and organizational change for implementation (LOCI) 
intervention in substance abuse treatment: a cluster randomized trial 
study protocol. Implement Sci. 2017 Mar 3;12(1):29.
---------------------------------------------------------------------------
    Harm Reduction Activities: The promotion and distribution of 
naloxone and fentanyl test strips, similar to the existing syringe 
services programs, represents an opportunity to not only promote life-
saving interventions, but to also provide education on drug potency and 
mortality.\10\ This might be achieved in partnership with public safety 
agencies, providers, community organizations and the public. 
Additionally, syringe services programs reduce transmission of HIV and 
viral hepatitis within the community. A comprehensive and coordinated 
approach must incorporate innovative and established prevention and 
response strategies, including those focused on polysubstance use. 
Among the programs that can support these efforts are the Treatment 
Systems for Homeless and Minority AIDS program, both of which request 
an increase in funding.
---------------------------------------------------------------------------
    \10\ Han JK, Hill LG, Koenig ME, Das N. Naloxone Counseling for 
Harm Reduction and Patient Engagement. Fam Med. 2017 Oct;49(9):730-733.
---------------------------------------------------------------------------
    Education: Medical school graduates play a pivotal role in 
educating their patients and colleagues; screening, diagnosing, and 
treating patients; and modeling positive attitudes to reduce the stigma 
attached to SUDs. Research demonstrates that SUD educational 
interventions, using various approaches and durations, produce a 
positive impact on medical students' knowledge, skills, and 
attitudes.\11\ Studies also reveal that simply increasing exposure to 
patients with addiction does not provide the formative knowledge 
required to identify, treat or even prevent SUDs without the presence 
of a concurrent, comprehensive didactic curriculum.\12\ Even as the 
overdose crisis deepens, there remains wide heterogeneity in SUD 
curricula across medical schools.\13\ This adversely impacts patient 
care--a lack of preparedness has been identified as a barrier in the 
provision of buprenorphine to patients with opioid use disorder by 
early career family physicians.\14\ Moreover, a lack of appropriate 
education has also been shown to foster negative attitudes towards the 
treatment of SUD with buprenorphine.\15\ Such negative attitudes 
adversely impact patient-physician dialogues and contribute to the 
under treatment of SUDs by primary care and specialty providers.\16\ 
Comprehensive and uniform medical school teaching on SUDs, addiction, 
and treatment modalities has the potential to overcome these deficits 
and to positively impact all graduates and their patients. It also 
represents an important area of engagement with academic institutions. 
The Provider's Clinical Support System--Universities (PCSS-
Universities) grant will be used to address this need and would be 
further supported by the increase proposed in the fiscal year 2022 
President's Budget Request.
---------------------------------------------------------------------------
    \11\ Muzyk A, Smothers ZPW, Akrobetu D, Ruiz Veve J, MacEachern M, 
Tetrault JM, Gruppen L. Substance Use Disorder Education in Medical 
Schools: A Scoping Review. Acad Med. 2019 Nov;94(11):1825-1834. doi: 
10.1097/ACM.0000000000002883. PMID: 31663960.
    \12\ Tetrault, J. Improving Health Professions Education to Treat 
Addiction: The Time Has Come. The Josiah Macy Jr Foundation, News and 
Commentary. May 2018.
    \13\ Blanco, C., Wiley, T.R.A., Lloyd, J.J. et al. America's opioid 
crisis: the need for an integrated public health approach. Transl 
Psychiatry 10, 167 (2020). https://doi.org/10.1038/s41398-020-0847-1.
    \14\ DeFlavio JR, Rolin SA, Nordstrom BR, Kazal LA Jr. Analysis of 
barriers to adoption of buprenorphine maintenance therapy by family 
physicians. Rural Remote Health. 2015;15:3019.
    \15\ Tong ST, Hochheimer CJ, Peterson LE, Krist AH. Buprenorphine 
Provision by Early Career Family Physicians. Ann Fam Med. 
2018;16(5):443-446. doi:10.1370/afm.2261
    \16\ Kennedy-Hendricks A, Busch SH, McGinty EE, et al. Primary care 
physicians' perspectives on the prescription opioid epidemic. Drug 
Alcohol Depend. 2016;165:61-70.
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    Reducing Stigma: Stigma can reduce willingness of policymakers to 
allocate resources, reduce willingness of providers in non-specialty 
settings to screen for and address substance misuse , and may limit 
willingness of individuals with SUDs to seek treatment.\17\ Negative 
attitudes toward patients with substance use disorder are common among 
health professionals, who generally lack adequate education, training 
and support structures to effectively serve patients with SUD. Health 
professionals' negative attitudes reduced patients' feelings of 
empowerment and diminished treatment outcomes. These attitudes resulted 
in less provider engagement, a more task-oriented approach to care 
delivery, and diminished empathy.\18\ All of these factors may help 
explain why so few individuals with SUDs receive treatment. Public 
education that reduces stigma and provides information about treatment 
is needed. This represents an opportunity to engage across multiple 
disciplines and modalities. Among others, PCSS-U and SOR grants seek to 
overcome stigma. The fiscal year 2022 President's Budget requested 
increases for both programs.
---------------------------------------------------------------------------
    \17\ Yang LH, Wong LY, Grivel MM, Hasin DS. Stigma and substance 
use disorders: an international phenomenon. Curr Opin Psychiatry. 
2017;30(5):378-388.
    \18\ van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. 
Stigma among health professionals towards patients with substance use 
disorders and its consequences for healthcare delivery: Systematic 
review. Drug and Alcohol Dependence. 2013;131(1):23-35.
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    Partnering With Public Safety Officials And Community 
Organizations: Working with law enforcement, community groups, 
patients, and treatment teams to address the growing overdose epidemic 
has the potential to channel new ideas, data sources, and efforts 
towards reducing mortality and use of illicit substances. Such 
engagement promotes cross collaboration and encourages the creation of 
innovative and community focused interventions, such as pre- and post-
arrest deflection to treatment. Increases proposed to SAMHSA grants 
such as the First Responder Training/Rural Emergency Medical Services 
can help address this need.
    Question. This Subcommittee has worked in a bipartisan fashion to 
provide $4 billion in fiscal year 2021 to address the opioid epidemic, 
including $1.5 billion for State Opioid Response grants. This is a 
flexible grant provided directly to states to use funds as they see 
fit. Unfortunately, we continue to hear that states are not spending 
those funds in a timely manner. Does HHS know why this is the case?
    Answer. The State Opioid Response (SOR) grants give states 
flexibility in providing a range of prevention, treatment, and recovery 
support services for opioid and stimulant use disorders. The grants 
also support infrastructure development to enhance/expand systems of 
care. One of the most common reasons grantees attribute spending 
challenges to is state procurement processes. Procurement challenges 
include state legislative timelines that do not align with Federal 
appropriation cycles; reluctance from contract bidders because of the 
short duration of the grant (i.e., 2 years); and delays that result 
from contract negotiations. Grantees have also cited challenges related 
workforce shortages. Additionally, the COVID-19 pandemic has also 
impacted states' ability to spend funds.
    Question. How does this trend align with the 50 percent budget 
increase for SOR?
    Answer. The fiscal year 2022 President's Budget increased the State 
Opioid Response grant program to allow grantees to enhance and expand 
evidence-based opioid and stimulant use disorder prevention, treatment 
and recovery support activities currently underway. Additionally, 
grantees will have the ability to increase their focus and efforts on 
continued areas of need such as workforce development, harm reduction 
and public education and training. This will also increase access to 
opioid and stimulant use disorder treatment services in states, 
territories, and tribes. Within this total, SAMHSA will direct $75 
million to the Tribal Opioid Response grant program to specifically 
address the opioid substance use needs in tribal communities. This 
critical investment will drive funding to States and Tribes to increase 
community-level response to the opioid crisis, expand access to 
evidence-based treatment and recovery services, and provide targeted 
investment to crisis services and recovery support services. HHS is 
committed to working to ensure that the SOR program supports states in 
addressing and investing in evidence-based treatment and recovery 
services for the ongoing opioid and substance use epidemic. SAMHSA is 
committed to providing technical assistance to ensure states understand 
how they can utilize these funds, as well as oversight to ensure funds 
are spent appropriately in a timely manner.
    Question. What can be done to increase the spending rates by 
states?
    Answer. Currently, SAMHSA monitors grantees' program implementation 
activities and provides feedback to states when benchmarks are not 
being met. SAMHSA also has a wealth of general and targeted technical 
assistance resources that SOR grantees may access. For example, the 
Addiction Technology Transfer Center (ATTC) Network is a 
multidisciplinary resource for professionals in the addiction treatment 
and recovery services field. The ATTC Network's mission and vision are 
to: accelerate the adoption and implementation of evidence-based and 
promising addiction treatment and recovery-oriented practices and 
services; heighten the awareness, knowledge, and skills of the 
workforce that addresses the needs of people with substance use or 
other behavioral health disorders; and foster regional and national 
alliances among culturally diverse practitioners, researchers, policy 
makers, funders, and the recovery community. SAMHSA also funds the 
Opioid Response Network (ORN) which was designed to provide training 
and other resources in efforts to address the opioid crisis. The ORN 
has local consultants in all 50 states and nine territories to respond 
to local needs by providing free educational resources and training to 
states, communities and individuals in the prevention, treatment and 
recovery of opioid use disorders and stimulant use. SAMHSA has also 
extended flexibilities to grantees considering the COVID-19 pandemic 
including granting no-cost extensions to give grantees up to an 
additional 12 months to use any unexpended funds from the official 
grant period.
    Question. To respond to the changing nature of the opioid epidemic, 
the fiscal year 2020 LHHS bill expanded the State Opioid Response grant 
authority to allow states to use funds on stimulants, like cocaine and 
methamphetamine. Mr. Secretary, how is the rising use of stimulants 
impacting the ability for state and local communities to provide 
effective treatment for opioid use disorders?
    Answer. The Department has no evidence to suggest that the rise in 
use of stimulants is impacting states' ability to provide effective 
treatment for opioid use disorders.
    It is important to consider stimulant misuse in the context of 
polysubstance misuse--increasingly, substances are not used in 
isolation. Individuals with polysubstance misuse involving alcohol, 
marijuana, opioids, and/or stimulants receive care in a variety of 
settings, and often require withdrawal management, psychological and 
FDA-approved pharmacological treatment, and monitoring as part of their 
care plan.
    SAMHSA recently created an Evidence-Based Practice Guide to address 
polysubstance misuse. Through a literature review and consensus from 
technical experts, SAMHSA identified three effective practices used to 
treat polysubstance misuse in adults. These are (1) FDA-approved 
pharmacotherapy with counseling; (2) Contingency management (CM) with 
FDA-approved pharmacotherapy and counseling, and (3) Twelve-step 
facilitation (TSF) therapy with FDA-approved pharmacotherapy. These 
treatments should be delivered in a patient-centered and integrated 
manner in order to achieve the best outcomes. Many facilities offer 
such treatments, and they demonstrate a high level of success.
    There currently are no Food and Drug Administration-approved 
medications specific for stimulant use disorders, making it important 
that behavioral health and healthcare service providers understand and 
offer (or offer referrals for) CM or other psychosocial treatments. 
Despite an increase in research into psychosocial treatments for people 
with stimulant use disorders, currently the only treatment with 
significant evidence of effectiveness is CM. Other psychosocial 
treatments that have some support (especially if used in combination 
with CM) are cognitive--behavioral therapy/relapse prevention, 
community reinforcement, and motivational interviewing. These 
interventions demonstrate efficacy in treating stimulant use disorder 
across age ranges. SAMHSA's State Opioid Response grants allow the use 
of Federal funds to provide CM. In treating stimulant use disorder, 
clinicians also are recommended to promote harm reduction (especially 
because of the high level of contamination of the drug supply with 
fentanyl and analogs) through educating about needle exchange programs, 
offering naloxone, and encouraging the use of fentanyl test strips, as 
these strategies can help save lives.
                       ``ending hiv'' initiative
    Question. I was pleased to see the fiscal year 2022 budget increase 
of $267 million for the Ending the HIV Epidemic initiative, started by 
this Subcommittee in fiscal year 2020. The Trump Administration, 
however, was notably more aggressive in their funding requests to 
address the HIV epidemic, requesting $716 million in the second year of 
the initiative. After the challenging year of the pandemic, where do we 
stand as a nation in combatting new HIV infections?
    Answer. Although it is too early to assess quantitatively the full 
impact of COVID-19 on HIV research, based on listening sessions 
conducted by the NIH OAR across the United States, the COVID-19 
pandemic has placed a tremendous strain on sustaining research in 
general. Basic and translational research unrelated to COVID-19 in 
academic settings was suspended for months, severely delaying progress 
for trainees and principal investigators. Healthcare workers and 
clinical researchers were diverted to the care of COVID-19 patients, 
while clinical research resources had to be redirected to COVID-19.\19\ 
Recruitment and staffing for HIV and other clinical trials was halted 
due to distancing, travel restrictions and ``lockdown'' measures. 
Broadly, public health measures required to control the spread of 
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have led 
to societal restrictions that have negatively impacted the economy and 
limited access to routine non-emergency healthcare. Specifically, the 
COVID-19 pandemic has had a negative effect on HIV testing, linkage to 
care, and access to treatment and HIV research laboratories and 
investigation sites.
---------------------------------------------------------------------------
    \19\ nature.com/articles/s41581-020-00336-9.
---------------------------------------------------------------------------
    Preliminary reports suggest that COVID-19 is likely to affect key 
HIV study outcomes. For example, adverse events may be caused by SARS-
CoV-2 infection or by deferral of care for other health issues due to 
fear of contracting SARS-CoV-2 infection. Research study participants 
likely changed their lifestyles to minimize contact with others, which 
may affect research outcomes. SARS-CoV-2 infection could worsen HIV 
comorbidities, such as glycemic control in persons with diabetes, blood 
pressure control in those with hypertension, or accelerate progression 
of chronic kidney disease.\20\
---------------------------------------------------------------------------
    \20\ academic.oup.com/jid/advance-article/doi/10.1093/infdis/
jiab114/6167835.
---------------------------------------------------------------------------
    The impact of COVID-19 on HIV research has been bidirectional. 
Contributions by the HIV researchers and community to COVID-related 
efforts are significant: from the successful mRNA vaccine platform, to 
clinical trials networks for testing candidate vaccines, to rapid 
testing and molecular epidemiology for tracking--the HIV research 
footprint is widely recognized in the response to COVID-19. In 
addition, there have been some positive aspects related to the COVID-19 
response, such as the accelerated innovations that have advanced the 
way we conduct clinical research overall. These include new approaches 
to conduct remote visits by telehealth, use home-based testing or 
monitoring technologies. The NIH OAR HIV and COVID-19 Taskforce is 
meeting to discuss further impacts of the COVID-19 pandemic on HIV 
research progress and investigator retention within the NIH extramural 
community.
    Question. What factors were considered for the fiscal year 2022 
funding request? Please provide an updated cost estimate of resources 
needed over the next 5-years, by fiscal year and Operating Division for 
the Ending the HIV Epidemic initiative.
    Answer. The Centers for Disease Control and Prevention (CDC) 
developed a methodology to estimate the number of people who need to be 
tested, diagnosed, and provided HIV medical care and treatment or PrEP. 
The CDC's methodology then informed the initial EHE budget for HRSA, 
which was developed to meet the EHE goal of enrolling newly diagnosed 
and people with HIV no longer in care into EHE-funded medical, 
treatment, and support services.
    CDC provided data to HRSA on the number of diagnosed people with 
HIV in each Eligible Metropolitan Area, Transitional Grant Area, or 
State (not just the county of interest). HRSA then used CDC estimates 
for the percent of people with HIV who are undiagnosed in each state to 
calculate estimated undiagnosed. Using this data, overall cost 
estimates were then developed using the average RWHAP costs per person 
served.
    The HRSA cost estimates for the EHE initiative are outlined in the 
table below. The Health Center fiscal year 2022 budget request for the 
EHE Initiative was developed in the context of increasing participation 
in the Phase I targeted areas. The estimated number of clients served 
(reflected below) through the EHE were adjusted from the initial 
estimates for the EHE initiative to align with appropriated funds.
    Projections for fiscal year 2023 and beyond are under development.


                          [Dollars in millions]
------------------------------------------------------------------------
                                                    Fiscal Year
                                         -------------------------------
                                           2021 Enacted     2022 Budget
------------------------------------------------------------------------
Health Centers..........................         $102.25         $152.25
HAB EHE.................................         $105.00         $190.00
                                         -------------------------------
    Total...............................         $207.25         $342.25
                                         -------------------------------
Estimated Clients:
Budget Health Centers (PrEP)............         285,000         425,000
HAB EHE.................................          27,000          50,000
------------------------------------------------------------------------

    Question. The jurisdictions involved in the Ending the HIV Epidemic 
program have invested significant resources. Do you anticipate any 
changes to the geographic distribution of the funding?
    How does the initiative account for new HIV outbreaks, such as 
what's happening in West Virginia, which wasn't one of the seven 
targeted states?
    Answer. No, HRSA does not anticipate any changes to the geographic 
distribution of funding in fiscal year 2022.
    HRSA health centers continue to make HIV prevention technical 
assistance and training available nationwide, including those centers 
with increasing HIV prevalence in their communities. In total for 
fiscal year 2020, health centers across the U.S. reported providing 
approximately 2.5 million HIV tests and PrEP related services to 
389,000 health center patients.
    HRSA also responds to HIV outbreaks through the RWHAP's established 
care, treatment and support systems in partnership with the CDC. Since 
2015, HRSA's RWHAP has worked closely with CDC to address HIV outbreaks 
that have resulted from injection drug use, such as what is happening 
in West Virginia. This collaboration has been crucial in helping states 
and local communities identify those at risk for HIV due to injection 
drug use, getting at-risk individuals tested for HIV and hepatitis C, 
and getting people linked to and engaged in services for HIV and 
hepatitis care or for pre-exposure prophylaxis, substance use disorder 
treatment and other needed services.
                supplemental and reconciliation funding
    Question. In response to the COVID-19 pandemic, states have 
received billions of dollars in aid, with the intent of giving them 
maximum flexibility to respond to their unique needs and challenges. It 
is my understanding there is a sizable portion of unobligated funds 
remaining from the bipartisan emergency supplemental bills. And now 
there is even more funding provided for similar activities as part of 
the partisan reconciliation bill. While it is important to know how 
fast HHS is getting this funding into the hands of the frontline 
responders on the state level, it is just as important to know if the 
states are actually spending the money. What are the spend rates that 
HHS is seeing at the state level?
    Answer. HHS has awarded over $146 billion to states across six 
supplemental appropriations. In many cases, funds were directed to 
states by Congress in the COVID supplemental appropriations. As of 
early November, award recipients have drawn down $29.5 billion, or 
twenty percent, of the total funding awarded. When examining the first 
four supplementals, state recipients have drawn down at least 50 
percent or significantly higher percentages for resources appropriated 
at the earliest stages of the pandemic. Evaluating how the funds are 
being used cannot be achieved by examining draw down data alone since 
it is not a good indicator of how much jurisdictions have spent. States 
and jurisdictions are able to bill again their awards through the end 
of the established period of performance for that specific award. 
Funding recipients will typically draw down funds as expenses are 
incurred or after activities are executed and invoices are reconciled 
to confirm reimbursement totals. Drawdowns may occur monthly, 
quarterly, or at another frequency depending on the awardee. As a 
result there can be a significant time lag in the draw down data since 
actual state and jurisdiction expenditures are usually greater than the 
amount reflected in our draw down data. HHS grants policies and 
regulations require monitoring and award recipient reporting and HHS 
agencies closely monitor award recipient performance, activities, and 
progress through regular engagement.
    Question. What accountability do the states have to tell the 
Department how they used the funds?
    Answer. With respect to Centers for Disease Control and Prevention 
(CDC) grant awards, HHS awarding agencies adhere to HHS Grant Policies 
and Regulations, which detail required monitoring and reporting for 
award recipients. These may differ in frequency by type of award or 
program.
    CDC for example continuously and closely monitors recipient/
jurisdiction performance, activities, and progress through regular 
engagement. Monitoring activities include routine and ongoing 
communication between CDC and recipients, site visits, and recipient 
reporting (including work plans, performance, and financial reporting). 
Monitoring includes tracking recipient progress in achieving the 
desired outcomes, ensuring the adequacy of recipient systems that 
underlie and generate data reports, and creating an environment that 
fosters integrity in program performance and results.
    Monitoring may also include the following activities deemed 
necessary to monitor an award.
  --Ensuring that work plans are feasible based on the budget and 
        consistent with the intent of the award.
  --Ensuring that recipients are performing at a sufficient level to 
        achieve outcomes within stated timeframes.
  --Working with recipients on adjusting the work plan based on 
        achievement of outcomes, evaluation results and changing 
        budgets.
  --Monitoring performance measures (both programmatic and financial) 
        to assure satisfactory performance levels.
    CDC complies with HHS requirements to implement internal tracking 
methods for issued Federal awards. Award recipients report expenditures 
into HHS' Payment Management System (PMS) quarterly and submit a Final 
Financial Report 90 days after the end of the budget period. All awards 
have assigned budget activity codes that are used to track and monitor 
funding
    Question. Given the unprecedented amount of funding going out from 
HHS as a result of the partisan reconciliation bill, can you explain 
HHS' decisionmaking process and planning mechanisms for deploying such 
large sums of money in such a short period of time?
    How does HHS plan for states and the public health infrastructure 
to sustain these advancements when the funding runs out?
    Answer. The American Recuse Plan provided over $160 billion for 
activities across HHS agencies. The legislation identified specific 
purposes for the resources appropriated to HHS agencies and many were 
intended to support states public health. In many cases, HHS was able 
to leverage existing program mechanisms to efficiently and quickly 
execute funding. For example, the American Rescue Plan appropriated 
substantial resources for existing block grants within ACF for child 
care development, and for mental health and to prevent substance abuse 
within SAMHSA. HHS was able to leverage existing program mechanisms to 
rapidly award funds when they were needed most by the population served 
by these critical programs. These large infusions of funds are 
supporting state implemented programs to meet both demands and other 
challenges presented during the COVID pandemic. Looking forward, HHS 
will work within the Administration to identify future investments in 
public health programs through the annual budget process taking into 
consideration experiences from the COVID response.
    Question. The Administration has placed an emphasis on addressing 
health equity, especially as it relates to the pandemic response 
efforts. What trends are you seeing in rural communities right now with 
regard to the pandemic?
    How does the HHS' health equity work account for the needs of rural 
communities?
    Answer. COVID had a disproportionate impact in rural areas given 
limited clinical infrastructure (for example, fewer number of beds, 
workforce staffing issues already a challenge pre-pandemic, challenges 
accessing PPE). Rural communities suffered with high case rates and 
high mortality rates, often worse than in urban areas.
    HHS has been intentional about targeting COVID relief to rural 
communities (and those populations with at higher risk within rural)--
for example HRSA provided funding to grantees in the Mississippi Delta 
Region to promote the vaccine, supported regional trainings for 
community health workers in that region as well as the region along the 
U.S.--Mexico border, programs that have been proven effective in 
populations of racial and ethnic minorities that often face even higher 
health disparities than the broader rural populations.
    Programs this year targeted Rural Health Clinics and small rural 
hospitals to support testing and mitigation activities for these key 
providers of the rural health safety net. Additionally, funding to 
support vaccine distribution and confidence was distributed to Rural 
Health Clinics--getting funding to trusted community providers.
    We are enhancing our focus on the need to look at rural health 
issues through the lens of health equity; expanding the use of our 
research centers to gather more data to inform future work in this 
area; and providing targeted outreach to key underserved communities 
and populations to help them leverage our funding.
    Question. Throughout the pandemic, and to date, we have heard 
concerns about the impact to the NIH research community. For example, 
scientists who had to close their labs and cull their animals lost 
valuable research data and post-doctoral candidates couldn't finish 
their research in time to get jobs in September. What is the strategy 
for using fiscal year 2021 or fiscal year 2022 dollars for COVID-19 
related expenses and how much of non-emergency supplemental funding has 
been used by agencies to address these concerns?
    Answer. As noted in the question, research on many NIH grants was 
impacted by the pandemic, causing delays in research activities and 
outcomes. NIH is considering various strategies to address these 
coronavirus disease 2019 (COVID-19) related expenses to support our 
recipients, such as:
  --Providing extensions, both funded and un-funded, for recipients of 
        NIH Fellowship (F) and NIH Career Development (K) awards who 
        have been impacted by COVID-19 \21\
---------------------------------------------------------------------------
    \21\ grants.nih.gov/grants/guide/notice-files/NOT-OD-21-052.html.
---------------------------------------------------------------------------
  --Supporting administrative supplements, competitive revisions, and 
        extensions to existing grants
  --Allowing extensions to one's early-stage investigator status due to 
        effects related to pandemic shutdowns \22\
---------------------------------------------------------------------------
    \22\ nexus.od.nih.gov/all/2020/04/09/can-esi-status-be-extended-
due-to-disruptions-from-covid-19/.
---------------------------------------------------------------------------
  --Temporary extensions of eligibility for select NIH programs, 
        including the NIH K99/R00 Pathway to Independence Award \23\
---------------------------------------------------------------------------
    \23\ NOT-OD-21-158 and NOT-OD-21-106, and those listed on 
grants.nih.gov/policy/natural-disasters/corona-virus.htm under 
Temporary Extension of Eligibility.
---------------------------------------------------------------------------
  --Flexibilities for NIH-funded clinical trials and human subjects for 
        the duration of the declared public health emergency \24\
---------------------------------------------------------------------------
    \24\ NOT-OD-20-087 and grants.nih.gov/sites/default/files/
Considerations-New-Ongoing-Human-Subjects-Research-During-the- COVID-
19-Public-Health-Emergency.docx.
---------------------------------------------------------------------------
  --Flexibilities for assured institutions for activities of 
        institutional animal care and use committees \25\
---------------------------------------------------------------------------
    \25\ 25 NOT-OD-20-088.
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    The budgetary impact of these flexibilities and additional funding 
on new grants funded is not yet fully known. NIH will continue to 
analyze the data on the impact of COVID-19 on the biomedical research 
community, and its potential impact on our budget and grant activities.
    NIH received the authority in Section 152 of the Continuing 
Resolution signed into law in September 2020 to extend multi-year 
funded grants awarded in fiscal year 2015, specifically for those 
active when the COVID-19 public health emergency was declared.\26\ The 
project period end dates for those limited number of awards were 
extended through August 31, 2021. NIH is also requesting a similar 
extended disbursement authority for certain amounts available for 
obligation through fiscal year 2016 that were obligated for multi-year 
research grants, such that those amounts would continue to be available 
through fiscal year 2022.
---------------------------------------------------------------------------
    \26\ 26 Section 152. (a) Funds made available in Public Law 113--
235 to the accounts of the National Institutes of Health that were 
available for obligation through fiscal year 2015 and were obligated 
for multi-year research grants shall be available through fiscal year 
2021 for the liquidation of valid obligations incurred in fiscal year 
2015 if the Director of the National Institutes of Health determines 
the project suffered an interruption of activities attributable to 
SARS--CoV--2. (b)(1) This section shall become effective immediately 
upon enactment of this Act.
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                               influenza
    Question. Influenza occurs seasonally each year, and has on 
occasion caused devastating pandemics in the past. Reports are already 
speculating that the next flu season may be bad after a year of hardly 
any flu cases. The budget requests an increase of $25 million for CDC 
Influenza Planning and Response and an increase of $48 million for 
ASPR's Pandemic Flu program. Are these resources sufficient to meet the 
needs outlined in the U.S. National Influenza Vaccine Modernization 
Strategy, which projected far greater needs over 10 years?
    How will the budget request advance the National Strategy?
    Answer. The budget request aligns with and supports the pandemic 
influenza strategy. The key investments you note are also critical down 
payments to incorporate what we are learning in the ongoing COVID-19 
response. Specifically, the budget provides $335 million, an increase 
of $48 million above fiscal year 2021 enacted, for pandemic influenza 
preparedness activities carried out by ASPR and the Office of Global 
Affairs (OGA). ASPR will continue to support priorities in the 2019 
Executive Order, ``Modernizing Influenza Vaccines in the United States 
to Promote National Security and Public Health,'' and apply lessons 
learned from the COVID-19 response to improve pandemic influenza 
response capabilities. Through established public-private partnerships, 
ASPR will advance non-egg-based vaccine platforms, including more 
flexible manufacturing technologies (e.g., cell-based and recombinant 
technologies) that can produce influenza vaccine more quickly in the 
event of a pandemic. The budget also supports the development of 
alternative devices for vaccine administration to allow for rapid, 
large-scale vaccinations. The COVID-19 pandemic response has 
demonstrated the importance of therapeutics that can prevent 
progression to severe disease and treat severely ill individuals.
    ASPR will continue to support the advanced development of new 
influenza therapeutics and diagnostic platforms to allow for earlier 
detection and, subsequently, faster treatment of influenza infections. 
OGA will continue to enhance international influenza preparedness by 
providing strategic coordination and technical expertise on health 
policy development and diplomacy to global partners, including nearly 
200 Ministries of Health.
    In addition, CDC provides technical expertise, resources, and 
leadership to support diagnosis, prevention, and control of influenza 
domestically and to address the threat posed by seasonal and pandemic 
influenza. The fiscal year 2022 Centers for Disease Control and 
Prevention budget request invests an additional $25 million to continue 
supporting implementation of the influenza planning and response 
activities outlined in the 2020-2030 National Influenza Vaccination 
Modernization Strategy. These activities include expanding vaccine 
effectiveness monitoring and evaluation, enhancing virus 
characterization, and expanding vaccine virus development for use by 
industry, increasing genomic testing of influenza viruses, and 
increasing influenza vaccine use.
                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby
    Question. On August 2, 2019, the Centers for Medicare and Medicaid 
Services (CMS) finalized the Inpatient Prospective Payment System 
(IPPS) payment rule, which updated Medicare payment policies for 
hospitals in states with a low Area Wage Index (AWI). CMS's AWI 
calculation has plagued states like Alabama since its inception. Prior 
to the IPPS rule being finalized in August 2019, Alabama had the lowest 
AWI floor and ceiling of any state in the country, around .66 and .8 
respectively. The IPPS rule made formula changes to Medicare's AWI for 
fiscal years 2020--2024, which have benefitted several states to this 
point, including Alabama, by boosting annual hospital revenue for 
Alabama hospitals collectively by $35--$40 million annually, which 
saved many rural hospitals from closing their doors prior to the COVID-
19 pandemic.
    This is an important issue to all residents of Alabama. The ability 
to deliver healthcare in small towns maintains their ability to recruit 
businesses to the area. What are your thoughts on the AWI changes that 
were made in the fiscal year 2020 IPPS final rule?
    Answer. The Inpatient Prospective Payment System (IPPS) pays 
hospitals for services provided to Medicare beneficiaries using a 
national base payment rate, adjusted for a number of factors that 
affect hospitals' costs, including the cost of hospital labor in the 
hospital's geographic area. This adjustment, or Area Wage Index, is 
updated by CMS annually.
    In the fiscal year 2020 IPPS Final Rule,\27\ to help mitigate wage 
index disparities between high wage and low hospitals, CMS adopted a 
policy to increase the wage index values for certain hospitals with low 
wage index values (the low wage index hospital policy). This policy was 
adopted in a budget neutral manner through an adjustment applied to the 
standardized amounts for all hospitals. CMS also indicated that this 
policy would be effective for at least 4 years, beginning in fiscal 
year 2020, in order to allow employee compensation increases 
implemented by these hospitals sufficient time to be reflected in the 
wage index calculation. For fiscal year 2022, CMS is continuing the low 
wage index hospital policy.
---------------------------------------------------------------------------
    \27\ Final Rule (CMS-1716-F) and Correction Notice (CMS-1716-CN2) 
available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AcuteInpatientPPS/fiscalyear2020-
IPPS-Final-Rule-Home-Page-Items/fiscalyear2020-IPPS-Final-Rule-
Regulations.
---------------------------------------------------------------------------
    Question. I understand that the pending fiscal year 2022 IPPS rule 
includes some significant policy changes regarding organ 
transplantation, which could yield a significant negative impact to 
transplant centers. Constituents have told me that the rule was written 
without input from stakeholders in the transplant community, without 
adequate analysis of the impact to patients' access to transplantation, 
and without consideration of budgetary impact, if any, on state 
Medicaid/CHIP programs. I am concerned about unintended consequences if 
this rule were to go into effect, including to access to care, 
especially for the children.
    Will you ensure that my concerns will be addressed before this rule 
is finalized? Will you also engage with all stakeholders on the issues 
I've raised?
    Answer. The Medicare Program supports organ transplantation by 
providing an equitable means of payment for the variety of organ 
acquisition services. I can assure you that CMS will take all comments 
and concerns into consideration before issuing a final decision on the 
proposed Medicare usable organ counting policy.
    Question. The overall budget requests $10.7 billion to fight the 
opioid epidemic. Previous Administrations have spent billions of 
dollars on all aspects of the epidemic including prevention, research, 
education, and treatment and there are still severe issues.
    Please provide details as to how the Department plans to spend this 
money and how it will have a different impact than the money spent 
before.
    Answer. The budget takes action to address the epidemic of opioids 
and other substance use, investing $11.2 billion, including $10.7 
billion in discretionary funding, across HHS, $3.9 billion more than in 
fiscal year 2021. The impact of this epidemic is felt in our 
communities, and the budget will direct funding to states and Tribes to 
increase community-level response. The budget will also increase access 
to medications for opioid use disorder and expand the behavioral health 
provider workforce, particularly in underserved areas. HHS will 
continue to build on the investments the American Rescue Plan provided 
to the Substance Abuse Prevention and Treatment Block Grant, Community 
Mental Health Services Block Grant, and Certified Community Behavioral 
Health Centers. This crisis is evolving--overdose deaths involving 
substances other than opioids are also increasing. HHS will ensure our 
work is responsive to the needs of communities across the country.
    Specifically, the $3.9 billion increase in funding includes:
  --FDA: +$38 million above fiscal year 2021, for a total of $113 
        million, to develop opioid overdose reversal treatments and 
        treatments for opioid use disorder and continue to support 
        opioid research efforts.
  --HRSA: +$190 million above fiscal year 2021, for a total of $1.1 
        billion to increase behavioral health workforce grant programs 
        and expand response to the opioid crisis in rural communities.
  --IHS: +$27 million above fiscal year 2021, for a total of $42 
        million to expand activities that increase access to culturally 
        appropriate opioid use interventions, including medication-
        assisted treatment, for American Indians and Alaska Natives 
        ($15 million) and improve prevention and treatment of Hepatitis 
        C and HIV in tribal communities ($27 million). The prevalence 
        of Hepatitis C and HIV in Indian Country is closely linked to 
        rates of injection drug use.
  --CDC: +$244 million above fiscal year 2021, for a total of $733 
        million to address infectious diseases associated with 
        injection drug use and expand opioid overdose prevention 
        programs to communities heavily impacted by the overdose 
        crisis. The additional resources will support collection and 
        reporting of real-time, robust mortality data and investments 
        in prevention for people put at highest risk as well as for 
        testing, diagnosis, linkage to care, and treatment for 
        infectious diseases related to injection drug use.
  --NIH: +$627 million above fiscal year 2021, for a total of $2.2 
        billion to increase opioid, stimulant, and substance use 
        research. Within this total, $811 million supports the Helping 
        to End Addiction Long-term (HEAL) Initiative, NIH's aggressive, 
        trans-agency effort to provide scientific solutions to the 
        opioid crisis. Over $1.4 billion supports ongoing research in 
        this critical area.
  --SAMHSA: +$2.7 billion above fiscal year 2021, for a total of $6.8 
        billion to increase funding for SAMHSA block grants and grant 
        programs directing funding to local public health response to 
        the substance use and opioid crisis, including Certified 
        Community Behavioral Health Clinics. This increase also will 
        expand access to treatment for pregnant and post-partum women, 
        access to medication-assisted treatment, access to recovery 
        support services, and access to drug treatment activities.
  --AHRQ: +$7 million above fiscal year 2021, for a total of $10 
        million for new research grants to increase equity in substance 
        use disorder (SUD) treatment access and outcomes, accelerate 
        the implementation of effective evidence-based care in primary 
        and ambulatory care, and develop whole person models of care 
        that address the social factors that shape SUD treatment 
        adherence and long-term recovery.
  --CMS: +$12.9 million above fiscal year 2021, for a total of $16.3 
        million, to increase opioid activities, including funding 
        certain SUPPORT Act provisions. The funding requested will be 
        used for data and information technology needs, provider 
        education, monitoring and auditing, performance measurement, 
        and claims analysis. CMS will continue to provide technical 
        assistance to states on behavioral health, developing an 
        updated opioid and SUD Action Plan, working with the Office of 
        National Drug Control Policy on the National Drug Control 
        Strategy, and collaborate with other HHS operating divisions on 
        opioid and SUD actions, behavioral health, and pain 
        initiatives.
  --ACF: +$40 million above fiscal year 2021, for a total of $140 
        million to increase state child abuse prevention grant funding 
        focusing on developing infant safe care plans and expansion of 
        kinship navigator and regional partnership grants which assist 
        families at risk due to substance use of a family member.
  --ACL: +$1 million above fiscal year 2021, for a total of $3 million 
        to increase grants for adult protective services and opioid-
        related activities to maximize the impact on direct services to 
        the most affected clients.
    The fiscal year 2022 President's Budget provides $713 million for 
CDC's opioid overdose prevention and surveillance activities, which is 
an increase of $239 million from fiscal year 2021. With the support of 
Congress and increases in appropriations in previous years, CDC has 
scaled its overdose surveillance and prevention program from 5 states 
in 2014 to 47 states, 16 localities, and two territories today.
    With the fiscal year 2022 increased funding request, CDC would 
continue improving the timeliness and comprehensiveness of drug 
overdose data and scaling overdose prevention strategies, evaluation, 
and applied research. Because successful response strategies must be 
tailored to local communities, CDC would also use the increased funding 
to scale local investments so more local communities can quickly 
identify changes in local drug supply and prevent overdoses. The 
increased funding would also support states and communities that 
require additional resources to respond to an increase in overdoses due 
to the COVID-19 pandemic.
    Question. After significant investment over the past several years, 
state Prescription Drug Monitoring Programs (PDMPs) are still not real-
time, not interoperable, and are not incorporated into a provider's 
workflow, yet the technology exists to fix all these issues. How does 
your budget support improvements to PDMPs and will any funds 
specifically support upgrading these systems to address the concerns 
I've outlined?
    Answer. CDC's goal is to maximize interconnectivity of all 
resources within this space. CDC's Overdose Data to Action (OD2A) 
program expanded previous Prescription Drug Monitoring Program (PDMP) 
investments and has worked to make PDMPs easier to use and more 
accessible to both clinicians and under-resourced communities. Under 
OD2A, required activities related to PDMPs include:
  --Universal use among providers within a state
  --Inclusion of more timely or real-time data contained within a PDMP
  --Actively managing the PDMP in part by sending proactive or 
        unsolicited reports to providers to inform prescribing
  --Ensuring that PDMPs are easy to use and access by providers
  --Propose activities to enhance and maximize the use of PDMPs, such 
        as moving towards real-time data collection
    In addition to the base OD2A funding provided to recipients to 
implement required PDMP activities, states were provided with the 
option to apply for additional funds to make PDMP data more actionable 
both within and across state borders. Activities under this 
supplemental funding include integrating state PDMPs with other health 
systems data and integrating the PDMP across state lines/interstate 
operability.
    With Federal funding and substantial technical assistance provided 
by CDC, the Bureau of Justice Administration (BJA), the Centers for 
Medicaid & Medicare Services (CMS),SAMHSA, and the Office of the 
National Coordinator for Health Information Technology (ONC), states 
have made significant strides in reporting data faster and achieving 
interstate and intrastate PDMP operability, most commonly via the 
RxCheck hub or PMP Interconnect. As of May 2021, there are 46 
jurisdictions that are live on the RxCheck hub and actively able to 
share data across state lines. PMP Interconnect, from the National 
Association of Boards of Pharmacy, currently includes 51 participating 
jurisdictions. In addition to those jurisdictions sharing data across 
states, 45 states and territories are also engaged in intrastate 
integration with electronic health records (EHRs), Health Information 
Exchanges (HIEs), and Pharmacy Dispensing Systems. CDC collaborated 
with other Federal partners to support PDMP/EHR integration in states 
through several different projects, including OD2A. CDC also 
collaborated with Office of the National Coordinator for Health 
Information Technology to select three states (Kentucky, Utah, and 
Illinois) as pilots to demonstrate how to integrate PDMP data with EHR 
information through the RxCheck Hub.
    Currently, only the Oklahoma PDMP has real-time data reporting. 
However, 49 state, district, and territory PDMPs have daily or next day 
reporting. CDC and BJA funds continue to help states report data 
faster. For example, Maine is moving towards real-time PDMP reporting 
by using CDC funds to support reporting dispensed controlled substances 
no later than the next business day. With fiscal year 2022 funds, CDC's 
OD2A program will continue supporting states to improve PDMPs and 
maximize interconnectivity. CDC will also support states to increase 
data sharing within states, particularly increasing PDMP data within 
EHRs and HIEs.
    Question. What are your thoughts on continuing the CMS issued 
flexibilities around telehealth once the Public Health Emergency has 
ended?
    Answer. Telehealth is an important tool to improve health equity 
and improve access to healthcare. Healthcare should be accessible, no 
matter where you live. HHS continues to examine the telehealth 
flexibilities developed for the current public health emergency and 
determine how we can build on this work to improve health equity and 
improve access to healthcare. In addition to looking at which 
flexibilities HHS can and should continue administratively, I look 
forward to working with Congress to address changes that may need to be 
done through legislation.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
    Question. Before turning to the fiscal year 2022 budget request, I 
would like to discuss the remaining money in the Provider Relief Fund. 
According to May data from the Health Resources and Services Agency, 
there is around $24 billion left in the PRF plus the additional $8.5 
billion allocated to rural healthcare providers in the American Rescue 
Plan. While HHS has rolled out programs using some of the remaining PRF 
funding, I want to ensure the PRF is still serving its original purpose 
of protecting healthcare facilities.
    Are you considering allocating any of the remaining PRF funds to 
assist rural hospitals who may still be struggling in the aftermath of 
the pandemic?
    Answer. HHS is committed to distributing the remaining provider 
relief payments as quickly, transparently, and equitably as possible 
while utilizing effective safeguards to protect taxpayer dollars. HHS 
is planning for future Provider Relief Fund (PRF) allocations, 
including the $8.5 billion from American Rescue Plan Act and Phase 4 of 
the General Distribution.
    HHS is actively considering feedback from stakeholders, as well as 
operational lessons learned from prior PRF payments, as part of the 
planning process. The feedback from Members of Congress and other 
stakeholders informs HHS' ability to administer the PRF in a manner 
that bolsters the healthcare system and helps providers experiencing 
COVID-related financial hardships during this crisis. HHS will publish 
additional information on future distributions on the Health Resources 
and Services Administration's PRF webpage, at www.hrsa.gov/provider-
relief, as soon as it becomes available.
    Question. The CARES Act established the PRF to prevent hospitals 
from closing during the most severe pandemic mitigation measures and 
rural hospitals in particular needed this financial assistance. While 
the PRF was largely successful, hospitals that opened in late 2019 did 
not receive enough relief and are now strapped for cash. Rock Regional 
in Derby, Kansas, which opened just months before the pandemic in 2019, 
is one such hospital that deserves more PRF funding under the 
guidelines of the Consolidated Appropriations Act of 2021.
    Would you consider reopening Phase 3 PRF applications to accept 
updated documentation consistent with guidelines of the Consolidated 
Appropriations Act?
    Answer. In processing PRF applications, HHS has sought to make 
payments as quickly and equitably as possible while taking appropriate 
precautions to safeguard taxpayer dollars. HHS recognizes that 
providers may have questions regarding the accuracy of their PRF 
payments. HHS will provide any updates on Phase 3 payments on the 
Health Resources and Services Administration's PRF webpage, at 
www.hrsa.gov/providerrelief, as soon as they becomes available.
    Question. Given the purpose of the PRF, if hospitals are still 
struggling, that ought to lead to consideration of a Tranche 4 
targeting such healthcare facilities, especially those that opened in 
2019.
    Is this something you will consider as you look at allocating the 
remaining PRF funding?
    Answer. As HHS plans for future Provider Relief Fund (PRF) 
allocations, including the $8.5 billion from American Rescue Plan Act 
and Phase 4 of the General Distribution, we are cognizant that 
hospitals that began operating in 2019 and 2020 are facing unique 
financial burdens related to the pandemic. Under the previous PRF 
distribution payment methodology, HHS paid new providers based on the 
average lost revenues and increased expenses for their provider type to 
avoid disadvantaging these entities.
    As we move forward, HHS is actively considering feedback from 
stakeholders, as well as operational lessons learned from prior PRF 
payments, as part of the planning process for future funding. The 
feedback from Members of Congress and other stakeholders informs HHS' 
ability to administer the PRF in a manner that bolsters the healthcare 
system and helps providers experiencing COVID-related financial 
hardships during this crisis.
    HHS will publish additional information on future distributions on 
the Health Resources and Services Administration's PRF webpage, at 
www.hrsa.gov/provider-relief, as soon as it is available.
    Question. I have been concerned with the challenges that the senior 
living community has faced throughout the duration of the pandemic. 
Long-term care and assisted living facilities were tasked with caring 
for the population most vulnerable to COVID-19. In caring for the over 
two million seniors across the country, these facilities faced 
increasing costs in protecting residents and their staff. As you have 
heard me mention before, these senior living facilities have not been 
receiving enough support from HHS and are in need of assistance.
    Can you confirm that senior and assisted living facilities will 
actually see meaningful financial support from the remaining Provider 
Relief Fund money in a timely manner?
    Answer. As of June 4, 2021, over 10 percent of the total PRF 
payments made and kept by providers were directed to nursing homes, 
assisted living facilities, and skilled nursing facilities, including 
more than $9 billion in PRF Targeted Distribution payments and over $3 
billion in PRF General Distribution payments to provider organizations 
with at least one nursing home, skilled nursing facility, assisted 
living facility, or long term care facility.
    HHS appreciates the care being given to seniors across the nation 
and recognizes that some assisted living facilities are still 
experiencing financial burdens related to the pandemic. HHS is 
committed to distributing the remaining provider relief payments as 
quickly and equitably as possible while utilizing effective safeguards 
to protect taxpayer dollars. At present, HHS is planning a Phase 4 of 
the General Distribution. Congress also appropriated an additional $8.5 
billion, which has not yet been obligated, in the American Rescue Plan 
Act for Medicare and Medicaid providers and suppliers in rural areas or 
who serve rural patients.
    HHS is actively considering feedback from stakeholders, as well as 
operational lessons learned from prior PRF payments, as part of the 
planning process. The feedback from Members of Congress and other 
stakeholders informs HHS' ability to administer the PRF in a manner 
that bolsters the healthcare system and helps providers experiencing 
COVID-related financial hardships during this crisis. HHS will publish 
additional information on future distributions on the Health Resources 
and Services Administration's PRF webpage, at www.hrsa.gov/provider-
relief, as soon as it becomes available.
    Question. I would like to ask about your approach to Community 
Health Centers. Health Centers in Kansas have been among the leaders in 
responding to the COVID-19 pandemic. Since the beginning of the year, 
Kansas Health Centers have tested nearly 20,000 patients and 
administered vaccines for over 48,000 patients. The fiscal year 2022 
budget request mentions the Administration looks forward to working 
with Congress to advance the President's goal of doubling the Federal 
investment in community health centers. However, the budget also 
included a $45 million cut to the overall program due to budget 
sequestration.
    Could you please discuss HHS' support for greater health center 
funding and how you intend to work with Congress to double Federal 
investments in community health centers?
    Answer. HRSA supports the President's goal to double the Federal 
investment in community health centers and looks forward to working 
with Congress to expand the Health Center Program to: (1) increase 
access to primary medical care services in the high need communities; 
(2) ensure that health center patients receive a full range of 
comprehensive primary healthcare services; (3) improve health outcomes 
and reduce health disparities through new, evidence-based and 
innovative approaches to care; and (4) invest in local healthcare 
infrastructure and expand employment opportunities in medically 
underserved communities.
    Question. As I'm sure you're aware, the Children's Hospital 
Graduate Medical Education (CHGME) program supports the specialized 
training that occurs in many children's hospitals. For example, 
Children's Mercy in Kansas City trains the majority of pediatricians 
that serve the state of Kansas, instructing nearly 230 pediatric 
residents and fellows annually. The fiscal year 2022 budget request 
included $350 million for CHGME, marking the first time since fiscal 
year 2021 the budget request included a separate request for CHGME.
    Could you expand on HHS' goals for the separate funding request and 
fiscal year 2022 increase for the CHGME?
    Answer. The budget requests $350 million for CHGME to provide 
continued support for the pediatric workforce. The funding amount of 
$350 million aligns with the fiscal year 2021 enacted funding level and 
is expected to support approximately 7,700 resident full-time 
equivalents (FTEs). CHGME payments are for direct and indirect medical 
expenses for medical residency training programs. The funding will also 
support contracts to meet legislative requirements such as the FTE 
reconciliation which ensures correct reporting and that residents are 
not funded by other Federal programs to prevent duplicate payments.
                                 ______
                                 
              Questions Submitted by Senator John Kennedy
    Question. A recent report indicated that HHS has approximately $24 
billion in unspent CARES funding. Many healthcare providers are still 
working their way through the financial effects of the COVID-19 
pandemic, and this funding is crucial.
    Can you indicate if healthcare providers, including air ambulances, 
can expect to see this funding made available, or will you be returning 
unspent CARES funding so that we can reduce the overall financial 
impact of spending related to the pandemic response?
    Answer. HHS is committed to distributing the remaining provider 
relief payments as quickly, transparently, and equitably as possible 
while utilizing effective safeguards to protect taxpayer dollars. HHS 
is planning for future Provider Relief Fund (PRF) allocations.
    HHS is actively considering feedback from stakeholders, as well as 
operational lessons learned from prior PRF payments, as part of the 
planning process. The feedback from Members of Congress and other 
stakeholders informs HHS' ability to administer the PRF in a manner 
that bolsters the healthcare system and helps providers experiencing 
COVID-related financial hardships during this crisis. HHS will publish 
additional information on future distributions on the Health Resources 
and Services Administration's PRF webpage, at www.hrsa.gov/provider-
relief, as soon as it becomes available.
    Question. If HHS is going to retain unspent CARES Act funds, can it 
be used to waive recoupment of Medicare Advanced Payments?
    Answer. HHS is committed to distributing the remaining provider 
relief payments as quickly, transparently, and equitably as possible 
while utilizing effective safeguards to protect taxpayer dollars. HHS 
is planning for future Provider Relief Fund (PRF) allocations.
    As we move forward, HHS is actively considering feedback from 
stakeholders, as well as operational lessons learned from prior PRF 
payments, as part of the planning process for future funding. The 
feedback from Members of Congress and other stakeholders informs HHS' 
ability to administer the PRF in a manner that bolsters the healthcare 
system and helps providers experiencing COVID-related financial 
hardships during this crisis.
    HHS will publish additional information on future distributions on 
the Health Resources and Services Administration's PRF webpage, at 
www.hrsa.gov/provider-relief, as soon as it is available.
                                 ______
                                 
            Questions Submitted by Senator Cindy Hyde-Smith
    Question. Secretary Becerra, new data has just been released by 
NORC at the University of Chicago finding that nearly two-thirds of 
assisted living facilities reported no deaths from COVID-19 in 2020. 
Despite this positive data, some have expressed concerns assisted 
living providers caring for nearly 2 million elderly individuals have 
received less than 1 percent of all provider relief funding to date. It 
is my understanding that assisted living providers expended a great 
deal of capital in order to ensure COVID-19 safety in their facilities, 
as well as to compete for staffing in a tight nursing labor market. I 
have been informed that assisted living caregivers will suffer $30 
billion in losses through June 2021 due to these efforts and that over 
half of assisted living facilities nation-wide are operating at a loss 
currently.
    How can HHS help support these assisted living providers, through 
the PRF and otherwise?
    Answer. As of June 4, 2021, over 10 percent of the total PRF 
payments made and kept by providers were directed to nursing homes, 
assisted living facilities, and skilled nursing facilities, including 
more than $9 billion in PRF Targeted Distribution payments and over $3 
billion in PRF General Distribution payments to provider organizations 
with at least one nursing home, skilled nursing facility, assisted 
living facility, or long term care facility.
    HHS appreciates the care being given to seniors across the nation 
and recognizes that some assisted living facilities are still 
experiencing financial burdens related to the pandemic. HHS is 
committed to distributing the remaining provider relief payments as 
quickly and equitably as possible while utilizing effective safeguards 
to protect taxpayer dollars.
    HHS is actively considering feedback from stakeholders, as well as 
operational lessons learned from prior PRF payments, as part of the 
planning process. The feedback from Members of Congress and other 
stakeholders informs HHS' ability to administer the PRF in a manner 
that bolsters the healthcare system and helps providers experiencing 
COVID-related financial hardships during this crisis. HHS will publish 
additional information on future distributions on the Health Resources 
and Services Administration's PRF webpage, at www.hrsa.gov/provider-
relief, as soon as it becomes available.
    Question. Your budget calls for the elimination of the Hyde 
Amendment to allow taxpayer funding of abortion through Medicaid, 
Medicare, and other programs under Labor/HHS appropriations.
    Why is this Administration insistent on reversing four decades of 
bipartisan precedent and ignoring the will of most Americans who object 
to their tax dollars funding the destruction of human life?
    Answer. The Hyde Amendment disproportionately impacts the growing 
number of low-income, women of color who are enrolled in Medicaid, and 
is a barrier to expanding access to healthcare. That is why the 
President's first budget calls for Congress to remove the restriction 
from government spending bills.
    The Department of Health & Human Services implements the laws that 
Congress passes. Implementation of any changes in coverage related to 
the President's Budget would depend on the final language Congress 
passes. After passage of any legislation, agency staff and counsel 
review the language to determine the agency's authority and options for 
implementation action, such as initiating notice and comment rulemaking 
or issuing guidance documents.
    Question. Your budget proposes a 19 percent increase in funding for 
the Title X family planning program by $53.521 million to $340 million 
from $286.479 million. I am concerned that Title X will be a slush fund 
for Planned Parenthood and the abortion industry.
    Can you ensure that these new funds will not be used to bolster 
abortion giant Planned Parenthood and its cohorts?
    Answer. The Title X program does not provide abortion services. 
Section 1008 of the Public Health Service Act specifically states that 
``None of the funds appropriated under this title shall be used in 
programs where abortion is a method of family planning.'' Consistent 
with the program's statute and regulations, any public or private 
nonprofit organizations, including faith-based organizations, state, 
county, local, and tribal governments, school districts, and public and 
state higher education institutions are eligible to apply for Title X 
grant funds. Title X's regulations, in the NPRM, also clearly define 
the criteria the Department uses to decide which family planning 
services projects to fund and in what amount.
    Question. As you know, the previous administration disallowed $200 
million in Medicaid funds from California because it was literally 
forcing nuns to buy abortion insurance in violation of conscience 
protection laws.
    Will you commit to not reversing the findings made by career 
professionals supporting the disallowance and not otherwise restoring 
the money to California?
    Answer. In my ethics agreement signed on January 17, 2021, and the 
subsequent authorization issued on March 31, 2021, I have agreed not to 
participate in any litigation involving the State of California that 
was pending during my tenure as Attorney General. I understand that 
there has been no litigation on this matter, however, as Attorney 
General I did issue a public statement on the matter. After consulting 
with the HHS Acting Designated Agency Ethics Official, I have 
determined that it is prudent for me to recuse myself from this 
Medicaid financing matter to avoid even an appearance of impropriety. I 
trust that the very talented employees of the Department who, at the 
working level, handle the vast amounts of work, including specific 
enforcement and program financing matters, will resolve this matter in 
a manner that is consistent with the Department's obligations and in 
the best interest of the American people. If leadership input is 
required, the Chief of Staff will either handle the case without any 
input from me or will refer the case to the appropriate person for 
decision.
    Question. Your budget asks for a $9 million increase for the Office 
for Civil Rights (OCR), yet OCR inherited over $60 million in 
enforcement settlement funds that you are free to use right now to 
support the bulk of OCR operations.
    Do you think it is appropriate for you to ask Congress for more 
taxpayer money for an Office that is sitting on such a huge sum of 
money?
    Answer. The Health Insurance Portability and Accountability Act of 
1996 ( HIPAA) law requires the Office for Civil Rights (OCR) to spend 
any money that it collects in HIPAA settlements on HIPAA enforcement 
only. This means that these funds are limited in their use as directed 
by Congress.
    The proposed increase in OCR's budget would support civil rights 
authorities and operations, specifically working on improving overall 
enforcement stemming from OCR's authority over healthcare.
    Question. Will you commit to preserving the Conscience and 
Religious Freedom Division as a Division within OCR?
    Answer. HHS will continue to protect the religious, civil, and 
constitutional rights of all Americans. This means that we will 
continue to enforce conscience and religious freedom protections, 
including receiving complaints, investigating cases, and making 
findings consistent with the law.
    Question. A few weeks ago you announced that HHS will interpret 
prohibitions on sex discrimination in healthcare to include ``sexual 
orientation and gender identity.''
    As I read your announcement, male or female are no longer to be 
understood as being based on biology. What does it mean to be a man or 
a woman going forward under these laws?
    Under your announcement, do doctors, who receive HHS funding, have 
a right to decline to perform procedures that violate their religious 
beliefs or conscience?
    Do you favor HHS funds being available for sex-reassignment 
surgeries in minors? If so, please explain your justification under 
current Federal law.
    Do you favor HHS funds being available for puberty blockers and 
cross-sex hormones for young children? If so, please explain your 
justification under current Federal law.
    Answer. HHS will continue to protect the religious, civil, 
constitutional rights of all Americans.
    Question. As of this week over 60 percent of Americans have 
received at least one dose of the COVID-19 vaccine. This extraordinary 
milestone was made possible by the unprecedented speed of developing a 
vaccine less than 1 year after the start of the COVID-19 pandemic. 
However, when the next pandemic hits, the U.S. will need to move even 
faster. With the frequency of epidemics and pandemics increasing, the 
next fast-moving, novel infectious disease pandemic could occur within 
the next 10 years. In addition to naturally occurring threats, rapid 
advances in biotechnology increase the chance that novel pathogens 
could be created with the potential to start major outbreaks. Given the 
uncertainty about how the next pandemic will arise, we must harness 
innovative technologies, outside the box thinking, and game changing 
science to develop countermeasures that are pathogen-agnostic. In the 
fiscal year 2021 House and Senate Committee Reports we included 
language that encouraged the Department to work with the Department of 
Defense to implement a dedicated medical countermeasures program 
focused on developing flexible vaccines and antiviral treatments to 
address emerging and previously unidentified infectious disease 
threats, referred to as Disease X.
    Mr. Secretary, what progress has the Department made in 
implementing such a program?
    How is the Department planning to develop countermeasures for 
previously unidentified viral threats?
    Answer. The U.S. Department of Health and Human Services recognizes 
the importance of developing flexible, broadly applicable technologies 
for the development of medical countermeasures, especially vaccines, to 
be able to respond quickly to emerging infectious diseases. The 
development of highly adaptable vaccine platforms and structural 
biology tools enabling the design of novel and improved immunogens have 
helped usher in a new era of vaccinology. In addition, the development 
of broadly acting antivirals and other therapeutics will be critical as 
we prepare to respond to a future Disease X.
    The National Institute of Allergy and Infectious Diseases (NIAID) 
at the National Institutes of Health (NIH) supports and conducts 
research to both identify previously unidentified viral threats and to 
develop medical countermeasures that can be used to respond to them. On 
August 27, 2020, NIAID established the Centers for Research in Emerging 
Infectious Diseases (CREID), a multidisciplinary global network that 
seeks to identify how and where viruses and other pathogens emerge from 
wildlife and spillover to cause disease in people. The CREID network, 
along with other U.S. Government funded global surveillance efforts, 
will enable early warnings of emerging diseases wherever they occur, 
facilitate a coordinated outbreak response to an emerging virus, and 
may be a crucial tool in early identification of a future Disease X 
with pandemic potential. This program will build upon prior U.S. 
Government efforts in global disease surveillance and complement 
important ongoing activities supported by Federal partners.
    NIAID supports basic, translational, and clinical research to 
develop novel medical countermeasures, including novel vaccine 
platforms, adjuvants, and directly acting oral antivirals. These 
medical countermeasures are often developed for broad pathogen families 
and can be quickly modified for efficacy against related emerging 
pathogens with pandemic potential. NIAID also makes available to the 
broader research community a suite of preclinical services that can 
help lower the risk to developers and help to advance novel 
diagnostics, therapeutics, and vaccines. In addition, NIAID has 
leveraged and strengthened global and domestic clinical research 
networks to facilitate preparedness for rapid launch of clinical trials 
in outbreak situations. These long-standing NIAID investments were 
crucial to the response to the emergence of severe acute respiratory 
syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. 
For example, the NIAID Vaccine Research Center played a key role in 
both the development of novel vaccine platforms and the design of the 
stabilized prefusion spike protein immunogen used in all three of the 
COVID-19 vaccines currently authorized under an Emergency Use 
Authorization from the FDA. The development--in record time--of these 
highly efficacious vaccines with the potential for saving millions of 
lives was only possible through an extraordinary multidisciplinary 
effort leveraging decades of basic, preclinical, and clinical science.
    NIH- and NIAID-supported advances in medical countermeasure 
research and development, as well as other efforts across HHS to 
prepare for novel disease threats, were vital to the Federal response 
to COVID-19. Throughout the COVID-19 pandemic, NIH has supported HHS' 
efforts to leverage highly productive public-private partnerships with 
industry, academia, and the public-sector; utilize longstanding 
relationships with community partners to facilitate the biomedical 
research response; and engage existing domestic and international 
research infrastructure to respond to COVID-19. The whole-of-government 
approach that began under Operation Warp Speed and has continued under 
the current HHS and Department of Defense Countermeasure Acceleration 
Group partnership has efficiently supported the development of safe and 
effective COVID-19 medical countermeasures. This effort led to the 
rapid identification and clinical testing of candidate therapeutics for 
the treatment of COVID-19, as well as multiple COVID-19 vaccine 
candidates that progressed in record time from concept to FDA emergency 
use authorization. Lessons learned from the Federal response to COVID-
19 will be used to inform future pandemic preparedness efforts at NIH 
and across HHS.
    In addition to developing platforms that allow for the accelerated 
development of vaccines for emerging pathogens, there is a need to move 
beyond chasing the different viral strains or variants as they emerge. 
NIAID is leading efforts to develop ``universal'' influenza vaccines to 
protect against multiple strains of seasonal and pandemic influenza 
viruses that may emerge. NIAID also is conducting early-stage research 
on the development of pan-coronavirus vaccines designed to provide 
broadly protective immunity against multiple coronaviruses, especially 
SARS-CoV-2 and others with pandemic potential. New viral threats will 
continue to emerge, and the development of universal influenza vaccines 
and pan-coronavirus vaccines will help us be better prepared for future 
infectious disease threats.
    Gaining a deeper understanding of the interplay between pathogens 
and the human immune system also could expedite the development of 
medical countermeasures against emerging pathogens. NIAID supports a 
number of research initiatives to define human immune mechanisms that 
provide protective anti-viral immunity or contribute to disease 
pathogenesis. For example, the NIAID Vaccine Research Center is 
establishing the Pandemic Response Repository through Microbial/Immune 
Surveillance and Epidemiology (PREMISE) program. This program will use 
data from T and B cell immune surveillance to inform diagnostic, 
prophylactic, and therapeutic countermeasures and accelerate the global 
response to pandemic threats. NIAID anticipates the research conducted 
by PREMISE, and other similar NIAID initiatives, will advance our 
knowledge of the immune response to vaccination and infection and help 
inform the response to future pandemic threats.
    The COVID-19 pandemic is an important reminder of the value of 
sustained and robust support for the U.S. biomedical research 
enterprise, which continues to accelerate the development of medical 
countermeasures to protect against emerging and re-emerging infectious 
diseases. NIH remains committed to working with our partners across the 
Federal Government to continue advancing the research that will help us 
respond to future pandemic threats from Disease X. NIAID will continue 
to support the development of flexible vaccine platforms, novel 
adjuvants, and antiviral treatments to address emerging and previously 
unidentified infectious disease threats. NIAID also anticipates 
launching new initiatives focused on preparing for future pandemic 
threats from Disease X. These initiatives will continue to build on 
long-standing NIAID efforts in this area, as well as lessons learned 
from the research response to COVID-19.
    Question. As you know from your previous role as a Member of the 
Ways and Means Committee, chronic kidney disease (CKD) is unique to 
Medicare in that individuals with irreversible kidney failure are 
eligible for Medicare regardless of age or other disability. Over its 
nearly 50-year existence, this unique coverage has saved tens of 
thousands of lives, including 750,000 Americans who currently are on 
dialysis or who have a functioning kidney transplant. Individuals with 
chronic kidney disease cost Medicare $130 billion in fee-for-service 
spending per year, almost $50 million of which is for patients with 
irreversible kidney failure. Kidney failure patients represent 1 
percent of Medicare beneficiaries but 7 percent of FFS expenditures. 
Improving detection and care of early stage CKD can help reduce health 
expenditures and improve patients' lives, yet an estimated 90 percent 
of our nation's 37 million adults with CKD are unaware they have it.
    How will you prioritize changes at your Department to expand the 
focus on awareness, early detection, and early treatment to help 
prolong kidney function and help ensure the solvency of Medicare?
    Nearly 20 years ago, the CDC created the Chronic Kidney Disease 
Initiative to increase awareness of the disease and expand public 
health surveillance activities. Unfortunately, funding has been mostly 
stagnant throughout its history, and it currently receives only $2.6 
million, despite the tremendous cost of CKD to society, Medicare, and 
Medicaid. The previous Administration created the Advancing American 
Kidney Health Initiative, which was very favorably received by the 
kidney community. One of the most important goals of AAKH, correlating 
to the CDC kidney initiative, was to increase awareness and early 
detection of kidney disease via a national kidney disease awareness 
public health initiative.
    Please comment on efforts to expand the Chronic Kidney Disease 
Initiative to meet this awareness and early detection need.
    COVID-19 has disproportionately affected kidney patients, who have 
experienced some of the highest rates of hospitalization and mortality 
from the pandemic. Additionally, COVID-19 is linked to acute kidney 
injury (AKI) and to kidney disease in recovering COVID-19 patients who 
have no prior history of kidney disease. A March 2021 study from Yale 
University indicates that AKI occurred in up to 57 percent of COVID-19 
hospitalizations and 78 percent of intensive care unit admissions. In 
addition, reports from early in the pandemic indicate that barely a 
third of patients who developed AKI had not yet recovered baseline 
kidney function at a median of 21 days after leaving the hospital. 
(https://www.ajmc.com/view/study-illustrates-kidney-impact-after-covid-
19-resolves)
    Without intervention, these patients could develop chronic kidney 
disease. What steps will HHS take to ensure COVID-19 patients have 
access to the kidney services and care they need going forward?
    Answer. Many beneficiaries with end-stage renal disease (ESRD) 
suffer from poor health outcomes and face increased risk of 
complications with underlying diseases. For example, people with ESRD 
who get coronavirus disease 2019 (COVID-19) have higher rates of 
hospitalization. Last year, CMS established the End-Stage Renal Disease 
(ESRD) Treatment Choices (ETC) Model, a mandatory Medicare payment 
model tested under the authority of section 1115A of the Social 
Security Act. The ETC Model tests the use of payment adjustments to 
encourage greater utilization of home dialysis and kidney transplants, 
in order to preserve or enhance the quality of care furnished to 
Medicare beneficiaries while reducing Medicare expenditures. This 
payment model is expected to encourage participating healthcare 
providers to invest in and build their home dialysis programs, allowing 
patients to receive care in the comfort and safety of their home. Home 
dialysis gives patients the freedom to choose the therapy that works 
best with their lifestyles, without being tied to the dialysis 
facility's schedule. The ETC Model also includes financial incentives 
for participating ESRD facilities and clinicians to encourage 
transplantation based on their transplant rate, calculated as the sum 
of the transplant waitlist rate and the living donor transplant rate.
    Increasing access to affordable coverage will increase access to 
care, including preventive services and treatments that prolong kidney 
function. The President's fiscal year 2022 Budget includes numerous 
provisions that would work together to give Americans additional, 
lower-cost coverage options. One provision would give people age 60 and 
older the option to enroll in the Medicare program with the same 
premiums and benefits as current beneficiaries, but with financing 
separate from the Medicare Trust Fund. In States that have not expanded 
Medicaid, the President has proposed extending coverage to millions of 
people by providing premium-free, Medicaid-like coverage through a 
Federal public option.
    Question. Sec Becerra, as you know, influenza occurs seasonally 
each year and throughout history has caused devastating pandemics--
including the 1918 pandemic that killed an estimated 675,000 Americans. 
While this year's flu season was extremely mild, next year's could be 
much worse. The U.S. National Influenza Vaccine Modernization Strategy 
was released 1 year ago, with an ambitious vision of a domestic 
influenza vaccine enterprise that is highly responsive, flexible, 
scalable, and more effective at reducing the impact of seasonal and 
pandemic influenza viruses. The HHS Budget included a $25 million 
increase within CDC's Influenza Division and a $48 million increase for 
ASPR Pan Flu.
    Are these resources sufficient? The previous administration 
estimated $1billion over 10 years would be needed to sufficiently 
resource the Strategy.
    Answer. ASPR/BARDA has a long and successful history of focused 
efforts to invest in increasing influenza vaccine production capacity 
in preparation for a pandemic influenza response. While these efforts 
benefit seasonal influenza (e.g., cell-based vaccine, recombinant 
protein vaccine), they are not specific for seasonal influenza. In 
2020, ASPR/BARDA also worked with industry to develop respiratory panel 
diagnostics that test for influenza and SARS-CoV-2 infection 
simultaneously. ASPR/BARDA looks forward to continuing these efforts as 
part of the National Influenza Vaccine Modernization Strategy and 
working with our colleagues at NIAID supporting early development of a 
universal influenza vaccine.
    Question. Sec Becerra, the Administration has requested $30 billion 
over 4 years in mandatory funding to protect Americans from the next 
pandemic. According to the latest budget request, $24 billion of that 
would be allocated to HHS for medical countermeasures manufacturing and 
other initiatives.
    Please elaborate on the need for this $30 billion investment.
    Answer. The President's request for $30 billion over 4 years would 
help protect Americans from future pandemics through major new 
investments in medical countermeasures manufacturing; research and 
development; and related biopreparedness and biosecurity. This includes 
investments to shore up our nation's strategic national stockpile; 
accelerate the timeline to research, develop and field tests and 
therapeutics for emerging and future outbreaks; accelerate response 
time by developing prototype vaccines through Phase I and II trials, 
test technologies for the rapid scaling of vaccine production, and 
ensure sufficient production capacity in an emergency; enhance U.S. 
infrastructure for biopreparedness and investments in biosafety and 
biosecurity; train personnel for epidemic and pandemic response; and 
onshore active pharmaceutical ingredients. COVID-19 has claimed 
hundreds of thousands of American lives and cost trillions of dollars, 
demonstrating the devastating and increasing risk of pandemics and 
other biological threats. The American Rescue Plan serves as an initial 
investment of $10 billion. With this new major investment in preventing 
future pandemics, the United States will build on the momentum from the 
American Rescue Plan, bolster scientific leadership, create jobs, 
markedly decrease the time from discovering a new threat to putting 
shots in arms, and prevent or mitigate future biological catastrophes.
    Question. Will any of these funds be targeted at influenza, which 
has the potential for a pandemic even more devastating than Covid-19?
    Answer. HHS will follow the requirements spelled out in statute and 
follow the latest science in directing resources toward current and 
future pandemics.
    Question. Please also provide greater clarity into how those funds 
would be allocated within HHS.
    Answer. HHS is thankful for the resources provided by Congress to 
address the COVID-19 pandemic. We will follow the statutory 
requirements for use of funds appropriated to HHS and take a broad 
approach to addressing COVID-19 by continuing to support research on 
prevention, therapeutics, and vaccines; supporting workforce expansion 
to ensure equitable distribution of vaccines and therapeutics; 
investing in testing and screening to allow our schools and businesses 
to remain open; addressing our supply chain and manufacturing 
challenges; as well as addressing the mental health of those affected 
by COVID-19 whether they lost a family member or friend, suffered 
COVID-19, or lost the ability to fully participate in significant life 
events over the past 18 months or more. We will invest in the science 
and follow the science during this unprecedented time and do our best 
to address the challenges it has brought to our public health 
infrastructure.
    Question. One of the silver linings of this pandemic has been the 
wide-spread adoption of technology to bring people together, whether it 
be families scattered across the nation or patients and their 
providers. We have seen exponential growth in telehealth adoption 
across Americans of all ages, locations, and conditions. Telehealth 
among Medicare beneficiaries has been made possible by temporary 
flexibilities in place for the duration of the public health emergency.
    These include allowing Medicare beneficiaries to have telehealth 
visits from their home, regardless of where they live across the 
country. This has also allowed new types of providers, such as physical 
therapists and speech pathologists to practice via telehealth.
    Sec. Becerra, do you agree that access to telehealth has been 
critical to protecting patients and providers during the nation's 
response to COVID-19? b.Sec. Becerra, do you agree that providers and 
beneficiaries have seen immense value from expanded access to 
telehealth over the past year? Do you agree that Americans have been 
overwhelming satisfied with care received virtually during the 
pandemic?
    Sec. Becerra, can you tell us where telehealth ranks in terms of 
your priorities? d.Sec. Becerra, how can Congress ensure that Medicare 
beneficiaries do not lose access to telehealth after the public health 
emergency expires?
    Will you commit to working with Congress to ensure that the 
millions of Medicare beneficiaries enrolled in fee-for-service Medicare 
do not face a telehealth service coverage cliff when the public health 
emergency expires?
    Sec. Becerra, as Congress considers permanent telehealth reform, we 
will need your support, including an evidence-based assessment of how 
many of the telehealth flexibilities extended in response to the 
pandemic impacted both the Medicare program and beneficiaries. With 
that said, do you believe that there are some telehealth regulatory 
restrictions that Congress and HHS can work together to address in the 
near term that do not require additional data?
    About 46 million Americans, nearly 15 percent of the U.S. 
population live in rural areas. Those living in rural areas are more 
likely to die prematurely and face higher risks for chronic conditions 
like heart disease and diabetes. Americans living in rural communities 
face 17 percent higher prevalence of diabetes than those living in 
urban areas and may have to wait months before needing to travel great 
distances to see an endocrinologist to help manage their condition. 
This scenario is not uncommon and instead is the reality of rural 
Americans that routinely encounter not just a lack of specialty care, 
but in my cases, primary care. Digital health tools, including 
telehealth and remote monitoring, have the potential to relieve some of 
the key healthcare challenges facing rural America.
    Sec. Becerra, can you speak to the promise and value of telehealth 
and digital health more broadly to rural communities?
    Answer. Telehealth is an important tool to improve health equity 
and improve access to healthcare. Healthcare should be accessible, no 
matter where you live. HHS continues to examine the telehealth 
flexibilities developed for the current public health emergency and 
determine how we can build on this work to improve health equity and 
improve access to healthcare. In addition to looking at which 
flexibilities HHS can and should continue administratively, I look 
forward to working with Congress to address changes that may need to be 
done through legislation.
    Throughout the pandemic, telehealth services have filled an urgent 
need to maintain access to care while social distancing was necessary. 
For example, federally Qualified Health Centers and Rural Health 
Clinics were able to be paid by Medicare as distant site telehealth 
service providers, which had not been permitted outside of the COVID-19 
public health emergency. After the pandemic, HHS will continue to 
support telehealth services. HHS is currently reviewing the telehealth 
flexibilities developed for the current public health emergency to 
determine which can and should continue after the public health 
emergency has ended. HHS plans to continue to support telehealth after 
the pandemic through resources like the Telehealth.HHS.gov website and 
the Telehealth Resource Centers so patients and providers have access 
to telehealth technical assistance.
    Question. More than 147 million Americans are living with chronic 
conditions. It's estimated that 180 million Americans are living with 
mental health challenges. According to a 2017 RAND Corporation Study, 
90 percent of the US healthcare spend is on chronic conditions, this 
includes $327 billion on diabetes and $131 billion for the treatment of 
hypertension. These are staggering figures. I believe that technology 
has the potential to empower patients, improve access and allow those 
Americans already living with these chronic conditions a chance at a 
happier, healthier life. Unfortunately, Medicare has been slow to adopt 
innovative digital health tools, some of which has been limited by 
outdated statutory limitations.
    Beyond telehealth, can you speak to the Administration's efforts to 
enable Medicare beneficiaries to leverage digital health tools for the 
prevention and treatment of disease?
    Are their limitations in your ability to expand access to these 
valuable resources for those that want to use them within Medicare?
    What do you see CMMI's role to be in facilitating the demonstration 
and evaluation of virtual care solutions and digital health tools?
    Could you discuss how remote patient monitoring is used today in 
Medicare and Medicaid today, in addition to telehealth, to help in the 
care of those living with chronic conditions like diabetes, 
hypertension, asthma or kidney disease?
    Remote patient or physiologic monitoring (RPM) has shown great 
value in facilitating the management of both acute and chronic 
conditions. Using connected devices, individuals can, in real time, 
have data shared back with their care team to allow for intervention 
and ultimately prevention of more severe health outcomes. While HHS has 
begun to allow for the reimbursement of RPM, use of the codes in 
Medicare fee-for-service remains rather low.
    Do you see value in enabling adoption of additional virtual care 
technologies, such as remote monitoring, for Medicare beneficiaries?
    From a health equity perspective, what more can be done to make 
resources like remote monitoring tools available to all Americans, 
especially those living with chronic conditions?
    RPM solutions, which for someone with diabetes, may be leveraged 
for years, warrants a recurring monthly 20 percent copay. Is there 
value in revisiting copay structures for remote monitoring and chronic 
care management services?
    Answer. Innovation is important to advancing goals in healthcare, 
including by learning how to better leverage digital health tools for 
the prevention and treatment of disease. Individuals with chronic 
disease benefit from access to comprehensive and coordinated care to 
manage and treat their chronic conditions and prevent the need for more 
costly care. Ensuring access to remote patient monitoring services, 
including through evaluating the adequacy of payments, will be 
important to beneficiaries who may benefit from these and other virtual 
services that allow their physicians to help manage and treat their 
health conditions outside of regular office visits. The CMS Innovation 
Center is integral to the Administration's efforts to promote high-
value care and encourage healthcare provider innovation, including 
virtual and digital health innovation. I look forward to hearing from 
Congress on ideas to change coinsurance for Medicare covered services.
                                 ______
                                 
               Questions Submitted by Senator Marco Rubio
    Question. I am incredibly concerned about the Biden 
Administration's decision to upend decades of bipartisan agreement by 
failing to include the Hyde Amendment in the proposed budget.
    Does the Administration support taxpayer-funded abortion?
    When Congress likely rejects this radical proposal and includes the 
Hyde Amendment in future spending bills--will the Administration follow 
the law and ensure that Federal Medicaid dollars are not used to 
finance abortions?
    Answer. The Hyde Amendment disproportionately impacts the growing 
number of low- income, women of color who are enrolled in Medicaid, and 
is a barrier to expanding access to healthcare. That is why the 
President's first budget calls for Congress to remove the restriction 
from government spending bills.
    The Department of Health & Human Services implements the laws that 
Congress passes.
    Question. Of additional concern, the NIH announced that it will end 
its Ethics Advisory Board for reviewing external research applications 
for Federal funding involving the use of human fetal tissue.
    Why has the NIH moved to end the Ethics Advisory Board?
    What plan does the NIH have in place to provide adequate oversight 
and ensure Federal laws are followed?
    Answer. NIH's mission is to seek fundamental knowledge about the 
nature and behavior of living systems and apply that knowledge to 
enhance health, lengthen life, and reduce illness and disability. Under 
its broad research mission, and as authorized by the Public Health 
Service Act, NIH conducts and funds biomedical research involving the 
study, analysis, or use of human fetal tissue for a range of diseases 
and conditions. NIH also funds research to develop, demonstrate, and 
validate experimental models that are alternatives to the use of human 
fetal tissue.
    Given the current administration taking a different position on the 
merit of this research, the U.S. Department of Health and Human 
Services decided to rescind the 2019 decision that all research 
applications for NIH grants and contracts proposing the use of human 
fetal tissue from elective abortions will be reviewed by an Ethics 
Advisory Board. So on April 16, 2021, NIH published an Update on 
Changes to NIH Requirements Regarding Proposed Human Fetal Tissue 
Research (NOT-OD-21-111),\28\ stating that HHS was reversing its 2019 
decision that all research applications for NIH grants and contracts 
proposing the use of human fetal tissue from elective abortions will be 
reviewed by an Ethics Advisory Board. Accordingly, HHS/NIH will not 
convene another NIH Human Fetal Tissue Research Ethics Advisory Board. 
Please note that all other requirements described in NOT-OD-19-128 \29\ 
and updated in NOT-OD-19-137 \30\ for extramural research remain 
unchanged. Furthermore, NIH reminded the scientific research community 
of expectations to obtain informed consent from the donor for any NIH-
funded research using human fetal tissue, and of continued obligations 
to conduct such research only in accord with any applicable Federal, 
state, or local laws and regulations, including prohibitions on the 
payment of valuable consideration for such tissue.\31\ The same 
requirements apply to the NIH intramural research program.
---------------------------------------------------------------------------
    \28\ grants.nih.gov/grants/guide/notice-files/NOT-OD-21-111.html.
    \29\ grants.nih.gov/grants/guide/notice-files/NOT-OD-19-128.html.
    \30\ grants.nih.gov/grants/guide/notice-files/NOT-OD-19-137.html.
    \31\ grants.nih.gov/grants/guide/notice-files/not-od-16-033.html.
---------------------------------------------------------------------------
    All NIH-supported organizations certify that they will comply with 
the NIH Grants Policy Statement,\32\ which summarizes NIH policies 
regarding the use of human fetal tissue in research and incorporates 
Federal statutory requirements for research with human fetal tissue 
(sections 498A and 498B of the PHS Act, 42 U.S.C. 298g-1 and 298g-2).
---------------------------------------------------------------------------
    \32\ grants.nih.gov/grants/policy/nihgps/HTML5/introduction.htm.
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    Question. With much of the country finally moving to pre-pandemic 
operations, and as Americans are taking flights, riding trains, and 
generally living their lives, all without a Federal vaccine 
requirement, there is one industry that the CDC continues to treat 
differently.
    The White House Press Secretary has stated: ``The government is not 
        now, nor will we be supporting a system that requires Americans 
        to carry a credential. There will be no Federal vaccinations 
        database and no Federal mandate requiring everyone to obtain a 
        single vaccination credential . . . Our interest is very simple 
        from the Federal Government, which is American's privacy and 
        rights should be protected so that these systems are not used 
        against people unfairly,''
    Mr. Secretary, if this were true, then the CDC would not be 
restricting cruise activities, and would not be putting unfair guidance 
in place that essentially requires that a minimum number of cruise 
passengers be vaccinated.
    If the Biden Administration wants to protect the rights of 
Americans and ensure that policies do not discriminate against certain 
Americans, then why does the Biden Administration support vaccine 
requirements for cruises that discriminate against families with young 
children?
    Answer. The Conditional Sail Order (CSO) is a phased approach for 
the resumption of passenger operations on cruise ships in the U.S. The 
timing of these phases depends on cruise ship operators' demonstrated 
ability to mitigate COVID-19 risk on board their ships with crew. 
Phases can also be adjusted based on lessons learned from the previous 
phases.
    Under the CSO, cruise ships are not mandated to require cruise 
passengers to be vaccinated. CDC recommended that cruise operators 
incorporate COVID-19 vaccination strategies to maximally protect 
passengers and crew in the maritime environment, seaports, and land-
based communities to further reduce spread of SARS-CoV-2.
    CDC is committed to ensuring that cruise ship passenger operations 
are conducted in a way that protects crew members, passengers, and port 
personnel, particularly with emerging COVID-19 variants of concern.
    Question. When does the Biden Administration plan to end 
discriminatory policies that make it more difficult for families with 
children to go on vacation?
    Answer. CDC currently recommends people delay travel until they are 
fully vaccinated. Fully vaccinated travelers are less likely to get and 
spread COVID-19 and can now travel at low risk to themselves within the 
United States. If people are traveling with children who cannot get 
vaccinated at this time, CDC recommends choosing safer travel options.
    Question. I assume the vaccine mandate is based on science? If so, 
can you elaborate on that science?
    Answer. Under the CSO, cruise ships are not mandated to require 
cruise passengers to be vaccinated. CDC recommended that cruise 
operators incorporate COVID-19 vaccination strategies to maximally 
protect passengers and crew in the maritime environment, seaports, and 
land-based communities to further reduce spread of SARS-CoV-2. COVID-19 
vaccinations significantly reduce the risk of severe illness, 
hospitalization, and death.
    Question. Does this science also apply to airlines, busses, or 
trains?
    Why or why not?
    Answer. Yes, CDC's science applies in all travel settings. CDC's 
current domestic and international travel recommendations suggest 
people delay travel until they are fully vaccinated. Fully vaccinated 
travelers are less likely to get and spread COVID-19 and can travel at 
lower risk to themselves.
                                 ______
                                 
              Questions Submitted by Senator Patrick Leahy
    Question. The COVID-19 pandemic has disproportionately impacted 
rural hospitals and healthcare providers that were already operating on 
shrinking margins. The Department has proposed an increase of $71 
million for Rural Health programs to ensure access to high-quality care 
that caters to the unique needs of rural communities. This funding is 
vital to ensure that our rural providers remain viable.
    The COVID-19 pandemic has also exposed serious inequities in 
healthcare for BIPOC and underserved populations. Rural communities 
have been no exception to this issue. How can any funding proposed for 
rural health programs help improve outcomes for BIPOC patients in rural 
areas?
    Answer. This is an important issue; one fifth of rural Americans 
are from a racial or ethnic minority group. The Federal Office of Rural 
Health Policy has added language in Notices of Funding Opportunity. 
Applicants for rural health grants will be expected to address issues 
of equity by targeting underserved communities and populations to 
ensure program dollars can reach the people most in need to improve 
their health outcomes.
    While rural Americans face a range of disparities in terms of 
mortality, life expectancy and chronic disease burden, those gaps are 
even more pronounced for members of racial and ethnic groups who live 
in rural communities, and ensuring the data analysis disaggregates race 
and ethnicity, when possible, helps monitor progress toward eliminating 
disparities. We will continue to do all we can to make sure rural 
communities with populations adversely affected by persistent poverty 
or inequality are leveraging our grant programs.

                          SUBCOMMITTEE RECESS

    Senator Murray. This committee will next meet in Dirksen 
138 Wednesday, June 16 at 10 a.m. for a hearing on the Biden 
administration's budget request for the Department of 
Education. The hearing is adjourned.
    [Whereupon, at 11:48 a.m., Wednesday, June 9, the 
subcommittee was recessed, to reconvene at 10 a.m., Wednesday, 
June 16.]