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



 
  DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND 
          RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2023

                              ----------                              


                         WEDNESDAY, MAY 4, 2022

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 9:35 a.m., in room SD-138, Dirksen 
Senate Office Building, Hon. Patty Murray (chairman) presiding.
    Present: Senators Murray, Reed, Shaheen, Baldwin, Manchin, 
Blunt, Moran, Hyde-Smith, and Braun.

                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 please come to order. Today we are having 
a hearing on the Biden Administration's fiscal year 2023 budget 
request for the Department of Health and Human Services. 
Senator Blunt and I will each have an opening statement, and 
then I will introduce our witness, Secretary Becerra.
    After his testimony, Senators will each have 5 minutes for 
a round of questions. And while we were unable to have the 
hearing fully open to the public or media for in-person 
attendance, live video is available on our committee website. 
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 glad to have you before our 
committee today to provide answers to the questions the 
American people have, especially this morning, given the 
alarming reporting that the Supreme Court is planning to end 
the Constitutional right to abortion in this country and 
overturn Roe v. Wade.
    If this is true, it will be devastating to many people 
across the country. I have been warning about this for years 
and I want you to know I am going to keep fighting back with 
all I have to protect every woman's rights in this country. But 
people across the country are worried.
    They need to see leadership from the Biden Administration 
on this. So I hope to hear more from you today about what the 
Administration's plan is to respond to this and protect women's 
health. Because make no mistake, women's lives are on the line. 
Later this week, you will be hearing from my constituents 
firsthand, coming out to Washington State. We will welcome you 
there.
    And Mr. Secretary, I want you to know, people are not just 
worried about this attack on abortion, they are worried about 
other challenges they are facing as well, because the past 2 
years, to say nothing of the past 2 days, have put such a 
strain on families and communities and our entire health care 
system. People are depending on the Biden Administration for 
support, for resources, and for real solutions, and I am 
pushing to make sure that they get them.
    After all of the hard won progress we have made in the 
fight against COVID-19, families in my State and across the 
country are depending on us to pass urgently needed emergency 
COVID funding for tests, for treatments, and vaccines to 
protect our communities across the country. But keeping up the 
fight against COVID is just the start.
    We have to learn from this pandemic and strengthen our 
public health system to make sure we are better prepared with 
more resources for CDC (Centers for Disease Control and 
Prevention), like this budget proposes, with sustained annual 
investments for local health departments, like my Public Health 
Infrastructure Saves Lives Act would provide, and with steps 
like my bipartisan Prevent Pandemics Act, because we know all 
too well things like modern data systems, a robust public 
health workforce, access to tests and vaccines, clearer 
information, and more can make all the difference when it comes 
to saving lives during a public health crisis.
    But Secretary Becerra, the past few years have also shone a 
harsh spotlight on the other healthcare challenges our 
communities are facing, like the mental health crisis, which 
the pandemic has made even more devastating, especially for our 
kids. Over the last 2 years, we have seen a sharp rise in youth 
mental health emergencies. I have heard from so many parents 
back home whose kids are just not okay.
    And over 200,000 kids have had their world shattered by the 
heartbreaking loss of a parent or a caregiver. And we are 
already stretched thin when it comes to providing communities 
the support they need to address these crises. In Washington 
State, our mental health workforce is only able to meet 17 
percent of our State's needs. We have just got to do better.
    This budget has crucial support for school based mental 
healthcare and training, which can help reach students in need, 
mental health support during early childhood, which is such an 
important time for kids, community health centers which help 
families across the country get connected to mental health 
services, and increased resources for the 9-8-8 Suicide 
Prevention and Crisis Lifeline.
    I will be digging in here during questioning and during 
your visit to Washington State later this week, because I want 
to know how the Administration is doing and what it is doing to 
address the mental health crisis. Secretary Becerra, I also 
want to hear more from you about how the Administration is 
working to address our Nation's substance use disorder crisis, 
which has gotten so much worse during this pandemic and has 
grown even more deadly due to fentanyl.
    I hear about the tragic consequences of this crisis every 
single day. Overdose deaths in Washington State have increased 
by two-thirds since 2019. And nationally, we recently passed 
the tragic milestone of over 100,000 overdose deaths in 1 year. 
Our communities are doing what they can. But, Mr. Secretary, we 
desperately need reinforcements.
    The significant increase in this budget for prevention, 
treatment, and recovery efforts is absolutely necessary. But it 
is going to take more to get this done. And that is why I am 
working with my Senate colleagues on bipartisan legislation. 
But I want to hear more from you about your plan to address 
this crisis.
    When it comes to women's health, I was relieved to see this 
budget does include significant resources for the Title X 
Family Planning Program, which helps get women birth control 
they need to plan a family on their own terms, lifesaving 
breast and pelvic exams that detect cancer early, and more.
    Mr. Secretary, I have fought hard to protect the Title X 
Program, and I heard from Washington State patients and 
providers recently about what this program means in their 
lives. They told me firsthand how it makes all the difference 
to people with the tightest budgets who might not have access 
to this basic lifesaving healthcare without Title X.
    It is unthinkable to me anyone would not support this 
program. But as we are being reminded every day, Mr. Secretary, 
reproductive healthcare is under attack at every angle, and we 
need to be doing everything we can to protect it. So I want to 
hear more from you today about what we can do to continue 
strengthening this program and do everything we can to support 
other programs that protect women's health.
    That is why I was so pleased to see this budget also 
increases resources to help lower our Nation's unacceptably 
high maternal mortality rate. And like so many other issues, we 
know our maternal death rate has been particularly devastating 
for black and Native American women, which is why the 
investments in this budget to advance equity and reduce health 
disparities are vital, especially the significant proposed 
increase to CDC's work in this space.
    This budget also calls for additional support in the fight 
against HIV, AIDS to increase access to lifesaving treatment, 
reduce new cases, and continue our progress towards ending this 
epidemic in our country. Finally, I want to make crystal clear 
how important it is that we invest in childcare and early 
education programs and bring down those costs for parents.
    This pandemic has made clear to everyone what I have been 
saying for years, quality, affordable childcare is not 
optional. It is essential for parents, for kids, for our 
businesses, for our economy, for everyone. When it comes down 
to it, parents not being able to work because they cannot find 
childcare is never just a problem for them, it is one more 
position a small business can't fill, and it is one less link 
in our supply chain moving things along.
    That is why I believe this has to be a top priority to help 
parents get back to work and to lower costs. That is such a 
massive strain on parents' budgets right now. Mr. Secretary, I 
know this budget includes a boost in childcare resources. I was 
glad to see that.
    But I need to be clear, right now millions of families 
across the country are struggling to find or afford childcare, 
providers are struggling to keep their doors open, and 
childcare workers cannot make ends meet and are leaving their 
jobs to find better pay.
    So we have got to go bigger to solve this problem here, and 
which is why I have been fighting so hard to make a truly 
historic investment in childcare that would bring down costs 
for families, bring up wages for workers, and all fully paid 
for simply by asking those at the top to pay their fair share.
    I am going to keep pushing to make sure we get that done 
through reconciliation, because at the end of the day, as happy 
as I am to see these boosts for childcare in this budget, which 
I have fought for a long time as well, it is clear to me we 
can't just tinker at the edges here, we need bold solutions.
    And that is why I will keep pushing to deliver on that, 
just as I am pushing for more progress in all the issues that 
we will be talking about today. I always like to say that a 
budget is a statement of values, and I am pleased to see this 
budget does make it crystal clear that the Administration's 
values are in the right place. But families back home need us 
to do more than just state our values, they need us to live up 
to them.
    They need us to act on them with steps that take stress off 
their shoulders, put money back in their pockets and actually 
solve the problems they are facing. So I look forward to 
working with you and President Biden to make sure that happens. 
Thank you again for being here. With that, I will turn it over 
to Senator Blunt.


                     statement of senator roy blunt


    Senator Blunt. Thank you, Chair Murray. Secretary Becerra, 
certainly appreciate you being here today. We served together 
in the House, but I think in the last year we have had a chance 
for our relationship to grow and I am grateful that that has 
happened. I am grateful that we have--I think you have made a 
better effort than we have seen sometimes in the past to get 
information to us as quickly as you could.
    And as you and I have talked about, sometimes we just need 
to know the direction you are headed in a quick way and find 
out all of the granular detail when you can get to it. But I am 
appreciative that I think that is headed on a better path. I 
think both Chair Murray and I are eager to try to get a bill 
completed this year.
    You are much better off if you have money to spend in next 
year's spending cycle, October 1, or even December 1 than if it 
is April 1 or March 1 or May 1, and I hope we can work together 
to continue to move this process forward. I do think that the 
completion of the process last year was late enough that some 
of the gains we made in the final appropriations bill aren't 
reflected in the budget that was submitted by the President, 
and I look forward to a chance to talk to you more about that.
    You know, at last year's hearing, my opening statement 
focused almost totally on the pandemic. At that point, we were 
a year in. The Trump Administration had provided the country 
with several FDA (Food and Drug Administration) authorized 
vaccines, tests, and treatments for COVID-19, while starting a 
campaign to vaccinate the most high risk Americans. And of 
course, the Biden Administration continued that vaccine 
campaign.
    Where we were last year was pretty significant in terms of 
the vaccines that were available and what we had done, 
considering the fact that a year earlier we had never heard of 
COVID-19, and we were making real progress. The Biden 
Administration came into the White House with lots of COVID 
promises on how it would get it under control and do so by 
following the science.
    Unfortunately, I have some concerns that the Administration 
has really abandoned the approach of following the science when 
it became clear over the last year and a half that Federal 
vaccine mandates, school closure guidance, mask requirements on 
public transportation have, I think, overreached the moment and 
overreached the science. Most recently, politics appear to have 
colored some of the COVID decisions the Department has made.
    The CDC announced the termination of the Title 42 order 
last month. They announced it would occur at a specific date in 
the future, but they announced it at a time when we were still 
trying to deal in the Congress and with your Department of the 
ongoing challenges of COVID. You know, COVID can't be a 
challenge one place and not a problem, in my view, at another 
place.
    Congress has been provided few details on the impact of the 
decision of what would happen if Title 42 goes away at the 
border. Yet no plans to see what we do with an influx of 
illegal individuals into the country, or in your Department, 
what happens with the unaccompanied children that come under 
your responsibility. I don't see the money in this budget 
reflecting every news story I see about how those numbers 
intend to grow.
    Further, CDC's decision to vastly increase the number of 
people coming into the country who are unvaccinated that was 
made after CDC said what they considered the current--this is 
their quote, ``current public health conditions and increased 
availability of tools to fight COVID-19 allowed the border to 
be looked at in a different way.'' Just days later, the 
Department made contradictory decisions to extend our own 
country's public health emergency.
    Emergency here, not a problem there really doesn't make 
much sense to many people and even people in the Congress who 
can be persuaded that things that don't make sense somehow do 
make sense. Just yesterday, the CDC updated guidance that two 
and a half years into the pandemic, it is now everyone--
recommending everyone get tested before domestic travel.
    It seems to me that it is so out of focus with every other 
discussion that is going on, and hopefully we will have a 
chance to talk about that today also. I think these decisions 
just aren't consistent and intellectually create lots of 
problems. How do you expect Americans to follow your 
recommendations when you say it is safe to open the borders to 
unvaccinated immigrants, but not safe enough to remove mask on 
planes, and not safe enough to have even domestic travel 
without a test?
    Meanwhile, even as the borders reopen as if the pandemic is 
over, Americans remain under Federal vaccine and mask mandates. 
And the Department is asking Congress to provide additional 
funding for therapeutics, for tests, for vaccines. And I want 
to make it very clear, I am actually for that funding. You and 
I have talked about it. I have worked hard to try to come up 
with a package that would provide the money we need.
    Those accounts, on my view, need to be restored. We are not 
out of the woods yet with COVID-19, and we need to be prepared 
for a future wave that very easily could happen. We need to 
think about what needs to happen with vaccinating the under-
five population, and to ensure that any American who needs a 
therapeutic can get one. Unfortunately, the Administration made 
two poor decisions that make this additional funding nearly 
impossible.
    First, it pushed through a $1.9 trillion COVID-19 funding 
bill that provided less than 6 percent of COVID and less than 1 
percent of funding toward vaccines and therapeutics, and only 5 
percent toward COVID public health.
    Simply put, the Administration had the opportunity to 
purchase more vaccines, more tests, more treatments, and to 
continue more research into additional therapeutics, and to 
prepare for a disease that we will likely be facing for the 
next several years, and in that huge package that went into the 
economy, not very much of it was dedicated to the purpose of 
the COVID-19 fight.
    Secondly, we were actively negotiating a bill last month to 
provide the Department with $10 billion to purchase those 
additional therapeutics, vaccines, and tests. And right at the 
end of that negotiation, before the Congress could vote on the 
bill, again CDC announced that COVID is not a problem at the 
border.
    Finally, Mr. Secretary, as it did in last year's bill, 
COVID-19, has overshadowed the budget request, and I think 
assuming that we will just continue to do all of the COVID 
spending as emergency spending. There are a lot of new plans in 
this budget that the Congress just rejected in the omnibus 
bill.
    And frankly, if we have a bill this year, and I hope we do, 
I think we have to look at what this Congress was willing to 
agree to after months of negotiation and use that as the 
blueprint. It doesn't mean the blueprint can't be adjusted, but 
assuming we are going to see dramatic changes like the removal 
of the long standing Hyde Amendment.
    You know, every person on this committee who has ever voted 
for a final Labor, HHS (Health and Human Services) bill has 
voted for Hyde since it first appeared in 1976. And the bills 
you and I voted for in the House, if we voted for the Labor, 
HHS bill, all had that amendment in them.
    Mr. Secretary, the committee been successful over the last 
several years of passing bipartisan bills because we have not 
made fundamental, drastic funding changes.
    I was concerned when I saw the money for ARPA-H (Advanced 
Research Projects Agency for Health), which I also support, but 
there was $4 billion of new money in the budget for ARPA-H and 
no money for the traditional research at NIH (National 
Institutes of Health), which of course is exactly what people 
who have been concerned about ARPA-H--have been concerned 
about, whether it was at NIH or somewhere else, does ARPA-H 
begin to slow down the momentum of the overall research that we 
need to continue to see in NIH?
    I hope we can set aside our partisan difficulties, as we 
did last year in this committee, and support programs like 
maternal mortality programs that benefit all Americans.
    The mental health programs. I will say that I was very 
heartened with the mental health program increases and had some 
concerns about some structural changes in the mental health 
agency of SAMHSA (Substance Abuse and Mental Health Services 
Administration) that you are responsible for.
    But we will get back to that and talk about that later. And 
again, while this will be a challenging hearing, as these 
always are, welcome and I have appreciated our chance to begin 
to work together with this new responsibility that you have 
taken in the last year and look forward to the time to ask 
questions today.
    [The statement follows:]
                Prepared Statement of Senator Roy Blunt
    Thank you, Chair Murray. I appreciate Secretary Becerra being here 
today to discuss the Administration's fiscal year 2023 budget request.
    At last year's hearing, my opening statement focused on the 
pandemic. At that point, we were a year in, and the Trump 
Administration had provided the country with several FDA-authorized 
vaccines, tests, and treatments for COVID-19, while starting a campaign 
to vaccinate the most high-risk Americans. That was a significant 
accomplishment considering the year before we had never heard of COVID-
19.
    The Biden Administration came into the White House with lots of 
COVID promises of how it would ``get it under control'' and do so by 
``following the science.''
    Unfortunately, it appears that the Administration has all but 
abandoned that approach, instead making pandemic decisions and policies 
based purely on politics.
    This has been clear over the past year and half with Federal 
vaccine mandates, school closure guidance, and mask requirements on 
public transportation that have been overreaching and ripe with 
partisan politics.
    Most recently, politics appear to have colored every COVID decision 
the Department has made.
    When CDC announced the termination of the Title 42 Order last 
month, which is a public health protocol that limits the number of 
illegal immigrants entering the country due to the pandemic, it appears 
to have made this decision in a bid to satisfy vocal opponents, without 
fully considering the impacts on any other agency, including the 
Department of Homeland Security.
    Congress has been provided few details as to the impact of this 
decision, and as far as I can tell, there is no plan in place for the 
influx of illegal immigrants, no real strategy to deal with the 
problem, and no money in place to do so.
    Further, CDC's decision to vastly increase the number of illegal, 
unvaccinated immigrants coming into the country was made after CDC 
considered ``current public health conditions and an increased 
availability of tools to fight COVID-19.''
    Yet just days later, the Department made contradictory decisions to 
extend our own country's Public Health Emergency and to appeal the 
Federal mask mandate on public transportation that was struck down in 
the courts. Even just yesterday, the CDC updated guidance that, two-
and-a-half years into the pandemic, it is now recommending everyone get 
tested before domestic travel.
    Mr. Secretary, these decisions make no sense. They are 
intellectually inconsistent and they send mixed messages to the 
American people.
    I am afraid that CDC and the Department have now clearly crossed a 
line with credibility. And I don't think the American public will 
follow public health guidance if they don't trust the agency providing 
the guidance. How do you expect Americans to follow your 
recommendations when you say it's safe to open the borders to 
unvaccinated illegal immigrants, but not safe enough to remove masks on 
planes?
    Meanwhile, even as the borders reopen as if the pandemic is over, 
Americans remain under Federal vaccine and mask mandates and the 
Department is asking Congress to provide additional funding for 
therapeutics, tests, and vaccines. I want to be very clear: I am 
supportive of this funding.
    We are not out of the woods yet with COVID-19 and we need to be 
prepared for a future wave, to vaccinate the under 5 population, and to 
ensure that any American who needs a therapeutic can receive one.
    Unfortunately, the Administration made two poor decisions that make 
this additional funding nearly impossible.
    First, it pushed through a $1.9 trillion, partisan COVID-19 funding 
bill that provided less than 1 percent of funding toward vaccines and 
therapeutics, and only 5 percent toward COVID-19 public health 
priorities.
    Simply put, when the Department had the opportunity to purchase 
more vaccines, tests, and treatments, to continue researching 
additional therapeutics, and to prepare for a disease that we will 
likely be facing for the next several years, it failed to do so.
    Second, as we were actively negotiating a bill last month to 
provide the Department $10 billion to purchase additional therapeutics, 
vaccines, and tests, CDC announced the termination of the Title 42 
Order.
    While this imprudent decision on Title 42 does not lessen the need 
for additional funding, it sure makes it significantly harder for 
Congress to provide it.
    Finally, Mr. Secretary, as it did last year, COVID-19 has once 
again overshadowed the budget request. That may actually be a good 
thing because this budget is wrought with recycled partisan programs 
that I had hoped had been resolved when Congress rejected them in the 
last Omnibus.
    I once again wholeheartedly disagree with the Administration's 
removal of the longstanding Hyde Amendment.
    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. 
Last year was not any different, and I do not expect this year to be 
either.
    Mr. Secretary, this Committee has been successful over the last 7 
years with passing bipartisan bills because we haven't made 
fundamental, drastic funding or policy changes. We've been able to find 
agreement on funding for important national priorities, such as ARPA-H 
and addressing the substance use disorder crisis and mental health 
needs.
    As we did in the Omnibus last year, I hope we will set aside 
partisan policies to support programs that benefit all Americans.
    Thank you, again, for being here today.

    Senator Murray. Thank you, Senator Blunt. Again, welcome, 
Secretary Becerra. Our witness today is Javier Becerra, the 
Secretary of the Department of Health and Human Services. 
Again, thank you for joining us. It is important that you are 
here. We look forward to your testimony. And with that, you may 
begin.

                SUMMARY STATEMENT OF HON. XAVIER BECERRA

    Secretary Becerra. Chairwoman Murray, Ranking Member Blunt, 
and members of the committee, I look forward to discussing with 
you the President's fiscal year 2023 budget. But it is most 
important that I begin today by responding to the chilling news 
that certain justices on the Supreme Court appear to be 
plotting to dismantle settled legal authority that recognizes 
and protects every woman's right to make her own decisions 
about her health and her body, including abortion.
    22 years into the 21st century and nearly 50 years after 
Roe v. Wade, some, mostly men, seek to impose their judgment 
over every woman in America who may seek to exercise their 
Constitutional right to privacy in personal decisionmaking. 
That is dangerous, that is wrong, and that, we must repel with 
every just bone in our body.
    America is not a Nation prone to regression, and the 
Department of Health and Human Services is not in the business 
of stripping Americans of access and protections to care. So at 
HHS, we will double down on our authorities to protect every 
American's right and access to reproductive healthcare, 
including abortion.
    Turning to the budget first, to recap, today more than 250 
million Americans have received at least one dose of a COVID-19 
vaccine, and two-thirds of adults over age 65 have gotten a 
booster shot. We have also closed the glaring gap in vaccine 
rates across communities often left behind. It has paid 
dividends to surge resources, including tests and treatment to 
our hardest hit and highest risk communities.
    340 million free COVID-19 at home test shipped across 
America. 270 million free N95 masks. 100 million booster shots. 
Almost $186 billion in provider relief funds distributed 
through more than 800,000 payments to over 441,000 providers 
for COVID losses and expenses. That is 441,000 hospitals, 
community health centers, doctors, pharmacies, nursing homes, 
rural health clinics, behavioral health providers, and many 
more. Real money, real relief, real results.
    That is why it is critical that we have the funds to finish 
the fight on COVID-19. It is not just a good investment for our 
health and all of our people's health, it is a smart investment 
for the health of our economy. Beyond COVID-19, today more 
Americans have insurance for their healthcare than ever before 
in our country.
    That includes a record breaking 14.5 million Americans who 
secured health insurance through the Affordable Care Act. Many 
of those insured Americans are paying less than $10 per month 
in premiums for that solid insurance coverage and the peace of 
mind that comes with it. I am also pleased that last week the 
FDA issued two proposed tobacco product standards, one 
prohibiting menthol as a flavor in cigarettes, and another 
prohibiting all flavors in cigars.
    These standards are based on scientific evidence and would 
improve the health of all Americans. In addition, we launched 
Operation Allies Welcome, an HHS led effort that has helped 
over 68,000 of our Afghan brothers and sisters resettle as 
refugees in America. And we have begun to extend support to 
Ukrainian refugees fleeing the Russian invasion of their 
homeland.
    As you know, we are working to tackle America's mental 
health challenges. We are coordinating nearly $300 million with 
our 50 States, Tribal governments, and territories to prepare 
for the launch of the new three digit 9-8-8 National Suicide 
Prevention Lifeline this July. What 9-1-1 is for local 
emergency, we are working hard to make 9-8-8 for Americans 
experiencing a mental or behavioral health crisis.
    On sexual and reproductive healthcare, including access to 
abortion care, which is still legal and available, the 
Department has worked to restore the Title X Family Planning 
Program, awarding $256.6 million in grant funding to restore 
access to care nationwide and strengthen program rules. This 
importantly, fills service gaps caused by more than a quarter 
of Title X providers withdrawing from the program under the 
previous Administration's rule.
    We have also made funds available to help with clinics in 
dire need. Issued guidance under EMTALA (Emergency Medical 
Treatment and Active Labor Act) to help patients' access 
emergency services safely, and guidance to support providers 
against discrimination. We are continuing to do our work to 
ensure access to quality care for all patients.
    We made these investments to close holes in our public 
health system in areas like maternal health, where we have 
extended Medicaid coverage for postpartum care for a new mother 
and her baby, from 2 months to 12 months. We recently awarded 
$16 million to community health organizations to expand HHS 
Maternal and Child Home Visiting Program. And we are working 
across agencies to make more children eligible for high quality 
early education programs like Headstart.
    The President's 2023 budget lets us build on that record of 
unprecedented investment in America's health. It proposes $127 
billion in discretionary budget authority and $1.7 trillion in 
mandatory funding, including a standout and historic investment 
to transform the mental health infrastructure in our country, a 
priority I know you share.
    We also ask for $82 billion for the President's pandemic 
preparedness and response to get ready for whatever might come 
next after COVID-19. Considering that COVID has cost our 
country more than $4.5 trillion in direct support from the 
Federal Government so far, this is a no brainer to continue 
fighting COVID-19 and prepare for any future pandemic.
    Madam Chair, members, we are here to turn hardship into 
hope, inclusion into opportunity. We look forward to working 
with you. And I look forward to answering any questions you may 
have.
    [The statement follows:]
                  Prepared Statement of 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) 2023 Budget for the Department of Health and Human Services (HHS). 
I am pleased to appear before you today, and I look forward to 
continuing to work with you to serve the American people.
    HHS addresses many of the challenges facing our country today--
ending the COVID-19 pandemic, reducing healthcare costs, expanding 
access to care, improving health equity, ending HIV/AIDS, enhancing 
child and family well-being, addressing the overdose epidemic, and 
strengthening behavioral health--and we are making meaningful progress 
on these priorities. Our work has never been more important, and I am 
honored to lead HHS at this critical moment.
    The Budget advances the HHS mission to enhance and protect the 
health and well-being of all Americans. We are proud to be Congress' 
partner in supporting the American people, and we are grateful for the 
funding you have provided in support of the HHS mission. We take very 
seriously our commitment to ensure we are good stewards of every dollar 
in our budget.
    Before I dive deeper, I first want to reflect on the Department's 
incredible achievements over the past year to save lives and improve 
health. Thanks to our work to develop and distribute vaccines and 
boosters, nearly 220 million Americans are fully vaccinated against 
COVID-19, and two-thirds of adults over age 65 have gotten their 
booster shots--an unprecedented accomplishment that saves lives every 
day. HHS procured and provided life-saving antivirals, monoclonal 
antibodies, and ongoing testing support, with more to come. To date, 
HHS has provided critical support that resulted in the emergency use 
authorization (EUA) of 3 vaccines (2 of which are now fully licensed), 
7 therapeutics, and 29 diagnostics against COVID-19. HHS has procured 
millions of COVID-19 treatment courses for Americans, and is supporting 
the President's pledge to directly provide 1 billion tests to American 
households for free.
    Testing capacity has dramatically increased, and we've supplied 
free, high-quality masks to the American people. HHS has invested $250 
million in U.S.-based manufacturing of personal protective equipment 
(PPE) and $950 million in manufacturing the supplies and equipment 
needed for vaccines, therapeutics, and diagnostic tests to strengthen 
the public health supply chain. We distributed Provider Relief Funds to 
support healthcare providers hit hard by the pandemic, and to reimburse 
providers for testing, treatment, and vaccine administration for 
uninsured patients. We provided guidance to support the safe return to 
the classroom, enabling schools nationwide to reopen.
    As the President has said, it is critical to get Americans back to 
our more normal routines, while still protecting people from COVID-19, 
preparing for new variants, and preventing economic and educational 
shutdowns. HHS contributions over the past 2 years position our country 
to move forward safely, and we look forward to working with you to 
continue these efforts.
    The country has seen historic increases in health insurance 
enrollment through the Marketplaces, with a record 14.5 million people 
signed up for 2022 healthcare coverage during the latest Marketplace 
Open Enrollment Period. Uninsured rates fell last year after the 
American Rescue Plan Act took effect, and continue to fall due to the 
success of innovative and targeted consumer outreach campaigns. We are 
implementing initiatives like the No Surprises Act, which establishes 
new Federal protections against certain kinds of surprise medical 
bills. We are preparing for the expansion of the Suicide Lifeline with 
the 9-8-8 implementation that will launch this summer. Working with our 
interagency partners, we also launched interagency initiatives like 
Operation Allies Welcome, a whole-of-government effort that helped over 
68,000 Afghans to permanently resettle in 2021.
    HHS has made key investments to address disparities and improve 
equity and launched new efforts to protect vulnerable communities who 
bear the brunt of climate change. We are prioritizing rural health and 
the needs of our Tribal partners. We released a new HHS Overdose 
Prevention Strategy and made significant investments in behavioral 
health. It is also an Administration priority to advance legislation 
that helps lower costs for families, including for child care, 
preschool, and long-term care, and I look forward to working with 
Congress to achieve this together.
    The President's Budget will enable us to continue these critical 
efforts and achieve our mission in fiscal year 2023. The fiscal year 
2023 Budget proposes $127.3 billion in discretionary and $1.7 trillion 
in mandatory budget authority, including newly proposed mandatory 
funding for the Indian Health Service and an historic mandatory funding 
request to transform our ability to protect the nation from future 
pandemics and other biological threats. The Labor-HHS-Education total 
is $123.4 billion, an increase of $12.9 billion. These investments 
support families through early education, behavioral health, and access 
to care. The Budget demonstrates the Administration's commitment to 
reinvesting in public health, research, and development to drive growth 
and shared prosperity for all Americans by making major investments in 
priority areas, including overdose prevention, mental health, maternal 
health, cancer, and HIV/AIDS. COVID-19 has shown that health inequities 
and insufficient Federal funding leave communities vulnerable to these 
crises. The Budget advances equity and helps ensure our programs serve 
people of color and other underserved communities with the 
opportunities promised to all Americans.
     tackling covid-19 and preparing for the next biological threat
    First, I want to highlight that although HHS has made tremendous 
progress in the fight against COVID, we now face a dire moment. As you 
know, the Administration requested $22.5 billion for immediate needs to 
avoid severe disruptions to our COVID response. We requested these 
funds as emergency resources, in the same way Congress provided 
multiple times on a bipartisan basis under the prior Administration. We 
face unavoidable impacts of not receiving these resources. Testing and 
treatment capacity will decline. The uninsured fund--which offers 
coverage of testing, treatments, and vaccinations for tens of millions 
of Americans who lack health insurance--will run out of money and stop 
paying provider claims. Already, it has stopped accepting provider 
claims for testing, treatment, and vaccine reimbursement. Many 
Americans will no longer be able to access life saving monoclonal 
antibodies and antiviral drugs. We will be unprepared for a new variant 
and unable to provide life-saving vaccines to the American people. It 
is critical that we work together to avoid these and other severe 
consequences.
    Beyond the need for investment in immediate COVID-19 response 
requirements, the fiscal year 2023 budget builds on Congress' response 
investments to transform our preparedness for biological threats and 
strengthen national and global health and health security. The Budget 
includes a historic $81.7 billion in mandatory funding over 5 years 
across the Office of the Assistant Secretary for Preparedness & 
Response (ASPR), CDC, the National Institutes of Health (NIH), and the 
Food and Drug Administration (FDA) to support the Administration's 
vision for pandemic preparedness.
    This request provides $40 billion to the Office of the Assistant 
Secretary for Preparedness and Response to invest in advanced 
development and manufacturing of countermeasures for high priority 
threats and viral families, including vaccines, therapeutics, 
diagnostics, and personal protective equipment. It provides $28 billion 
for the Centers for Disease Control and Prevention (CDC) to enhance 
public health system infrastructure, domestic and global threat 
surveillance, public health workforce development, public health 
laboratory capacity, and global health security. It provides $12.1 
billion to NIH for research and development of vaccines, diagnostics, 
and therapeutics against high priority biological threats; biosafety 
and biosecurity research and innovation to prevent biological 
incidents; and safe and secure laboratory capacity and clinical trial 
infrastructure. The Budget also includes $1.6 billion for the Food and 
Drug Administration to expand and modernize regulatory capacity 
information technology, and laboratory infrastructure to support the 
evaluation of medical countermeasures.
    Collectively, these activities will build capabilities the nation 
urgently needs to respond to future pandemics and biological threats 
from any source, strengthen international systems so that we can detect 
threats early and respond to threats quickly, and enable us to boldly 
and decisively act on the lessons from COVID-19.
    In addition to this mandatory investment, the Budget also funds 
critical ongoing response and preparedness efforts through 
discretionary budgets. The HHS Coordination Operations and Response 
Element (H-CORE) within ASPR is responsible for coordinating the 
development, production, and distribution of COVID-19 vaccines and 
therapeutics. The Budget requests $133 million for H-CORE, which is 
critical to beat COVID-19 and for future emergency response efforts 
beyond the pandemic, as ASPR builds an enduring response 
infrastructure. These resources will support the necessary staffing, 
acquisition support, and data analytics for COVID-19 countermeasures 
when emergency funding is no longer available to cover these costs.
    The Budget requests $828 million for the Biological Advanced 
Research and Development Authority (BARDA), to develop novel medical 
countermeasure platforms to enable quicker, more effective public 
health and medical responses to detect and treat infectious diseases. 
The Budget also requests $975 million for the Strategic National 
Stockpile to sustain and expand the current inventory of supplies to 
ensure readiness for potential future pandemics.
    COVID-19 has shown the importance of timely, reliable data to 
respond effectively to public health threats. The Budget makes robust 
investments in science and public health to improve and protect health 
at home and abroad, including at CDC for public health infrastructure 
and capacity, data modernization, global public health protection, and 
the Center for Forecasting and Outbreak Analytics. The Budget also 
includes $197 million to expand state, local, tribal, territorial, and 
international capacity to combat antibiotic resistance at CDC, as well 
as an HHS-wide mandatory proposal to encourage the development of 
innovative antimicrobial drugs.
                     advancing science and research
    The Budget prioritizes research and scientific advancement. We are 
grateful for the support from Congress to establish the Advanced 
Research Projects Agency for Health (ARPA-H), and the Budget proposes 
$5.0 billion to revolutionize how to prevent, treat, and even cure a 
range of diseases including cancer, infectious diseases, Alzheimer's 
disease, and many others. This funding is part of a proposed $49.0 
billion in discretionary funds for NIH to continue its incredible track 
record of turning discovery into health. NIH invests in basic research 
and translation into clinical practice to address the most urgent 
challenges including preparing for future pandemics, reducing health 
disparities and inequity, driving innovative mental health research, 
and ending the overdose crisis.
    The Budget proposes investments in NIH, CDC, and FDA to reignite 
the President's Cancer Moonshot with an ambitious goal to reduce the 
death rate from cancer by at least 50 percent over the next 25 years, 
improve the experience of people and their families living with and 
surviving cancer, and end cancer as we know it today. The Budget 
includes increases for CDC to enhance a range of cancer related 
programs and for FDA's Oncology Center of Excellence.
    The Budget proposes $6.8 billion for FDA to continue to work with 
developers, researchers, manufacturers, and other partners to help 
expedite the development and availability of therapeutic drugs and 
biological products, and to apply the best science in its food and 
tobacco work. The Budget also proposes $527 million program level 
resources for the Agency for Healthcare Research and Quality (AHRQ) to 
support evidence-based research, data, and tools to make healthcare 
safer, higher quality, more accessible, equitable, and affordable for 
all Americans.
    Importantly, the Budget also includes $25 million for CDC and $20 
million for AHRQ to launch Centers for Excellence to study long COVID 
conditions and equip healthcare providers and systems to deliver 
patient-centered, coordinated care for this patient population.
        reducing health care costs and expanding access to care
    To enhance the health and well-being of all Americans, the Budget 
makes access to more affordable healthcare a top priority. The 
Affordable Care Act (ACA), bolstered by the American Rescue Plan, has 
expanded health insurance coverage to historic numbers of Americans and 
the Budget builds on that legacy.
    The American Rescue Plan made groundbreaking investments in the ACA 
by expanding premium subsidies to make coverage affordable for millions 
more Americans. As I mentioned earlier, a record-breaking 14.5 million 
people have signed up for 2022 healthcare coverage through the 
Marketplaces during the latest Marketplace Open Enrollment Period, 
including nearly 6 million people who have newly gained coverage. The 
American Rescue Plan lowered healthcare costs for most consumers and 
increased enrollment to record levels. In fact, consumers saw their 
average monthly premium fall by 23 percent compared to the prior open 
enrollment period. As you know, the American Rescue Plan subsidies will 
expire at the end of 2022 and without new legislation this will result 
in millions of Americans losing this more affordable coverage. I look 
forward to working with the Congress on this key priority. We are also 
concerned about millions of vulnerable Americans who could lose their 
Medicaid coverage when the COVID-19 Public Health Emergency ends. To 
address this concern, CMS has provided multiple rounds of guidance to 
state Medicaid and CHIP agencies that include a robust selection of 
best practices and recommended strategies allowed under current law 
when returning to routine operations after the Public Health Emergency 
ends. For example, recently, CMS released a State Health Official 
Letter that extends the time states have to process Medicaid 
redeterminations after the end of the Public Health Emergency from 12 
months to 14. HHS is also working to increase awareness of coverage 
options through targeted outreach campaigns and making renewal of 
coverage for those eligible easier to navigate. We also look forward to 
working with the Congress to find solutions to providing coverage 
options for the nearly 4 million Americans in non-covered states. 
Additionally, the Administration supports strengthening home and 
community-based services as an alternative to institutionalized care, 
to ensure people have access to safe options that work for them.
    Rising healthcare costs affect all Americans. HHS has taken steps 
to increase competition, improve transparency, and strengthen consumer 
protections. Under the No Surprises Act, a critical bipartisan law 
passed by Congress, HHS continues to implement the law that shields 
consumers from certain kinds of surprise medical bills and requires 
greater transparency from providers. HHS also issued a proposed rule to 
make hearing aids available to individuals over-the-counter that can 
help provide consumers with more affordable options and lead to a more 
competitive market.
    I look forward to working with the Congress to lower healthcare 
costs and expand and improve coverage for all Americans. Reaffirming 
the President's charge in his State of the Union address, we will work 
to lower the costs of prescription drugs, such as by capping the cost 
of insulin at $35 per month, and to allow Medicare to negotiate payment 
for certain high-cost drugs.
    During the COVID-19 public health emergency, telehealth has been a 
reliable resource for providers to reach patients directly in their 
homes to ensure access to care and continuity of services. The 
Administration is committed to supporting a temporary extension of 
broader telehealth coverage under Medicare beyond the declared COVID-19 
Public Health Emergency to study its impact on utilization of services 
and access to care. I want to thank Congress for provisions included in 
the fiscal year 2022 Omnibus spending bill that extend Medicare 
telehealth flexibilities for 5 months after the end of the public 
health emergency.
    Additionally, the COVID-19 pandemic highlights the importance of 
vaccines and prevention. Long- standing, deep disparities exist in 
adult vaccination coverage based on race and ethnicity, particularly 
among Black and Hispanic populations as compared to other groups. The 
Budget proposes Vaccines for Adults, a new mandatory program modeled 
after the existing Vaccines for Children (VFC) program, to provide 
uninsured adults with access to vaccines, free of charge, that are 
recommended by the Advisory Committee on Immunization Practices. The 
Budget further expands the VFC program to include all children under 
age 19 enrolled in the Children's Health Insurance Program. The Budget 
also includes a proposal to consolidate Medicare coverage of vaccines 
under Part B, which will make vaccines more accessible, remove 
financial barriers, and streamline the process for Medicare 
beneficiaries and providers.
    The Budget continues to support the fourth year of the Ending the 
HIV Epidemic initiative with $850 million in funding across CDC, HRSA, 
IHS, and NIH for fiscal year 2023. The initiative is critical to 
achieve President Biden's plan to end the HIV/AIDS epidemic by 2030 and 
ensure access to HIV prevention, care, and treatment. HHS works closely 
with communities to support the four key strategies--Diagnose, Treat, 
Prevent, and Respond--to end the HIV epidemic. The Budget also creates 
a national program that invests $9.8 billion over 10 years to provide a 
financing and delivery system to ensure everyone has access to pre-
exposure prophylaxis, also known as PrEP, and essential wraparound 
services.
             tackling health and human services disparities
    Advancing equity is at the core of the Budget. HHS works to close 
the gaps in access to healthcare and human services to advance 
equitable outcomes for all, including people of color and others who 
have been historically underserved, marginalized, and adversely 
affected by persistent poverty and inequality. HHS is committed to 
carrying out the President's Executive Order 13985 on Advancing Racial 
Equity and Support for Underserved Communities Through the Federal 
Government. Even before the pandemic, we were not doing enough to 
provide equitable preventive measures, services, and treatment options 
in every community--and COVID has only made this disparity worse.
    Maternal mortality in the United States is significantly higher 
than most other developed nations and is especially high among Black 
and Native American/Alaska Native women, regardless of their income or 
education levels. The Biden-Harris Administration is committed to 
promoting maternal health and ensuring equitable access to affordable, 
quality healthcare for our nation's mothers. The Budget invests over 
$470 million across AHRQ, CDC, HRSA, IHS, and NIH to reduce maternal 
mortality and morbidity. This includes increased funding to CDC's 
Maternal Mortality Review Committees and other Safe Motherhood 
programs, HRSA's State Maternal Health Innovation Grants program and a 
new Healthy Start program initiative, and other maternal health 
programs across HHS.
    The Budget also invests in maternal and broader women's health and 
health equity, including $86 million for the Office of Minority Health 
to focus on areas with high rates of adverse maternal health outcomes 
and areas with significant racial or ethnic disparities. In addition, 
the Budget also includes $42 million for the Office on Women's Health 
to fund prevention initiatives that address health disparities for 
women.
    Black and Latino/Hispanic people, along with American Indian/Alaska 
Native people, are much less likely than white people to have health 
insurance. Evidence shows that expanding coverage is not only essential 
for facilitating equitable access to healthcare, but also is associated 
with reduced morbidity and mortality, poverty reductions, and 
protection from debilitating financial bills. The Budget supports 
policies to promote a stronger and more equitable health insurance 
system beginning with new requirements for data on race and ethnicity 
in Medicare.
    The Budget also invests $35 million for a new initiative to 
systematically identify and resolve barriers to equity in each Centers 
for Medicare & Medicaid Services (CMS) program through research, data 
collection and analysis, stakeholder engagement, building upon rural 
health equity efforts, and technical assistance. CMS is committed to 
obtaining more accurate and comprehensive race and ethnicity data on 
Medicare beneficiaries, and to require reporting on social determinants 
in post-acute healthcare settings. CMS also proposes to add Medicare 
coverage for services furnished by community health workers who often 
play a key role in addressing public health challenges for underserved 
communities. These proposals will help identify, mitigate, and lessen 
health disparities.
    Health Centers are the first line of defense in addressing 
behavioral health issues nationwide when resources are available. This 
is particularly true for underserved populations, including low-income 
patients, racial and ethnic minorities, rural communities, and people 
experiencing homelessness. The Budget provides $5.7 billion for health 
centers, including $3.9 billion in mandatory resources.
    The COVID-19 pandemic has further disrupted access to reproductive 
health services and exacerbated inequalities in access to care. HHS 
commits to protecting and strengthening access to reproductive 
healthcare, and the Budget proposes $400 million to the Title X family 
planning program to address increased need for family planning 
services. Title X is the only Federal grant program dedicated solely to 
providing individuals with comprehensive family planning and related 
preventive health services in communities across the United States.
    The Budget increases services to prevent child maltreatment and the 
need for foster care, and supports states in moving towards child 
welfare systems that provide more tailored and comprehensive prevention 
services to a broader, more diverse group of families. Prevention 
services and support are particularly important for at-risk Black, 
Latino, Indigenous, Native American, and members of other under-served 
communities, which have disproportionate involvement with the child 
welfare system.
    The Budget provides $3.1 billion for the Administration for 
Community Living (ACL), reflecting significant demand increases for 
critical services caused by population growth and pandemic impacts. ACL 
supports caregivers and advances equitable access to healthcare, 
education, employment, transportation, recreation, and other systems, 
resources, and opportunities. ACL advances equity by targeting those in 
greatest social and economic need, with particular attention on people 
with disabilities and older adults who are marginalized due to race, 
ethnicity, sexual orientation, gender identity, poverty, language 
spoken, and who are at risk of institutionalization.
    Lastly, the Budget takes a historic first step toward redressing 
health disparities faced by American Indians and Alaska Natives by 
proposing all funding for the Indian Health Service (IHS) as mandatory. 
In fiscal year 2023, the Budget provides $9.3 billion, which includes 
$147 million in current law funding for the Special Diabetes Program 
for Indians. This substantial funding increases of $2.5 billion above 
fiscal year 2022 enacted will support direct healthcare services, 
facilities and IT infrastructure, and management and operations. It 
also provides targeted increases to address key health issues that 
disproportionately impact American Indians and Alaska Natives such as 
HIV, Hepatitis C, opioid use, and maternal mortality. With current law 
funding for the Special Diabetes Program for Indians, the total program 
level for IHS is $9.3 billion in fiscal year 2023.
    To address chronic underinvestment in IHS, the Budget increases 
funding for each year over 10 years, building to $36.7 billion in 
fiscal year 2032. This increase of 296 percent over the ten-year budget 
window accomplishes funding growth beyond what can be accomplished 
through discretionary spending. Over a five-year period, the budget 
will reduce existing facilities backlogs, fully fund the level of need 
identified by the Federal-Tribal Indian Health Care Improvement Fund 
workgroup and support the modernization of the IHS electronic health 
record system. Additionally, the Budget grows IHS funding to keep pace 
with inflation and population growth. This request responds to the 
long-standing recommendations of tribal leaders shared in consultation 
with HHS to make IHS funding mandatory, and HHS will continue 
consulting with tribes to inform future policy and budget requests. HHS 
appreciates the strong partnership with Congress to grow funding for 
the IHS budget over the last decade, and looks forward to continuing 
our shared efforts to improve healthcare in Indian Country.
                    strengthening behavioral health
    HHS is committed to combating America's mental health and substance 
use crises. The pandemic has had a devastating impact on mental health, 
particularly for young people, by dramatically changing Americans' 
experience of home, of school, of work, and in their communities. The 
President has outlined a bold strategy for tackling the nation's mental 
health crisis, calling for an increased focus on building system 
capacity, connecting more people to care, and creating a continuum of 
support to keep people healthy and help Americans thrive. I also 
recently launched a National Tour to Strengthen Mental Health, to hear 
directly from Americans across the country about the mental health and 
substance use challenges they're facing and to engage with local 
leaders to strengthen the mental health and crisis care system in our 
communities. We are also working with the Department of Education to 
develop and align resources to ensure children have the physical and 
behavioral health services and supports that they need to build 
resilience and thrive. Individuals who develop substance use disorders 
are often also diagnosed with mental disorders--the budget addresses 
the significant connection between mental health and substance use by 
investing in a broad spectrum of behavioral health services.
    The Budget includes new, historic mandatory investments in totaling 
$51.7 billion over 10 years to address the nation's behavioral health 
crisis. In support of the President's call for reforming our mental 
healthcare system to fully meet the needs of our communities, the 
Budget includes a new $7.5 billion Mental Health Transformation Fund, 
allocated over a 10 year period, to increase access to mental health 
services through workforce development and service expansion, including 
through healthcare and community settings that have not traditionally 
provided mental health services but that are well-positioned to reach 
more people. The Mental Health Transformation Fund will also support 
the expanded use of evidence-based practices for mental healthcare, to 
ensure that families and communities affected by mental illness receive 
the highest quality care and supports.
    The Budget improves Medicare coverage of mental healthcare and 
makes access to such care more affordable by eliminating the 190-day 
lifetime limit on psychiatric hospital services and requiring Medicare 
to cover three behavioral health visits per year without cost-sharing. 
In addition, the Budget would recognize licensed professional 
counselors and marriage and family therapists as independent 
practitioners who are authorized to furnish and receive direct Medicare 
payment for their mental health services, aligns the criteria for 
psychiatric hospital terminations from Medicare with that of other 
healthcare providers, and applies the Mental Health Parity and 
Addiction Equity Act to Medicare.
    Additionally, the Budget establishes a Medicaid provider capacity 
demonstration program for mental health treatment and establishes a 
performance bonus fund to improve behavioral health services in 
Medicaid. The Budget also expands and converts the Demonstration 
Program to Improve Community Mental Health Services into a permanent 
program. Further, the Budget prevents states from prohibiting same day 
billing and allows providers to be reimbursed for Medicaid mental 
health and physical health visits provided to a Medicaid beneficiary 
that occur on the same day and requires that Medicaid behavioral health 
services, whether provided under fee-for-service or managed care, be 
consistent with current and clinically appropriate treatment 
guidelines.
    For people with private health insurance, the Budget requires all 
health plans to cover mental health and substance use disorder benefits 
and ensures that plans have an adequate network of behavioral health 
providers. The Budget also establishes grants to states to enforce 
parity between mental and substance use disorder and other medical 
benefits.
    The Budget also proposes $20.8 billion in discretionary funding for 
behavioral health programs in fiscal year 2023, including significant 
investments in mental health programs such as the National Suicide 
Prevention Lifeline, a free, confidential 24/7 phone line that connects 
individuals in crisis with trained counselors across the United States. 
The Lifeline receives calls from people with substance use; depression; 
mental and physical illness; economic worries; loneliness; and concerns 
about relationships and sexual identity. Ensuring the success of the 
Lifeline particularly as it transitions to the universal 3-digit number 
988 is a top priority for HHS.
    To support the health workforce, the Budget includes $397 million 
for Behavioral Health Workforce Development Programs and $25 million in 
the National Health Service Corps funding specifically for mental 
health providers. The Budget also includes $50 million for the Health 
Resources and Services Administration (HRSA) for Preventing Burnout in 
the Health Workforce. This investment will provide crucial support for 
health workforce retention and recruitment, which is essential for 
addressing current and future behavioral health workforce shortages.
    Suicide remains the second leading cause of death among young 
people between the ages of 10 and 34. Many youth, especially young 
people of color, Indigenous youth, and LGBTQ+ youth, still lack access 
to affordable healthcare coverage that is necessary for them to receive 
treatment for mental health conditions.
    The Budget also includes $308 million for Project AWARE and the 
Mental Health Awareness Training program to expand support for 
comprehensive, coordinated, and integrated state and tribal efforts to 
adopt trauma-informed approaches and increase access to mental health 
services. School and community-based programs like Project AWARE have 
been shown to improve mental health and emotional well-being of 
children at low cost and high benefit. Prevention is an investment in 
our future, and it lowers adverse outcomes with high societal impact.
    According to CDC data, drug overdose deaths increased nearly 30 
percent in 2020. Last fall, I announced the release of a new, 
comprehensive HHS Overdose Prevention Strategy for the nation, designed 
to increase access to the full range of care and services for 
individuals with substance use disorders and their families. This new 
strategy focuses on the multiple substances responsible for overdose 
and the diverse treatment approaches needed to address them.
    The Budget invests $11.0 billion to combat the overdose crisis 
across HHS in support of four key target areas--primary prevention, 
harm reduction, evidence-based treatment, and recovery support--and 
reflects the Biden-Harris Administration principles of equity for 
underserved populations, reducing stigma, and evidence-based policy.
    The Budget also proposes $553 million for Certified Community 
Behavioral Health Centers Expansion Grants to provide coordinated, 
high-quality, comprehensive behavioral health services. The Budget also 
proposes to remove the word ``abuse'' from the agency names within 
HHS--including the Substance use And Mental Health Services 
Administration, the National Institute on Alcohol Effects and Alcohol-
Associated Disorders, and the National Institute on Drugs and 
Addiction. Individuals do not choose to ``abuse'' drugs and alcohol; 
they suffer from addiction, which is a chronic medical condition. It is 
a high priority for this Administration to move past outdated and 
stigmatizing language that is harmful to these individuals and their 
families.
               supporting children, families, and seniors
    HHS has a responsibility to ensure our programs serve children 
equitably, and the high-quality care of children positively impacts 
their success later in life. The Budget proposes $20.2 billion in 
discretionary funding for the Administration for Children and Families' 
early care and education programs. This includes $12.2 billion for Head 
Start to provide services to more than a million children, pregnant 
women, and families, $7.6 billion for the Child Care and Development 
Block Grant, and $450 million for Preschool Development Grants to 
increase capacity of states to expand preschool programs.
    The Budget expands home visiting programs over 5 years to provide 
economic assistance, child care, and health support for up to 165,000 
additional families at risk for poor maternal and child health 
outcomes. This funding will help strengthen and expand access to home 
visiting programs that provide critical services directly to parents 
and their children in underserved communities.
    The mandatory budget includes a $4.9 billion expansion of services 
to prevent child maltreatment and the need for foster care. For 
children who must be removed from their parents, the Budget includes 
$1.3 billion in support for states to prioritize placing children with 
kin, as well as a $3 billion increase for programs to stabilize and 
support families and adoptive families, and a $1 billion increase in 
support for the transition to adulthood for youth who experienced 
foster care. While not part of HHS's budget, the Budget proposes to 
make the adoption tax credit fully refundable so that more families can 
benefit and to expand the credit to include qualifying legal 
guardianships.
    We face a public health crisis of violence in our communities, 
which disproportionately affects communities of color. The Budget 
includes $250 million for CDC for the Community Violence Intervention 
initiative, in collaboration with Department of Justice to implement 
evidence-based community violence interventions at the local level, as 
well as funding for firearm violence prevention research. The Budget 
also promotes prevention of and early intervention after adverse 
events, like community violence, to mitigate longer term impacts, 
including $15 million for CDC to advance surveillance and research 
aimed at preventing Adverse Childhood Experiences. The Budget also 
includes $519 million for ACF's Family Violence Prevention and Services 
programs, including $250 million to provide direct cash assistance to 
survivors of domestic violence.
    The Budget supports FDA's public education campaigns to educate 
youth about the dangers of e-cigarette use; provide resources to 
educators, parents, and community leaders to prevent youth use; and 
provide resources to help kids who are already addicted to e-cigarettes 
quit using these harmful products. The Budget includes $812 million for 
FDA's tobacco program, an increase to enhance product review and 
evaluation, research, compliance and enforcement, public education 
campaigns, and policy development.
    The Administration for Community Living (ACL) protects seniors and 
persons with disabilities from abuse through investments in Adult 
Protective Services and the Long-Term Care Ombudsman Program. As the 
populations served by ACL continue to grow, the Budget provides $139 
million to protect vulnerable older adults. The Budget also bolsters 
ACL's role as an advocate for older adults and people with 
disabilities.
                  refugees and unaccompanied children
    Amid the COVID-19 pandemic, large numbers of unaccompanied children 
continue to arrive at our Southern border. HHS is committed to 
fulfilling our legal and humanitarian responsibility to care for all 
unaccompanied children (UC) referred to us by Federal partners. The 
fiscal year 2023 Budget includes $6.3 billion in discretionary funding 
for the Office of Refugee Resettlement, including $4.9 billion for the 
unaccompanied children program so that HHS may continue to care for UC 
safely and humanely, in alignment with child welfare best practices. 
The Budget also proposes a mandatory contingency fund to provide 
additional funds if there is a surge in UC referrals, as well as 
mandatory funding to build towards universal UC legal representation. 
HHS is committed to unifying these children with vetted sponsors, 
usually a parent or close relative, as safely and quickly as possible, 
and the Budget includes funding to implement critical programmatic 
reforms and service expansions. The Budget also builds on the nation's 
refugee infrastructure to support resettling of up to 125,000 refugees 
in 2023, and requests authority to use these funds to support the 
successful reunification of families who were cruelly separated under 
the Trump Administration.
              improving safety and oversight nursing homes
    Building on the President's State of the Union Address, the Budget 
is committed to ensuring nursing homes are safe and providing high 
quality care to vulnerable Americans by increasing funding for nursing 
home health and safety inspections by nearly 25 percent. Additionally, 
by increasing nursing home owners' accountability for minimum quality 
standards, noncompliant facilities can be held financially responsible 
for poor safety and care. The Budget also requests authority to publish 
accreditation surveys for other healthcare facilities, like hospitals, 
rural health clinics, and ambulatory surgical centers, which will 
better inform the public when selecting care locations for loved ones. 
The Administration also supports strengthening home and community-based 
services to ensure people have access to safe options that work for 
them.
                    funding core program operations
    While the service provided by HHS continues to grow, investment in 
the Department's operational needs ensures HHS can carry out its 
mission to enhance and protect the health and well-being of all 
Americans while maximizing our resources. This investment 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 importance and magnitude of HHS' work, ensuring the 
integrity of our spending is a core value and responsibility of HHS. 
The Budget increases discretionary Heath Care Fraud and Abuse Control 
program spending to a total of $899 million to provide oversight of CMS 
health programs, strengthen OIG investigations, and protect 
beneficiaries against healthcare fraud, yielding a return-on-investment 
of $13.6 billion over 10 years. The pandemic has unleashed new 
healthcare fraud risks related to the implementation of billions in new 
Federal spending, as well as multiple provider regulatory and other 
flexibilities. These funds are critical to help HHS root out bad actors 
and ensure program integrity.
                               conclusion
    I want to thank the Committee for inviting me to discuss the 
President's fiscal year 2023 Budget for HHS. The Budget offers a vision 
for the nation that reinvests in America's health, supports growth and 
prosperity, and meets our commitments to the American people and 
especially to the most vulnerable. I look forward to working with you 
to fulfill that vision. If we step up in this moment, we can lay the 
foundation now.
    These are critical programs and issues that deserve attention and 
adequate funding. Thank you for your partnership in advancing our 
shared goal to improve the health, safety, and well-being of our 
nation.

    Senator Murray. Thank you very much, Mr. Secretary. We will 
now begin a round of 5 minute questions of our witness. I ask 
my colleagues, please keep track of the clock and stay within 
your 5 minutes.

                                TITLE X

    Secretary Becerra, when Texas passed its highly restrictive 
abortion ban, President Biden promised a whole of Government 
response. And in a statement yesterday, he said the 
Administration will be ready when any ruling is issued. What 
can you tell us about the Administration's plan for a whole of 
Government response to defend the right to abortion?
    Secretary Becerra. Madam Chair, as I mentioned before, we 
are working at HHS through a reproductive healthcare task force 
that we established to make sure that we continue to protect 
the rights of women that exist today. Those rights that exist 
today to have access to care. We have expanded program services 
like Title X, and we will work with all of our partners 
throughout the Federal Government to make sure that every woman 
has the legal right to access the care that she is entitled to.
    Senator Murray. Well, I have been really alarmed that some 
Republicans have made it clear they don't intend to stop at 
abortion. Some saying the case that ruled against birth control 
bans was wrongly decided.
    And they have refused to increase funding for the Title X 
program, which I have been talking about, that provides funding 
for birth control, cancer screening, and lifesaving care. And 
in fact, they voted to undermine that program just last week.
    Now, HHS approved, but had to turn away dozens of highly 
qualified applicants for this program in March as a result of 
that funding. Can you tell us what that means for patients?
    Secretary Becerra. First, I want to make note that because 
Congress was successful in passing its omnibus budget, we are 
going to be able to do far more than what the President's 
budget first proposed, because it was based on a baseline using 
the continuing resolution funding levels.
    So we will do much more working with you to make sure 
adequate funds are available for programs that provide women 
access to the care that they need. We are also going to make 
sure that we speak to all those providers who are out there who 
have an obligation to make sure women are receiving the 
services they are entitled to.
    I yesterday spoke to a number of health plans and 
representatives of various health plans throughout the country 
to make it clear that we intend to enforce the law when it 
comes to women accessing the care that they are entitled to.
    Senator Murray. Can you tell us how the proposed increase 
in HHS will expand access for women of color and low income 
women?
    Secretary Becerra. We are working hard to make sure that we 
are addressing some of the maternal mortality and morbidity 
circumstances that we see in this country, where typically a 
woman in the black community and in our native populations will 
suffer the consequences of lost birth, possibly a loss of life, 
in far greater numbers, probably 3 to 1 compared to in the 
white community.
    And so we are investing in the President's budget close to 
half a billion dollars to increase our services in maternal 
health and mortality. We are also calling on States through the 
American Rescue Plan to increase the number of days that a 
woman is entitled to postpartum care from 60 days under 
Medicare, Medicaid--excuse me, to 365 days under Medicaid. 
COVID-19 Funding
    Senator Murray. Okay. Thank you. On another topic, I am 
really concerned that further delay in passing emergency COVID 
funding could undermine our hard won progress. What are the 
immediate effects if Congress does not provide more funding for 
the COVID-19 response as soon as possible?
    Secretary Becerra. Madam Chair, thank you for that 
question. I have said this publicly many times, we have been 
first in line to receive vaccines, some of the therapeutics, 
the antiviral medications, because we have been at the 
beginning of the negotiations to have access to those therapies 
and drugs.
    Without the money to make the long term commitment going 
forward, we can't assume that we will get first in line. Many 
other countries are already negotiating for access to those 
treatments. And what we need to do is plan ahead. We have a 
stock right now of vaccines and treatments that cover us for 
the next several months.
    But we can't say that if there is a new variant that hits 
or if we need to buy the next generation vaccine that we'll be 
the first in line if we don't have the money.
    Senator Murray. Meaning there is a limited supply, and we 
won't have access to that supply unless we have the funds 
available now?
    Secretary Becerra. Correct.
    Senator Murray. Okay. Parents across the country are 
waiting anxiously for vaccines for young kids. I know FDA is 
working on this, but having safe, effective vaccines is the 
first step, and we need the Administration to be ready to 
distribute enough doses and make it easy for parents to get 
them for their kids. Are you ready for that?
    Secretary Becerra. We are ready and anxious, as anxious as 
you are. As you said, safe and effective are the key words. FDA 
will move when they have the data that reflects if they are 
safe and effective to use for those under 5 years of age. And 
we are already coordinating with a number of providers, 
including pediatricians, to make sure we are making those 
available as quickly as possible.
    Senator Murray. Do we have enough doses available, once it 
is approved?
    Secretary Becerra. We will be able to purchase, because we 
made a reservation of funds to make sure we could purchase. But 
once again, how much, how far, and what the vaccine might look 
like will determine whether or not we have access to the supply 
we need.
    Senator Murray. Thank you very much. Senator Blunt.

                                 ARPA-H

    Senator Blunt. Thank you, Chair. Let's talk about ARPA-H 
for a little bit. This for people who have not been thinking 
about--an idea the President has to take the long experience 
with DARPA, Defense Advanced Research, which is different than 
the way we have done basic health research, and in those 
instances where we can work toward a rapid conclusion and a 
more hands together partnered way to do that, I am for that.
    Chair Murray has supported the approach of trying to get 
there quickly as she and Senator Burr have introduced 
legislation to codify this concept. I really want to ask two 
questions here, and one is, talk a little bit about your 
decision to structurally put ARPA-H under the NIH umbrella but 
directly reporting to you, and then we will come to the 
spending decision later.
    Secretary Becerra. Senator, thank you for the question and 
the support you provided to ARPA-H. ARPA-H at the end of the 
day is like NIH, an agency that takes that research. But how it 
differs from NIH is it wants to be able to launch from the pad 
very quickly. And working in partnership with the private 
sector, those innovators that are out there, the biomedical 
scientists, be able to actually give the American people a 
product quickly.
    And that is why we want ARPA-H to be more nimble, more 
facile, and have the opportunity to break away from the tethers 
of governance that you see at NIH to be able to launch as 
quickly as possible. We believe we are going to be able to do 
that while using the efficiencies at NIH has.
    So, for example, starting up, your human relations office, 
your payroll office, your accounting office, rather than have 
ARPA-H have to start from very scratch, make use of what NIH 
provides, but give them the autonomy to launch the way they 
think fit.
    Senator Blunt. And at ARPA-H, I think is, I have heard that 
discussed while all of those assets would be there, the 
umbrella agency of NIH, the ARPA-H system would not necessarily 
work like the NIH system.
    You would have the ability to bring people in for shorter 
periods of time, understanding that this is a project, we are 
bringing you in to work on it, and at the end of, say, 3 years, 
we expect this project to be done and you will have the ability 
to go on to some other work somewhere else. Is that your 
understanding of this as well, Secretary?
    Secretary Becerra. That is correct. It will not work the 
way NIH works. It will work much closer to what you understand 
the way DARPA works in the Department of Defense.
    Senator Blunt. I do think that NIH showed during COVID with 
RADx and with some of the Warp Speed involvement that even NIH 
had, but particularly gives RADx the ability to do things in a 
different way. But I think looking at how that worked and how 
DARPA works and figuring out how they all work together would 
be a good thing.
    So Senator Murray and I have worked together on this 
committee for 7 years, and have increased the NIH funding by 
more than 50 percent after a decade with no real increase. It 
has been an important goal that we have worked on together. The 
concern at NIH about ARPA-H--or the NIH advocates, not 
necessarily the people working there, but the support groups 
and advocates of NIH, has always been that it would take money 
that otherwise would go to NIH. It appears that is exactly what 
is happening here.
    We did $1 billion for startup money for ARPA-H last year. 
This budget proposes another $4 billion for ARPA-H and zero for 
NIH. I am confident that based on our past, working on this 
topic, zero will not be the number we come up with. But why did 
you submit zero as opposed to an increase in NIH and money for 
ARPA-H as well?
    Secretary Becerra. Appreciate the question and to explain. 
We, when the President asked us to submit our budgets to 
Congress, we had to work with the baseline that we knew that 
was in front of us.
    At that point, Congress had not completed the work on a 
fiscal year 2022 budget, and so we had to operate expecting 
that our baseline would be the continuing resolution, which is 
far lower than what you ultimately passed in the omnibus bill 
for 2022.
    Certainly now, knowing what the omnibus bottom line is for 
NIH, we will work using that bottom line to talk about 
increases for NIH. And we look forward to working with you to 
make sure that NIH continues to receive the robust funding that 
it has always received from Congress.
    Senator Blunt. Thank you, Senator Murray. I will have some 
other questions, but I assume we will have a chance to ask a 
second round of questions.
    Senator Murray. Yes, we will do that. Thank you. Senator 
Manchin.

                              SUPPLY CHAIN

    Senator Manchin. Secretary, thank you for being here. 
Appreciate it. Thank you for your service. On supply chains, we 
have spoken quite a bit about supply chains, and we learned 
that during the COVID-19 pandemic, how fragile it is and trying 
to make sure that we are able to meet the needs of the people.
    This Administration, Biden Administration, they instituted 
a whole of Government effort to assess what can be done to 
strengthen competitiveness and supply chain resilience, 
including the 100 day reviews. And later this year, I think you 
all will issue your first annual report to provide an update on 
the challenges, developments, and opportunities.
    So the only thing, I know that we are running into these 
timeframes and everything, so I guess what progress has the 
Department made in confronting this supply chain crisis that 
jeopardizes the supply of medications that patients are going 
to rely on and need?
    Secretary Becerra. Senator, I look forward to working with 
you on that. As you know, this Administration has used the 
Defense Production Act on several occasions to try to increase 
and expand our supply chain. Quick example.
    Last year, all the manufacturers of COVID test kits were 
not domestic, and we worked really hard not only to expand the 
number of testing kits that would be available for Americans to 
test themselves against COVID, but we worked really hard to 
make sure those were domestically manufactured.
    And today we have several in America that are domestically 
manufactured, which, by the way, they will begin to shut down 
those lines of production if we don't have the monies to 
guarantee that we will be able to fund test kits moving into 
the future.
    Senator Manchin. You have been able to track manufacturing, 
but people are willing to come back into our manufacturing 
base?
    Secretary Becerra. Absolutely.

                                 LIHEAP

    Senator Manchin. You show them the support, they will be 
there. Okay. The other thing is on LIHEAP, the LIHEAP, Low 
Income and Energy Assistance Program. We are having a hard 
time, and advocates both from back home in West Virginia and 
nationally, challenge in the States facing administering this 
program. They are having trouble getting the people to 
administer the program and getting the money to be 
administered.
    So I guess, quickly, have you all looked into this, and can 
you look into it on LIHEAP, how you can maybe help or make sure 
that money is getting there, or they have the administration 
that they are going to need, the support that they are going to 
need to get this money out, because it just has been very, very 
difficult for a lot of poor people.
    Secretary Becerra. Americans need heat in the winter, and 
they need to be cool in the summer. And we will do everything. 
We have expanded LIHEAP. We will do everything we can, Senator, 
working with you and others to make sure that the resources 
that you all provided get to people who need it.
    Senator Manchin. I think basically just accept--helping 
them with their application approval process. That will help 
tremendously, if you can look into that. The other thing is 
that I had one thing that I wanted to mention to you, and I 
think we have talked about before, I have been trying to 
support and trying to pass the Lifeboat Act.
    And only thing it does, Lifeboat truly is saying that we 
are going to charge manufacturing of opiates one penny per 
milligram. That one penny per milligram goes to treatment 
centers all over America. Every one of us in our States have an 
addiction problem. But we have so few facilities, and the 
Government can only do so much. But I think the manufacturing 
that is a manufacturing fee, it won't be passed on as far as 
cost to the consumer.
    But for--if you are going to put this product on the 
market, you ought to know the damage it does. And right now, we 
see lawsuits all over the country. I would hope you are looking 
into that and see if it is something you all could support. It 
is not onerous at all. It basically directs every penny to 
treatment centers.
    And the final thing I want to ask you about, the $10 
billion that we are stuck on, I cannot believe it. What is it 
going to do? What risk are we really going to be faced if we 
don't get this funding?
    Secretary Becerra. Well, the $10 billion is certainly not 
enough to carry us to the end of the fiscal year. But what it 
does do is it lets us stay at the front of the line to make 
sure we are purchasing the medicines, the treatments, and the 
vaccines that we need moving forward. Without that, again, we 
could lose our place in line.

                                COVID-19

    Senator Manchin. This is like the different variants, that 
first of all, we thought COVID-19 was over. Then we have been 
told, Dr. Fauci told us, that there are going to be different 
variations. And it is exactly true what he said. And now we 
even have more. But what is the time element? Where are you 
going to be crunched on if politics is being played? Democrats 
and Republicans got to come together for the health of all 
Americans.
    Secretary Becerra. Our scientists are telling us that in 
the fall, winter, we probably will see another surge. How big, 
who knows. But in order to be ready for that fall or winter, we 
have got to start purchasing today, not in the fall or winter.
    Senator Manchin. I just, I know you all have a yeoman's 
task in front of you, and I appreciate the job you are doing. 
And I just want make sure that we can help you and assist in 
any way possible. So communications between the offices have 
been great and I appreciate that. We need a lot more and we are 
going to try to do all we can to make sure we can protect 
Americans.
    Secretary Becerra. Thanks, Senator.
    Senator Manchin. Thank you. Thank you.
    Senator Murray. Thank you. Senator Hyde-Smith.
    Senator Hyde-Smith. Thank you, Chairwoman Murray and 
Ranking Member Blunt, for holding this hearing today. And I 
also want to thank the Secretary for being here and your 
willingness to serve and your willingness to answer these 
questions. On March 11, 2021, President Biden signed the 
American Rescue Plan Act of 2021 into law. Out of the nearly $2 
trillion in this bill, only 6 percent went to vaccines and 
public health.
    Despite the fact that a lot of ARPA funding has yet to be 
disbursed, the Biden Administration continues to press Congress 
for more money. Over the past few months, your Department in 
particular has asked Congress for more funding to ensure 
continuation of critical aspects of the U.S. healthcare 
response to COVID-19.
    Knowing that there would be a continued need for pandemic 
related healthcare, why did HHS divert healthcare related funds 
toward the care of illegal immigrants who were coming here due 
to the Biden Administration's open borders policy?
    Secretary Becerra. Senator, thank you for the question. And 
as you recall, in the midst of the American Rescue Plan, 
America was sinking and the rescue plan was to do more than 
just the healthcare side, it was to make sure that those 
families who had lost their jobs, those business owners who 
were losing their businesses, could survive the pandemic. And 
so that is why so many of the resources went to keep America 
afloat. And today we see that very few Americans are 
unemployed.
    The economy is moving. But I get--to your point on the 
resources, we used resources to deal with COVID in its many 
different facets, including at the border. And so when it came 
to those migrant children, we wanted to make sure that everyone 
was safe, including those children.
    So we used some of the COVID money to make sure for COVID 
related reasons, we kept America safe and including those 
children safe from any particular spread. And so we documented 
the spending on those programs to Congress, and we continue to 
show that the success of keeping COVID from spreading, 
including on the border, was not only important, but kept our 
economy moving.
    Senator Hyde-Smith. I am well aware of the need for that 
funding and all the American children that needed the vaccines 
as well. Knowing these healthcare needs exist, why isn't your 
Department working with the Office of Management and Budget to 
shift undisbursed funds toward the healthcare priorities before 
asking for more money?

                                COVID-19

    Secretary Becerra. Senator, we are more than willing to go 
through with you and your team the way we have used the money. 
We have allocated all the dollars we have, the discretion to 
move towards the task of dealing with unaccompanied children or 
dealing specifically with COVID, but we are more than willing 
to get into some of the specific if you would like to see how 
we have been able to use the resources you provided.
    Senator Hyde-Smith. And staying on the topic of COVID-19, 
this is incredibly important to me. I have been in touch with 
your Department for months on behalf of a gentleman by the name 
of Cody Flint in Mississippi. He is an agricultural pilot in 
Mississippi. Cody received his first dose of the Pfizer vaccine 
on February the 1st, 2021, and immediately began experiencing 
very adverse side effects, such as headaches, vision, and 
hearing issues, dizziness, loss of balance, and a lot of pain.

              COUNTERMEASURES INJURY COMPENSATION PROGRAM

    Due to these serious health issues, he has not been able to 
fly as an Ag (Agricultural) pilot since receiving the COVID 
vaccine shot, rendering Cody unable to provide for his family 
as an Ag pilot in Mississippi. For more than a year, Mr. Flint 
has been painstakingly going through the Countermeasures Injury 
Compensation Program, seeking compensation he may be entitled 
to based on his experience.
    I have worked with him to try to navigate this process. And 
I have been stunned not only by your agency's lack of urgency 
in refusing such claims, many claims, but also the lack of the 
transparency in that process. I certainly still advocate for 
the vaccine, and I myself received the vaccine, and I encourage 
others to speak to their doctors about receiving it, however, 
as with any new medical product, some people will have side 
effects.
    The CICP (Countermeasures Injury Compensation Program) 
exists for that very reason, and I am very concerned about the 
amount of time it takes your agency to process claims and the 
lack of clarity given to those folks who were adversely 
affected. Can you tell me what you are going to do to address 
the thousands of claims currently in backlog at HHS?
    And what are you doing to improve the transparency of the 
CICP process so that Americans like Mr. Flint are properly 
compensated in a reasonable time period?
    Secretary Becerra. Senator, well, you have asked a very 
important question not just to Mr. Flint, but to so many 
Americans who did what they should, which is to get vaccinated. 
We are finding that there are a number of Americans who are 
suffering from what we are calling today long COVID, and we are 
doing everything we can to make sure we provide them with the 
support that they need to get through this, who knows how long 
it may be. We are doing research on this as well.
    I will say this, transparency is important. Accountability 
is important. And we want to make sure that those who really do 
have a medical issue to report are the ones who are receiving 
the assistance. We, as you are aware, in some cases, some of 
the COVID money has been used fraudulently by many.
    We want to make sure that no one is trying to game the 
system to get relief for something that doesn't exist, that way 
we can reserve the funds that we have for people like Mr. Flint 
and provide him with some help.
    And so why don't we do this? I am more than willing to have 
my team reach out to you, and we can see about Mr. Flint and 
where he is in his process, because we have heard this story on 
many occasions. We know that millions have been saved because 
of the vaccine, but we also know that many people are still 
suffering, so we look forward to working with you.
    Senator Hyde-Smith. He has totally lost his income and the 
financial burden is just unbelievable, but the frustration of 
trying to just get some answers of when something could be done 
for him for this compensation has been very great. Thank you 
for your help and for answering my questions.
    Senator Murray. Thank you. Senator Reed.

                                 LIHEAP

    Senator Reed. Thank you very much, Madam Chairman. Let me 
go back, Mr. Secretary, to an issue that Senator Manchin 
raised, that is LIHEAP. I am pleased to say that the President 
slightly increased LIHEAP in his budget this year, but the 
reality is that energy prices are just exploding. In the past 
12 months alone, the price of natural gas has increased by 22 
percent and the price of heating oil has increased by 70 
percent.
    So would you support any type of supplemental funding to 
enhance the LIHEAP so that we can deal with this extraordinary 
increase in prices?
    Secretary Becerra. Senator, we will support any effort to 
try to further fund LIHEAP given the circumstances that we are 
in.
    Senator Reed. Thank you very much. Also, let me go back to 
the point you raised, which I am pleased that you are moving 
aggressively. That is the 9-8-8 number. We all understand that 
we were in a mental health crisis in the country. I hear that 
not only from my constituents, but as I visit troops around the 
globe, I hear it from our military personnel also. And we just 
had a terrible incident, you know, multiple suicides at one of 
our Navy carriers. 9-8-8 is a great idea, I think.

                  NATIONAL SUICIDE PREVENTION LIFELINE

    I had something to do with it and that is why I think that 
way. But anyway, it is going to allow someone to call who has a 
suicidal ideation and try to get help. But it has to be 
implemented thoroughly throughout the Nation. In Rhode Island, 
my State has done, I think, a very good job of setting up the 
counseling centers, the technology, and etcetera. But as I 
understand the system, if someone calls in and a State doesn't 
have the infrastructure, they are referred someplace else.
    So you have a not a very good relationship, long distance, 
and also adding more work to States that have enough work 
already. So can you give us sort of a sense of how the Nation 
is doing and are we all going to come online together?
    Secretary Becerra. Thank you, Senator. And I do believe 
your State is doing very well in moving forward. We have a 
patchwork right now of call centers that accept these calls 
from folks who are suffering from mental stress. We are trying 
to turn that into one cohesive network. It is difficult because 
it won't be run by the Federal Government, it will be run by 
the 50 States, the territories, and the Tribal governments.
    But what we are doing is working with them with your 
support. We have so far invested $300 million throughout the 
country with all the States, local governments to try to make 
it work. We will also provide back up call centers to make sure 
that if any particular location is receiving a large volume of 
calls, there will still be someone who answers the phone, 
because the worst thing you can have when someone reaches out, 
instead it goes in the wrong direction, is to get a busy signal 
or be put on hold.
    Senator Reed. No, I completely agree, Mr. Secretary. And, 
you know, there are long term costs to not implementing 
something properly. We understand that. And this is an 
opportunity. We have to get it right. I also understand the 
President has requested nearly $700 million in his budget for 
the National Suicide Prevention Lifeline.
    And I think you will need that money, but I think right now 
we have a few months to get it right. And if you need 
additional help or assistance, please let us know.
    Secretary Becerra. Thank you. We are keeping tabs. We are 
contacting every Governor of every State every month to let 
them know where they stand.
    Senator Reed. Well, thank you, Mr. Secretary. It was a 
pleasure working with you in the House, and it is a pleasure 
working with you in your capacity. Thank you.
    Secretary Becerra. Thank you, Senator.
    Senator Murray. Senator Moran.

                             ORGAN SHARING

    Senator Moran. Chairwoman, thank you very much. Mr. 
Secretary, good morning. Let me start with a topic that I asked 
you about in your confirmation hearing or in our conversation 
prior to your confirmation hearing, organ transplants. For over 
30 years, HHS has contracted with United Network for Organ 
Sharing, UNOS, yet it is currently under a Congressional 
investigation by the Senate Finance Committee.
    I would tell you my experience is their attitude approach 
to their policy has been very discouraging and detrimental to 
the lives and well-being of those individuals who are hoping to 
be a recipient of an organ transplant. Damaging geographically 
in their outlook and damaging geographically in their policy. 
The contract that UNOS holds with HHS for organ procurement and 
transplantation is up for competition in 2023.
    A recently published request for information on the 
contract, which I joined Senator Grassley and Senator Wyden and 
Young in supporting--this RFI (request for information) is an 
essential step to improving the Nation's organ transplant 
network. Numerous reports have highlighted the best way to 
increase competition for the contract is to divide it up.
    I don't know whether that is the right answer or not, but I 
would love to hear from you what specific steps--I want to know 
that you are aware of these problems and what specific steps 
you intend to take to increase competition for potential organ 
procurement and transplant network contractors.
    Secretary Becerra. Senator, this is an issue where you have 
real people who come to you and tell you about their real life 
circumstances. So we absolutely know about this. We are trying 
to prepare to make sure that in the process of coming up with 
these new contracts, we increase supply, not diminish supply, 
that we make it a more fair distribution of these organs and 
that we make it more transparent.
    And that is in the works. And what I offer to you, because 
I think it is so important across the country, we will work 
with you if you and your team have any particular ideas, if we 
haven't already incorporated them. I am more than willing to 
make sure we take that into consideration.
    Senator Moran. If you would give me a name of a contact, 
you give my staff a name of a contact today, we would be glad 
to follow up. I would love for your team to hear from not only 
me, but from those who are actively engaged in trying to make 
the system work better.
    Secretary Becerra. I will follow up with you at the end of 
the hearing. Whether we meet directly or through our staffs, I 
will make sure that happens.

                    THE NATIONAL STRATEGIC STOCKPILE

    Senator Moran. Xavier, thank you very much. Let me 
highlight a couple of other things. The National Strategic 
Stockpile, Strategic National Stockpile, you request, the 
budget requests $975 million for the national stockpile for 
fiscal year 2023. Ensuring that--and I raised this topic in the 
authorizing committee, and I want to make sure that it is not 
lost between the two committees. I serve on both of them.
    But ensuring that the SNS (Strategic National Stockpile) is 
restocked and maintained to its maximum capacity is important. 
I think it became more important with Russia's invasion of 
Ukraine, and I would ask your commitment to prioritizing fully 
stockpiling the biodefense and pandemic response supplies 
maintained by the SNS.
    Secretary Becerra. You have got my commitment, and I hope 
you will take a look at the President's pandemic preparedness 
plan moving forward. I think you will like what you see.

                          PROVIDER RELIEF FUND

    Senator Moran. Thank you very much. And I will do that. 
Rock Regional Medical Center is a new hospital in the suburbs 
of Wichita. We have been, me and my office have been working 
with the Health Resources and Services Administration for the 
past year flagging Rock Regional, which did not receive a fair 
allocation of provider relief funding.
    It is a new hospital and was treated in a way that--it 
seemed to me that HRSA (Health Resources and Services 
Administration) seemed uncaring about solving this problem, and 
it is not the only hospital in which that is the circumstance. 
And I don't think I am the only member of the Senate who 
believes that. So why is HRSA so unwilling to reconsider their 
methodology for PRF (Provider Relief Fund) funding for new 
hospitals?
    Secretary Becerra. Senator, you are absolutely correct. You 
are not the first and Rock Creek is not the only facility. Here 
is the difficulty. All those funds that were dispersed before 
2021 were done under a formula that we could not change. That 
formula, to your point, relied on looking at past performance. 
If you are a new hospital, it is hard to talk about your past 
performance.
    That did damage a lot of these facilities that were newer. 
The difficulty, as you will understand, is we could not change 
the statutory framework of the provider relief fund and the 
distribution. To undo that would have meant to have to pull 
back all the funds. What we did do was we changed the formula 
with the tranches of dollars that was still existed that we 
could move forward with.
    But we are more than willing to work with you and those 
providers in your State so we can try to address some of that. 
But it is tough because we can't undo what was previously used.
    Senator Moran. You described it--I am always pleased when 
an administration official of any administration says they want 
to follow the Congressional law. That is pleasing to me. It is 
not always the case that I find it to be the case that it 
happens. But I would indicate that we thought this could be 
better addressed in the later phases, and our conclusion was 
that it was not. So I would be glad if you will, again, help me 
get again to somebody who can address this issue.
    Secretary Becerra. And if you will permit me a quick 
response, it is not that we don't want to, it is just that what 
was left with the final phases was so little, and there were 
still so many new incoming requests and some facilities that 
had gotten no money whatsoever. For example, nursing homes had 
been left out in the first tranches. So it is not that we 
didn't want to go back. It is that with what was left, we 
couldn't try to undo the formula requirements of the previous 
Administration.
    Senator Moran. Thank you for your explanation.
    Senator Baldwin [presiding]. I will now recognize myself 
for 5 minutes of questions. Secretary Becerra, thank you so 
much for appearing here today. I am, as are you, prepared to 
talk about the fiscal year 2023 budget, but I did want to 
acknowledge what we saw from the Supreme Court on Monday night. 
If the court is really going to legislate from the bench and 
turn back the clock 50 years on Roe v. Wade, then I think the 
Senate needs to pass the Women's Health Protection Act, an act 
that I have co-led with Senator Blumenthal.
    And frankly, I would say that if we need to eliminate the 
filibuster to get it done, that is what we should do. And I 
encourage strongly my colleagues to support that effort. Now, 
the Biden Administration has worked to expand access to 
comprehensive, affordable coverage through the Affordable Care 
Act.

                            INSURANCE PLANS

    And I support these efforts. But unfortunately, we continue 
to wait for the Administration to address the issue of junk 
insurance plans. I wanted to share the story of Phillip from 
Janesville, Wisconsin. He received a $34,000 bill for an 
emergency room visit and an overnight stay at an area hospital. 
Rather than paying the bill, his junk insurance plan rescinded 
coverage due to an alleged preexisting condition. When Phillip 
wrote to my office, he said he wanted to warn people about the 
dangers of these plans.
    And he shouldn't have to do that. So, Secretary Becerra, 
during the hearing to consider last year's budget request, I 
asked why the Administration hadn't yet taken action to address 
these junk insurance plans. It has been a year. Can you tell me 
when the Administration will take action to address these 
plans?
    Secretary Becerra. Senator, absolutely an appropriate 
question. And we are in the midst of rulemaking. As you know, 
rulemaking could take a little while, but we started that 
process because of what you have explained. It does happen. 
Junk plans are leaving Americans with these tremendously 
expensive bills.
    Fortunately, with your help, the No Surprises Act is now 
law. And so individuals who get these surprise bills will no 
longer have to worry about paying such exorbitant bills. We 
hope that what we find is between the No Surprises Act statute 
and are changed to try to undo these junk insurance plans--that 
we will provide Americans the protections they thought they 
had.

                  NATIONAL SUICIDE PREVENTION LIFELINE

    Senator Baldwin. Yes. Well, please keep me apprised of the 
timeline. We are very anxious to see this addressed in 
rulemaking. I know that you were just asked some questions 
about the 9-8-8 Suicide Prevention and Lifeline Hotline.
    I want to just add that I was very proud to be the co-lead 
on the 9-8-8 bill and very supportive of the additional funding 
in the budget to prepare the States to make this line live. I 
still, though, hear from leaders in Wisconsin who are concerned 
that our State may not be fully prepared for the 9-8-8 
transition.
    So can you tell me a little bit more about the guidance 
that the Department is giving to States when it comes to 
securing the additional funding? And do we need to take more 
action to make sure that there is adequate preparation in the 
States for this transition?
    Secretary Becerra. Senator, the most important thing you 
can do is to continue to advocate that your State build the 
capacity to handle its 9-8-8 response. There are several States 
that have. We are working with every State with the resources 
you have made available to us to work with States, the 
territories, and the Tribal governments.
    But without the States taking control of this, it will be 
very difficult to believe that they will be able to manage the 
calls that they will get. And the last thing any of us want is 
for someone who is reaching out at a time of pain to not have a 
real person respond.
    Senator Baldwin. Can you, as a follow up, make me aware of 
the interactions that you have had with Wisconsin? It is 
troubling to hear these concerns raised by mental health 
leaders. And I want to make sure that our State is accessing 
the Federal funding that is available.
    Secretary Becerra. Senator, I can make sure we give you a 
copy of the letter we sent to every Governor, in this case, 
your Governor, to let them know where they stand in 
implementation.
    Senator Baldwin. I see I have run over my time. We might 
start a second round of questioning now, and I will call on 
Senator Blunt for a second round.
    Senator Blunt. Thank you, Senator. Let's talk about mental 
health for just a little bit. I was pleased in the budget that 
you have shown--asked for a substantial increase in the 
certified community behavioral health clinics, allowing them to 
continue to treat mental health like all other health, and also 
making the current demonstration program permanent and allowing 
all the States and territories to participate.
    So I am pleased to see that. I look forward to seeing how 
far we can go to create a reality of that request. One thing I 
did want to talk to you about with the mental health agency, 
SAMHSA. The budget was released on March 29. Three weeks later, 
we got the first of two notices of a fairly substantial 
reorganization, three reorganizations. One established a new 
Office of Recovery within the Office of the Assistant 
Secretary.
    Another created an Office of 9-8-8, which is the suicide 
helpline number, Behavioral Health Crisis Coordination. A third 
established a new program of prevention initiative. I have 
several concerns here. One is, there is nothing in the budget 
that reflects these agencies being there or so far no direction 
as to where money should come from to fund them.
    Two, I think some of the prevention efforts have become 
more harm reduction efforts than I think that Congress would 
have intended for, or certainly that I would intend for. And 
three, there are even press reports that the Administration is 
thinking about safe injection sites under the guise of 
prevention, even though I believe those sites are against the 
law.
    Now, we did have an update just yesterday, the first update 
of our staff of what that Office of Prevention might do. And we 
asked about some of these controversial things. I think we are 
not at all sure yet that there is enough information out there 
to not be concerned about this or not stay fully engaged.
    One, why would we get that kind of reorganization 3 weeks 
and only 3 weeks after the budget was submitted? And two, how 
do you expect us to incorporate this into the budget that you 
have already asked for?
    Secretary Becerra. Senator, thanks for the chance to 
respond. And as I mentioned to you previously in a 
conversation, we would reach out to your team. We have reached 
out to your team. Let me tell you what my team is explaining to 
me. First, the reorganization does not impact the budget. We 
are going to work with the monies that we have.
    We don't need new authorities because what we are simply 
doing is reflecting the President's priority on behavioral 
health, to really tackle this, and also to focus on trying to 
have a new strategy on drug use. And so what these offices are 
doing is essentially consolidating what exists in our agencies 
to really focus in more directly on these very important 
subjects.
    And so what we could do is we will follow up again with 
your team to give you details. As I said, it doesn't impact the 
budget. And what we can do is explain how the reorganization 
helps us achieve the President's desire to really tackle mental 
health and drug use as directly as we can. We established, for 
example, a coordinating council among all of HHS's agency so 
that we wouldn't wait to learn what each other is doing.
    SAMHSA and the Office of Public Health are coordinating 
that. So we are working immediately to deal with mental health, 
and so we are going to do more of that so we can make the best 
use of our money. But we will follow up.
    Senator Blunt. Well, we need you to do that. And it will 
impact the budget to the extent that we need to know where that 
funding comes from and what new authority--new line items, 
lines need to be created for that reorganization if there need 
to be new items. And we look forward to continuing to work with 
you on that.
    Secretary Becerra. Thank you.
    Senator Blunt. Thank you, Chair.
    Senator Murray [presiding]. Thank you. Senator Baldwin.

                     PERSONAL PROTECTIVE EQUIPMENT

    Senator Baldwin. Thank you. So I am thinking back to the 
first months of our struggles with the COVID-19 pandemic and 
all of the work we were doing with first responders and 
hospitals and others to secure PPE (Personal Protective 
Equipment).
    And in particular, respirator, N95 masks were in 
desperately short supply. And at that time, American companies 
began stepping up and they retooled manufacturing lines to help 
compensate for these weaknesses in the supply chain when there 
was a global demand.
    And working around the clock, they met the need for 
essential products, including N95 respirator masks and other 
PPE. These companies helped save lives, and now they are in 
trouble. I wrote to President Biden earlier this year urging 
him to prioritize long term contracts for the purchase of masks 
made by American workers in American factories with American 
materials.
    So I wonder, Secretary Becerra, as Health and Human 
Services works to replenish the Strategic National Stockpile, 
can you commit to prioritizing American made PPE?
    Secretary Becerra. Senator, absolutely. That is what we 
have done. As I mentioned earlier, we made it possible to 
actually have tests that were manufactured here. But to keep 
those lines of production going domestically, we have to be 
able to commit now, otherwise they are going to start to phase 
those lines down and it would take months for them to try to 
ratchet back up, which could cause us to have to go to foreign 
sources for that supply of tests or masks.
    Senator Baldwin. Are you procuring American made N95 masks 
right now for the national stockpile? Have you been?
    Secretary Becerra. We--and I will get back to you on 
exactly how much of that might be domestic production. But you 
will recall that we put out about 270 million N95 masks to 
Americans free of charge to help people deal with COVID the 
pandemic. We are resupplying the stockpile, and we are doing 
everything we can to make sure that when we do resupply, it is 
with domestic manufactured product.
    Senator Baldwin. Okay. Thank you.
    Senator Murray. Senator Braun.

                         GENDER AFFIRMING CARE

    Senator Braun. Thank you, Madam Chair. So when we have had 
an opportunity to talk, you know, early on I have been a 
proponent of reforming healthcare by making it more 
transparent, more competitive. I think that has largely been 
lost in all the other issues that have come up. Still 
interested in that. But the subject that is really creating 
controversy across the country would be gender affirming care 
for young people, and it is on the HHS website.
    I would like to work through what gender affirming care 
actually means and do it with a couple of subjects in mind, 
drugs and surgeries. Let's start with prescription drugs. I 
don't think these drugs have been proven safe and effective for 
the use you are recommending. That is probably why the FDA has 
not approved puberty blocking and hormone therapy drugs for 
gender transition.
    Any time a physician, you know, prescribes it, they are 
doing it off label. Would you agree that off label 
prescriptions for usages not approved by the FDA are 
potentially dangerous for patients, especially kids?
    Secretary Becerra. Senator, thank you for the question. And 
that is a question that HHS, including FDA, CDC, have been 
tackling quite a bit as a result of the pandemic. What I would 
simply say to you is that the FDA would raise alarms if they 
saw that a particular medicine or a treatment were being 
misused.
    And at this stage, what we know is that for a drug to be 
out there available, it has to be safe and effective as FDA has 
found it. So, what I would simply say with regard to this 
particular subject is, when individuals go in for care, it is 
their physician who is making that decision with them about 
what type of medicine or treatment they should receive.
    Senator Braun. You know, if you use that same logic on what 
we have just navigated through COVID, it seems like there would 
have been a different point of view. And to me, for many 
parents across the country, this has more potentially tragic 
consequences and it seems like it is a double standard.
    Let's look at surgeries that would be even more impactful. 
And I am not going to mention the particulars there. It is 
almost grotesque to mention what could occur. Could you explain 
what irreversible top and bottom sex change surgeries are and 
why that is on the portal as well?
    Secretary Becerra. Senator as you have just indicated, 
there are many different types of procedures that can be 
deployed. What I will say to you is, again, in any case, no 
individual, no patient will proceed forward unless his or her 
doctor has advised of the procedure. And it is considered by 
the FDA and others who have to go ahead and certify a medicine 
or a procedure to be safe and effective.
    Senator Braun. So I will try to distill it into a more 
simple form. In what case would it be appropriate to perform 
irreversible sex change surgery on kids?
    Secretary Becerra. Those decisions are made by that 
individual in consultation with physician and caregivers, and 
no decision would be made without having consulted 
appropriately.
    Senator Braun. You know, I think the Government shouldn't 
be pushing or have it out there on a portal that moves you 
towards irreversible sex change therapy. And I think we just 
need to think about it carefully because we are navigating into 
territory that we have never done before as a government.
    Kids going through this are having a hard time. We should 
be maybe focusing more on mental health and not things that are 
irreversible. And I think leading the HHS, it might be a little 
more important to be a little more definitive rather than 
making it look like, well, a laissez faire approach and 
whatever happens, happens. I think that is out of sync with 
most of America. And it seems to me it would be wise to maybe 
back up a little bit.
    Secretary Becerra. Senator, I hear what you are saying. I 
believe that we should help those have the life affirming care 
that they need. There are many transgender youth who have 
actually gone in the opposite direction, taking their life. If 
we can make a life better for someone in America, we should, 
especially if, in consultation with their physician, they 
approve of those procedures.
    Senator Braun. You think it would be reasonable, my last 
question, in the meantime to maybe take this off the site until 
there is a little more kind of science built into the approach, 
a little more discussion about what may or may not make sense, 
rather than having an out there where it looks like it condones 
the process?
    Secretary Becerra. I would say to you that many of our 
medical experts would tell you that we have explored this 
subject for a long time, and what we find is that we are 
helping improve the lives of many Americans by providing them 
with the care that they have chosen, with the informed consent 
of family, and also with the consent and advice of their own 
physician.
    Senator Braun. Thank you.
    Senator Murray. Thank you. Senator Shaheen.

                           WOMEN'S HEALTHCARE

    Senator Shaheen. Thank you, Madam Chairman. And thank you, 
Mr. Secretary, for being here this morning and for the work 
that you and everyone at the Department of Health and Human 
Services does to promote the healthcare of the people of this 
country.
    I was stunned, as I am sure all of us were, by the news on 
Monday when we saw the draft opinion leaked from the Supreme 
Court that proposed eliminating access to safe and legal 
abortions for women and for healthcare that goes along with 
that. I think it is stunning. And this is a statistic that I 
found incomprehensible, that the United States could become one 
of only 25 countries in the world that would totally ban 
abortion.
    And if this decision is correct and this is what the court 
decides, it would leave up to the States decisions about 
women's reproductive freedom that presents challenges in States 
like mine, New Hampshire, where we have seen funding denied to 
family planning centers on the front lines of these efforts, 
even though it is funding that does not support performing 
abortions.

                                TITLE X

    But these family planning centers provide healthcare to 
thousands of women in New Hampshire. We appreciated your visit 
to see how Title X is working to keep doors open for family 
planning services for thousands of women in the Granite State. 
So I am very concerned about what is going to happen.
    And I wonder if you could update us on the work of Health 
and Human Services Reproductive Health Care Access Task Force?
    Secretary Becerra. Senator, thank you very much. We are 
going to double down on the effort to make sure that the legal 
rights of all Americans, women, to access the care that they 
are entitled to continue forward.
    Yesterday I had an opportunity to address a number of the 
representatives of many of the insurance plans, health 
insurance plans in America, and made it very clear that we 
intend to continue to enforce the law. We have heard complaints 
that some women are not being provided with access to the care 
that they are entitled to through their insurance plans.
    We will continue to do that. We will continue to support 
the efforts of family planning efforts that are available 
through Title X. We will also make it clear what the law 
requires of anyone who accepts Federal funding through 
Medicare, Medicaid to provide services to all Americans without 
discrimination.
    As I said, we are going to double down to make sure that no 
one goes without the care that they are entitled to.

                      STATE OPIOID RESPONSE GRANTS

    Senator Shaheen. Thank you very much. I appreciate that. 
Another crisis that New Hampshire and so many other States in 
the country are dealing with is substance use disorder 
epidemic. And we have seen how the COVID pandemic has 
exacerbated that. In New Hampshire, we are still in the middle 
of this crisis, and the State opioid response grants have 
really been a vital source of funding for our State to provide 
treatment that people need.
    So as you work to administer those grants this year, will 
you commit to working with me and with other members of New 
Hampshire's delegation to ensure that changes in a State's 
ranking in opioid overdose deaths don't result in large scale 
reductions in funding.
    One of the things that I am--I should preface that with 
saying, one of the things that we have seen in New Hampshire is 
that our overdose deaths have leveled out to some extent 
because we have gotten so good at using Narcan and providing 
Narcan to local police departments and firefighters so that 
they can respond when someone has overdosed, but that doesn't 
mean the underlying problem isn't there.
    Secretary Becerra. Senator, first, thank you for keeping 
this issue of the SOR (State Opioid Response) grants top of 
mind to make sure that no State, no community suffers a cliff 
in the funding that they need to continue to provide service to 
those who are suffering from drug use. We will continue to work 
with you.
    We have provided additional resources. The budget proposes 
$475 million above the previous fiscal Year because we 
understand how important it is. But I have no doubt that you 
will continue to insist that we do this the right way and that 
no one loses the funding they need.

                   AFFORDABLE CARE ACT PREMIUM RELIEF

    Senator Shaheen. Well, thank you. I know that is of 
interest to others on this subcommittee. So thank you very 
much. A final question has to do with the Affordable Care Act 
premium relief, which one of the very positive aspects of the 
American Rescue Plan was the Act's premium tax credits that 
extend for 2 years to help provide coverage for people who 
can't afford the cost of healthcare.
    Those provisions are set to expire at the end of this year. 
Can you talk about what the plans are to ensure that we don't 
see a number of people kicked off of the Affordable Care Act 
insurance because those premium tax credits are expiring?
    Secretary Becerra. Senator, thank you for what you and your 
colleagues did to make that possible. As a result, today, more 
Americans have access to healthcare, they have insurance, 
health insurance, than at any point in our country's history, a 
greater number. And part of that is the 14.5 million Americans 
who receive their coverage through the Affordable Care Act 
marketplace.
    That came because you made it possible for us to avoid the, 
again, the cliff that some families faced when it came to the 
cost of coverage by providing those subsidies and made it very 
affordable. And in some cases for some families so affordable 
that they were finding that they were paying $10 or less per 
month for their monthly premiums.
    And as I always try to say, go try to see a movie in 
America for less than $10 a month, for one movie, not for a 
whole month. And so we will continue to work with you, because 
it has clearly proven itself successful to make sure Americans 
can afford to have their health insurance coverage.
    Senator Shaheen. Can I just ask one follow up----?
    Senator Murray. Yes----
    Senator Shaheen [continuing]. Madam Chair. So when you say 
you will continue to work with us, should we expect a proposal 
coming from the Administration to extend those premium tax 
credits or to look at other ways to provide help to people who 
need help with the cost of health insurance?
    Secretary Becerra. The President has made it very clear, we 
want to see those premium tax credits extended. In the 
President's proposals, Build Back Better proposals, and others, 
we have talked about how we continue to expand access to 
healthcare and reduce costs, and we will continue to work with 
you.
    Senator Shaheen. Thank you. Thank you, Madam Chair.
    Senator Murray. Senator Moran.

                  NATIONAL SUICIDE PREVENTION LIFELINE

    Senator Moran. Thank you, Chairman. Mr. Secretary, in the 
time that I have been here, you have been asked a number of 
times about 9-8-8. Let me just ask a specific question about 
your plans.
    Would you fill in the details on the $700 million request 
for the National Suicide Prevention Hotline with the 
opportunity to explain the reasoning behind that amount and 
what it would be used for?
    Secretary Becerra. Senator, thank you. We are finding that 
because we have had this patchwork, as I have mentioned before, 
of response and we are trying to make it into one unified 
response--so if you today are in D.C. and you are feeling 
stressed, but then you travel into Maryland or West Virginia, 
you don't find that you lose the same access to services that 
you might have had if you were in one of those different 
locations.
    To make that happen so it is seamless, requires a great 
deal of support because the States are accustomed to dealing 
only with the folks in their communities. We are trying to make 
it so that there are--it makes no difference. If you have an 
area code phone from the State of Kansas, but you happen to 
find yourself in my State of California, you are still going to 
get response regardless of where you are. That requires 
resources. Some States have moved to actually provide a 
permanent line of funding for their 9-8-8 services.
    Others have not. We don't want to see anyone fall through 
the cracks. And so we are working hard to provide them with 
services. We put in over $300 million in this current fiscal 
year. The President is requesting more because we know it is 
not just a matter of making sure that the system works, but 
moving forward, we want to make sure that the follow up 
services are available so that you don't just get a voice that 
says we are here to help, but that the services will be there 
to follow within the States.
    Senator Moran. So is the $700 million utilized for the 
technology of the phone call? Or in providing actual services 
once you get somebody on the line?
    Secretary Becerra. More for the services. So for example, 
many States are not able to handle the call volume they get. We 
want to make sure that regardless of where you are, even if a 
State is receiving a high volume or exceeds its capacity, that 
that call will still get answered. So we have backup call 
centers that are set up.
    That is something that we are really supporting because 
States, if they don't have enough in their own State, are 
probably not prepared to fund a callback--or call capacity. So 
we are trying to make sure we have those fallback centers in 
place.
    Senator Moran. Excuse my obtuseness, but that sounds to me 
as if that is the technology of the phone call, the access to 
reaching somebody, not--that is not money to provide the 
psychologist to talk to or the mental health counselor on the 
other end of the line?
    Secretary Becerra. The technology isn't that difficult. We 
are actually working with the FCC (Federal Communications 
Commission) right now to try to make sure that those calls can 
be connected regardless of where the individual is and who the 
responder will be.
    So we are going through those technical aspects, but the 
resources are to make sure there is actually a professional, a 
health professional who will be available to answer those 
calls. Some States, as I said, are more prepared than others. 
That shouldn't be a reason why an individual who is crying out 
for help doesn't get support.
    Senator Moran. Secretary, so if a State is lax in their 
implementation of this legislation, there will be a Federal 
response to the phone call from that State?
    Secretary Becerra. Well, that is the thing. We don't--you 
all did not give us the resources or the authority to 
essentially run the whole lifeline. But what you did give us 
was the capacity to help States lift up their capacity. And so 
we are working very hard right now and for the immediate future 
to make sure that July 16, if someone calls 9-8-8, they get a 
response.
    Some States will be better prepared July 16 than others. 
The funding that we are requesting lets us get everybody up to 
speed.
    Senator Moran. I think the way I would say what you are 
saying is they get a response, and the response is more than 
someone saying, hello.
    Secretary Becerra. Yes.
    Senator Moran. It is the follow on to that.
    Secretary Becerra. So crucial. So crucial.
    Senator Moran. Okay. Thank you. I was one of the original 
sponsors of this bill. I am trying to see and figure out how--I 
guess what you are describing is that the legislation, it 
provides what you are supposed to do, and you are trying to do 
it.
    Secretary Becerra. Yes. And we can provide you with an 
update on where Kansas is because we are providing every 
Governor with an update every month of where they stand so they 
are aware of what they need to do or how well they have done.
    Senator Moran. Okay. Thank you, Madam Chairman.

                             OPIOID CRISIS

    Senator Murray. Thank you. Secretary Becerra, I want to go 
back to a topic that Senator Shaheen mentioned, and that is 
that our communities are really being hammered by the opioid 
crisis. Just last year, more than 105,000 Americans died from a 
drug overdose. In Washington State, synthetic opioid use is up 
drastically.
    Overdose deaths are now up 66 percent since 2019, and over 
half of those are attributable to fentanyl. This is just 
unacceptable. We really need some urgent action from the 
Administration. Can you talk to us about what your plan is to 
stop the harm being caused by opioids, especially fentanyl?
    Secretary Becerra. Madam Chair, in response to some of 
Senator Blunt's questions, I mentioned that we have reorganized 
within HHS to make it a priority to address drug use and 
address the disorder that is there, especially with opioid.
    So we have come up with a different strategy where we 
forget about the stigma, we forget about the old way of doing 
it. And our strategy now not only relies on prevention and 
treatment, but on harm reduction and follow up services so that 
we don't let people regress.
    And so what we are doing right now is working with local 
communities, because we don't do it at the Federal level, we 
work with local communities, with the resources you all are 
giving us to help beef up their capacity to provide not just 
testing and treatment, but also to help them with harm 
reduction.
    Senator Murray. Well, I am especially alarmed by the rise 
in overdose deaths among adolescents. Fatal overdoses among 
youth nearly doubled in 2020 and have continued to rise since 
then, which appears to be driven by these counterfeit pills 
that are laced with fentanyl.
    Parents in my State want to know, what is the Biden 
Administration doing to protect our kids and prevent young 
people from seeking out illicit drugs and make life saving 
overdose reversal drugs more available?
    Secretary Becerra. Well, Senator, we broke through that 
ceiling that existed that prevented us from supporting local 
successful operations that, for example, let someone know if 
the drug they were about to take was laced with fentanyl.
    The bugaboo back then, the stigma was, oh, you are helping 
someone take drugs. We would rather save a life than judge that 
person who is about to take a drug because they will take the 
drug, whether we try to help them or not.
    And so today, the Federal Government will support those 
local programs that are, for example, providing fentanyl strips 
to people so they can test that drug that they may be about to 
use to find out if it is going to have a harmful----
    Senator Murray. Does that help adolescents?
    Secretary Becerra. That would help anyone who comes in and 
who has access to that service from that local provider.
    Senator Murray. And kids would seek that out?
    Secretary Becerra. Madam Chair, there is--everyone, every 
walk of life, every age as well, who is coming to some of these 
centers. And some of these kids may require some adult 
authorization in order to take certain treatments, but fentanyl 
strips are available for those who are about to inject 
themselves or use a drug that is--could likely kill them.
    Senator Murray. And kids know about this?
    Secretary Becerra. I suspect many adolescents are aware of 
some of the local anti-drug programs that are available. I 
can't tell you I know if they make use of them directly or not. 
And I can't tell you what every State has in terms of laws and 
making some of these services available to those who are 
adolescents. But I do know that those programs are made 
available to those who have drug issues.
    Senator Murray. Okay. Well, let me just change the topic a 
little bit. The pandemic, as you know, has been really hard on 
our kids and it has turned their lives upside down. They have 
lost time at school, time with their friends.
    Some have lost loved ones and they are dealing with a lot 
of stress and anxiety and trauma, and they really need our 
help. But even before the pandemic, I was hearing from parents 
who are frustrated by how hard it is to find mental health 
services for their kids.
    The President's budget would invest heavily in crisis care 
systems, which I agree are important to handle emergency 
situations and prevent tragic outcomes. But let me be clear, 
children should not have to wait until their mental health hits 
this crisis point to be able to get care. Parents are really 
desperate to get help for their children here.
    How would this budget, particularly your proposal, allowing 
States to use 10 percent of their mental health block grant 
funding for prevention and early intervention programs help 
with that?
    Secretary Becerra. Madam Chair, let me point out one 
particular program that I know you and Senator Blunt have 
worked hard on over the course of some time, and that is a 
certified community behavioral health clinics and how we are 
planning to expand access to those.
    We provide about a quarter of a billion dollars for the 
expansion of those services because we know that locally in the 
community, if a family, if a young person has access to those 
services, we get to them a lot sooner and perhaps save a life. 
And so we are going to try to expand that.
    The $51.7 billion, 10 year investment that the President is 
making in mental health services is transformative. If you all 
pass that in the President's budget, we will be able to do far 
more in reaching these families because too many, as you said, 
don't have the access they need.
    Senator Murray. Okay. Thank you very much. That will end 
our hearing today. And I want to thank my fellow committee 
members and Secretary Becerra for a very thoughtful discussion 
about how we can do more to support our communities, and keep 
people safe and healthy, and address the challenges we hear 
about from back home.

                     ADDITIONAL COMMITTEE QUESTIONS

    For any Senators who wish to ask additional questions, 
questions for the record will be due May 13 at 5 p.m. The 
hearing record will also remain open until then for members who 
wish to submit additional materials 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\1\
              Questions Submitted by Senator Patty Murray
    Question. The fiscal year 2023 President's Budget includes $400 
million for the Title X--Family Planning program, which provides birth 
control, cancer screening, and other lifesaving care. Unfortunately, 
HHS approved but had to turn away dozens of highly qualified applicants 
in March as a result of the flat funding in fiscal year 2022.
---------------------------------------------------------------------------
    \1\ Responses are current as of the date of the hearing.
---------------------------------------------------------------------------
    What does that mean for patients? How many women will not have 
access to life-saving healthcare services this year as a result of flat 
funding?
    Answer. Title X has not received an increase in service delivery 
funding in the annual appropriations in 8 years. In total, we received 
more than $420 million in requests for the $256 million that was 
published available, meaning that approximately $165 million in 
requests went unfunded. Due to internal budget adjustments, an 
additional $3 million was used to award grants. It means that there 
remains a high need for Title X reproductive health services needed 
across the nation.
    Question. How would HHS use the proposed increase for next year to 
expand access for women of color and low-income women?
    Answer. In fiscal year 2022, all new Title X grantees were awarded 
at a 20-40 percent reduction of their requested amount, which reduced 
the overall projected number of individuals that will be served in year 
one. In many instances, that translated to significantly less than they 
received in fiscal year 2021 because that funding has been redirected 
to cover service areas that were entirely unfunded. Also, existing 
Title X grantees that were approved in the grant review but not funded 
were awarded funds for 1 year to help them serve and transition their 
clients to other locations as they closed out their grants.
    If $400 million were allocated to the Title X program in fiscal 
year 2023, all of the Title X service grantees would be funded at their 
original requested amounts. Additionally, those Title X approved but 
not funded grantees would be fully funded for another year. As a 
result, approximately 3.5 million clients would be served.
    Question. The fiscal year 2023 President's Budget request includes 
$975 million, an increase of $130 million, for the Strategic National 
Stockpile. The request states that the SNS investments would ``make 
meaningful investments across several portfolios necessary to ensure 
readiness for future public health emergencies.'' Among such threats, I 
remain concerned about the perennial danger of another influenza 
pandemic, which infectious disease experts believe is not a matter of 
``if'' but ``when.''
    Do you share my concern about a flu pandemic, and would you support 
the procurement of available medical countermeasures for the SNS to 
prepare for this possibility?
    Answer. The United States Government has and continues to support 
preparedness for a flu pandemic. Influenza antivirals were originally 
purchased by SNS using funds provided in 2005 under a pandemic 
influenza supplemental. SNS has worked closely with the Food and Drug 
Administration (FDA) to extend the expiration dates of many of the 
influenza antivirals held by the SNS. The most recent extension of 
expiration dates for influenza antivirals held by SNS was granted in 
April 2022.
    Question. The fiscal year 2023 President's Budget for Sexually 
Transmitted Disease (STD) prevention is funded at the same level as 
fiscal year 2022. These funds provide the bulk of the Federal dollars 
going to State departments of public health to help prevent the spread 
of STDs. Recently, the CDC has released data showing that STD rates 
continue to climb and are at a 20-year high. The COVID-19 pandemic 
likely contributed to the spread of STDs, since most of the health 
departments across the country discontinued STD fieldwork because their 
contact tracers were diverted to work on COVID-19.
    What is your plan to ensure that when the next pandemic or other 
public health crisis hits, we will have enough resources to address 
both STDs and any new maladies that may be coming down the pike?
    Answer. CDC's STD Program is utilizing the disease intervention 
specialists (DIS) Workforce American Rescue Plan Act (ARPA) funding 
(fiscal year 2021-fiscal year 2026) for COVID-19 and other infectious 
diseases to directly fund DIS hiring, retention, and support by state 
and local health departments; training and formal certification for 
DIS; and providing DIS with critical tools such as diagnostic tests for 
use in the field. CDC's STD Program will award a total of $1 billion to 
state and local health departments from fiscal year 2021-fiscal year 
2026. fiscal year 2021 and fiscal year 2022 funds ($200 million each 
fiscal year) have been awarded through a supplement to CDC's 
Strengthening STD Prevention and Control for Health Departments 
cooperative agreement, which funds all 50 states and 9 local/
territorial health departments. These funds can be used to address the 
existing emergencies of COVID-19, STDs, and HIV, as well as emerging 
issues such as monkeypox or other public health crises.
    Question. Given the dramatic rise in STDs, why did the Department 
not ask for a more robust budget to combat STD rates?
    Answer. The Administration, the Department and CDC must assess a 
wide range of funding priorities when developing the President's Budget 
request, within constrained resources. CDC is the only Federal agency 
that directly supports and funds sexually transmitted infection 
prevention and control activities of state, territorial, and local 
health departments. STIs compromise Americans' health and cost 
billions. To address the substantial increases in the rates of STIs, 
CDC will continue to conduct STI surveillance and support states to 
conduct STI prevention and control activities (e.g. contact tracing), 
support training and educational materials for healthcare 
professionals, and studies to translate STI research to practice and to 
improve program delivery. CDC will also continue to support efforts in 
alignment with the HHS STI Federal Action Plan and continue to bridge 
implementation science, public health program management, and STI 
prevention services that are high impact, scalable, cost-effective, and 
sustainable.
    Question. 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--and the horrifying 
reality is that the vast majority of these deaths are preventable. And 
Black women, Tribal women, and women who live in rural areas are at 
much greater risk. I've been constantly pushing for more investments 
here, and it's good to see this budget does the same. But we still 
haven't managed to provide what's needed here.
    What are the gaps in care that HHS won't be able to address this 
year due to Congress' failure to fully fund your department's request.
    Answer. The fiscal year 2023 President's Budget includes $164 
million, an increase of $81 million over the fiscal year 2022 enacted 
level, for the Safe Motherhood and Infant Health Activities at CDC. The 
requested funding level included to expand the Enhancing Reviews and 
Surveillance to Eliminate Maternal Mortality (ERASE MM) Program to all 
50 states, Washington D.C., and territories for organizations 
coordinating and managing Maternal Mortality Review Committees to 
identify, review, and characterize maternal deaths and identify 
prevention opportunities. With the lower funding level in the fiscal 
year 22 omnibus, CDC will be able to fund 38 awards in 39 states which 
falls short of a national ERASE MM program.
    Wide disparities exist in maternal morbidity and mortality, with 
racial and ethnic minority women and women in rural communities at 
higher risk of pregnancy-associated death and complications. The trans-
NIH Implementing a Maternal health and Pregnancy Outcomes Vision for 
Everyone (IMPROVE) Initiative, launched in 2020, supports research 
focused on reducing preventable causes of maternal deaths and improving 
health for women before, during, and after delivery. IMPROVE also 
focuses on health disparities and populations disproportionately 
affected (African American/Black women, American Indians/Alaska 
Natives, Asian Pacific Islanders, Hispanics/Latinas, and people with 
disabilities). One of the goals in fiscal year (FY) 2023 is to 
establish a national network of Maternal Health Research Centers of 
Excellence (COE). These COEs will conduct research to mitigate 
preventable maternal mortality, decrease severe maternal morbidity, and 
promote health equity by engaging communities, addressing health 
disparities, and including communities that are maternity health 
deserts.
    The fiscal year 2023 budget request dedicates $276 million across 
HRSA to improve maternal health; $202 million above fiscal year 2022 
enacted funding levels. This includes funding for new and existing HRSA 
programs that prioritize reducing maternal mortality and addressing the 
disparity in maternal outcomes for women of color. The initiatives aim 
to:
  --Increase access to equitable, high quality maternity care services 
        for all pregnant and postpartum individuals;
  --Expand and diversify the perinatal workforce; and
  --Support strategies that impact maternal health where women live, 
        learn, work, and play.
    This investment will help address gaps in care, including patient-
centered services, care to tribal communities, and direct support to 
rural communities to respond to hospital closures and workforce 
shortages.
    Without the funding requested in the fiscal year 2023 President's 
Budget for these new or expanded programs, HRSA will be unable to 
adequately support these important efforts. These critical investments 
will help transform maternal healthcare to better meet women where they 
are with the services they need, especially women of color and those in 
underserved and rural communities, and to reduce health disparities and 
improve maternal health outcomes.
    The fiscal year 2023 budget addresses gaps in care by expanding and 
diversifying the perinatal workforce with new investments in the doula 
($20 million) and certified nurse midwife ($25 million) workforces, 
along with funding to create a research network for minority-serving 
institutions to advance maternal health research and practice that 
focuses on addressing health disparities and equity ($10 million).
    The budget also proposes new investments to address social and 
structural determinants of health including:
  --A new program, Addressing Emerging Issues and Social Determinants 
        of Maternal Health ($55 million), that will:
    --Support communities in addressing social determinants of maternal 
            health for pregnant and postpartum individuals to address 
            racial and ethnic disparities;
    --Expand access to behavioral health services;
    --Promote equitable access to care through digital tools; and
    --Support technology-enabled collaborative learning to build 
            provider capacity to improve maternal health outcomes.
  --Increased funding for Healthy Start ($145 million, $13 million 
        above fiscal year 2022 enacted) to support new programs in 
        communities with the highest rates of disparities to address 
        factors that contribute to disparities in poor outcomes for 
        mothers and their babies, including mothers of color.
    The budget also includes a Pregnancy Medical Home Demonstration 
Project ($25 million) to support integrated healthcare services to 
pregnant women and new mothers; Implicit Bias Training Grants for 
Health Care Providers ($5 million); and a National Academy of Medicine 
Study on incorporating bias recognition in clinical skills testing ($1 
million).
    The budget proposes increases for existing programs that help 
expand access and improve quality of maternal health for women of 
color. These include the State Maternal Health Innovation Grants ($55 
million, $26 million increase from fiscal year 2022 enacted) that 
implement state specific innovative action plans to improve access to 
maternal care services and address workforce needs and the Alliance for 
Innovation on Maternal Health ($15 million, $3 million above fiscal 
year 2022 enacted) to expand the implementation of maternal safety 
bundles.
    To increase access in areas with healthcare shortages, the budget 
increases funding for Rural Maternity and Obstetrics Management 
Strategies ($10 million, $4 million above fiscal year 2022 enacted) to 
expand access to maternal and obstetrics care in rural communities. The 
budget also invests in
    Maternity Care Target Areas ($5 million, $4 million above fiscal 
year 2022 enacted) to help better identify areas in need of provider 
capacity.
    The budget expands access to behavioral healthcare for pregnant and 
postpartum women through increased investments in the Screening and 
Treatment for Maternal Depression program ($10 million proposed for 
reauthorization, $3.5 million above fiscal year 2022 enacted) and the 
Maternal Mental Health Hotline ($7 million, $3 million above fiscal 
year 2022 enacted).
    Finally, the budget also increases funding for the Maternal, 
Infant, and Early Childhood Home Visiting Program (MIECHV) ($467 
million, an increase of $67 million from the fiscal year 2022 enacted 
level of $400 million) to expand the capacity of MIECHV awardees to 
reach more women, families, and communities. Current authorization of 
the MIECHV Program is set to expire at the end of fiscal year 2022.
    The HHS Office on Women's Health initiated an $8 million nationwide 
contract with a healthcare improvement company to improve maternal 
health data and recruited 220 nationally representative hospitals to 
deploy clinical, evidence-based best practices in maternity care. The 
Maternal Morbidity and Mortality Data and Analysis Initiative builds 
upon HHS's maternal health work as outlined in the President's fiscal 
year 2021 Budget. This vital data will inform policy and validate 
evidence-based practice to improve maternal and infant health outcomes. 
OWH would have used additional funds to recruit more hospitals that 
serve Black women, Tribal women, and women who live in rural areas to 
participate in the Maternal Morbidity and Mortality Data and Analysis 
Initiative.
    Question. How will the $470 million requested in the President's 
new budget address the disparities for women of color and women who 
live in rural areas?
    Answer. The fiscal year 2023 President's Budget invests in several 
HRSA programs to address disparities for women of color and women who 
live in rural areas, including:
  --An increase to the Healthy Start program ($145 million, $13.16 
        million above fiscal year 2022 enacted) to support new programs 
        in communities with the highest rates of disparities, focusing 
        on addressing the unique structural, environmental, and 
        systemic factors that contribute to disparities in poor 
        outcomes for mothers and their babies.
  --New funding to support an Addressing Emerging Issues and Social 
        Determinants of Maternal Health program ($55 million) that will 
        support community-based investments to improve outcomes 
        particularly in areas with high rates of adverse maternal 
        health outcomes and/or significant racial and ethnic 
        disparities in maternal health outcomes. Efforts may focus on 
        addressing social determinants of maternal health for pregnant 
        and postpartum individuals; expanding access to behavioral 
        health services for women; promoting equitable access to care 
        through digital tools; and supporting technology-enabled 
        collaborative learning to build provider capacity to improve 
        maternal health outcomes.
  --A proposed $10 million in funding for minority-serving institutions 
        to support research on health equity and racial disparities in 
        maternal health. Institutions may use funds to promote 
        diversity within the workforce and advance research into the 
        field of maternal minority health to best serve their patient 
        populations.
  --An increase in funding for MIECHV ($467 million, an increase of $67 
        million from the fiscal year 2022 enacted level of $400 
        million) would expand the capacity of MIECHV awardees to reach 
        more women, families and communities. Current authorization of 
        the MIECHV Program is set to expire at the end of fiscal year 
        2022.
    --The MIECHV Program supports voluntary, evidence-based home 
            visiting services for pregnant people and parents with 
            young children up to kindergarten entry living in 
            communities that face greater risks and barriers to 
            achieving positive maternal and child health outcomes. 
            MIECHV-funded programs currently serve 71,000 families, 
            reaching only approximately 15 percent of the more than 
            465,000 families who are likely eligible and in need of 
            MIECHV services. With the proposed five-year funding 
            increase, HRSA anticipates the MIECHV Program could provide 
            home visiting services to up to 165,000 additional families 
            in over 600 additional communities through targeted 
            evidence-based home visiting over the course of 5 years.
    --The MIECHV Program also includes a 3 percent set-aside for grants 
            to Tribal organizations to implement home visiting programs 
            in American Indian and Alaska Native communities, which 
            include geographically rural areas.
  --The budget also expands the Screening and Treatment for Maternal 
        Depression and Related Behavioral Disorders (MDRBD) program 
        ($10 million, $3.5 million above fiscal year 2022 enacted) to 
        expand healthcare providers' capacity to screen, assess, treat, 
        and refer pregnant and postpartum individuals for maternal 
        depression and related behavioral disorders, including in rural 
        areas and medically underserved areas. Current authorization of 
        the MDRBD program is set to expire at the end of fiscal year 
        2022.
    The fiscal year 2023 President's Budget includes $164 million, an 
increase of $81 million over the fiscal year 2022 enacted level, for 
the Safe Motherhood and Infant Health Activities at CDC. This increase 
would help optimize critical public health infrastructure, improve 
maternal health outcomes, and eliminate persistent racial/ethnic and 
geographic disparities in healthcare outcomes. Investments in state, 
local, and territorial public health infrastructure would dramatically 
improve timely and relevant clinical, non-clinical, and systems level 
data to guide implementation and evaluation of maternal and infant 
health policies and programs. In addition to expanding the ERASE MM 
Program to all 50 states, Washington D.C. and territories, the fiscal 
year 2023 President's Budget includes support for key public health 
infrastructure, including expanding Maternal Mortality Review 
Committees (MMRCs) capacity to acquire detailed and complete data on 
maternal mortality and develop recommendations for prevention. CDC is 
partnering with HHS' Office of Minority Health and others to build a 
health equity framework for maternal mortality review and prevention. 
With this proposed increase, CDC would also modernize the Pregnancy 
Risk Assessment Monitoring System (PRAMS) to test and implement 
strategies for rapid-data collection and dissemination, including 
facility-based data collections; establishing individual, facility, and 
community level data linkages); improve response rates and 
representative samples; and develop a queryable data system. PRAMS 
collects jurisdiction-specific, population-based data on maternal 
attitudes and experiences before, during, and shortly after pregnancy 
and are used to better understand emerging issues in the field of 
reproductive health. CDC would also support significant expansion of 
the Hear Her Campaign, which is an effort to prevent pregnancy-related 
deaths by sharing potentially life-saving messages about urgent warning 
signs. Finally, CDC would promote diverse and representative community 
engagement in MMRCs and Perinatal Quality Collaboratives (PQCs).
    OWH initiatives aim to address disparities and advance health 
equity for women across the life course for women of color and women 
who live in rural areas. The President's new budget will allow OWH to 
continue ongoing initiatives, such as our Breastfeeding Education and 
Promotion Campaign for African American Mothers and Families. An 
increase in the budget would also allow OWH to increase the funding 
amount for the Reducing Maternal Deaths due to Substance Use Disorder 
grant opportunity.
    Question. The President's budget includes increased funding to end 
HIV in the U.S. as well as an increased focus on PrEP for medications 
that prevent HIV. These drugs, which can be a daily oral regimen or 
now, long acting injectables, are underutilized in the communities that 
need them most, such as Black and Latino gay men, and Black women, 
particularly in the South. The budget proposes a new $9.8 billion 
mandatory spending PrEP delivery program that largely focuses on bulk 
purchasing of generic drugs.
    Please provide detail to support how HHS calculated the $9.8 
billion figure over 10 years.
    How will the $9.8 billion be allocated for different services and 
distributed to communities throughout the country? Please provide 
detail on what is needed to cover the costs of the drug, as well as 
community outreach, and provider education and training programs.
    Answer. The new mandatory Pre-Exposure Prophylaxis Delivery Program 
to End the HIV Epidemic in the United States (``PrEP Delivery 
Program'') is designed to expand access to PrEP and essential 
wraparound services for uninsured and underinsured individuals at high 
risk of HIV infections across the United States.
    This national program would create a financing and delivery system 
for PrEP. Currently, there is a patchwork of PrEP access programs for 
uninsured individuals; this comprehensive new program is a key pillar 
of the Administration's efforts to meet the commitments laid out in the 
National HIV/AIDS Strategy for the United States 2022-2025 to reduce 
HIV infections by 75 percent by 2025.
    The PrEP Delivery Program will guarantee access to PrEP at no cost; 
eliminate costs for essential associated services; and establish a 
network of providers in underserved communities that provide culturally 
and linguistically appropriate services. It will create an efficient, 
systematic approach to drug acquisition and distribution and also 
provide the critical wrap-around services that make it possible for 
individuals to successfully participate in the ongoing intervention.
    The Department will purchase PrEP medications in bulk directly from 
manufacturers, leveraging its large purchasing power to obtain the 
lowest possible price, creating a long-term, sustainable model for 
purchasing medication. The PrEP Delivery Program will expand PrEP 
access at clinical settings through on-site dispensing and lab services 
for those without healthcare coverage.
    Additionally, the PrEP Delivery Program will establish and support 
PrEP programs for state, tribal, and local public health departments, 
community-based organizations (CBOs), and healthcare facilities that 
serve the highest risk populations, such as the CDC's health department 
and CBO grantees, tribal-servicing organizations, STI clinics, 
community health centers, Title X clinics, substance use disorder 
treatment programs, mobile prevention units, homeless shelters, and 
domestic violence shelters. These organizations will administer the 
program for clients and work to implement PrEP education campaigns, 
medication support services, and provide outreach and education to 
increase utilization of PEP and PrEP among individuals at risk of HIV 
infection.
    Question. Nationwide, we're facing a child care crisis. Parents are 
struggling to find or afford child care, and too many can't get the 
early education or pre-k that would help their children thrive. At the 
same time, early educators are making poverty wages and can't make ends 
meet, and are leaving the field to get higher pay elsewhere, which is 
creating real problems in Head Start classrooms, where programs cannot 
find enough staff to fully operate.
    A cost-of-living adjustment is critical in the Head Start Program 
to allow programs to keep up with inflation, but may not adequately 
address the issues programs are having recruiting and retaining highly-
qualified educators. How does the proposed budget address the child 
care and early educator shortages we are seeing nationwide?
    Answer. Head Start programs across the nation are facing workforce 
challenges and this instability prevents classrooms from being fully 
staffed. Low wages have been a key driver for turnover among the early 
childhood education workforce. With that in mind, the fiscal year 2023 
President's Budget includes a request for funding to provide a cost-of-
living adjustment and allow programs to keep pace with inflation. While 
this does not help make wages to be more competitive, it does help 
preserve their real value.
                                 ______
                                 
            Questions Submitted by Senator Richard J. Durbin
    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 these emotional scars can harm the 
developing brain, change the way a child sees the world, and 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 substance use disorder--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. We have 
now secured $17 million over the past 3 years for this work. We also 
created the Interagency Task Force on Trauma-Informed Care that brings 
our Federal agencies around the table to promote trauma ``best 
practices'' in every grant program, we were pleased to secure $1 
million in fiscal year 2022 for this effort. And in fiscal year 2022, 
we provided $7 million for the first time to stand up a trauma and 
mental health support program in schools, under Project AWARE (Sec. 
7134 of the SUPPORT Act).
    Now, the 2023 budget proposes a $250 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 needed to grapple with our gun violence 
epidemic--including street outreach efforts, and trauma programming in 
schools.
    Under a program called the HEAL Initiative that I launched with the 
ten largest hospitals serving Chicago, as hospitals stitch up their 
physical wounds, they also pair victims of violence with counselors to 
address their trauma to prevent retaliations--otherwise nearly half of 
those gunshot victims would wind up back in the hospital within 5 
years. They are also improving data-sharing across hospitals and 
getting into the community to delivery violence prevention and 
intervention services.
    Secretary Becerra, can you explain how this new community-violence 
proposal can support programs like those in Chicago, and how you 
envision these various Federal trauma and violence prevention programs 
working together?
    Answer. SAMHSA leads the Interagency Task Force for Trauma-Informed 
Care. The Task Force is comprised of 21 agencies and has been 
identifying, evaluating, and making recommendations regarding best 
practices for children and families who have experienced trauma or are 
at risk of experiencing trauma and ways Federal agencies can better 
coordinate responses to families affected by substance use disorders 
and trauma. The Task Force developed a National Strategy for Trauma-
informed Care grounded in four pillars: best practices, research, data, 
and Federal coordination. The fiscal year (FY) 2023 budget request will 
help support SAMHSA in leading the Task Force; collecting data and 
identifying and evaluating trauma-informed resources for practice; 
making recommendations to the general public and to Federal agencies 
through an Internet website; ongoing solicitation of input from 
stakeholders to inform the work; and coordinating Federal agencies in 
their integration of trauma-informed principles and interventions into 
their ongoing work.
    The ACEs work is a critical priority at CDC. People who experience 
ACEs are more likely to have physical, mental and behavioral health 
challenges, including future experiences with violence. We understand 
even more now that protective factors, including but not limited to 
growing up in communities with access to nurturing and safe childcare 
and strong partnerships with businesses, healthcare, government, and 
other sectors, help establish safe and stable environments across 
generations. Through our program Preventing ACEs: Data to Action (PACE: 
D2A), we currently fund six states to build a state-level surveillance 
infrastructure that ensures enhances the capacity to collect, analyze, 
and use ACEs data to inform ACEs prevention activities and to support 
implementation of ACEs primary prevention strategies selected from the 
best available evidence.
    CDC will continue to work to better understand both protective and 
risk factors as well as primary prevention strategies and contribute to 
the evidence base for community violence prevention work. In addition, 
there is a great need at the state and local level for resources to 
support this critical work. The fiscal year 2023 President's Budget 
includes a request for an additional $8 million in funding to further 
support states in ACEs prevention.
    The $250 million investment proposed for community violence 
intervention in the fiscal year 2023 President's Budget has been 
designed to stem the rise of violence in cities across the country 
through prioritizing evidence based-prevention strategies, research, 
and data to inform action. With these funds, CDC would support up to 75 
cities and communities disproportionately impacted by homicides to 
establish a collaborative, community driven approach to reduce 
community violence. CDC would also expand our research and evaluation 
investments to further build the evidence base for preventing violence 
in communities experiencing the greatest burden, and to reduce the 
racial, ethnic, and economic inequities that characterize such violence 
across our country.
    Hospital-community partnerships, such as the Chicago Hospital 
Engagement, Action and Leadership (HEAL) Initiative that you mentioned, 
represent one type of strategy to prevent and reduce community violence 
and could be supported under the proposed community violence 
initiative. Rigorous evaluation will be an important component of CDC's 
community-violence prevention work to help us identify the most 
effective programs for reducing community violence and re-injury.
    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 hospital-
community partnerships, can create safer, healthier, and more resilient 
communities. For more information about these upstream approaches, we 
would recommend CDC's A Comprehensive Technical Package for the 
Prevention of Youth Violence and Associated Risk Behaviors.
    Question. Too often in our country, new moms and infants--
especially women and babies of color--are dying from preventable health 
problems. Nationwide, more than 800 women die every year as a result of 
pregnancy--more than 70,000 others have near-fatal complications. And 
it's getting worse--we saw a 15 percent increase in maternal deaths in 
2020 compared with 2019.
    In Illinois, more than 70 women die every year due to pregnancy-
related complications--70 percent of these deaths are preventable.
    Not only are we losing new moms, we also are losing their babies. 
Annually, more than 23,000 babies die in the U.S., many due to 
preventable factors, such as pre-term birth and low birth weight.
    I introduced a bill--the MOMMA's Act--to expand Medicaid coverage 
to new moms for a year post-partum, versus 60 days. A version of my 
bill was included in the American Rescue Plan, and Illinois was the 
first state to offer this expanded Medicaid coverage.
    How many states have now expanded their Medicaid programs for new 
moms, and how do you think this change will improve health outcomes for 
new moms and babies?
    Answer. CMS has taken a series of actions to further advance the 
safety and quality of maternal care. CMS is encouraging hospitals to 
implement evidence-based patient safety practices for managing 
obstetric emergencies along with interventions to address other key 
contributors to maternal health disparities.
    CMS encourages states to take advantage of the American Rescue 
Plan's option to provide 12 months of postpartum coverage to pregnant 
individuals who are enrolled in Medicaid or CHIP beginning April 1, 
2022. Even before this option became available, in 2021, CMS approved 
section 1115 demonstrations in Georgia, Illinois, New Jersey, and 
Virginia to extend Medicaid and CHIP postpartum coverage beyond the 
required 60-day postpartum period.
    On April 1, 2022, Louisiana became the first state to use the ARP 
option to extend Medicaid postpartum coverage to 12 months, covering an 
estimated 14,000 pregnant and postpartum individuals. Two weeks later, 
Michigan received CMS approval to extend postpartum coverage to 12 
months for an estimated 16,000 pregnant and postpartum individuals. CMS 
continues working with other state partners to extend coverage for 12 
months after pregnancy, which has also been proposed in several other 
states, including Indiana, Maine, Minnesota, New Mexico, Pennsylvania, 
West Virginia, North Carolina, South Carolina, Tennessee, Washington, 
and Connecticut, as well as the District of Columbia. As a result of 
these efforts, as many as 720,000 pregnant and postpartum individuals 
across the United States, annually, could be guaranteed Medicaid and 
CHIP coverage for 12 months after pregnancy.
    Question. A large majority of Americans take dietary supplements 
daily--from calcium chews, to multi-vitamins, to fish oil. Yet, there 
is very little oversight or transparency into these products--we do not 
even know how many supplements are on the market today, with guesses 
ranging anywhere from 50,000 to 80,000.
    We don't know because FDA doesn't currently have the authority to 
require dietary supplement companies to register their products, nor 
are they required to submit ingredient lists, allergen statements, 
health claims, or even the copies of the labels for these products.
    Senator Braun and I introduced the bipartisan Dietary Supplement 
Listing Act to change all of that. Our bill--which is supported by 
dietary supplement companies, as well as consumer and physician 
groups--would require companies to provide basic, vital information 
about their products.
    Mandatory listing of dietary supplements was a new authority that 
President Biden--and President Trump--requested in their budgets. Can 
you tell the Committee why you think this issue is so important?
    Answer. The dietary supplement industry has grown ten times the 
size it was when the Dietary Supplement Health and Education Act 
(DSHEA) was enacted in 1994. Under DSHEA, FDA does not approve dietary 
supplement products, and generally does not review and approve label 
claims before dietary supplements are introduced to consumers. As a 
result, FDA has no systematic way to know when new dietary supplements 
are introduced or what they contain; therefore dangerous and otherwise 
unlawful products that contain undeclared or otherwise improper 
ingredients continue to be marketed.
    The fiscal year 2023 President's Budget includes a legislative 
proposal--similar to proposals offered in other recent budgets--for a 
mandatory listing requirement for dietary supplements. Under this 
proposal, FDA is seeking to modernize DSHEA to strengthen and clarify 
FDA's authorities relating to products marketed as ``dietary 
supplements.'' These new authorities would allow FDA to know when new 
products are introduced and enhance FDA's ability to quickly identify 
and act more effectively against dangerous or otherwise illegal 
products.
    Question. Last year, the President signed into law the Accelerating 
Access to Critical Therapies for ALS Act (ACT for ALS)--legislation 
spear-headed by Senators Coons and Murkowski. I was pleased to 
cosponsor this important legislation, which will fund essential 
research into fast-progressing terminal diseases like ALS, and expand 
access to promising investigational new therapies.
    This issue is personal to me. My friend, and constituent, Brian 
Wallach is a 41-year-old man living with ALS. He, and his wife Sandra, 
took Brian's terminal diagnosis and turned it into hope-- starting I Am 
ALS, an organization that advocates for real, tangible results in the 
fight against ALS.
    Secretary Becerra, last year, you joined a Zoom with Brian and 
Sandra to celebrate ACT for ALS becoming law. Can you talk about the 
importance of engagement, input, and collaboration from the ALS patient 
leadership community as HHS, NIH, and FDA work to urgently implement 
this law?
    Answer. The National Institutes of Health (NIH) agrees that 
engagement, input, and collaboration with the ALS community will be 
crucial for implementing the law. To that end, the U.S. Food and Drug 
Administration (FDA) and NIH held a listening session with leaders in 
the patient community on March 25 to discuss Access to Critical 
Therapies (ACT) for ALS implementation. Additionally, NIH plans to 
include people affected by ALS on the review panel for expanded access 
grant applications, and the request for applications for this program 
strongly encourages applicants to establish relationships with patient 
groups and solicit their input on recruitment, the clinical 
meaningfulness of the question under study, the relevance of the 
proposed clinical outcomes, and approaches to minimizing the burden on 
study participants.
    Question. Please also clarify what resources you need from Congress 
to get this law implemented quickly and efficiently.
    Answer. Fiscal Year (FY) 2022 appropriations for NIH included $25 
million for ACT for ALS implementation. These funds should be 
sufficient for NIH to support the expanded access grant program in 
section 2 of ACT for ALS for fiscal year 2022 and to initiate the 
Public Private Partnership in section 3 of the statute this fiscal 
year.
    Question. Secretary Becerra, the budget proposes $848 billion for 
Medicare. One of the greatest drivers of outlays by the Medicare 
program is the cost of chronic conditions. By some estimates, 10 
percent of Medicare spending is attributable to smoking and its health 
harms. So it would seem that the Department would want to be doing 
everything it can to prevent tobacco use, especially among youth.
    While I was pleased to see FDA finally act to ban menthol 
cigarettes and all flavors in cigars, I remain concerned that JUUL e-
cigarette products--which fueled the youth vaping epidemic in our 
country--remain on the market EIGHT months past a court- ordered 
deadline for FDA to act.
    For years, FDA refused to act in the face of mounting evidence that 
millions of children were becoming addicted to nicotine because of 
JUUL--or JUUL knock-off--products. Mango, cool mint, fruit medley--
these were the flavors JUUL used to hook our children. And, today, 
despite millions of other products being ordered off the market, JUUL 
remains on store shelves--despite not having authorization from FDA.
    One could argue that the FDA's actions to regulate virtually every 
vaping product except for JUUL is tantamount to clearing the market so 
that JUUL can sell its products without competition. In fact, these 
products are only on the market today because FDA is exercising 
enforcement discretion. They can and should take JUUL off the market 
TODAY.
    Secretary Becerra, why is the FDA now 8 months past the court 
order?
    Answer. FDA's review of premarket tobacco product applications 
(PMTAs) for electronic nicotine delivery systems (ENDS) continues to be 
a high priority for the Department of Health and Human Services and for 
FDA, and FDA is committed to completing its review of premarket 
applications as soon as possible. FDA has made significant progress on 
the entire body of submissions, taking action on 99 percent of the 
applications for about 6.7 million products received by the September 
9, 2020 deadline. As the Agency has described publicly, FDA has 
dedicated resources to the review of applications from companies whose 
products account for the largest share of the ENDS market, including 
JUUL. These PMTAs tend to be voluminous and complex and have required 
additional review time. The Agency has issued decisions for products 
from four of the five brands that held more than 95 percent of the ENDS 
market in the summer of 2020, when applications were due. But we have 
more work to do, including completing review of all of the applications 
from the larger market share companies. FDA continues to work 
expeditiously on the remaining applications and is issuing decisions on 
a rolling basis. The Department and FDA continue to work steadfastly to 
transform the ENDS market to one where all products have undergone 
thorough scientific review.
    Question. Because we are 8 months past the September 9th court-
permitted window, all e-cigarettes that have not been authorized yet 
remain on the market currently are only allowed to do so because of 
FDA's enforcement discretion. Why not restore the statutory burden of 
proof as envisioned in the Tobacco Control Act for manufacturers to 
prove to FDA that their products are appropriate for the protection of 
public health, by removing all yet-unauthorized products from the 
market UNTIL their PMTAs are adjudicated?
    Answer. All new tobacco products on the market without the 
statutorily required marketing authorization are marketed unlawfully 
and are subject to enforcement by FDA. FDA continues to make 
enforcement decisions on a case-by-case basis according to its 
enforcement priorities and individual circumstances.
    FDA is committed to working as quickly as possible to transition 
the current marketplace for deemed new tobacco products to one in which 
all products available for sale have undergone a careful, science-based 
review by FDA and met the statutory standard. It is imperative that we 
get it right.
    It is also important to note that FDA does not possess independent 
litigation authority. FDA works closely with the Department of Justice 
(DOJ), without whose support neither injunctive actions nor seizures 
can occur. FDA regularly consults DOJ with respect to potential 
enforcement actions, including in relation to unauthorized tobacco 
products that are the subject of pending applications. Although the 
Agency does not discuss the substance of its internal deliberations 
with the dedicated attorneys at DOJ, their legal analysis and expert 
legal judgment greatly inform FDA's enforcement decisionmaking.
    Question. Do you believe that JUUL products--which have been proven 
to hook kids on nicotine--benefit the public health?
    Answer. At this time, FDA has not authorized any JUUL tobacco 
products for marketing.
    As you know, premarket tobacco product applications (PMTAs) must 
provide scientific data to FDA that demonstrate that permitting the 
product to be marketed would be appropriate for the protection of the 
public health (APPH). As set forth in Section 910(c)(4) of the Federal 
Food, Drug, and Cosmetic Act, the finding as to whether the marketing 
of each tobacco product for which an application has been submitted is 
APPH shall be determined with respect to the risks and benefits to the 
population as a whole, including users and nonusers of the tobacco 
product.
    FDA continues to work expeditiously on the remaining PMTA 
applications and is issuing decisions on a rolling basis. We will keep 
your office apprised of any updates and would be happy to offer 
briefing or discussion as those decisions are made.
    Question. I recently met with the Illinois Health and Hospital 
Association, who shared that their top concern is workforce shortages. 
But this is not a new problem caused by the pandemic. Even before 
COVID, our nation faced a shortfall of 120,000 doctors and a quarter- 
million nurses.
    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 
averaging 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. And less than 10 percent of doctors are Black 
or Latino, which can lead 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 Corps.
    It will help surge tens of thousands of new clinicians into under-
served areas, and already has built the healthcare pipeline by 
quadrupling the number of scholarship recipients.
    Secretary Becerra, your budget proposes a significant increase to 
the National Health Service Corps. Can you talk about the importance of 
this program in addressing our workforce needs, our preparedness, and 
health disparities?
    Answer. For the past 50 years, the National Health Service Corps 
(NHSC) has been a dedicated resource for building healthy communities 
by mobilizing a primary care workforce to serve in the nation's high-
need areas. The NHSC does this by providing scholarships and loan 
repayment for clinicians who commit to practice in underserved 
communities. NHSC-approved sites provide care to individuals regardless 
of their ability to pay. Currently, there are approximately 20,000 
medical, dental, and behavioral healthcare clinicians, the largest 
cohort ever, providing quality care to more than 21 million Americans 
in rural, urban, and tribal communities. The increase to the number of 
clinicians providing care is the result of the $800 million 
appropriated for the NHSC in American Rescue Plan (ARP) Act in fiscal 
year 2021, $700 million of which is for the NHSC Scholarship Program 
(SP), Loan Repayment Programs (LRPs), and Students to Service (S2S). 
These funds enabled the NHSC to award all qualified applicants; the 
remainder of these funds will be fully obligated in fiscal year 2022.
    In recent years, the NHSC has demonstrated the ability to be agile 
and address the emerging heath needs across the U.S. States and 
Territories. This includes, but is not limited to, supporting a 
workforce dedicated to addressing the Zika epidemic (2016), combatting 
the nation's substance use disorder crisis (2018-present), and 
expanding access to care during the height of the COVID-19 pandemic 
(2021-present). Further, NHSC appropriations have been dedicated to 
deliver healthcare services in Indian Health Service facilities, 
Tribally-Operated 638 Health Programs, and Urban Indian Health Programs 
(ITUs). With this directed funding, the NHSC has awarded all eligible 
clinicians serving in ITUs who applied to the NHSC Loan Repayment 
Programs (LRPs).
    Through the NHSC Substance Use Disorder (SUD) Workforce loan 
repayment program and Rural Community loan repayment program, HRSA is 
working to support the SUD workforce needs of underserved communities 
by helping to recruit and retain health professionals to improve access 
to quality opioid and evidence-based SUD treatment in rural and 
underserved areas nationwide, and to prevent overdose deaths. As of 
September 30, 2021, there are more than 44,000 clinicians in the NHSC 
providing substance use disorder treatment.
    Additionally, ensuring greater racial and ethnic diversity of the 
healthcare workforce is essential for increasing access to culturally 
competent care for all patients, improving opportunities and 
representation of all groups within the health professions, and meeting 
the overall needs of our diverse population, particularly in the most 
underserved areas.\2\ Many racial and ethnic minority groups are 
underrepresented nationally within the major health professions,\3\ and 
the share of racial and ethnic minority NHSC providers exceeded their 
share in the national workforce:
---------------------------------------------------------------------------
    \2\ Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the 
healthcare workforce. Health Aff (Millwood). 2002 Sep-Oct; 21(5): 90-
102 (http://content.healthaffairs.org/content/21/5/90.full).
    \3\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration, National Center for Health Workforce 
Analysis. Sex, Race, and Ethnic Diversity of U.S. Health Occupations 
(2010-2012), Rockville, Maryland; 2014 (https://bhw.hrsa.gov/sites/
default/files/bhw/nchwa/diversityushealthoccupations.pdf).
---------------------------------------------------------------------------
Primary Care
  --Black or African American physicians represented 14.9 percent of 
        the NHSC LRP and Scholarship Program (SP) participants, 
        exceeding their 5.0 percent share in the national physician 
        workforce.\4\
---------------------------------------------------------------------------
    \4\ Association of American Medical Colleges, Diversity in 
Medicine: Facts and Figures, 2019. (https://www.aamc.org/data-reports/
workforce/interactive-data/figure-18-percentage-all-active-physicians-
race/ethnicity-2018).
---------------------------------------------------------------------------
  --Hispanic or Latino physicians represented 12.9 percent of the NHSC 
        LRP and SP participants, exceeding their 5.8 percent share in 
        the national physician workforce.\5\
---------------------------------------------------------------------------
    \5\ Ibid.
---------------------------------------------------------------------------
  --American Indian and Alaska Native physicians represented 1.6 
        percent of the NHSC LRP and SP participants, exceeding their 
        0.3 percent share in the national physician workforce.\6\
---------------------------------------------------------------------------
    \6\ Ibid.
---------------------------------------------------------------------------
  --Black or African American nurse practitioners represented 15.7 
        percent of the NHSC LRP and SP participants, exceeding their 
        9.1 percent share in the national healthcare workforce averages 
        of nurse practitioners.\7\
---------------------------------------------------------------------------
    \7\ U.S. Department of Labor, Bureau of Labor Statistics Labor 
Force Characteristics by Race and Ethnicity, 2020, November 2021, 
Report 1095.
---------------------------------------------------------------------------
  --Hispanic or Latino nurse practitioners represented 9.1 percent of 
        the NHSC LRP and SP participants, exceeding their 6.3 percent 
        share in national healthcare workforce averages of nurse 
        practitioners.\8\
---------------------------------------------------------------------------
    \8\ Ibid.
---------------------------------------------------------------------------
Mental and Behavioral Health
  --Asian health services psychologists represented 5.8 percent of the 
        NHSC LRP participants, exceeding their 4.1 percent share in the 
        national healthcare workforce averages of health services 
        psychologists.\9\
---------------------------------------------------------------------------
    \9\ Ibid.
---------------------------------------------------------------------------
  --Hispanic or Latino health services psychologists represented 20 
        percent of the NHSC LRP participants, exceeding their 3.5 
        percent share in the national healthcare workforce averages of 
        health services psychologists.\10\
---------------------------------------------------------------------------
    \10\ Ibid.
---------------------------------------------------------------------------
Oral Health
  --Black or African American dentists represented 13 percent of the 
        NHSC LRP and SP participants, exceeding their 1.4 percent share 
        in the national healthcare workforce averages of dentists.\11\
---------------------------------------------------------------------------
    \11\ Ibid.
---------------------------------------------------------------------------
  --Hispanic or Latino dental hygienists represented 20 percent of the 
        NHSC LRP participants, exceeding their 10.5 percent share in 
        the national healthcare workforce averages of dental 
        hygienists.\12\
---------------------------------------------------------------------------
    \12\ Ibid.
---------------------------------------------------------------------------
    Based on self-reports of the 2,523 NHSC scholars (i.e., those in 
school, pursuing post-graduate training, or awaiting placement in an 
NHSC-approved service site), 22 percent are Black or African American, 
16.8 percent are Asian or Pacific Islander, 2.3 percent are American 
Indian or Alaska Native, and 14.1 percent of NHSC scholars self-
reported as Hispanic or Latino. Black or African American NHSC scholars 
exceeded national student enrollment averages in dentistry, medicine, 
physician assistant, and nursing disciplines.\13\ Hispanic or Latino 
NHSC scholars exceeded student enrollment averages in dentistry, 
representing 15.7 percent of the Corps' dental participants, compared 
to their 9.0 percent share of the national student enrollment.\14\ 
American Indian and Alaska Native NHSC scholars exceed national student 
enrollment averages in dentistry, medicine, physician assistant, and 
nursing disciplines.\15\
---------------------------------------------------------------------------
    \13\ American Dental Association, 2018-2019 Survey on Dental 
Education: Academic Programs, Enrollments, and Graduates. Association 
of American Medical Colleges Total U.S. Medical School Enrollment, 
2020-2021. American Association of Colleges of Nursing, 2021. 35th 
Physician Assistant Education Association Annual Report, 2019.
    \14\ Ibid.
    \15\ Ibid.
---------------------------------------------------------------------------
                                 ______
                                 
              Questions Submitted by Senator Brian Schatz
    Question. I am concerned we are facing a cliff for digital health 
when the public health emergency ends. Last month you said that when it 
comes to telehealth we cannot let the ``old way of business get in the 
way''. I agree, and so do 61 of my colleagues who have cosponsored my 
CONNECT for Health Act. HHS's current authority to expand Medicare's 
coverage of telehealth expires 151 days after the public health 
emergency ends. Unless Congress acts to ensure permanent expansion of 
Medicare coverage authorities, we will go back to the dark ages with 
very limited access to telehealth. During the pandemic, you also waived 
requirements for other communication technology-based services that CMS 
could amend without additional authorities needed from Congress. 
Finally, CMS provided robust guidance to states to increase access to 
telehealth for individuals in Medicaid and CHIP during the pandemic.
    What are the factors you are considering for when this public 
health emergency could be declared over?
    What is CMS's plan regarding the pandemic flexibilities granted for 
communication technology-based services, such as remote physiologic 
monitoring, remote therapeutic monitoring, and virtual check-ins?
    How is HHS continuing your work with states beyond the public 
health emergency to ensure that individuals enrolled in Medicaid and 
CHIP have the same access to telehealth services as those with 
commercial insurance?
    Answer. During the COVID-19 public health emergency, telehealth has 
been a reliable resource, allowing healthcare providers to reach 
patients directly in their homes to ensure access to care and 
continuity of services. The Biden-Harris Administration is committed to 
supporting a temporary extension of broader telehealth access under 
Medicare beyond the declared COVID-19 Public Health Emergency (PHE) in 
order to study its impact on utilization of services and access to 
care. Telehealth, including audio-only telehealth, can greatly expand 
access to services for individuals who may not have access to broadband 
or technology to support 2-way audio-video. This is particularly true 
in rural and underserved areas, and among older populations.
    The Administration is also expanding access to mental health and 
beneficiary-centered care under Medicare through greater use of 
telehealth and other telecommunications technologies to provide 
behavioral healthcare, among other services. Medicare beneficiaries can 
access care directly in their homes thanks to recent statutory 
amendments (CAA, 2021), and using audio-only technology where 
appropriate based on the patient's needs thanks to changes in 
regulations, including in CMS's CY 2022 Physician Fee Schedule (PFS) 
final rule, that allow payment for certain behavioral health services 
via audio-only telephone calls.
    In addition, the President's fiscal year 2023 Budget includes a 
proposal to remove statutory limits on the list of practitioners that 
are authorized to receive direct Medicare payment for their mental 
health services, which would expand access to mental health services in 
Medicare, especially in rural and underserved areas with fewer mental 
health professionals or in communities more likely to receive care from 
the referenced practitioners.
    CMS has released numerous resources to help states identify 
opportunities for increasing the use of telehealth services within 
Medicaid and CHIP. For example, CMS developed Medicaid & CHIP 
Telehealth toolkit to help states accelerate adoption of broader 
telehealth coverage policies in Medicaid and CHIP during the COVID-19 
PHE. This toolkit provides states with statutory and regulatory 
infrastructure issues to consider as they evaluate the need to expand 
their telehealth capabilities and coverage policies. The toolkit also 
includes a compilation of frequently asked questions and other 
resources available to states. CMS also released a supplement to the 
toolkit to provide additional support to state Medicaid and CHIP 
agencies in their adoption and implementation of telehealth as they 
begin to plan beyond PHE flexibilities. States may use this 
supplemental toolkit to help think through how they will explain and 
clarify which policies are temporary or permanent, when flexibilities 
will expire, which services can be accessed through telehealth, which 
providers may deliver those services, the modality they may use to 
deliver telehealth services, and the circumstances under which 
telehealth can be reimbursed. Several state profiles are included in 
this toolkit.
    Question. Healthcare workforce shortages are at critical levels in 
many parts of the country. In addition to workforce training and 
retention programs, state licensure portability can be an important 
strategy to increase access to care. As states have begun rescinding 
licensure waivers, providers are confronting a state patchwork that 
impacts some from effectively practicing across state lines.
    Keeping patient safety in mind, what authority do you need to 
enhance licensure portability and reciprocity and address regulatory 
restrictions for providers?
    Answer. HRSA's Office for the Advancement of Telehealth supports 
the Licensure Portability Grant Program under the authority of Section 
330L of the Public Health Service Act. States establish their licensure 
requirements for healthcare providers. However, the Licensure 
Portability Grant Program assists providers with cross-state licensure 
by providing funding to work with state licensure boards to create 
multi-state licensure compacts. Through this program, HRSA provides 
support to the Federation of State Medical Boards (FSMB) and the 
Association of State and Provincial Psychology Boards (ASPPB). The FSMB 
created the Interstate Medical Licensure Compact (IMLC), which offers a 
voluntary, expedited pathway to licensure for qualified physicians to 
practice in multiple states, including physicians participating in 
Medicare and Medicaid. The ASPPB created the Psychology 
Interjurisdictional Compact (PSYPACT) to facilitate telehealth and 
temporary in-person, face-to-face practice of psychology across 
jurisdictional boundaries.
    Question. Please list and describe the state policies that HHS 
helped to enact and/or implement through its Licensure Portability 
Program.
    Answer. The purpose of the Licensure Portability Grant Program is 
to provide support for state professional licensing boards to carry out 
programs under which licensing boards of various states cooperate to 
develop and implement state laws and related policies that will reduce 
statutory and regulatory barriers to telemedicine, such as creating 
multi-state licensure compacts. Since states establish their licensure 
requirements, HHS does not have the authority to change state policies.
    Question. What resources would be needed to ramp up HHS's efforts 
to support state licensure portability?
    Answer. The two grantees supported through the Licensure 
Portability Program, the FSMB and ASPPB, have developed several tools 
to facilitate access to inter-state telehealth services. These include 
the Interstate Medical Licensure Compact (36 states, Guam, and the 
District of Columbia), the Provider Bridge (www.ProviderBridge.org), 
the Psychology Inter- jurisdictional Compact, also known as PSYPACT (33 
states), and the Licensure Project (www.LicensureProject.org). 
Together, these tools support a range of clinicians, including 
physicians, physician assistants, nurses, occupational therapists, 
physical therapists, psychologists, and social workers. Resources could 
be used to continue the use of tools such as www.ProviderBridge.org and 
www.LicensureProject.org, expand on efforts to get more states to join 
the compacts, and support new grantees through the Licensure 
Portability Program, which would expand the types of healthcare 
disciplines that are included in the Licensure Portability Program.
    HHS is committed to continuing to work within the confines of the 
law to strengthen the healthcare workforce and connect skilled 
providers with communities in need including through the use of 
telehealth. Medicare defers to state law with regard to licensure 
issues.
    Question. Remote patient monitoring (RPM) allows providers to track 
patients' health metrics and empowers individuals to effectively manage 
their conditions at home. These tools can improve access to care and 
health outcomes. Through its Physician Fee Schedule rulemaking, CMS has 
eliminated some barriers to coverage and payment for RPM services. 
However, some policies may not adequately address the 77 percent of 
older adults with at least two chronic conditions who are 
disproportionately low-income and from minority communities, and could 
benefit from multiple technologies.
    How is HHS enabling the use of technology, such as remote 
physiologic monitoring and remote therapeutic monitoring, for Medicare 
beneficiaries who have comorbid chronic health conditions, e.g., 
diabetes, hypertension, obesity, depression?
    Answer. CMS is committed to ensuring our beneficiaries receive 
high-quality, coordinated care that helps them manage their health. 
Care coordination and tools such as telehealth and other virtual 
services can be particularly beneficial for those with one or more 
chronic health conditions. The COVID-19 public health emergency (PHE) 
has highlighted that telehealth and other communications technologies 
can be a reliable resource that allows healthcare providers to reach 
patients directly in their homes in order to ensure access to care and 
continuity of services.
    In recent years, we have engaged in efforts to update and improve 
care management and coordination services within the physician fee 
schedule including chronic care management services, which involve 
patients with at least two chronic conditions. We also established 
payment for remote therapeutic monitoring services which can be used to 
monitor a variety of chronic and acute health conditions.
    The Biden-Harris Administration is also committed to supporting a 
temporary extension of broader telehealth access under Medicare beyond 
the COVID-19 Public Health Emergency declaration in order to study its 
impact on utilization of services and access to care. Telehealth, 
including audio-only telehealth, can greatly increase access to 
services for individuals who may not have sufficient bandwidth or 
technology to support 2-way audio-video, particularly in underserved 
areas and among older populations.
    Question. The Native Hawaiian Health Care Improvement Act (NHHCIA) 
was enacted in furtherance of the Federal trust responsibility of the 
U.S. government to provide resources to raise the health status of 
Native Hawaiians. By statute, Papa Ola Lokahi is identified as the 
single administrative entity responsible for carrying out specific 
functions. In this capacity, Papa Ola Lokahi must utilize its community 
expertise to administer the program and work with the five mandated 
Native Hawaiian healthcare systems to ensure delivery of culturally 
appropriate care that improves the health status of Native Hawaiians. 
The NHHCIA does not list among the Secretary's responsibilities the 
role of identifying a grantee through a competitive application or 
evaluation process. Instead, the Secretary is obligated to execute a 
grant or contract with Papa Ola Lokahi and to evaluate its performance.
    How is HHS applying its special obligations under Federal trust 
responsibility to administer the NHHCIA grants?
    Answer. In fiscal year 2021, HRSA released a Notice of Funding 
Opportunity to make available appropriated funding authorized by the 
Native Hawaiian Health Care Improvement Act for a service grant to Papa 
Ola Lokahi for activities described in the NHHCIA, including 
coordination of healthcare programs and services provided to Native 
Hawaiians, and service grants to 5 certified community-based Native 
Hawaiian Health Care Systems (NHHCS) to provide a full range of 
services identified by the legislation and tailored to fit the needs of 
their respective island communities.
    Question. How is HHS applying culturally appropriate standards 
aligned with the specific goals of the NHHCIA to hold Papa Ola Lokahi 
and the Native Hawaiian healthcare systems accountable for raising the 
health status of Native Hawaiians?
    Answer. The most recent Notice of Funding Opportunity (NOFO) 
identifies that funding is intended to improve the provision of 
comprehensive disease prevention, health promotion, and primary 
healthcare services for Native Hawaiians. The requirements outlined in 
the NOFO hold Papa Ola Lokahi and the Native Hawaiian healthcare 
systems accountable for reporting the following: progress towards goals 
that align with the NHHCIA, strategies used to overcome challenges 
encountered in meeting those goals, and changes in the needs of the 
target population and service area. Clinical quality measures focus on 
progress made by NHHCS towards health needs pertinent to the target 
population and are aligned with standardized measures in HRSA's Uniform 
Data System for the Health Center Program. HRSA monitors POL and the 
five NHHCS through annual progress reports, regular monitoring calls, 
the annual submission of performance data, as well as operational site 
visits. HRSA continues to ensure that this oversight is culturally 
appropriate.
    Question. How is HRSA collaborating with and leveraging the Indian 
Health Service's expertise in the Federal trust relationship to 
administer the NHHCIA and evaluate grant performance?
    Answer. HRSA collaborates with IHS on reporting data methods and 
effective community engagement. HRSA also continues to explore new ways 
to improve the administration and evaluation of this grant funding.
    Question. If the final Supreme Court decision for Dobbs v. Jackson 
Women's Health Organization results in the same legal decision as the 
leaked draft opinion, Americans will lose their constitutional abortion 
rights protections. After Texas passed its six-week abortion ban, 
President Biden stated his administration would take a ``whole-of-
government approach'' to abortion rights. During your opening testimony 
you noted HHS would ``double down on our authorities''. I appreciate 
this commitment, and greater action is needed by HHS to meet this 
moment. In a major step last December, the FDA revised its Risk and 
Evaluation Mitigation Strategy (REMS) for mifepristone, removing the 
in-person dispensing requirement. This decision was consistent with the 
legal action Dr. Graham Chelius of Kauai took against HHS when he 
recognized that his patients had to fly to Oahu to obtain a drug safer 
than Tylenol or Viagra. While I applaud FDA for its revised REMS, I am 
concerned that it retained unnecessary requirements.
    What is FDA's rationale for maintaining its Patient Agreement Form 
requirement when in 2016, FDA staff recommended removal of this 
requirement stating it is duplicative of information and counseling 
provided to patients under standard informed consent practices and 
professional guidelines?
    Answer. As part of FDA's 2021 review of the Mifepristone REMS 
Program, which involved a detailed analysis of a significant amount of 
data, FDA concluded that the Patient Agreement Form remains necessary 
to assure the safe use of mifepristone for medical termination of early 
pregnancy. This form documents that the prescriber has counseled the 
patient on the use of mifepristone, what the serious risks are, and 
what to do if the patient experiences an adverse event. FDA's review of 
the published literature suggests that the removal of the in-person 
dispensing requirement may result in an increase in the number of 
providers becoming certified prescribers. The Patient Agreement Form is 
an important part of standardizing the medication information on the 
use of mifepristone that prescribers communicate to their patients, and 
provides the information in a brief and highly understandable format.
    Question. FDA justifies mifepristone's provider certification 
requirement by noting medical professionals' lack of familiarity and 
experience with medication abortion. Simultaneously, it is within your 
authority to strengthen the workforce and increase training for 
providers. What is HHS's plan to increase the number of providers with 
the necessary skills to deliver appropriate care?
    Answer. Last January, the Secretary launched an HHS-wide Task Force 
on Reproductive Healthcare Access to protect and bolster access to 
sexual and reproductive healthcare. This includes looking to ways to 
expand access to safe and legal abortion care, permissible under the 
law, and includes working to increase information and engagement with 
patients and providers to help ensure care. We are continuing to 
evaluate and look at our authorities and programs and services and will 
continue to keep you apprised of our thinking on this critical issue.
    Question. Is FDA considering modifying its REMS for mifepristone, 
including its requirement that drug manufacturers must certify 
prescribing clinicians and pharmacists, and the rule that patients must 
sign an agreement that they understand drug risks?
    Answer. To determine whether a modification to the Mifepristone 
REMS Program is warranted, in 2021 FDA conducted a comprehensive review 
of the published literature, other relevant safety data (including 
adverse event data), and information provided by advocacy groups, 
individuals, and the applicants. Based on this review, FDA concluded 
that mifepristone will remain safe and effective for medical 
termination of early pregnancy if the in-person dispensing requirement 
is removed, provided all the other requirements of the REMS are met, 
and pharmacy certification is added.
    Accordingly, on December 16, 2021, FDA sent REMS Modification 
Notification letters to the applicants, notifying them that a 
modification is necessary and must include removal of the in- person 
dispensing requirement and the addition of pharmacy certification. 
Following receipt of these letters, the applicants prepare proposed 
REMS modifications and submit them to FDA. Once those submissions are 
approved, the REMS modifications will be effective.
    Question. Is the administration considering challenging state laws 
that contradict the mifepristone REMS?
    Answer. Last January, the Secretary launched an HHS-wide Task Force 
on Reproductive Healthcare Access to protect and bolster access to 
sexual and reproductive healthcare. This includes looking to ways to 
expand access to safe and legal abortion care, permissible under the 
law, and includes working to increase information and engagement with 
patients and providers to help ensure care. We are continuing to 
evaluate and look at our authorities and programs and services and will 
continue to keep you apprised of our thinking on this critical issue.
    Question. Does HHS have a plan to increase awareness of medication 
abortion--including its safety and efficacy--particularly among 
communities whose access to care is limited? Can you please describe 
this plan? What resources are needed to execute?
    Answer. Last January, the Secretary launched an HHS-wide Task Force 
on Reproductive Healthcare Access to protect and bolster access to 
sexual and reproductive healthcare. This includes looking to ways to 
expand access to safe and legal abortion care, permissible under the 
law, and includes working to increase information and engagement with 
patients and providers to help ensure care. We are continuing to 
evaluate and look at our authorities and programs and services and will 
continue to keep you apprised of our thinking on this critical issue
                                 ______
                                 
            Questions Submitted by Senator Joe Manchin, III
    Question. One of the most pressing issues West Virginia faces is 
shortages across the healthcare sector. Nurses, specialists, you name 
it, we likely don't have enough of them. As we continue to address the 
COVID-19 pandemic, hospital capacity remains a big issue, especially in 
rural areas of the state that already faced significant access to care 
issues. In West Virginia, there are about 7,000 licensed hospital beds, 
but only enough staff to operate 5,000 of them. That is why Senator 
Manchin pushed to include $8.5 billion in the American Rescue Plan 
specifically to assist rural healthcare providers, including with 
staffing expenses.
    What can the Department do to help ensure places like West Virginia 
can offer healthcare professionals the resources and tools they need to 
continue providing care?
    Answer. HRSA is focused on workforce needs in rural areas generally 
and hospital capacity in rural areas specifically. In fiscal year 2022, 
HRSA will be awarding new programs under the Public Health Workforce 
Training Network Program to expand the public health capacity by 
supporting healthcare job development to help to address workforce 
shortages in rural areas. Additionally, several of HRSA's rural 
community-based programs offer non-categorical funding that allows 
applicants to propose and build a program in response to an area of 
need. HRSA has funded many programs that focus on workforce development 
through the Rural Health Network Development, Rural Health Care 
Coordination, Rural Health Care Services Outreach, and Delta States 
Rural Development Network grant programs. The fiscal year 2023 
President's Budget also supports a new pilot program to enable Rural 
Health Clinics (RHCs) to strengthen their workforce and bring critical 
services to rural communities. The request will fund approximately 18 
Rural Health Clinics.
    HRSA supports education and training to West Virginians through 
grant programs focusing on training primary care providers, nurses, 
preventive medicine and addiction specialist physicians, and physician 
assistants. These healthcare providers are training in hospitals and 
community-based organizations to provide care to rural and medically 
underserved communities. In addition, trainings support community-based 
collaboration, technology, medically underserved communities, oral 
health, minority health, geriatric health, behavioral health focused on 
substance use disorder and primary care integration. Course delivery 
modes include: classroom-based, self-paced distance learning, real-
time/live distance learning, online webinars, and hybrid trainings with 
workshops and clinical rotations.
    HRSA will continue to provide resources and tools to assist the 
heath care workforce provide quality care. Demonstrated efforts are 
shown through the following grant programs:
  --The National Health Service Corps (NHSC) increases access to care 
        in underserved areas by supporting qualified healthcare 
        providers dedicated to working in underserved communities. The 
        NHSC received supplemental funds through the American Rescue 
        Plan Act to support the nation's COVID-19 response and to help 
        address primary care provider need. In fiscal year 2021, there 
        were 242 NHSC clinicians serving in West Virginia.\16,17\
---------------------------------------------------------------------------
    \16\ Bureau of Health Workforce Clinician dashboards. (n.d.). 
Retrieved June 9, 2022, from https://data.hrsa.gov/topics/health-
workforce/clinician-dashboards.
    \17\ Bureau of Health Workforce Clinician dashboards. (n.d.). 
Retrieved June 9, 2022, from https://data.hrsa.gov/topics/health-
workforce/clinician-dashboards.
---------------------------------------------------------------------------
  --The Primary Care Training and Enhancement--Physician Assistant 
        Rural Training (PCTE-PAR) Program develops and implements 
        longitudinal clinical rotations in primary care in rural areas. 
        The program also supports the training and development of 
        preceptors in rural areas. In fiscal year (FY) 2022, West 
        Virginia University and Marshall University were awarded PCTE-
        PAR Program grants.
  --The Nurse Corps Program received supplemental funds through the 
        American Rescue Plan Act to support our Nation's COVID-19 
        response and to help address nursing staffing. In fiscal year 
        2021, Nurse Corps awarded three nursing scholarships in West 
        Virginia and 14 Nurse Corps loan repayment awards.
  --The Behavioral Health Workforce Education and Training (BHWET) 
        Program aims to increase the supply of behavioral health 
        professionals while also improving distribution of a quality 
        behavioral health workforce.
    In fiscal year 2021, West Virginia University was awarded a BHWET 
Program for Professionals grant. The purpose of their proposed Rural 
Integrated Behavioral Health Training (RIBHT) program is to prepare 
Master of Social Work students for behavioral health practice, with a 
focus on integrated and rural service delivery.
    Marshall University was also awarded a BHWET Program for 
Professionals grant between AY 2017-2021. The primary focus of the 
project is to increase the number of training slots that provide 
experience in integrated behavioral health within the primary care 
setting for trainees from programs that have previously not offered 
such training opportunities. These programs include the Master's 
program in Psychology with Clinical and School emphasis, the Masters in 
Counseling, and the Psychiatry residency program. Specific attention is 
given to understanding the unique needs of rural and underserved 
populations in West Virginia and Appalachia in general and how those 
needs may impact both behavioral and physical health.
    Question. Last month, the Administration released its National Drug 
Control Strategy. This strategy lays out the steps the Administration, 
in coordination with Federal agency staff across the government, will 
take to address the drug epidemic, which Senator Manchin has said time 
and time again continues to grow in West Virginia and across the 
nation. Prevention and early intervention are listed in the National 
Drug Control Strategy as a priority, as they should be. In 2020, the 
Substance Abuse and Mental Health Services Administration issued its 
annual report on substance use. The report found that 158,000 people 
ages 12 to 17 started using prescription pain relievers for the first 
time in 2020. While this a decline from previous years, youth substance 
use needs our full attention before we lose the next generation of 
leaders to the drug epidemic.
    What efforts are underway at HHS to address substance use by our 
youngest and most vulnerable populations?
    Answer. SAMHSA oversees grant programs that utilize evidence-based 
programs and promising practices to address substance use by youth ages 
12 to 17, among other efforts.
    For instance, SAMHSA's Enhancement and Expansion of Treatment and 
Recovery for Adolescents, Transitional Aged Youth, and their Families 
(Youth and Family TREE) grant program supports substance use disorder 
(SUD) treatment specifically for youth, young adults, and their 
families with these conditions. Many of SAMHSA's programs include 
elements that address youth and young adult SUD issues.
    The Screening, Brief Intervention, and Referral to Treatment 
(SBIRT) program aims to implement screening, brief intervention, and 
referral to treatment services for individuals of varying age groups 
and across different settings. The program includes a focus on 
screening for underage drinking, opioid use, and other substance use 
among youth and young adults in primary care and other health settings 
that serve this population (e.g., pediatric healthcare providers, 
Children's Hospitals, federally Qualified Health Centers (FQHCs).
    Grants to Expand Substance Misuse Treatment Capacity in Family, 
Juvenile, and Adult Treatment Drug Court programs support courts that 
employ the treatment drug court model to provide SUD treatment 
(including recovery support services, screening, assessment, case 
management, and program coordination) to youth and young adults 
involved in the court system or their parents who are at risk of having 
dependency petitions filed against them.
    The Sober Truth on Preventing Underage Drinking Act (STOP Act) 
program works to prevent and reduce alcohol use among youth and young 
adults ages 12-20 in communities throughout the United States. STOP Act 
grant recipients serve as a catalyst for increased citizen 
participation and greater collaboration among all sectors and 
organizations of a community to foster a long-term commitment to 
reducing alcohol use among youth. Grant recipients disseminate timely 
information to communities regarding state-of-art practices and 
initiative that have proven to be effective in prevention and reducing 
alcohol use among youth. By being deeply rooted in the community, grant 
recipients utilize town halls to gain feedback from communities and 
utilize that feedback to implement change and enhance local community 
initiatives and strategies.
    The Strategic Prevention Framework--Partnership for Success (SPF-
PFS) program works to prevent the onset and reduce the progression of 
substance use and its related problems while strengthening prevention 
capacity and infrastructure at the community and state level. Utilizing 
a data-driven approach, grant recipients identify communities of high 
need and at-risk populations of focus, including youths. Grant 
recipients utilize community coalition building strategies to advance 
substance use prevention efforts across the community and develop 
prevention messaging and other prevention strategies to ensure the 
dissemination of these messages and strategies.
    Additionally, SAMHSA has state level programs that also include 
services for youth. SAMHSA's State Opioid Response (SOR) program 
provides resources to states and territories, to continue and enhance 
the development of comprehensive strategies focused upon preventing, 
intervening in, and promoting recovery from issues related to opioid 
use, and increasingly stimulant use. The Tribal Opioid Response (TOR) 
program provides dedicated resources to perform these activities in 
Tribal communities. Both programs aim to address the overdose crisis by 
increasing access to the three FDA-approved medications for the 
treatment of OUD, reducing unmet treatment need, and reducing opioid-
related overdose deaths through the provision of prevention, harm 
reduction, treatment, and recovery support for OUD (including 
prescription opioids, heroin and illicit fentanyl and fentanyl analogs) 
and stimulant use disorder as so elected by states.
    A key component of SOR/TOR grantees' substance use prevention 
strategy is the implementation of Evidence Based Practices (EBPs). For 
prevention, EBPs are approaches and strategies shown to be effective in 
reducing the impact of social and population-based substance use 
concerns.
    Examples of EBPs that SOR grantees are implementing include Botvin 
Life Skills Training; Strengthening Families Program for Parents and 
Youth ages 10-14; Project Success; and Sources of Strength, Positive 
Action. All of these strategies focus on preventing the initiation of 
substance use for at-risk youth. SOR grantees also use funds to support 
interventions through Teen Courts, Recovery High Schools, Peer Mentor 
Programs, and Clubhouses. Between fiscal year 20 and fiscal year 2021, 
approximately 7 percent of individuals receiving treatment and recovery 
support services with SOR funds were under the age of 24 at the time-
of-service delivery.
    The Substance Abuse Prevention and Treatment Block Grant (SABG) 
Program provides funds to all 50 states, the District of Columbia, 
Puerto Rico, the U.S. Virgin Islands, 6 Pacific jurisdictions, and 1 
tribal entity to prevent SUD, provide treatment and promote recovery 
for those with SUD. Under the SABG program, grantees have the 
discretion to identify adolescents with SUDs and/or mental health 
disorders and children/youth at risk for behavioral health disorders as 
priority populations. Between fiscal year 2018-fiscal year 2021, the 
SABG program served 330,192 clients ages 17 and under and 729,024 
clients ages 18-24.
    In addition to directly supporting services for youth and young 
adults across the SUD intervention, treatment, and recovery support 
continuum, SAMHSA believes that education of the workforce and young 
people themselves is needed to have an impact in this area. SAMHSA has 
taken concrete steps to educate providers and those who use substances 
on the harms of opioid use (prescription and synthetic). SAMHSA 
supports a broad range of training and technical assistance resources 
that reach the specialty behavioral health treatment community, general 
healthcare professionals including students, and the general public. 
Providing education on the impact of using opioids empowers these 
audiences to educate individuals (youth and adults) on the risks and 
harms of using opioids. In addition, reaching youth and young adults 
with evidence-based information on avoiding exposure to harmful 
substances puts knowledge directly into the hands of those who may be 
at highest risk and their peers. This work is augmented through cross-
agency collaboration. SAMHSA representatives regularly meet with other 
agencies to foster synergy in the expansion or improvement of SUD 
treatment, and how public education might be augmented.
    The National Institute on Drug Abuse (NIDA), part of the NIH, 
supports research to understand and address substance use and its 
consequences across the lifespan, including among vulnerable children 
and adolescents. Research findings indicate that substance use and 
other drug-related harms are more likely to occur in the presence of 
specific risk factors, such as adverse social determinants of health, 
and less likely to occur among certain protective factors, like healthy 
family and peer relationships and financial stability. Prospective, 
longitudinal studies like the HEALthy Brain and Child Development 
(HBCD) \18\ and the Adolescent Brain Cognitive Development (ABCD) \19\ 
studies will help us better understand the specific brain, cognitive, 
social, and emotional factors that underlie healthy and unhealthy 
development from the prenatal period through young adulthood. These 
studies will contribute immeasurably to future substance use prevention 
strategies.
---------------------------------------------------------------------------
    \18\ https://heal.nih.gov/research/infants-and-children/healthy-
brain.
    \19\ https://heal.nih.gov/research/infants-and-children/healthy-
brain.
---------------------------------------------------------------------------
    Because most opioid and other substance misuse begins during 
adolescence and young adulthood, this is a critical period for 
prevention. Older adolescents and young adults are at the highest risk 
for initiation of opioid use, opioid misuse, opioid use disorder (OUD), 
and death from overdose, and there is a need for evidence-based 
interventions to prevent OUD. With funding from the Helping to End 
Addiction Long-term Initiative (NIH HEAL Initiative), NIDA leads 
studies on effective strategies to identify and reach at-risk 
individuals in various settings, such as schools, healthcare, justice, 
and child welfare systems. For example, one study is testing a video 
game opioid use prevention intervention for older teens in school-based 
health centers (UH3DA050251-03).\20\ Another study utilizes a 
convenient smartphone application to engage high-risk youth in a 
mindfulness-based intervention to help them reduce or quit their 
substance use (UH3DA050189-03).\21\ Other NIDA-supported studies are 
aimed at improving the uptake and reach of existing evidence-based 
prevention interventions across settings, developing tailored 
approaches for diverse populations, and improving our understanding of 
the mechanisms of action for effective prevention approaches. NIDA also 
supports research to expand effective screening approaches for pregnant 
and postpartum women and school-age children in healthcare settings 
(NOT-OD-22-106 \22\ and NOT-OD-22-107) \23\ and, through its NIDAMED 
initiative, translates research findings into evidence-based resources 
and tools for clinicians to screen for problematic substance use 
(Screening for Substance Use in the Pediatric/Adolescent Medicine 
Setting).\24\
---------------------------------------------------------------------------
    \20\ https://reporter.nih.gov/search/q7GOLosA3kSsoyk3nLnCtQ/
project-details/10408897.
    \21\ https://reporter.nih.gov/search/q16mokkSqkSYJFFKEUseMA/
project-details/10441666.
    \22\ https://grants.nih.gov/grants/guide/notice-files/NOT-OD-22-
106.html.
    \23\ https://grants.nih.gov/grants/guide/notice-files/NOT-OD-22-
107.html.
    \24\ https://nida.nih.gov/nidamed-medical-health-professionals/
science-to-medicine/screening-substance-use/in-pediatric-adolescent-
medicine-setting.
---------------------------------------------------------------------------
    Finally, monitoring real-world substance exposure among youth is 
also critical for informing prevention efforts. NIDA's Monitoring the 
Future study, an annual survey of substance-related behaviors, 
attitudes, and values of Americans from adolescence through adulthood, 
and the Population Assessment of Tobacco Health (PATH) Study, a 
national longitudinal study of tobacco and health, are helping us to 
better understand the landscape of adolescent substance use to better 
target interventions to prevent and reduce youth substance use.
    Question. The 340B Drug Pricing Program is essential for providing 
access to safe and affordable medications for West Virginians. Senator 
Manchin has consistently advocated for the Department of Health and 
Human Services to safeguard this essential program and ensure that 
pharmaceutical companies cannot blatantly disregard the statutes they 
agreed to. We are hearing about practices that undercut this program by 
pharmacy benefit managers, or PBMs, known as white bagging or brown 
bagging, which puts patients' safety at risk and can dramatically raise 
the out-of-pocket costs for patients. This can also force patients to 
forgo treatment all together, all so PBMs can receive rebates from the 
manufacturers.
    What is the Department doing to clamp down on these practices?
    Are you monitoring this issue?
    How can we as legislators help our constituents who are falling 
victim to these bad practices?
    Answer. We are aware of the practices of pharmacy benefit managers 
under the 340B Drug Pricing Program (340B Program) that you reference. 
While there is no statutory provision in the 340B statute prohibiting 
the pharmacy benefit management programs from utilizing this approach, 
these practices are counter to the intent of the Program, which allows 
safety net providers to stretch scarce Federal resources and ensure 
that the safety net has access to discounted drugs for its patients. By 
pursuing this policy, pharmacy benefit management programs may make it 
cost prohibitive for certain covered entities to participate in the 
340B Program and reduce services to their patients. We look forward to 
working with you on this issue and to continue to support the important 
work of the 340B program.
    Question. Each year, the Secretary of Labor is required to submit a 
report regarding compliance with mental health parity laws. Mental 
health parity laws generally prohibit restrictions on mental health 
services that are more restrictive than those for all medical and 
surgical benefits. Secretary Becerra, in January, your Department, 
along with the Department of Labor and the Department of Treasury, 
released a report showing that health insurers for the most part are 
failing to deliver parity for mental health and substance use disorder 
benefits to beneficiaries. Senator Manchin's office has heard from 
several constituents who work in the mental health and substance use 
disorder workforce that mental health parity laws are simply not being 
followed. What's worse, mental health parity laws are not really being 
enforced. The bad actors aren't seeing any consequences for their 
actions, which are limiting patient access to mental health and 
substance use disorder services.
    What is the Department doing to ensure mental health parity laws 
are being enforced?
    Answer. Although SAMHSA has no direct enforcement role in the 
implementation of Mental Health Parity and Addiction Equity Act 
(MHPAEA), it has been a valued collaborator, partner, and leader on 
parity. SAMHSA has actively supported MHPAEA implementation by working 
closely with other agencies such as the Centers for Medicare & Medicaid 
Services and Departments of Labor and Treasury, as well as the Office 
of National Drug Control Policy. For instance, in partnership with the 
Department of Labor, the HHS and SAMHSA developed new, free 
informational resources that inform Americans of their rights under law 
on coverage for mental health benefits. The following resources are 
available on SAMHSA's website:
  --``Know Your Rights: Parity for Mental Health and Substance Use 
        Disorder Benefits,'' an updated trifold pamphlet explaining 
        mental health parity, detailing what it means to the consumer, 
        and listing the protections the parity law provides.
  --``Understanding Parity: A Guide to Resources for Families and 
        Caregivers,'' which provides an overview of parity geared 
        toward parents, family members or caregivers with information 
        and tools to help them obtain behavioral health services for 
        children or family members in their care.
  --``The Essential Aspects of Parity: A Training Tool for 
        Policymakers,'' which provides state regulators and behavioral 
        health staff an overview of mental health and substance use 
        disorder parity and how to implement and comply with the 
        Federal parity law regarding employee-sponsored health plans 
        and group and individual health insurance.
    We are committed to working with our Federal and state partners to 
ensure that health plans and insurance companies are accountable for 
delivering comprehensive care that includes protections on mental 
health and substance use disorder parity. Non-compliance, both 
intentional and unintentional, is a widespread problem, and additional 
investments are needed to conduct enforcement activities on an 
appropriate scale. While CMS has some enforcement authority, states are 
the primary enforcers of mental health parity for health insurance 
issuers in the small group and individual markets.
    In the 2022 MHPAEA Report to Congress, the Departments of HHS, 
Labor, and the Treasury (the Departments) highlighted their recent 
emphasis on greater Mental Health Parity and Addiction Equity Act 
(MHPAEA) enforcement and discussed the significant resources dedicated 
to supporting these efforts. The Departments provided examples, 
including how the Departments requested comparative analyses of plans' 
and issuers' nonquantitative treatment limitations (NQTLs), which is a 
process provided by the Consolidated Appropriations Act, 2021, and the 
impact of the corrections.
    In addition, HHS, together with the Departments of Labor and the 
Treasury, intends to release additional rulemaking on the MHPAEA. There 
have been a number of changes related to MHPAEA since issuance of the 
final regulations, including the 21st Century Cures Act, the Substance 
Use-Disorder Prevention that Promotes Opioid Recovery and Treatment 
(SUPPORT) for Patients and Communities Act, and the Consolidated 
Appropriations Act, 2021. This rule would propose amendments to the 
2013 final rules (78 FR 68239) and incorporate examples and 
modifications to account for this legislation and previously issued 
guidance.
                                 ______
                                 
                Questions Submitted by Senator Roy Blunt
Title 42
    Question. Has the Department of Health and Human Services been 
asked to provide or provided any vaccines to the Department of Homeland 
Security for efforts to vaccinate illegal immigrants at the Southern 
border?
    If yes, how many?
    Answer. No.
    Question. If no, where is DHS procuring vaccines from and is it 
from manufacturers directly? And if it is, is it part of a HHS 
contract?
    Answer. HHS defers to the Department of Homeland Security for 
information on their procurements.
    Question. On March 30, 2022, DHS released a Fact Sheet entitled DHS 
Preparations for a Potential Increase in Migration. It states that 
``DHS has also been providing the COVID-19 vaccines to noncitizens in 
ICE custody since summer 2021.'' It goes on to state that ``Beginning 
March 28, 2022, DHS expanded those efforts to cover migrants in CBP 
custody, so as to further safeguard public health and ensure the safety 
of border communities, the workforce, and migrants.'' What role is HHS 
playing in this decision?
    Has HHS provided any funding to support the mass vaccination of 
illegal immigrants either in CBP or ICE custody?
    Answer. HHS has allocated $48 million from CDC ARP funding via 
Interagency Agreement with DHS to support certain vaccine related 
services (e.g., vaccine event adverse reporting, inventory, 
coordination with state/local Federal agencies) associated with DHS/
CBP's migrant vaccination programs.
    Question. How many Public Health Service Corps members are 
currently deployed to the Southern border?
    Answer. Operation Artemis consisted of 71 unique missions, with a 
total of 938 separate deployments occurring to support. A total of 805 
unique officers deployed, with some officers deploying multiple times 
to meet the 938 deployments.
    Question. What are the costs associated with their deployment?
    Answer. The average cost per officer to support a deployment is 
$8000, totaling an estimated $7,504,000 to include officer travel, per 
diem, rental vehicles, and miscellaneous expenses.
    Question. What is their role and/or what mission are they 
supporting?
    Answer.
  --USPHS deployed a flag officer, RADM Richard Childs, as the officer 
        in charge of Operation Artemis, due to the significance of the 
        operation and to ensure dedicated leadership personnel.
  --Officers provided administrative support, facility and engineering 
        support, and clinical support on these deployments. Clinical 
        support included: COVID-testing, nursing case management, COVID 
        vaccination administration, general clinical evaluation and 
        care, pharmacological management, infectious disease support, 
        behavioral health management, and clinical coordination of 
        services across multiple agencies for unaccompanied children 
        and their families.
  --Some of the roles in which officers were deployed to support these 
        missions included: Incident Commander, Site Lead, Chief Medical 
        Officer, Chief Nurse Officer, Safety Officer, Force Health 
        Protection, Nurse/Medical/Quality Control/Engineering/Pharmacy/
        Mental Health Officers to name the most common.
    Question. Are they providing vaccinations to illegal immigrants in 
DHS custody?
    Answer. Officers did provide vaccinations to unaccompanied children 
to prevent the spread of COVID-19 and other communicable diseases.
    Question. What is the policy for treating illegal immigrants in the 
Department of Homeland Security's custody with COVID-19 therapeutics if 
they test positive while in custody and what is HHS' role in this 
activity?
    Answer. CDC does not provide treatment or therapeutics for COVID-
19. CDC provides technical assistance and guidance to the Department of 
Homeland Security to implement COVID-19 mitigation procedures in DHS 
facilities. For more information regarding implementation of these 
procedures, please contact DHS.
Aduhelm Decision
    Question. In the last 7 years, this Subcommittee has written bills 
that have more than quintupled funding for Alzheimer's research. That 
is how critical of an issue it is to address. FDA has finally approved 
a drug to treat mild-to-moderate Alzheimer's disease last year. But 
last month, CMS made a historic decision to limit coverage only to 
those participating in an NIH or FDA trial. And, interestingly, CMS 
made a distinction between drugs approved through FDA's traditional 
drug approval process and those that receive accelerated approval. I 
don't believe that this distinction has ever been applied to a FDA-
approved treatment before.
    I recognize that there is a lot of controversy around Aduhelm, its 
data, its price, and potentially its approval. But putting that aside, 
I am concerned that CMS, and ultimately HHS, has made a critical error 
by making a coverage decision that affects not only
    Aduhelm, but all other monoclonal antibody treatments coming down 
the pike. Further, the decision calls into question FDA's entire 
accelerated approval process and by doing so, clearly undermines the 
scientific decisions made by FDA. Can you address what this CMS 
decision means for the future of FDA's accelerated approval process?
    Answer. The agency is committed to using expedited programs to 
bring medicines to underserved populations with serious conditions and 
unmet medical need when the science supports the decision within the 
statutory authorities given to FDA by Congress. Our decision regarding 
Aduhelm exemplifies that commitment. It is important to distinguish 
between FDA's and CMS' role. The standard for Medicare coverage is not 
the same as the standards for FDA approval of a drug. Our role is to 
determine if drug is safe and effective. The agency cannot speak for 
CMS. We continue to see sponsors pursue accelerated approval.
    Ensuring the availability of innovative interventions for people is 
a shared priority for both the Centers for Medicare & Medicaid Services 
(CMS) and the U.S. Food and Drug Administration (FDA). Underpinning 
both agencies' work is the unwavering commitment to use reliable data 
to ensure that effective treatments are made available to patients. The 
FDA's decision to approve a new medical product is based on a careful 
evaluation of the available data and a determination that the medical 
product is safe and effective for its intended use. CMS can conduct its 
own independent review to determine whether an item or service should 
be covered nationally by Medicare, including examining whether it is 
reasonable and necessary for use in the Medicare population.
    The final National Coverage Determination (NCD) ensures access to 
and coverage for Aduhelm and other drugs in the antiamyloid monoclonal 
antibody class that receive accelerated approval. The decision also 
supports innovation and certainty of coverage by creating a long-term 
coverage pathway for new drugs in this class that obtain FDA 
traditional approval, without requiring a new NCD.
    The work of both agencies is critical to ensure that medical 
products are available to people across the country. We recognize the 
impact these decisions have on people with serious and life-threatening 
conditions and their loved ones. We share a common goal of wanting to 
advance the development and availability of innovative medical 
products. The agencies remain committed to using our distinct set of 
authorities to ensure the continued availability of medical products 
that meet our respective standards to care for the people we serve.
    In issuing this NCD, HHS is not making any statement about coverage 
of accelerated approval drugs. This decision is specific to the 
antiamyloid monoclonal antibody class of drugs. HHS looks forward to 
continuing our work on the innovative Cancer Moonshot initiative. All 
Americans are invited to share perspectives and ideas, and 
organizations, companies, and institutions to share actions they plan 
to take as part of this mission at whitehouse.gov/cancermoonshot.
    Question. How does the decision on Aduhelm affect other Alzheimer's 
monoclonal antibody therapies that are under development?
    Answer. NIH notes that the decisions issued by the FDA and Centers 
for Medicare & Medicaid Services (CMS) are regulatory decisions, and 
NIH defers to these agencies on such matters.
Supply Chain
    Question. What is the Department's plan for investing in supply 
chain resiliency for active pharmaceutical ingredients (API), 
particularly those for essential medicines?
    Answer. The HHS Office of the Assistant Secretary for Preparedness 
and Response (ASPR) made a $354 million investment in Phlow, a 
consortium of organizations that will expand domestic manufacturing of 
raw materials and active pharmaceutical ingredients for drugs. This 
effort includes support for continuous manufacturing. The efforts will 
target drugs on the FDA drug shortage list that have become even more 
critical during the COVID-19 response. I will be happy to keep you and 
your staff informed of activities related to this initiative.
    Question. Is the Administration leveraging existing manufacturers 
and their ability to expand US capacity in the short term (i.e., within 
1-2 years)?
    Answer. With our initial award to PHLOW, we immediately began 
supporting efforts to enhance domestic capacity immediately.
    In addition, we have been supporting efforts to strengthen the 
overall domestic manufacturing base to ensure we are better positioned 
and prepared for whatever comes next. Within HHS/ASPR, we are working 
to institutionalize efforts to support domestic manufacturing efforts. 
Specifically, we are integrating and organizing supply chain 
situational awareness and industrial analysis, domestic industrial base 
expansion, and supply chain logistics. Bringing these pieces together 
will strengthen our industry partnerships and support our work to 
establish and maintain resilient supply chains. A new office within 
ASPR will pull together several lines of effort across--PPE, Durable 
Medical Equipment, Testing and Diagnostics, API, etc. While the new 
office won't necessarily manage every program within that space--SNS, 
BARDA and H-CORE will continue in key roles--the new office will be a 
driving force in ensuring coordination of ASPR's efforts to expand the 
industrial base and solidify the nation's supply chains.
    Question. How much funding has been obligated or committed for this 
activity?
    Answer. Specific to the Phlow contract, an initial award of $354 
million was issued. Phlow is a consortium of organizations that will 
expand domestic manufacturing of raw materials and active 
pharmaceutical ingredients for drugs.
    Question. Does the current investment include a plan for warm based 
manufacturing capabilities and a vendor managed model that would allow 
for these newly manufactured APIs to support the underlying healthcare 
marketplace both during and outside of public health emergencies?
    Answer. Current investments are focused on generating highly 
distributed continuous manufacturing capacities for APIs and finished 
drug products allowing the U.S. to build resilient supply chains for 
drug substances and drug products, both during and outside of public 
health emergencies.
COVID-19 Education Campaign
    Question. The HHS congressional justification references a 
commitment to use local broadcasters and local newspapers for the 
COVID-19 education campaign, but does not provide additional details on 
how the Department will do so. What steps will the Department take to 
ensure that local broadcasters and newspapers, especially in small and 
rural communities, play a role in the ongoing educational campaign on 
COVID-19?
    Answer. Since onset, the Campaign has committed to using local 
broadcasters and local newspapers to supplement broad-reaching national 
outreach. Doing so has allowed for consistent surround-sound presence 
to adults across America, with a layer of focused messaging directed to 
the critical audiences. How the campaign has executed local media buys 
to reach Americans where they live and from the channels they trust 
most:
    The Campaign greatly prioritizes placing paid advertising via local 
media outlets, and specifically on local television, local cable, local 
radio, local newspapers and local websites. These run consistently in 
20+ markets per month (in some months up to 100 markets) directed to 
different Campaign audiences.
    These local buys run as a supplement to the Campaign's foundation 
of national ads on broadcast and cable television (and sometimes 
national radio).
    Importantly, national, and local media outlets that are at least 50 
percent owned by Minorities are prioritized, provided they provide 
efficient outreach and are qualitatively suitable for Campaign 
messages.
    As one example, the Campaign designed a hyper-local campaign to 
reach Black and Hispanic residents of Milwaukee, WI with an invitation 
to visit a regional Community Vaccine Clinic. The four-week buy 
included ads on:
  --Radio: WJMR-FM (Urban Adult Contemporary), WNOV-AM/FM (Urban/Talk/
        Community) WKKV-FM-(Urban Contemporary) WJYI-FM-(Contemporary 
        Christian/Christian preaching), WDDW-AM/FM (Regional Mexican) 
        and WJTI-FM (Regional Mexican)
  --Print: Milwaukee Community Journal, Milwaukee Courier, Milwaukee 
        Times, Journal Sentinel Community NOW papers (targeted to 
        specific zip codes), Urban Milwaukee, El Conquistador, Hispanic 
        Reflections, Spanish Journal, La Comunidad News.
  --OOH: Hyper-local poster boards within highly populated B/AA and 
        Hispanic communities and zip codes. Highly visible billboards 
        on heavy traveled roads and highways. Mobile targeted ads, geo-
        targeted around vaccine clinic(s). DOOH (malls, office 
        buildings, gas stations, fitness centers, etc.)
  --Digital: Urbanmilwaukee.com, sherpardexpress.com, Onmilwaukee.com, 
        bizjournal.com, milwaukeens.com for programmatic placements. 
        Site direct partners i.e. Nextdoor.
  --Social: Facebook, Instagram, Twitter (geotargeted to Milwaukee 
        metro area)
  --SEM: Google, Bing, Yahoo, Duck Duck Go (geotargeted to Milwaukee 
        metro area)
    In order to continue to ensure that local broadcasters and 
newspapers, especially in small and rural communities, play a role in 
the ongoing educational campaign on COVID-19, it is critical to keep 
Campaign messages in very local programming (including news, regional 
entertainment and sports):
    The campaign has made a dedicated effort to invest paid media 
dollars in media channels that are located in and trusted by rural 
populations. The ``We Can Do This'' campaign has had a dedicated rural 
audience effort with tailored creative and media buys across efforts to 
increase first doses for ``movable middle'' adults, parents with 
unvaccinated children, and encouraging booster doses.
    In addressing rural audiences, the campaign has focused on the more 
than 46 million Americans who live in ``micropolitan'' or ``noncore'' 
counties according to the National Center for Health Statistics 2013 
Urban-Rural classification scheme. On a monthly basis, the campaign has 
identified heavy-up markets for additional local media purchases, and 
concentrations of population in the media market that reside in rural 
counties has been a factor when determining audiences.
Percentage of the paid budget spent on local paid--ideally compared to 
        industry benchmarks
  --Of the Campaign's entire budget, approximately 70 percent is 
        allocated to the placement of paid advertising. More than half 
        of these dollars (51 percent) are directed locally in one of 
        two ways, either through direct purchase of space with 
        community media outlets or through national channels' reach 
        into specific locations.
    In addition to collaborating with thousands of local media outlets 
to run paid advertising, we have also engaged in partnerships and 
relationships with community-based organizations. Many of the 
organizations with whom we work allow us to affect hyper-local, highly 
vulnerable populations who may not otherwise be reached with critical 
information about how, where, and why to get vaccinated. For example, 
we're working with:
  --National PTA activating 34 local PTAs in priority markets to host 
        events and conduct outreach to parents of children eligible to 
        get vaccinated. Since the start of the partnership, PTA has 
        conducted a total of 86 pop-up vaccine clinics and vaccinated 
        (first shot or booster) 2,050 people.
  --The Cobb Institute of the National Medical Association has been 
        hosting a series of ``Stay Well Community Health Fair and 
        Vaccine'' events in priority markets targeted at reaching Black 
        and African American families. Since the start of the 
        partnership, they have hosted sixteen events, 1,475 individuals 
        have been vaccinated or been given booster shots at these 
        events.
  --Eighteen Asian American, Native Hawaiian, and Pacific Islander 
        organizations across the country to conduct in-person and 
        digital outreach. From November 2021 to June 2022, we reached 
        over 3,000,000 people. Some of the organizations include, The 
        Asian American Pacific Community Health Organization, Asian and 
        Pacific Islander Vote, and The National Association of Pasifika 
        Organizations.
  --In partnership with Copa Univision, we attended a community sport 
        event in Dallas, TX on June 4-5, to share COVID-19 information 
        with over 800 Latino families participating at the amateur 
        soccer event. The Campaign will participate in three other Copa 
        Univision events in Houston, Chicago, and New York.
  --National Day Laborer Organizing Network (NDLON) has been reaching 
        migrant workers and farm workers with key information about 
        vaccines through in-person events and radio. The organizations 
        will also share new videos produced in five different 
        indigenous languages.
  --Vaccine Hunters distributed 2,274 Campaign materials at six 
        canvassing sites and hosted 48 vaccination clinics in Maryland 
        to reach Spanish-speaking Latino people. The organization has 
        already vaccinated 2,426 people.
  --Working with the National Diaper Bank and Alliance for Period 
        Supplies to distribute campaign information among 200 local 
        banks across the country. These will include fact sheets, 
        drafted press release, postcards, and other materials in diaper 
        and period supply boxes.
  --The United Methodist Health Ministry Fun posted seven video 
        testimonials reaching an online audience of more than 200,000 
        and hosted a webinar for 82 Kansas faith-based, healthcare and 
        childcare providers as well as published an op-ed in Topeka 
        reaching more than 31,000 print and 500,000 online subscribers.
  --The National Rural Education Association created three video 
        testimonials with teachers from Missouri, Iowa and Northern 
        California reaching more than 50,000 online viewers; shared 
        information with 300 educators in Victoria, TX at a state 
        conference; published a podcast with a pediatrician from West 
        Virginia with 3,400 downloads; and published a social media 
        toolkit and newsletter for their national network of rural 
        educators and state directors with a reach of more than 
        100,000.
    Question. Please provide details on obligations to date to local 
broadcasters and newspapers for education campaigns from both the 
COVID-19 supplemental funds and the American Rescue Plan, broken out by 
bill, year, and agency.
    Answer.

 
 
                    Fiscal Year 2020
 
Local Radio.............................................      $8,512,770
                                                         ---------------
    Fiscal Year 2020 Total..............................      $8,512,770
 
Fiscal Year 2020--Funding Source
 
    IAA with the CDC funded by CARES Act appropriation
     to CDC, Public Law 116-136, 134 Stat. 281, 554-55.
 


 
 
                    Fiscal Year 2021
 
Local Newspapers........................................     $11,136,940
Local Radio.............................................    $14, 526,430
Local Television........................................      $4,428,756
                                                         ---------------
    Fiscal Year 2021 Total..............................     $30,092,126
 
Fiscal Year 2021--Funding Source
 
    CARES Act appropriation to CDC, Public Law 116-136,
     134 Stat. 281, 554-55.
 
    American Rescue Plan (ARP) Public Law 117-002.
 


 
 
                    Fiscal Year 2022
 
Local Newspapers........................................      $7,482,218
Local Radio.............................................     $14,916,933
Local Television........................................     $11,082,786
                                                         ---------------
    Fiscal Year 2022 Total..............................     $33,481,938
 
Fiscal Year 2022--Funding source
 
    CARES Act appropriation to CDC, CARES Act, div. B,
     title VIII, Public Law 116-136, 134 Stat. 281, 554-
     55.
 
    American Rescue Plan (ARP) Public Law 117-002.
 


HRSA Poison Control
    Question. I remain concerned that the Department has failed to 
address the issue of misdirected calls to poison control centers, as 
required under the Poison Center Enhancement Act that passed in 2019 as 
part of the fiscal year 2020 appropriations bill. It is my 
understanding that poison centers in 12 states and the District of 
Columbia have more than 10 percent of their calls misrouted to the 
wrong poison center. Critical medical treatment can be delayed when 
this occurs.
    The Poison Center Enhancement Act requires the Secretary of HHS to 
coordinate with the FCC within 18 months of enactment to ensure calls 
are routed to the proper poison center based on the location of the 
caller to the ``extent technically and economically feasible.'' From 
what I can tell little progress has been made on this issue. Please 
provide an update on this issue, as well as a plan of action to 
improve, if not solve, this growing problem.
    Answer. HRSA recognizes the importance of proper routing of the 
Poison Help Line calls.
    HRSA is engaging with our internal and external partners to 
identify technologically feasible solutions to address the longstanding 
issue associated with caller's area codes versus geographical location 
being used for call routing. We are currently engaged with Verizon (the 
toll-free vendor), an industry technology solutions organization 
(ATIS), the American Association of Poison Control Center (AAPCC), and 
FCC to identify potential technology-based solutions to the call 
routing issue. Verizon has submitted a formal issue statement to ATIS 
to initiate an industry review of potential methods to improve the 
routing information wireless providers over 4G mobile networks; this 
issue statement was accepted by ATIS and is currently under review. 
HRSA also conducted individual calls with several vendors to further 
stimulate telecommunication contractors to propose solutions.
    We are committed to continuing to work with industry on a solution 
to this important issue.
COVID-19 Commercialization
    Question. Products are able to go into the commercial market once 
they receive FDA approval. For COVID-19 related products that have FDA 
approval, like COVID-19 vaccines for adults, when will the Department 
transition from being the sole purchaser of these products?
    Answer. To date in the COVID-19 response, HHS has supported efforts 
to ensure that vaccines are available to all states and communities. As 
of April 1, 2022, HHS has procured approximately 2 billion doses of 
vaccine and 10.4 million therapeutics and has provided these resources 
to states and territories at no cost. As Congress has not provided the 
resources requested for these efforts, the Department is thinking 
through courses of action to manage the transition away from Federal 
acquisition. There are a number of potential issues that need to be 
considered related to licensure, access, and coverage, which may 
require possible statutory or regulatory changes to resolve. Additional 
funding is required to ensure that there is a smooth transition and 
that challenges are addressed as we move forward with shifting vaccines 
to the commercial market.
COVID-19 Tests
    Question. What is the Department's funding plan for COVID-19 
testing manufacturers?
    Answer. The Administration has been working closely with domestic 
suppliers and manufacturers since the very beginning. From its first 
days in office, the Administration has used the Defense Production Act 
(DPA), industrial mobilization, and advance market commitments to 
accelerate production of tests. The Administration has also invested 
billions of dollars in industrial base expansion and procurement of a 
large quantity of tests from a variety of domestic manufacturers, 
including Abbott, Quidel, Orasure, and others, as part of the 
COVIDTest.Gov initiative, and other testing initiatives. We also 
continue to find ways to maximize any level of support we can provide, 
including through existing contracts for tests for Long-Term Care 
Facilities, federally Qualified Health Centers, other Community Health 
Centers, food banks, and schools. However, as we have been saying for 
the past months, we need the additional requested funding to provide 
ongoing support and avoid further production cuts and job layoffs 
during this time. Without additional funding, there are risks that we 
will not have the testing capacity we need during a future surge.
    Question. Earlier this year, the Department purchased 1 billion at-
home tests to be distributed to Americans. The majority of those tests 
were purchased from Chinese manufacturers. Should a spike in cases 
cause the Department to purchase additional at-home tests, is there a 
plan in place to make these purchases from domestic manufacturers?
    Why were domestic manufacturers not used for the 1 billion at-home 
tests the Administration purchased in January 2022?
    Answer. When the Administration began offering COVID-19 tests, at 
no cost, to any person who requested such tests, the intention was to 
increase the number of tests available without impacting the supply of 
tests in the commercial market and without impairing existing state/
territorial contracts for the procurement of tests. However, from 
November 2021 to February 2022, we saw a strained domestic 
manufacturing and supply chain for COVID-19 tests due to an increase in 
cases. During this timeframe, domestic capacity was not large enough to 
produce the number of tests required to achieve this initiative. To 
avoid further straining the domestic market and to further increase 
access to free tests for the American public, the Administration made 
the decision to purchase tests from international manufacturers for the 
larger test initiative. Since the market has stabilized, the 
Administration has once again shifted to purchasing domestic tests. Our 
goal is to continue to prioritize the purchase of tests domestically, 
but we must continue to provide stability and predictability to the 
domestic market.
    Question. As of May 4, testing companies have not received 
additional volume commitments, but have been provided guidance from the 
Department to ramp up to maximum capacity. Will these domestic 
manufacturers receive a concrete order from the Department?
    Answer. As we have been saying for the past months, we need the 
additional requested funding to be able to provide ongoing support to 
domestic manufacturers in order to avoid production cuts and job 
layoffs. We have already heard from companies that they have reduced 
their production capacity by as much as 85 percent compared with 
maximum production capacity and laid off thousands of workers. We need 
the additional requested funding from Congress to avoid further 
reductions and ensure we have sufficient testing supply and capacity in 
the event of another surge.
    Question. What is the Department's plan for warm-basing domestic 
testing manufacturing?
    Answer. The ability of manufacturers to continue to produce at high 
levels requires a commitment by the Federal government. Tests purchased 
by consumers on the retail market tend to ebb and flow as cases rise 
and fall. Given this, the Federal Government serves as the only real 
backstop that can guarantee purchases for domestic manufacturers. The 
Administration will continue to emphasize the need for Congress to 
provide the requested funding for these purposes. Our inability to fund 
warm basing within domestic testing manufacturing risks us not having 
the testing capacity we need in the event of a fall or winter surge.
988 and Behavioral Health Crisis Services
    Question. The Substance Abuse and Mental Health Services 
Administration (SAMHSA) submitted the ``Report to Congress on 988 
Resources'' (Report to Congress), which was required by the National 
Suicide Hotline Designation Act of 2020, more than 8 months after it 
was due. The new three-digit lifeline is set to launch in July this 
year, and the budget requests an increase of nearly $600 million for 
fiscal year 2023. SAMHSA has known about the July 2022 launch date for 
some time, yet SAMHSA's delay puts Congress in a difficult position to 
provide a fivefold increase or else appear to shortchange this critical 
effort. Further, the fiscal year 2023 funding will not be available for 
988 for months after the launch, and that is a best case scenario.
    While the Report to Congress outlines projected annual resources to 
sustain 988, the fiscal year 2023 budget does not provide any detail as 
to how SAMHSA would allocate $696.9 million. While appreciated, the 
Report to Congress is not a budget document. Please provide a breakout 
of funding for the fiscal year 2023 request and a detailed description 
of each activity for the 988 and Behavioral Health Crisis Services, 
along with the allocation method for each activity.
    Answer. First, it is important to note that July 2022 and the 
transition to 988 and the impacts on volume are as yet unknown. SAMHSA 
is projecting resource needs based upon the best available current 
data, and will continue to provide ongoing assessments to respond to 
potential alternate scenarios. These ongoing assessments may alter 
projected resource needs outlined below.
    The fiscal year 2023 Budget Request for 988 and Behavioral Health 
Crisis Services is $696.9 million. The budget proposes an historic 
investment in the 988 program to ensure there is sufficient funding to 
support crisis response. The proposed funding will play an essential 
role in advancing the crisis system to meet the once-in-a lifetime 
opportunity of 988 by:
    Increasing crisis center capacity ($545 million): This funding will 
enhance local capacity through partnerships in behavioral health crisis 
response--Local center capacity is critical to ensuring that 
individuals in crisis receive responses that are tailored to the 
service system where they are located and that services across the 
continuum are linked and coordinated. We expect the greatest resource 
needs in supporting 988 response across the national crisis back up 
centers (Federal) and local crisis centers (combined Federal and non-
Federal). SAMHSA's budget projections are based on volume expectations 
at an $82 cost per contact and volume estimates that project 7.6 
million contacts in fiscal year 2023. Given current estimates of local 
capacity and non-Federal funding sources to support local response, 
SAMHSA expects a Federal resource need of $545 million. This funding 
shores up our crisis centers around the country to ensure that they 
have the ready workforce available to staff and answer calls, chats and 
texts for help and strengthens partnerships that decrease law 
enforcement response to individuals in crisis.
    Strengthening network operations ($117 million): As the network 
continues to scale, additional funding will be required for the 
Lifeline administrator and centralized network functions, including 
data and telephony infrastructure; standards, training, and quality 
improvement; evaluation and oversight.
    Funding will also be required to sustain and expand technology to 
promote access for marginalized populations. The fiscal year 2023 
investment further increases the capacity and performance of these key 
network infrastructure components and functions to the standard 
required for the projected contacts anticipated in fiscal year 2023 and 
support collaborative efforts with partner organizations to improve 
local routing of contacts.
    Sustaining the 988 & Behavioral Health Crisis Coordination Office 
($10 million): The 988 transition will require continued extensive 
coordination at the Federal, state, and local levels. Coordination 
activities led at a Federal level include technical assistance to 
states, and crisis centers; strategic planning, performance management, 
evaluation, and oversight; and formal partnerships, convenings, and 
cross-entity coordination.
    Supporting public awareness with targeted 988 national messaging 
($25 million): The 988 code will provide a universal, easy-to-remember, 
three-digit phone number and connect people in crisis with life- saving 
resources. As 988 is implemented, SAMHSA anticipates the need and 
additional costs to educate the public on services covered by 988, and 
the differences between 988 and 911. This funding would permit 
continuation of focused work on populations known to be at high risk of 
suicide, building upon formative research processes that were launched 
in fiscal year 22. This funding is not for a larger scale public 
awareness campaign, but is targeted, foundational work needed to 
educate the public and local communities on the function of 988.
    Question. The Report to Congress indicates that $560 million would 
be needed to strengthen local crisis call center capacity from Federal 
and non-Federal funding. How does the budget request account for non-
Federal resources? Please provide an estimate and description of non-
Federal resources.
    Answer. SAMHSA is working with its partners to track state-level 
legislative and non-legislative activity aimed at supporting local 
crisis capacity. To date, only four states have passed legislation with 
corresponding 988 state cell phone fees, including Colorado, Nevada, 
Washington, and Virginia. Other states have passed appropriation 
legislation not connected to cell phone fees, some have ordered 
commissions without any specific funding allocation, and many states 
have either legislation in progress or no current plans for legislative 
activity. Some states have also looked to Medicaid and payer 
reimbursement to support crisis center development though this is in 
very early stages in most areas. SAMHSA expects that it will take time 
for most states to develop sustainable and comprehensive mechanisms to 
support 988.
Organ Procurement and Transplantation Accountability
    Question. The HHS budget documents appear to be sending a mixed 
message with regard to the Administration's position on holding Organ 
Procurement Organizations (OPOs) accountable for poor performance. The 
fiscal year 2023 HHS Budget in Brief document includes a section called 
``Remove Restrictions on the Certification of New Entities as Organ 
Procurement Organizations and Increase Enforcement Flexibility,'' which 
proposes flexibility to recertify poor performing OPOs that lose 
certification because of failure to meet certain criteria. This 
narrative runs counter to the Final rule ``Organ Procurement 
Organizations Conditions for Coverage: Revisions to the Outcome Measure 
Requirements for Organ Procurement Organizations'' (42 CFR Part 486), 
which will bring much needed standardization to how OPOs measure 
performance and ensure all OPOs are performing at high quality 
standards. What is intended by this budget narrative and why is it 
proposed in light of the Final rule 42 CFR Part 486?
    What is the status of implementation of 42 CFR Part 486 and what 
guidance has CMS provided to OPOs regarding its implementation?
    Answer. Organ procurement organizations (OPOs) are vital partners 
in the procurement, distribution, and transplantation of human organs 
in a safe and equitable manner for all potential transplant recipients. 
The role of OPOs is critical to ensuring that the maximum possible 
number of transplantable human organs is available to individuals with 
organ failure who are on a waiting list for an organ transplant. HHS is 
dedicated to improving health equity and access in the organ 
procurement and transplantation system, including by holding OPOs 
accountable for their performance.
    In December 2020, CMS published ``Medicare and Medicaid Programs; 
Organ Procurement Organizations Conditions for Coverage: Revisions to 
the Outcome Measure Requirements for Organ Procurement Organizations''. 
This rule finalized new outcome measures OPOs are required to meet for 
re-certification and was published with the intention of increasing 
donation and organ transplantation rates by replacing the previous 
outcome measures with new transparent, reliable, and objective outcome 
measures that are used to make better certification decisions and 
incentivize better performance. At the end of the re-certification 
cycle, each OPO will be assigned a tier ranking based on its 
performance for both the donation rate and transplantation rate 
measures, as well as the re-certification survey. The highest 
performing OPOs will be assigned in Tier 1 which means the donation and 
transplantation rates of the top 25 percent of OPOs, and automatically 
recertified for another 4 years. OPOs with rates that are below the top 
25 percent will be in either Tier 2 or 3. Tier 2 OPOs are not 
automatically recertified but they will have to compete to retain their 
donation service area (DSA). Tier 3 OPOs are the lowest performing OPOs 
and will be decertified and lose their service area. CMS believes that 
increasing competition between the OPOs will incentivize them to 
maximize their performance and consequently increase the number of 
organs available for transplantation.
    OPOs will be held accountable for the new measures for 
recertification purposes in 2026. While CMS will conduct activities for 
OPO recertification in 2026, the timeline for OPOs to implement needed 
improvements occurs much earlier than 2026. OPOs will be notified of 
their performance on the new outcome measures at the end of each 12-
month period of the 4-year recertification cycle, which starts in 2022. 
OPOs will be accountable to this requirement when they receive their 
first results in the next re-certification period. The target data for 
this first report is spring of 2023. By identifying the performance of 
OPOs annually, poor performing OPOs can appropriately change and adopt 
effective practices that improve their performance in donation and make 
more organs available for transplantation.
    The President's fiscal year 2023 Budget includes a proposal that 
would certify new entities as organ procurement organizations and 
recertify certain organ procurement organizations that do not meet the 
criteria for recertification based on outcome measure performance, but 
which have shown significant improvement during a re-certification 
cycle. The proposal will provide the flexibility CMS needs to avoid 
organ procurement disruptions due to the certification status of 
certain organ procurement organizations and provide these organizations 
with an incentivize to maximize performance even if they do not believe 
they could satisfy the outcome requirements at the next 
recertification.
    Question. I was pleased to see HRSA released a Request for 
Information regarding the Organ Procurement and Transplantation Network 
(OPTN), seeking ways to improve and strengthen the OPTN ahead of the 
fiscal year 2023 Request for Proposal. Throughout the last 4 years, the 
OPTN contractor United Network for Organ Sharing (UNOS) has been 
exposed for its regional bias and inability to effectively improve the 
organ procurement and transplantation system. For example, records that 
UNOS fought vigorously to keep hidden from the public reveal UNOS 
colluded against certain regions of the country when it issued the 
liver allocation policy in December 2018. Further the National 
Academies of Science, Engineering, and Medicine (NASEM) revealed an 
astounding number of organs continue to unused, and NASEM made several 
recommendations related to the OPTN contract and HHS oversight to 
improve accountability, improve policymaking, and modernize the 
transplantation network. How is HHS planning to update the OPTN 
contract to hold the contractor accountable for system improvements?
    Will HHS break up the OPTN contract to separate the policymaking 
functions from the IT functions?
    Answer. HRSA recognizes that the Organ Procurement and 
Transplantation Network (OPTN) contract is critical to the oversight 
and accountability of the organ donation and transplantation system and 
intends to be appropriately deliberative about decisions impacting the 
effectiveness and efficiency of the system. As you note, HRSA issued a 
Request for Information (RFI) to solicit feedback about opportunities 
to strengthen the OPTN. In particular, the RFI sought feedback on the 
ways to address many of the National Academies of Science, Engineering, 
and Medicine findings and recommendations in its report titled 
Realizing the Promise of Equity in the Organ Transplantation System. 
HRSA released the RFI to better support HRSA's efforts to increase 
accountability in OPTN operations, modernize performance of the OPTN IT 
system and related tools, and improve engagement with donors and 
patients. It specifically focuses on opportunities to strengthen 
equity, access, and transparency in the organ donation, allocation, 
procurement, and transplantation process. In addition, it also sought 
stakeholder input on the governance, finance, IT, data collection, 
policy, and operational components of the OPTN. HRSA is appreciative of 
the response to the RFI and is actively reviewing this important 
feedback to inform the development of the next contracting cycle. We 
look forward to continuing to engage with Congress as we develop the 
next contracting cycle and continue to identify strategies for 
modernization and accountability across the organ procurement and 
transplantation system.
Provider Relief Fund (PRF)
    Question. Hospitals and providers that opened their doors in 2020 
and 2021 have not had equitable access to the PRF, despite experiencing 
some of the same challenges during the COVID-19 pandemic as established 
healthcare providers. What has the Administration done to ensure 
equitable access to the PRF dollars Congress provided for this subset 
of providers?
    Answer. As part of the Administration's ongoing commitment to 
equity, and to support providers with the most need, HHS included new 
elements in Phase 4 of the Provider Relief Fund (PRF). Rather than 
paying the same percentage of losses for all providers as in Phase 3, 
PRF Phase 4 reimburses smaller providers for their operating revenues 
net expenses at a higher rate compared to larger providers. That means, 
new providers who just opened their doors and have $10 million or less 
in annual patient care revenues in 2020 would receive 45 percent of 
their adjusted quarterly losses, compared to 25 percent or 10 percent 
for medium and large providers.
    In addition, HHS allocated approximately 25 percent of the $17 
billion allocation to Phase 4 Bonus payments based on the amount and 
type of services to Medicare, Medicaid, and Children's Health Insurance 
Program (CHIP) patients. HHS used a similar methodology for the $8.5 
billion in ARP Rural payments, making payments based on the amount and 
type of services provided to Medicare, Medicaid, and CHIP patients who 
live in rural areas, as defined by the Federal Office of Rural Health 
Policy. Bonus payments relied on claims submitted from January 1, 2019 
through September 30, 2020 in order to capture both pre-pandemic care, 
as well as care delivered during the pandemic. This allowed providers 
that opened their doors in the first three quarters of CY 2020 to be 
eligible for additional funds.
    Question. How many hospitals and healthcare providers opened their 
doors in 2020, 2021, or 2022? Can HHS please provide a breakout by 
provider type, year, and an estimate of the emergency relief funding 
that these providers have requested and received from the PRF?
    Answer. Attached, please find the Phase 3 and Phase 4/ARP Rural 
payments to new provider in 2020 by self-selected provider type.
    Please note, new providers in 2021 and 2022 were not eligible for 
PRF or ARP Rural payments. Furthermore, the application portals for 
Phase 3 and Phase 4/ARP Rural did not collect providers' emergency 
funding requests. The data attached are Quarterly Losses, which are 
calculated based on changes in operating revenues and expenses pre-
pandemic and COVID-19, as reported by applicants. For new providers 
where there is no comparable pre-pandemic time period, the revenue loss 
was estimated using the revenues reported by the provider and the 
average loss rate for that category of provider.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


Substance Use Harm Reduction
    Question. Thank you for your prompt response to my letter in 
February on HHS' harm reduction grant. As many in Congress were, I was 
concerned that HHS was on the precipice of providing Federal funding to 
purchase crack pipes. After the controversy that funding announcement 
stirred up, what did HHS do to ensure these grants will not go toward 
purchasing illegal drug paraphernalia, like syringes and crack pipes?
    Answer. In the Notices of Award, SAMHSA included terms and 
conditions explicitly restricting funds from directly or indirectly 
purchasing or promoting the use of drug paraphrenia, including pipes/
pipettes in safer smoking kits. Syringes to prevent and control the 
spread of infectious disease are allowed for purchase. Harm reduction 
programs that use Federal funding must adhere to Federal, state, and 
local laws, regulations, and other requirements related to such 
programs or services. A comprehensive program monitoring and oversight 
plan is being implemented to ensure that funds are not misused. Please 
see the Notice of Funding Opportunity for more information: https://
www.samhsa.gov/sites/default/files/grants/pdf/fy22-harm-reduction-
nofo.pdf.
    Question. Drug overdose trends are a cause for alarm. In my time as 
the lead Republican on this Subcommittee, we have increased funding by 
$4 billion toward addressing the opioid crisis, which suffered a 
setback during the pandemic. There's no doubt we need to continue to 
address this crisis. I'm concerned, however, with the push to expand 
overdose prevention activities and similar harm reduction activities at 
the expense of primary prevention activities. Since 2019, in a 
bipartisan manner, this Subcommittee has explicitly funded harm 
reduction activities through the Center for Substance Abuse Treatment. 
This was done to not undercut programs that are focused on primary 
prevention of substance use and to ensure people who suffer an overdose 
have access to treatment, yet SAMHSA has blatantly ignored 
Congressional intent. This willful disregard for Congressional intent 
is inexcusable and a cause for concern. Why did SAMHSA continue to fund 
the administration of ``Grants to Prevent Prescription Drug/Opioid 
Overdose,'' ``First Responder Training for Opioid Overdose Reversal 
Drugs,'' and ``Improving Access to Overdose Treatment'' out of the 
Center for Substance Abuse Prevention, after Congress specifically 
moved the programs to the Center for Substance Abuse Treatment in 2019?
    Will you work with us to make sure both the administration and 
funding for harm reduction activities align with congressional intent?
    Answer. Since 2019 and up to the present time, SAMHSA has followed 
Congressional guidance and funded PDOA, FRT, and IAOT out of CSAT. 
However, in recognition that the most effective harm reduction 
strategies are implemented across the *behavioral health continuum, 
CSAP subject matter experts have been heavily involved in the 
administration of these programs. This management approach has not been 
implemented at the expense of SAMHSA's primary prevention efforts but 
have enhanced the effectiveness of behavioral health services and 
interventions across the continuum of care.
    Unfortunately, traditional primary prevention programs are not 
always effective in preventing substance misuse and/or overdose deaths. 
CSAP programs that expand beyond primary prevention utilize data that 
targets trends and themes associated with overdose deaths and increased 
substance use. Including indicated and selective prevention activities 
such as psychosocial supports in CSAP programs is critical to 
connecting at risk individuals to support services and treatment 
services that are funded by CSAT. Funding multiple types of prevention 
programs that utilize evidence-based approaches saves lives.
SAMHSA's Behavioral Health Continuum:
    Promotion: These strategies are designed to create environments and 
conditions that support behavioral health and the ability of 
individuals to withstand challenges. Promotion strategies also 
reinforce the entire continuum of behavioral health services.
    Prevention: Delivered prior to the onset of a disorder, these 
interventions are intended to prevent or reduce the risk of developing 
a behavioral health problem, such as underage alcohol use, prescription 
drug misuse, and illicit drug use.
    Treatment: These services are for people diagnosed with a substance 
use or other behavioral health disorder.
    Maintenance: These services support individuals' success and 
include long-term treatment, continuing care, and recovery support.
    Question. It has been reported that the Biden Administration is 
considering support for safe injection sites. These sites allow drug 
users to consume illicit drugs under medical supervision and are 
against the law. The Associated Press reported in February that the 
Department of Justice is ``talking to regulators about `appropriate 
guardrails''' for such sites. What is the status of these discussions 
and is HHS or SAMHSA involved?
    What are the ``appropriate guardrails'' that are under discussion?
    Answer. SAMHSA is not involved in safe injection sites. Given the 
legal status, we have and continue to refrain from involvement.
Unaccompanied Children
    Question. In fiscal year 2021, the Department had the largest 
number of referrals of unaccompanied children ever. It spent almost $7 
billion on the program, including almost $4 billion transferred from 
funding that was supposed to be spent on COVID-19 activities. fiscal 
year 2022 referrals to date are almost 40 percent higher than they were 
at this time in fiscal year 2021, and Congress has provided $8 billion 
to care for unaccompanied children this fiscal year. However, for 
fiscal year 2023, the Administration only requested $4.9 billion in 
discretionary funding for the program. Why do you think the Department 
will be able to cut $3.1 billion in costs when referrals of UACs and 
program costs have gone up the past 2 years?
    Answer. The Administration requested a $4.9 billion discretionary 
appropriation for fiscal year 2023 as well as two mandatory 
appropriations. With the funding provided by the discretionary 
appropriation, ACF will continue to effectively care for children 
referred by the Department of Homeland Security (DHS), ensure 
facilities meet FSA standards, and work to expand post-release services 
to all children released from ORR care. The Budget also proposes 
mandatory appropriations for a contingency fund, recognizing the 
unpredictable fluctuations in program needs, and a fund for UC legal 
representation. Additionally, the number of permanent shelter beds will 
increase, reducing the amount of funding needed for more expensive 
temporary shelter beds. Approximately 75 percent of budget costs go 
directly to care for unaccompanied children (UC) in ORR shelters. Other 
services for UC such as medical care and family unification services, 
including background checks, make up approximately 20 percent of the 
budget. Administrative expenses to carry out the program total 
approximately 5 percent of the budget. The UC program will keep the 
appropriations committees apprised of changes to program costs as 
needed.
    Question. As I mentioned in my opening statement, I'm concerned 
about the impact of the termination of the Title 42 Order. Even though 
unaccompanied children have been exempted from the order since January 
2021, the Department of Homeland Security is projecting a large 
increase in illegal border crossings which will likely include 
unaccompanied children. What are your plans to handle a surge in UACs? 
Can the program support a surge at the level requested in the 
President's budget?
    If not, why wouldn't you provide Congress with a budget request 
that reflects the actual costs of the program?
    Answer. ORR will continue to care for children referred by DHS and 
ensure their safety and well-being. However, this program's costs are 
inherently unpredictable and challenging to budget for with any degree 
of certainty. Despite this uncertainty, we have an obligation to 
provide appropriate services to all unaccompanied Children.
    HHS's mission is to care for UC until they are safely released to a 
vetted sponsor or leave ORR custody following an immigration judge's 
order of removal, turn 18 years of age, or obtain legal immigration 
status in the United States. The number of children referred by DHS in 
ORR care can fluctuate, which is why ORR continuously reviews capacity 
needs throughout the year.
    These estimates are based on historic data and DHS predictions and 
consider several factors such as UC referral numbers, trends, 
projections, and COVID-19 infection rates and impact on staffing and 
bed availability. These estimates further inform program costs in real-
time and impact budget numbers accordingly.
    Because of the inherent uncertainty in the UC program, it is 
extremely challenging to fund it through the conventional annual 
appropriations process. For this reason, the 2023 Budget would 
establish a mandatory contingency fund, which would provide additional 
resources when there are unexpected surges in the number of 
unaccompanied children requiring care.
    HHS/ORR continuously plans for increases in migration. This 
includes projecting influx capacity needs, expanding bed capacity, 
adding more beds through entering into cooperative agreements with 
existing grantees, and adding new grantees to ORR's network of 
facilities. Associated program costs are included in the current budget 
proposal before the committee. ACF maintains regular dialogue with the 
appropriations committees and will continue to keep
    Members and staff apprised of changes in funding needs.
    Question. The budget proposes, again, a contingency fund for the 
UAC program. This has never been an effective way to manage the 
program, as witnessed in an fiscal year 2017 CR when the Democrats 
forced the inclusion of $200 million in funding for a contingency fund, 
its threshold trigger was set too high, and that funding was wasted. 
Knowing that, why would the Department propose a contingency fund 
again? It appears that it is simply a budget gimmick.
    Answer. We do not view the contingency fund as a gimmick. Instead, 
we view it as a reasonable way to deal with the inherent uncertainty in 
the UC program, allowing the program to have a reliable source of 
funding to activate new shelter capacity to handle unexpectedly high UC 
referrals.
    ACF analyzed the previous iteration of the contingency fund and 
designed this proposal accordingly to be more effective and 
operational. We concur that the threshold trigger in the fiscal year 
2017 CR was set too high. ORR took that miscalculation into account and 
designed the current proposal to be more efficient. Specifically, the 
fund would pay out $27 million for each increment of 500 referrals 
above a threshold of 7,500 UC referrals per a month, which is a 
historically high level of monthly referrals.
                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby
    Question. Review Choice Demonstration for Inpatient Rehabilitation 
Facility services
    The inpatient rehabilitation facility review choice demonstration, 
or IRF RCD, is slated to begin in Alabama at some point, perhaps later 
this year. What steps has HHS/CMS taken to identify qualified auditors 
who have experience caring for IRF patients, given the increased 
auditing that will occur under IRF RCD? We have about 20 rehabilitation 
hospitals and hospital-based inpatient rehabilitation units in Alabama, 
and this IRF RCD program is going to be a big challenge for them. Will 
HHS/CMS commit to collaborate with them so that the RCD doesn't become 
an overwhelming burden of paperwork and claim denials? If so, what 
actions will the Department and agency take to minimize the 
administrative burden and promote access to care?
    Answer. The proposed Inpatient Rehabilitation Facility (IRF) Review 
Choice Demonstration (RCD) would allow the agency to better understand 
the scope and causes of improper payments and work with IRFs to reduce 
documentation errors. This would allow CMS to focus on the prevention 
of improper or fraudulent IRF claims and assist in developing improved 
procedures for the identification, investigation, and prosecution of 
Medicare fraud occurring among IRFs providing services to Medicare 
beneficiaries. Additionally, the proposed IRF RCD would offer IRFs 
provisional assurance of payment and would reduce the burden of audits 
and associated appeals while protecting beneficiary access to care in a 
timely manner.
    This proposed demonstration would not create new clinical 
documentation requirements; rather, it would only require submission of 
the same information providers are currently required to maintain. IRFs 
would have flexibility as they can choose their path to demonstrate 
compliance with Medicare requirements. IRFs would initially select, for 
the first 6 months, between two review choices: 100 percent pre-claim 
review or 100 percent post payment review. Providers who select pre- 
claim review may resolve any documentation issues and resubmit their 
requests an unlimited number of times prior to submitting the claim for 
payment. IRFs that have a high pre-claim review affirmation rate or 
post payment review claim approval rate would have additional options 
from which to choose, including relief from most reviews which will 
offer providers the flexibility to choose a review option that would 
work for them based on their resources and financial needs. No matter 
which choice is selected, beneficiary access to treatment will not be 
delayed.
    To ensure consistency in operations and to eliminate potential 
contractor variation in medical review, we will ensure there is 
vigorous oversight of demonstration operations, including quality 
assurance and accuracy reviews of Medicare Administrative Contractor 
(MAC) review decisions to ensure they are reviewing in accordance with 
CMS policies. The MAC reviewers will undergo training to ensure 
consistency before beginning the reviews. The MACs involved in the 
demonstration regularly perform Medicare reviews on behalf of CMS and 
will be following all applicable statutes and regulations that are in 
effect when the demonstration is implemented. Both the MAC and CMS will 
monitor the reviewers' accuracy throughout the demonstration. In 
addition, CMS medical staff will conduct reviews on a selection of pre-
claim review requests and claims to ensure the MAC decisions are 
accurate and consistent across reviewers.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
    Question. Mr. Secretary, Congress has provided bipartisan support 
to help extend the reach of state and Federal programs to serve more 
families and improve the overall quality of care. I was pleased to 
support significant funding increases for the Child Care Development 
Block Grant and Head Start in particular in the fiscal year 2022 
omnibus. I am also a cosponsor of the Child Care and Development Block 
Grant Reauthorization Act of 2022, which would build on the bipartisan 
Child Care and Development Block Grant program to provide greater 
support to working families to afford child care.
    Can you please speak to how additional funding for CCDBG will help 
low- and middle-income families be able to continue to access and 
afford high- quality child care?
    Answer. In fiscal year 2020, the CCDF program served 1.49 million 
children and 900,300 families despite minimal or even inadequate 
funding. The number of children served has steadily declined over the 
last decade from a high of 1.7 million children in fiscal year 2010. 
Only about 15 percent of federally eligible children receive child care 
subsidies. Moreover, almost all states establish child care provider 
payment rates that fail to reimburse providers for the full cost of 
quality child care, which reduces parent choice, inhibits supply, and 
contributes to high staff turnover and low wages. In turn, states are 
forced to limit eligibility, enforce waitlists, charge unaffordable 
family co-payments, and establish payment rates that fail to reimburse 
providers for the full cost of quality child care. CCDF needs 
significantly more resources to ensure that additional families have 
access to child care, improvethe quality of care, increase wages, and 
strengthen the child care sector.
    Question. During the Senate Appropriations Subcommittee hearing on 
May 4th, you committed to fully stocking the biodefense and pandemic 
response supplies maintained by the Strategic National Stockpile. It is 
also imperative that the Stockpile is maintained with products 
manufactured in the U.S. and not depend on China as we did when COVID-
19 first arose. I'm troubled to learn that HHS has cancelled 3 
contracts to manufacture gowns for the Strategic National Stockpile in 
the past 6 months. We've also been told there are currently zero 
sterile surgical gowns in the Stockpile. However, your fiscal year 2023 
budget does note that you have a target of 265M gowns and that 
procurements are in process.
    Can you confirm for me specifically how many sterile surgical gowns 
are currently in the Strategic National Stockpile and what are your 
plans to procure additional U.S.-made sterile surgical gowns to meet 
your stated targets?
    Answer. The SNS currently holds approximately 60 million deployable 
isolation gowns.
    While SNS has made progress in building its inventory of gowns, 
holding more than 12 times the amount held at the beginning of the 
COVID-19 response, the progress has been exclusively to the inventory 
of isolation gowns rather than surgical gowns. SNS currently holds 
fewer than 1000 surgical gowns. SNS previously signaled its intention 
to procure domestically manufactured surgical gowns to help close the 
gap between current holdings and the COVID-19 target of 265 million 
gowns.
                                 ______
                                 
              Questions Submitted by Senator John Kennedy
    Question. Secretary Becerra committed to ``robust enforcement'' 
during his confirmation hearing before the Senate HELP Committee (2/23/
21) to become the Secretary of the Health and Human Services 
Department. Despite this commitment and widespread non- compliance, HHS 
has failed to meaningfully enforce the hospital price transparency 
rule.
    A recent national survey found an overwhelming bipartisan majority, 
87 percent of Americans, support the requirement for hospitals to post 
prices, and nearly 79 percent want critical measures like transparency 
in coverage to be implemented immediately without further delay.
    A comprehensive study published February 2022 by Patient Rights 
Advocate, reviewed 1,000 hospitals nationwide and found only 14.3 
percent of hospitals are compliant with the HHS rule that went into 
effect over 1 year ago.
    Mr. Secretary, first can you tell the Committee how many hospitals, 
as of today's hearing, have received warning letters and/or corrective 
action plans for non-compliance?
    Of the letters that went out to non-compliant hospitals, can you 
please tell me how many responded?
    Mr. Secretary, can you also tell me how many hospitals, who again 
have had over 15 months to comply, have been issued a civil monetary 
penalty?
    When do you expect to issue your first civil monetary penalty for 
non- compliance?
    Can you commit to this committee, Congress, and the American people 
that your Department will immediately post both compliant and non-
compliant hospitals on your website and begin issuing fines to non-
compliant hospitals?
    Answer. CMS is committed to ensuring consumers have the information 
they need to make fully informed decisions regarding their healthcare. 
Hospital price transparency helps Americans know what a hospital 
charges for the items and services they furnish.
    The hospital price transparency final rule was published in 
November 2019 and became effective January 1, 2021. The final rule 
implements section 2718(e) of the Public Health Service Act (as added 
by the Affordable Care Act) and requires each hospital, for each year, 
to establish, update, and make public a list of the hospital's standard 
charges for items and services provided by the hospital. The final rule 
superseded guidance issued by CMS in 2015 and 2019. The rule requires 
hospitals to make public five types of 'standard charges:' gross 
(chargemaster) charges, discounted cash prices, payer-specific 
negotiated charges, and the minimum and maximum de-identified 
negotiated charges.
    The final rule also specified methods by which CMS may monitor 
hospitals' compliance with the requirements, including evaluating 
complaints made to CMS, reviewing analyses sent by third parties 
regarding hospital noncompliance, and auditing hospitals' websites. 
Should CMS conclude a hospital is noncompliant with one or more of the 
requirements to make public standard charges, CMS may take any of the 
following actions, which generally, but not necessarily, will occur in 
the following order:
    (a) Provide a written warning notice to the hospital of the 
specific violation(s).
    (b) Request a corrective action plan from the hospital if its 
noncompliance constitutes a material violation of one or more 
requirements.
    (c) Impose a civil monetary penalty not in excess of $300 per day 
on the hospital and publicize the penalty on a CMS website if the 
hospital fails to respond to CMS's request to submit a corrective 
action plan or comply with the requirements of a corrective action 
plan.
    We expect hospitals to comply with these requirements and are 
enforcing these rules to make sure Americans have information regarding 
what the hospital will charge for their healthcare in advance. Prior to 
the effective date, CMS developed a dedicated hospital price 
transparency website found here: https://www.cms.gov/hospital-price-
transparency. This website includes resources to help hospitals comply 
with the rule in addition to a method for consumers to contact CMS and 
submit specific complaints related to hospital noncompliance.
    In January 2021, we began proactive audits of hospital websites as 
well as review of complaints submitted to CMS via the hospital price 
transparency website. In April 2021, we issued the first set of warning 
letters to noncompliant hospitals. These letters list specific areas of 
deficiencies identified through CMS compliance review and request 
hospital action to remedy the deficiencies. We intend to continue to 
send warning letters on a rolling basis as we identify noncompliant 
hospitals through our proactive audits and review of complaints. 
Hospitals that fail to submit a corrective action plan or comply with 
the requirements of a corrective action plan will be subject to a civil 
monetary penalty. In the event CMS issues a civil monetary penalty 
(CMP), CMS will identify the hospital and display the hospital's name 
on a CMS website.
    In November 2021, in the Hospital Outpatient Prospective Payment 
System and Ambulatory Surgical Center Payment System Final Rule (CMS-
1753FC), CMS increased the civil monetary penalties that will apply to 
noncompliant hospitals. The final rule set a minimum CMP of $300/day 
for smaller hospitals with a bed count of 30 or fewer, and a penalty of 
$10/bed/day for hospitals with a bed count greater than 30, not to 
exceed a maximum daily dollar amount of $5,500. Under this approach, 
for a full calendar year of noncompliance, the minimum total penalty 
amount would be $109,500 per hospital, and the maximum total penalty 
amount would be $2,007,500 per hospital. This approach to scaling the 
CMP amount retains the original penalty amount for small hospitals, 
increases the penalty amount for larger hospitals, and affirms the 
Administration's commitment to enforcement and public access to pricing 
information. The revised CMP policy took effect January 1, 2022.
    Question. I understand that implementing a monumental law, such as 
the No Surprises Act, takes time. To that extent, I am grateful that 
the Federal Independent Dispute Resolution (IDR) portal was officially 
opened in April. However, I am concerned as I have heard from providers 
who have thousands of claims ineligible for the IDR process. Once the 
Federal Portal was opened, providers were given 15 business days to 
submit all claims to IDR where the 30-business day, post Open 
Negotiation limit had expired. However, this extension does not apply 
to claims where no Open Negotiation was initiated. This is worrisome as 
I have heard from providers who did not submit claims for Open 
Negotiation, as the portal was not open to file for IDR within the 
required 4 days.
    Would the Department of Health and Human Services (HHS) be willing 
to open a 30-day window for reconsideration of all claims between 
January 1, 2022 and April 14, 2022, allowing providers to initiate Open 
Negotiations now that the Federal IDR portal has been established?
    Answer. The Federal Independent Dispute Resolution (IDR) system 
went live on April 15, 2022, and CMS has posted operational guidance 
for providers and plans on the CMS No Surprises Act website. As 
described in regulations and operational guidance, a 30-day open 
negotiation period may begin after a provider or facility receives a 
payment or denial notice from a health plan or issuer for applicable 
out-of-network services. At the end of the 30-day open negotiation 
period, if the health plan or issuer and provider or facility haven't 
agreed on a payment amount, either party can submit the item(s) or 
service(s) for review in the IDR process. If the disputing parties 
experience extenuating circumstances during the IDR process that 
prohibit them from complying with deadlines to submit information, they 
may email the Departments at: [email protected] and 
include the IDR dispute reference number, if known, to receive a 
Request for Extension Due to Extenuating Circumstances form and 
instructions for next steps. Consumers, providers, facilities, plans, 
issuers, and FEHB carriers with questions about the No Surprises Act 
can call the No Surprises Help Desk at 1-800-985-3059.
    Question. According to the No Surprises Act Interim Final Rules, 
insurers must provide an email and physical address to submit Open 
Negotiations. However, I have heard from many providers that insurers 
are inhibiting the flow of claims information by creating unnecessary 
steps for providers who wish to exchange information on claims and 
submit open negotiations, such as by withholding the required contact 
information, withholding information on payment remittances, or by 
requiring providers to register with various websites.
    Will there be proper oversight to ensure these obstructive 
practices are not occurring, and that proper transparency, as required 
by law, is taking effect? What will the Administration to do prohibit 
these burdensome hurdles impacting Open Negotiations?
    Answer. HHS--together with our colleagues at the Department of 
Labor, Department of the Treasury, and Office of Personnel Management--
has been working to implement the No Surprises Act (NSA) and ensure 
that consumers receive the benefits of the protections included in the 
law by Congress. We have released regulations and guidance for 
providers, group health plans, health insurance issuers, and FEHB 
carriers that explain the requirements related to the processing of 
claims and the open negotiation process. We will continue to work to 
provide additional training and technical assistance to help 
stakeholders understand their obligations and comply with key 
requirements of the NSA.
    We are committed to ensuring compliance with the requirements of 
the NSA and its implementing regulations. If you are hearing from 
providers or plans about issues regarding compliance with the 
requirements of the NSA, they should submit a complaint to the No 
Surprises Help Desk at https://www.cms.gov/nosurprises/consumers/
complaints-about-medical-billing or by calling 1-800-985-3059.
    Question. It was clear that the No Surprises Act was intended to 
force providers and insurers to move in-network, avoiding the IDR 
process altogether, creating a smoother process for all parties 
involved. I am concerned, because in reality, everything I was afraid 
of happening, is. I have heard from various providers that insurers are 
using the No Surprises Act as leverage to cut in-network provider 
contracts in half during negotiations. Others who have established the 
necessary amount of contracts to establish a ``Median In-Network'' rate 
are sending providers notices stating their networks are ``closed'' to 
additional providers.
    How is HHS addressing the issue of narrowing of networks and these 
predatory practices?
    Answer. Under CMS's Notice of Benefit and Payment Parameters for 
2023 Final Rule, CMS finalized regulatory changes in the individual and 
small group health insurance markets and establishes parameters and 
requirements issuers need to design plans and set rates for the 2023 
plan year. The rule also includes regulatory standards to help states, 
the Marketplaces, and health insurance companies in the individual and 
small group markets better serve consumers.
    Under the final rule, CMS finalized changes to ensure that patients 
have access to the right provider, at the right time, in an accessible 
location. The rule requires qualified health plans (QHPs) on the 
federally-facilitated Marketplaces (FFMs) to ensure that certain 
classes of providers are available within required time and distance 
parameters. For example, a QHP on the FFMs will be required to ensure 
that its provider network includes a primary care provider within ten 
minutes and five miles for enrollees in a large metro county. The rule 
also sets a standard, starting in the 2024 plan year, requiring QHPs on 
the FFMs to ensure that providers meet minimum appointment wait time 
standards. For example, QHPs will be required to ensure that routine 
primary care appointments are available within 15 business days of an 
enrollee's request. Additionally, HHS will review additional 
specialties for time (i.e., the time it takes the enrollee to get an 
appointment) and distance (i.e., the distance between the provider and 
enrollee)--including emergency medicine, outpatient clinical behavioral 
health, pediatric primary care, and urgent care. OB/GYN parameters will 
also be aligned with the parameters for primary care.
    Additionally, Section 109 of Title I of Division BB of the 
Consolidated Appropriations Act, 2021, requires HHS, in consultation 
with the Federal Trade Commission and the Attorney General, to conduct 
a study of the effects of the No Surprises Act on market concentration, 
healthcare costs, and access. The first report is due no later than 
January 1, 2023, and four additional reports shall study the effects of 
the Act in the four subsequent years.
    Question. I understand that medical procedures account for 96 
percent of all human exposure to man- made radiation. This can result 
in severe burns, cataracts, cognitive dysfunction, immunosuppression, 
and even cancer--in patients and clinicians. While the CDC embraces the 
guiding principle for radiation safety of ``as low as reasonably 
achievable,'' or ``ALARA'', it is not aligned with current medical 
procedures; increased use of high- radiation procedures like 
fluoroscopy to place stents; extensive clinical data on the dangers of 
radiation exposure and need for utilizing better precautions; and the 
latest shielding technologies that can prevent this excessive, 
avoidable radiation exposure.
    How can we address this with appropriate guidance communicated 
effectively to providers to prevent harm to them and their patients, 
especially regarding simple changes like appropriate radiation 
shielding?
    Answer. Keeping in mind the diagnostic and potentially life-saving 
value that these procedures provide to the public, the principles of 
justification and optimization are essential to the practice of 
radiation medicine. Are the diagnostic procedures indicated or 
warranted (justification), and if so, are the procedures of high 
quality to gain the needed diagnostic information with minimal dose 
(optimization)? CDC sponsored the National Council on Radiation 
Protection and Measurements (NCRP) to conduct the most recent estimate 
of radiation doses to the U.S. population. This NCRP study provided an 
update to the earlier estimate in 2009 that indicated the sharp 
increase in average dose to the U.S. population due to the evolving 
technology and use of these diagnostic tools.
                                 ______
                                 
               Questions Submitted by Senator Hyde-Smith
    Question. Local pharmacies and pharmacists have long been a trusted 
and vital part of our local healthcare community. 9 in 10 Americans 
live within 5 miles of a pharmacy, and many of those Americans have 
come to rely on their pharmacy during the pandemic to provide vital 
access to COVID-related services, including testing, vaccinations, and 
treatments. Pharmacists were central to combating COVID-19, providing 
more than 245 million vaccine doses and millions of tests across 
20,000+ pharmacies nationwide. However, CMS treats pharmacists 
differently than other healthcare professionals when it comes to 
providing these services, and, ultimately, CMS does not have the 
necessary payment structure to appropriately reimburse pharmacists for 
these services.
    Secretary Becerra, can you please elaborate on the efforts CMS has 
taken to expand pharmacist provider status/reimbursement during the 
COVID-19 PHE, and clarify which flexibilities granted to pharmacists 
can and will be extended beyond the PHE? Specifically, how will 
pharmacists receive reimbursement for COVID-19 tests and vaccine 
administration after the PHE?
    Answer. Pharmacists are essential parts of our healthcare system 
and are playing an important role in the response to the COVID-19 
public health emergency. Pharmacists may perform certain tests if they 
are enrolled in Medicare as a laboratory, in accordance with a 
pharmacist's scope of practice and state law. In addition, pharmacists 
can enroll as mass immunizers and bill Medicare for administering Part 
B vaccines.
    We have explicitly clarified that pharmacists fall within the 
regulatory definition of auxiliary personnel under our regulations. As 
such, pharmacists may provide services incident to the professional 
services and under the appropriate level of supervision of the billing 
physician or practitioner, if payment for the services is not made 
under the Medicare Part D benefit. This includes providing the services 
incident to the services of the billing physician or practitioner and 
in accordance with the pharmacist's state scope of practice and 
applicable state law.
    Question. 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 
$3.5 million, despite the tremendous cost of CKD to society, Medicare, 
and Medicaid. We must increase awareness and early detection of kidney 
disease via a national kidney disease awareness public health 
initiative, which the CKD Initiative at CDC is poised to do with proper 
funding and community partnership.
    Please comment on efforts to expand the Chronic Kidney Disease 
Initiative to meet this awareness and early detection need.
    Answer. The Chronic Kidney Disease (CKD) Initiative currently 
conducts several activities to promote kidney health, including 
collaborating with partners to support and enhance the CKD Surveillance 
System. This system tracks kidney disease and its risk factors over 
time and monitors progress in prevention, detection, and management.
    The CKD initiative works to:
  --Increase public awareness of CKD, its risk factors, and 
        complications through scientific publications, provider 
        resources, featured articles, and other educational resources.
  --Promote early diagnosis and treatment of CKD by
    --Encouraging providers to use the CKD e-phenotype to detect CKD in 
            people early on, help manage CKD, and help reduce CKD-
            related complications such as heart disease and kidney 
            failure.
    --Publishing on the state-level awareness of CKD in the U.S.
    --Sharing information for the public on prevention and risk 
            management, and how to take care of your kidneys.
  --Conduct surveillance, epidemiology, health outcomes, and economic 
        studies in partnership with other offices at CDC, other 
        government agencies, universities, and national organizations.
    CDC is committed to the CKD Initiative, and its important work has 
been highlighted in HHS' Advancing American Kidney Health Initiative. 
In the fiscal year 2022 Omnibus, the CKD Initiative received an 
increase of $1 million dollars from fiscal year 2021 funding (total of 
$3.5 million). While continuing the current work of the CKD Initiative, 
CDC is using the funding increase to:
  --Study the effects of youth-onset type 2 diabetes on kidney 
        structure, function, and complications to identify novel and 
        specific targets for CKD prevention and treatment.
  --Update the CKD cost effectiveness studies to include new data, 
        treatments, and numerous advances in our understanding of CKD 
        and its causes, progression, and treatment.
  --Expand the analytical capacity of the CKD Surveillance System, 
        including analysis of large datasets and incorporating new 
        indicators of the social determinants of health and CKD 
        morbidity at the national, state, and county levels.
  --Examine trends in incidence of end stage kidney disease, diabetes 
        complications, and impact on high-risk populations.
    Question. There have been recent positive changes to clinical 
practice in the diagnosis of kidney disease, namely the adoption of new 
equations for estimating GFR that do not include race as a modifier.
    What else is NIDDK doing to elevate kidney-specific research and 
interventions to eliminate racial and ethnic disparities in kidney 
care? Specifically, can you comment on investments in research 
initiatives that bridge existing deficits in CKD management and 
treatments to reduce incidence and progression, increase the number of 
CKD clinical trials related to kidney disease (including efforts to 
enhance participation of under- represented populations), identify 
strategies to improve the delivery of evidenced-base care in under-
represented populations, and address issues related to kidney patients' 
quality of life?
    Answer. Addressing disparities in kidney disease outcomes is a 
major research priority for the National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK). Recognizing that new approaches 
are needed, the Institute held a workshop in February 2022 aimed at 
helping design interventions to address structural racism in kidney 
health disparities. An important outcome of this effort is a 
forthcoming initiative, recently approved by the NIDDK's Advisory 
Council, inviting clinical trials to develop and implement these and 
other interventions in hopes of providing new, evidence-based solutions 
to overcome disparities in chronic kidney disease and end stage renal 
disease (also known as ESRD or kidney failure) care and outcomes.
    The NIDDK is also determined to improve care and reduce disparities 
in management of advanced kidney disease. For example, ESRD 
disproportionately affects African Americans and can severely affect 
quality of life, particularly for the roughly half of ESRD patients who 
experience severe pain. The Hemodialysis Pain Reduction Effort (HOPE) 
clinical trial is exploring non-opioid methods of pain management and 
improving quality of life, with a focus on heavily affected 
communities. The trial is engaging participants as partners in the 
research process and study management to strengthen the science--
efforts that have also helped accelerate recruitment of new 
participants.
    A variation in the APOL1 gene that is more common in people of 
African descent than in other populations is one factor accounting for 
kidney disease disparities among African Americans. However, it is not 
yet well understood how APOL1 variation might affect outcomes for 
kidney donors or recipients. The APOL1 Long-term Kidney Transplantation 
Outcomes Consortium is currently addressing these vital questions, 
while employing a ground-breaking patient-engagement effort that served 
as a model for HOPE and other studies. Another factor that worsens 
disparities in outcomes for people with ESRD is the relative lack of 
access to transplanted kidneys for communities of color. The NIDDK and 
the Patient Centered Outcomes Research Institute are therefore working 
together to fund the System Interventions to Achieve Early and 
Equitable Transplants (STEPS) Study, an intervention designed to 
improve access to transplantation for African Americans through 
healthcare system change.
    Question. Studies indicate that we could have over one million 
people in kidney failure and need a transplant by 2030. Yet, each year, 
thousands of recovered kidneys go un-transplanted, while every day, 12 
people die waiting for a kidney transplant. Recently there has been 
additional scrutiny into our organ procurement and transplantation 
system, yet no major policy proposals have been announced to improve 
this appalling failure of care. Organ Procurement Organizations are the 
sole stakeholders in the transplant ecosystem responsible for 
recovering and transporting deceased organs without legitimate 
oversight and accountability to ensure quality assurance and 
performance improvement. Transplant centers desperately need financial 
incentives to accept less than perfect kidneys and care for complex 
transplant patients. People of color and underserved communities face 
numerous hurdles in being referred for a transplant evaluation.
    What is HHS planning to do to reduce organ discards, improve 
transplantation, and minimize racial and ethnic disparities in 
transplantation access?
    Answer. Organ procurement organizations (OPOs) are vital partners 
in the procurement, distribution, and transplantation of human organs 
in a safe and equitable manner for all potential transplant recipients. 
The role of OPOs is critical to ensuring that the maximum possible 
number of transplantable human organs is available to individuals with 
organ failure who are on a waiting list for an organ transplant. HHS is 
dedicated to improving health equity and access in the organ 
procurement and transplantation system, including by holding OPOs 
accountable for their performance.
    In December 2020, CMS published ``Medicare and Medicaid Programs; 
Organ Procurement Organizations Conditions for Coverage: Revisions to 
the Outcome Measure Requirements for Organ Procurement Organizations''. 
This rule finalized new outcome measures OPOs are required to meet for 
re-certification and was published with the intention of increasing 
donation and organ transplantation rates by replacing the previous 
outcome measures with new transparent, reliable, and objective outcome 
measures that are used to make better certification decisions and 
incentivize better performance. The revised measure will encourage OPOs 
to pursue all potential donors, even those who are only able to donate 
one organ. CMS estimates that if every OPO were to meet or exceed this 
measure, we could have approximately 5,600 more organs per year to 
transplant.
    HRSA is committed to an equitable and timely organ donation and 
transplant system. This spring, HRSA issued a Request for Information 
(RFI) to solicit feedback about opportunities to strengthen the Organ 
Procurement and Transplantation Network (OPTN). In particular, the RFI 
sought feedback on the ways to address many of the National Academies 
of Science, Engineering, and Medicine findings and recommendations in 
its report titled Realizing the Promise of Equity in the Organ 
Transplantation System. HRSA released the RFI to better support HRSA's 
efforts to increase accountability in OPTN operations, modernize 
performance of the OPTN IT system and related tools, and improve 
engagement with donors and patients. It specifically focuses on 
opportunities to strengthen equity, access, and transparency. HRSA is 
appreciative of the response to the RFI and is actively reviewing this 
important feedback to inform the development of the next contracting 
cycle. We look forward to continuing to engage with Congress as we 
develop the next contracting cycle and continue to identify strategies 
for modernization and accountability across the organ procurement and 
transplantation system. In addition, HRSA is collaboratively working 
with its CMS colleagues on an End Stage Renal Disease Treatment 
Learning Collaborative (ETCLC) project designed to capture and share 
best practices and processes to increase transplants and reduce 
discards. The ETCLC focuses on kidney transplants, which make up 
approximately 85 percent of the total waiting list. Improvements in 
this area will have a broad impact on the system. HRSA is committed to 
the critical work of continuously improving the organ donation and 
transplantation system, and looks forward to continuing to work with 
you on this issue.
                                 ______
                                 
              Questions Submitted by Senator Patrick Leahy
    Question. Due to a long-standing Federal policy known as the 
`institutes of mental disease' (IMD) exclusion, states are prohibited 
from claiming Federal Medicaid funds for in-patient mental health 
services delivered to eligible individuals residing in hospitals or 
institutions of more than 16 beds. While the exclusion was originally 
intended to ensure that maintained primary financial responsibility for 
inpatient psychiatric care and reduce the Federal cost share, it has no 
clinical rationale and inhibits access to critical services for 
Medicaid beneficiaries. This includes individuals suffering from 
substance use disorders, which has hit an all-time high during the 
COVID-19 pandemic. Many states such as Vermont are facing a critical 
shortage to appropriate and timely mental healthcare that results from 
a lack of funding for in-patient psychiatric beds.
    What would be the fiscal cost over 10 years to repealing the IMD 
exclusion?
    How can Congress work with the agency to overcome the barriers 
caused by the IMD exclusion and increase access to much needed in-
patient mental health treatment?
    Concurrently, how will the President's budget be used to 
incentivize and help states develop and provide community-based 
services for individuals suffering from mental health disorders?
    Answer. The Biden-Harris Administration is committed to expanding 
access to affordable care, including inpatient psychiatric and 
substance use disorder care when appropriate. While the Medicaid 
statute prohibits states from receiving Federal financial participation 
for services delivered to most individuals residing in an IMD, CMS has 
worked within the confines of the law to provide states with 
flexibility to increase access to these services. For example, CMS has 
approved Medicaid section 1115 demonstrations that allow state Medicaid 
programs to pay for services provided to adults with serious mental 
illness/serious emotional disturbance or substance use disorder who are 
short-term residents in an institution for mental disease (IMD). 
Similarly, managed care organizations (MCOs) are permitted to reimburse 
up to 15 days per month of treatment in IMDs as an in-lieu of service--
that is, a service that is not included under the state plan, but is a 
clinically appropriate, cost-effective substitution for a similar, 
covered service.
    When appropriate, the Biden-Harris Administration also supports 
strengthening home and community-based services (HCBS) as an 
alternative to institutionalized care, in order to ensure that people 
have access to safe options that work for them. People are happier and 
healthier when they live in their community, and living in one's own 
home and community usually costs less than care in an institution. The 
department is working hand-in-hand with states to ensure they have the 
time and support they need to strengthen their home care systems. HHS 
recognizes the importance of HCBS which allow millions of Medicaid 
beneficiaries to receive services in their own home or community rather 
than institutions or other isolated settings. HHS looks forward to 
working with Congress to improve this access.
    Question. The COVID-19 pandemic has exacerbated a youth mental 
health crisis in our country. A recent NIH-funded study revealed that 
since the start of the pandemic, there has been an increase in the 
number of suicides among youth 10-to-19 years of age. In the past year, 
nearly 200 Vermont children have sought care for mental health related 
issues at emergency rooms. Many of these children had to wait an 
average of over 24 hours before they were seen for care. Rural states 
like Vermont also face significant barriers to meeting the demand for 
mental healthcare, the most prevalent being the shortage of behavioral 
healthcare clinicians. I strongly support proposed investments in 
school-based mental healthcare, early childhood intervention, community 
mental health centers, and the 988 suicide prevention and crisis 
support line to start to address these issues.
    How will the agency use the proposed investments for youth mental 
health to ensure that rural areas can adequately train, recruit and 
retain behavioral healthcare providers that are pediatric specialists?
    Answer. SAMHSA oversees multiple grant programs that support 
training pediatric behavioral healthcare providers.
    SAMHSA's Infant and Early Childhood Mental Health grant program 
helps to address the national shortage of mental health professionals 
with infant and early childhood expertise by training early childhood 
providers and clinicians to identify and treat behavioral health 
disorders of early childhood. In fiscal year 2021, grantees trained 
4,003 clinicians and early childhood providers on evidence-based mental 
health treatments for infants and young children. The Mental Health 
Awareness Training grant program trains individuals, including primary 
care and specialty healthcare providers, how to respond to individuals 
with mental disorders appropriately and safely. The Certified Community 
Behavioral Health Clinic Improvement and Advancement grant program 
includes a staff training requirement as part of the overarching goal 
of enhancing and improving community behavioral health systems.
    SAMHSA also supports technical assistance centers that provide, 
among other things, training to pediatric healthcare providers. These 
centers include the Suicide Prevention Resource Center, National Child 
Traumatic Stress Network, and Mental Health Technology Transfer Center 
Network.
    To strengthen the mental health and substance use disorder 
workforce, the fiscal year 2023 budget provides an investment of $397 
million for HRSA's Behavioral Health Workforce Development Programs, 
which is $235 million above fiscal year 2022 enacted level. This 
funding will increase training of new behavioral health providers, 
including a track for health support workers such as peer support 
specialists and community health workers and place an emphasis on team-
based care. In order to promote inclusive and equitable behavioral 
healthcare for youth, this investment will support a special focus on 
the knowledge and understanding of children, adolescents, and youth at 
risk for a mental health disorder, Serious Emotional Disturbance, or 
substance use disorder. The Behavioral Health Workforce Development 
Programs includes $225.8 for Behavioral Health Workforce Education and 
Training (BHWET) Programs. In fiscal year 2023, the BHWET Programs seek 
to establish and expand field placements, internships, and experiential 
sites for behavioral health professionals and paraprofessionals to 
train, especially among children- and youth-focused community-based 
partners who are able to conduct trainings in school-based settings. A 
special focus is placed on the knowledge and understanding of children, 
adolescents, and transitional-aged youth at risk for a mental health 
disorder, Serious Emotional Disturbance (SED), and/or substance use 
disorder.
    The Budget also includes increases in Primary Care Training and 
Enhancement and Nurse Education, Practice and Retention to expand 
behavioral health services into primary care.
    In fiscal year 2022, HRSA received $5 million for a pediatric 
specialty loan repayment program under which participants will be 
employed full-time for a specified period, of not less than 2 years, in 
providing pediatric medical subspecialty, pediatric surgical specialty, 
or child and adolescent mental and behavioral healthcare, including 
substance use disorder prevention and treatment services. Program 
participants will be required to work in, or for a provider serving, a 
health professional shortage area or medically underserved area, or to 
serve a medically underserved population.
    The fiscal year 2023 President's Budget proposes $10 million for 
the Pediatric Mental Health Care Access (PMHCA) program, which has 
played an important role in helping to increase access to specialized 
mental health providers and build provider capacity for children in 
rural areas. The PMHCA program promotes behavioral health integration 
in pediatric primary care through new or expanded statewide or regional 
pediatric mental healthcare telehealth programs. These networks of 
specialized pediatric mental healthcare teams provide tele-
consultation, training, technical assistance, and care coordination to 
assist pediatric primary care providers.
    Through the PMHCA Program, pediatric primary care providers are 
able to diagnose, treat and refer children to the care they need for 
behavioral health concerns. Telehealth technologies promote long-
distance clinical healthcare, clinical consultation, and patient and 
provider education, helping address challenges in accessing behavioral 
health clinicians who treat behavioral concerns in children and 
adolescents.
    The number of primary care providers enrolled in the PMHCA Program 
increased from 1,963 in fiscal year 2019 to 4,511 in fiscal year 2020. 
Authorization for the PMHCA program expires at the conclusion of fiscal 
year 2022.
    In addition, the fiscal year 2023 President's Budget includes $57.3 
million, a $3 million increase over fiscal year 2022 enacted, for 
HRSA's Autism and other Developmental Disorders program. Among other 
programs, this investment supports the Developmental-Behavioral 
Pediatrics Training Program (DBP) that trains Fellows in developmental 
behavioral pediatrics to address the broad range of behavioral, 
psychosocial, and developmental concerns that pediatric primary care 
providers see. The program also supports practitioners' ability to 
provide proven interventions to children's behavioral and developmental 
concerns, including for individuals with autism spectrum disorder and 
other developmental disabilities. In fiscal year 2020, the DBP Training 
Program trained over 1,400 DBP Fellows, medical students and pediatric 
residents. DBP graduate survey results show that 5 years following 
completion of the program, 100 percent of DBP Fellows demonstrated 
leadership, worked in an interdisciplinary manner, and worked with 
maternal and child health populations, including those considered to be 
underserved. The proposed fiscal year 2023 increase will help support 
the DBP program, as well as the Leadership Education in 
Neurodevelopmental and Other Related Disabilities (LEND) Training 
program to address unmet needs and disparities in evaluation, 
diagnosis, and treatment. For DBP, funding will allow expansion of the 
DBP program including increased fellowship opportunities for existing 
awardees.
    Finally, the fiscal year 2023 President's Budget supports the Child 
and Adolescent Health Promotion Services Program, referred to as the 
Bright Futures Program. This program supports quality health promotion 
and preventive services for all children, adolescents, and young adults 
through evidence-driven, strengths-based clinical guidance. This 
includes the Periodicity Schedule of the Bright Futures Recommendations 
for Pediatric Preventive Health Care (``Periodicity Schedule''), which 
includes preventive services that group health plans and health 
insurance issuers must cover without cost sharing. The Periodicity 
Schedule recommends several mental and behavioral health screenings be 
conducted during well visits. This program serves providers across the 
country, including those in Health Provider Shortage Areas (HPSA), 
Medically Underserved Areas (MUA), and providers who serve patients 
from historically marginalized backgrounds.
    Question. Vermont, like many other states, is currently facing a 
severe nursing shortage. The State has forecasted 6,244 vaccines within 
the nursing professions within the next 2 years, largely caused by an 
aging workforce and mental burnout that has been accelerated by the 
COVID-19 pandemic. There is also an inadequate number of nursing 
educators to train the next generation of nurses.
    How can HHS help states to build and bolster resilient nursing 
pipelines and nurse training programs?
    Answer. CDC makes essential workforce and training resources 
accessible across the globe through the Department of Health and Human 
Services, CDC, and state and local health departments. CDC's 
fellowships are a pathway for training and recruiting the next 
generation of public health leaders, including nurses.
    With short-term ARP funds, CDC is working with the Corporation for 
National and Community Service (CNCS) to place members onsite at public 
health departments to help meet current staffing needs for the COVID 
response. This is one component of a longer-term program to support 
ongoing public health staffing needs and future surge staffing needs 
for emergencies. While meeting immediate staffing needs, the Public 
Health AmeriCorps, established jointly between CNCS and CDC will also 
include a goal of creating a pathway of entry level, future public 
health professionals, including nurses. The joint venture between 
AmeriCorps and the CDC received 122 applications representing community 
organizations from 41 of 50 states. Funding decisions and notices of 
awards from AmeriCorps were released in April 2022. For more 
information: https://americorps.gov/newsroom/press-release/americorps-
cdc-award-more-60-million-public-health-americorps-programs-part.
    CDC is providing $3 billion in grants to state, territorial, and 
local jurisdictions. CDC plans has posted the notice of funding 
opportunity, and awards will be made in 2023. Funding will support 
hiring, retention and training of public health workers, particularly 
from the communities they are intended to serve, and will permit the 
funding of a broad range of public health workers, including nurses and 
public health nurses and other community health professionals.
    The nursing pipeline is supported and enhanced through HRSA 
programs:
  --The Nurse Corps Scholarship and Loan Repayment Programs assist in 
        the recruitment and retention of nurses while reducing the 
        financial barrier to nursing for all levels of professional 
        nursing students and increase the pipeline of nurses by 
        supporting nurses and nursing students committed to working in 
        communities with high need. Additionally, the Nurse Corps 
        program supports nurse faculty who will train the next 
        generation of nurses. In fiscal year 2023, HRSA anticipates 
        funding scholarship and loan repayment awards.
  --Another challenge for advancing and growing the nursing field is 
        recruitment and training of nurse faculty. To address this 
        issue, in fiscal year 2023, HRSA will also support the Nurse 
        Faculty Loan Program (NFLP), which provides funding to 
        accredited schools of nursing to establish and operate a 
        student loan fund and provide loans to students enrolled in 
        advanced education nursing degree programs who are committed to 
        becoming nurse faculty. In exchange for completion of up to 4 
        years of post-graduation full-time nurse faculty employment in 
        an accredited school of nursing, the program authorizes 
        cancelation of up to 85 percent of the student loan.
  --An additional area of focus in our nursing work is recruiting and 
        training nurses who are underrepresented in the nursing 
        profession. The Nursing Workforce Diversity (NWD) Program 
        supports nurse training for individuals from disadvantaged 
        backgrounds (including racial and ethnic minorities 
        underrepresented among registered nurses).
  --The fiscal year 2023 Budget Request also would support the Advanced 
        Nurse Education Program at $105.6 million, $20 million above 
        the fiscal year 2022 enacted level. The Budget includes an 
        increase of $20 million for grants to grow and diversify the 
        maternal and perinatal health nursing workforce by increasing 
        and diversifying the number of Certified Nurse Midwives with a 
        focus on practitioners working in rural and underserved 
        communities.
  --The Scholarships for Disadvantaged Students (SDS) Program dedicates 
        16 percent of its total budget to providing scholarships to 
        educate and train bachelor and graduate-level nurses and nurse 
        midwives from disadvantaged backgrounds to address nursing 
        shortages in rural and underserved communities. The SDS Program 
        currently funds 25 bachelor and graduate-level nursing schools 
        across the United States and its territories.

                          SUBCOMMITTEE RECESS

    Senator Murray. The committee will next meet in Dirksen 
138, Wednesday, May 17, at 10 a.m. for a hearing on the Biden 
Administration's budget request for the National Institutes of 
Health. The committee is adjourned.
    [Whereupon, at 11:10 a.m., Wednesday, May 4, the 
subcommittee was recessed, to reconvene at 10 a.m., Wednesday, 
May 17.]