[Senate Hearing 117-341]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 117-341

                    NOMINATIONS OF ANDREA JOAN PALM 
                       AND CHIQUITA BROOKS-LaSURE


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

                                HEARING

                               before the

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                                 on the

                             NOMINATIONS OF

  ANDREA JOAN PALM, TO BE DEPUTY SECRETARY, DEPARTMENT OF HEALTH AND 
   HUMAN SERVICES; AND CHIQUITA BROOKS-LaSURE, TO BE ADMINISTRATOR, 
               CENTERS FOR MEDICARE AND MEDICAID SERVICES

                               __________

                             APRIL 15, 2021

                               __________







 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




				                                         
                                     

            Printed for the use of the Committee on Finance
                             _________
                              
                 U.S. GOVERNMENT PUBLISHING OFFICE
                 
48-327                   WASHINGTON : 2022























                          COMMITTEE ON FINANCE

                      RON WYDEN, Oregon, Chairman

DEBBIE STABENOW, Michigan            MIKE CRAPO, Idaho
MARIA CANTWELL, Washington           CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey          JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware           JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland         RICHARD BURR, North Carolina
SHERROD BROWN, Ohio                  ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado          PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania   TIM SCOTT, South Carolina
MARK R. WARNER, Virginia             BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island     JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire         STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada       TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts      BEN SASSE, Nebraska
                                     JOHN BARRASSO, Wyoming

                    Joshua Sheinkman, Staff Director

                Gregg Richard, Republican Staff Director

                                  (ii)





















                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee 
  on Finance.....................................................     1
Crapo, Hon. Mike, a U.S. Senator from Idaho......................     3
Menendez, Hon. Robert, a U.S. Senator from New Jersey............     6

                         CONGRESSIONAL WITNESS

Baldwin, Hon. Tammy, a U.S. Senator from Wisconsin...............     5

                        ADMINISTRATION NOMINEES

Palm, Andrea Joan, nominated to be Deputy Secretary, Department 
  of Health and Human Services, Washington, DC...................     7
Brooks-LaSure, Chiquita, nominated to be Administrator, Centers 
  for Medicare and Medicaid Services, Department of Health and 
  Human Services, Washington, DC.................................     9

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Baldwin, Hon. Tammy:
    Testimony....................................................     5
Brooks-LaSure, Chiquita:
    Testimony....................................................     9
    Prepared statement...........................................    49
    Biographical information.....................................    50
    Responses to questions from committee members................    59
Crapo, Hon. Mike:
    Opening statement............................................     3
    Prepared statement...........................................   103
Menendez, Hon. Robert:
    Opening statement............................................     6
Palm, Andrea Joan:
    Testimony....................................................     7
    Prepared statement...........................................   104
    Biographical information.....................................   105
    Responses to questions from committee members................   113
Wyden, Hon. Ron:
    Opening statement............................................     1
    Prepared statement with attachments..........................   137

                                 (iii)

 
                    NOMINATIONS OF ANDREA JOAN PALM, 
                 TO BE DEPUTY SECRETARY, DEPARTMENT OF 
                     HEALTH AND HUMAN SERVICES; AND 
                     CHIQUITA BROOKS-LaSURE, TO BE 
       ADMINISTRATOR, CENTERS FOR MEDICARE AND MEDICAID SERVICES 

                              ----------                              


                        THURSDAY, APRIL 15, 2021

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 9:30 a.m., 
via Webex, in the Dirksen Senate Office Building, Hon. Ron 
Wyden (chairman of the committee) presiding.
    Present: Senators Stabenow, Cantwell, Menendez, Carper, 
Cardin, Brown, Bennet, Casey, Warner, Whitehouse, Hassan, 
Cortez Masto, Warren, Crapo, Grassley, Cornyn, Thune, Cassidy, 
and Daines.
    Also present: Democratic staff: Michael Evans, Deputy Staff 
Director and Chief Counsel; Ian Nicholson, Investigative and 
Nominations Advisor; and Joshua Sheinkman, Staff Director. 
Republican staff: Kellie McConnell, Health Policy Director; and 
Gregg Richard, Staff Director.

   OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM 
             OREGON, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The Finance Committee will come to order. 
Today, the committee meets to discuss two important health-care 
nominations. Chiquita Brooks-LaSure has been nominated to serve 
as Administrator for the Centers for Medicare and Medicaid 
Services, and Andrea Palm is nominated to serve as Deputy 
Secretary of the Department of Health and Human Services.
    Ms. Brooks-LaSure has served at OMB, on the staff at Ways 
and Means, at the Department of Health and Human Services, and 
she has worked in the private sector. She helped craft policies 
bringing down costs for older people. She helped to develop and 
pass key portions of the Affordable Care Act. She helped 
implement the law, and she worked hard to make sure that 
middle-class families shopping for private health options would 
get a fair shake thanks to strong consumer protections.
    Now, the Trump administration later undermined a lot of 
those protections, and that has created a host of new 
challenges for the committee and for the Biden administration.
    Ms. Brooks-LaSure is also very well-versed in Medicaid 
policy, which is a hugely important part of this committee's 
responsibility. She has worked closely with the Federal 
Government, States, and private organizations to expand 
coverage.
    Continuing on the theme of impeccable qualifications and 
experience, Ms. Palm is a proven health-care agency leader who 
knows what it takes to run HHS in a smooth way. She previously 
served as the Department's Chief of Staff and Senior Counselor 
to the Secretary during the Obama administration. Most 
recently, she served as Secretary-Designee of the Wisconsin 
Department of Health Services, a $12-billion agency. She has 
been the point person when it comes to COVID response in the 
State of Wisconsin. There she led efforts to expand insurance 
coverage, improve mental health care, and reduce hunger.
    My bottom line: these are two individuals who are 
extraordinarily qualified for these essential positions and 
would be ready to go on Day 1 after they are confirmed by the 
Senate. There is a lot of work to be done at HHS; vaccinations 
are way up, but cases and deaths are still awfully high. Long, 
long way to go on the pandemic.
    Now, the committee is also going to keep working on other 
important health challenges, which I and other members have 
discussed with our nominees. For example, I have said that 
every single time this committee talks about Federal health 
programs, we are going to be talking about updating the 
guarantee of Medicare. When I was coming up with the Gray 
Panthers, Medicare was an acute-care program. If you broke your 
ankle, it was Part A, or if you had a horrible case of the flu, 
then you went to the doctor or hospital for the broken ankle. 
Today, Medicare is cancer and diabetes and heart disease and 
strokes, and so many older Americans have two or more of these 
conditions.
    So this committee led the bipartisan passage of the CHRONIC 
Care Act in 2017. The Trump administration slow-walked the 
implementation. So I am looking forward to working with both of 
our nominees to turn this situation around.
    Second, the American Rescue Plan made a big down payment on 
mental health services. Senator Stabenow has worked tirelessly 
on this issue. And I was very pleased that now in the Medicaid 
program, for several years, we will have the CAHOOTS program, 
which is a fresh and exciting model so that mental health 
professionals and law enforcement professionals are teaming up 
to deal with the tragedies we see on our streets that so often 
involve mental health needs. I am very proud that Oregon has 
been a pioneer, and I gather, based on reports, that the Oregon 
program, their phones are ringing off the hook from around the 
country, from communities that want to copy what we have done.
    A special priority for us on the Finance Committee is 
dealing with the issue of inequality in Federal health 
programs. We saw once again, during the pandemic, the results 
of health-care disparities up close. Blacks, Latinos and Native 
Americans have suffered and died from COVID-19 at much higher 
rates. Now, it is not just about COVID-19; it is about maternal 
health, because women today are more likely to die in 
childbirth than their mothers were a generation ago.
    It is outrageous, I say to our nominees and colleagues, 
that in affluent white suburbs there are all kinds of health-
care services of the most sophisticated nature, and in so many 
communities of color, it is like a health-care desert, and this 
committee is determined to change that.
    Finally, we will be working closely with all of you on the 
issue of lowering prescription drug costs. A lot of Americans 
feel they are just getting mugged when they go to the pharmacy 
counter, and we have concrete ideas for doing something about 
it.
    In addition to the CAHOOTS program, there will be other 
mental health issues. I am very troubled about the fact that 
the parity law, which is supposed to give mental health and 
physical health the same treatment, seems to be honored too 
often in the breach rather than in the observance. We will talk 
to you about that as well.
    I want to thank both of you for being willing to do another 
stint in public service. We will hear from Senator Crapo, our 
ranking member, also from the Pacific Northwest, and then we 
have our colleagues here to introduce our nominees.
    Senator Crapo?
    [The prepared statement of Chairman Wyden appears in the 
appendix.]

             OPENING STATEMENT OF HON. MIKE CRAPO, 
                   A U.S. SENATOR FROM IDAHO

    Senator Crapo. Thank you, Mr. Chairman.
    When we held our hearing for Xavier Becerra to be Secretary 
of Health and Human Services, I noted the size and importance 
of the department he would lead.
    In normal times, HHS and its agencies provide health-care 
service to nearly 150 million people, and those agencies affect 
the lives of many, many more on a daily basis. The COVID-19 
pandemic has raised the salience of the Department. The 
Department's leadership, including the Deputy Secretary, will 
continue to play a key role in bringing us out of this public 
health emergency.
    Similarly, Medicare and Medicaid are providing essential 
health care to patients who have suffered disproportionately 
from the COVID-19 pandemic. Looking to the future, the 
Secretary, the Deputy Secretary, and the CMS Administrator must 
carefully evaluate how best to use resources available to them 
to promote the health of our citizens. They must do so 
carefully, constructively, and creatively.
    Two months ago, I outlined several issues in the health-
care space where I intend to focus my efforts as ranking 
member, including fostering innovation to improve patient care 
and make our health-care system more efficient. The COVID-19 
pandemic has threatened Americans' physical and economic 
health, but it has also reinforced the value of innovation and 
provided an opportunity to test changes that foster it.
    HHS has used this authority under the public health 
emergency to waive numerous requirements to ensure Medicare and 
Medicaid beneficiaries and other patients receive care during 
the pandemic. Patients and providers have benefited from 
expanded access to telehealth and expedited approval of COVID-
19 vaccines, diagnostics, and treatments. Going forward, 
Medicare and Medicaid patients must have the same access to 
those innovative items and services as those with commercial 
insurance.
    We must carefully evaluate our response to the pandemic and 
implement appropriate reforms based on the lessons we have 
learned. HHS should partner with this committee in that effort.
    However, media reports about certain health-care policies 
that may come before Congress, or be enacted through executive 
actions, are concerning to me. Some of these policies, such as 
including additional benefits under Medicare, could experience 
bipartisan support if considered through a transparent, 
cooperative, bipartisan process. Unfortunately, reconciliation 
does not afford Congress the opportunity to work together to 
evaluate these changes and make necessary reforms to protect 
the long-term financial viability of the program.
    Other policies, such as expanding Obamacare's premium 
subsidy to everyone, regardless of income, would be incredibly 
expensive for taxpayers without taking appropriate steps to 
lower the cost of health insurance.
    Creative, bipartisan ideas to lower the cost of insurance 
in the individual market have been raised by States and my 
colleagues in this committee. I welcome the opportunity to work 
together on these ideas, such as allowing States to use waivers 
to their full potential, diversifying benefit designs and 
incentivizing competition.
    Finally, I am concerned about paying for some of these 
policies through changes in our drug pricing system that could 
stifle innovation. We can see the end of the COVID-19 pandemic 
approaching, thanks to groundbreaking vaccines developed by 
pharmaceutical manufacturers. In this crisis, industry 
responded to the Nation's call to arms, code-named Project Warp 
Speed, developing powerful and effective vaccines in record 
time.
    This success was possible because of the private sector. I 
strongly agree with my colleagues that this innovation is only 
valuable if patients can afford it. We should establish an out-
of-pocket spending cap and reform Medicare Part D with the 
market-based principles of competition and transparency in 
mind.
    Ms. Palm and Ms. Brooks-LaSure, if you are confirmed, I 
look forward to working with you to improve our health-care 
system. I ask you to commit to careful assessments of the risks 
and considerations in every policy decision you make.
    Political pressures possibly make unilateral actions seem 
attractive, but you should also consider how the market, 
individual choice, public policy, and incentives play vital 
roles in development and delivery of health care.
    I look forward to hearing your testimony and your responses 
to questions.
    These positions to which you have been nominated have 
substantial influence over policy. The members of this 
committee need to understand how you will implement the 
administration's agenda. And we expect your answers here and in 
response to the QFRs to be detailed and candid.
    I look forward to the opportunity to visit with you today.
    Thank you, Mr. Chairman.
    [The prepared statement of Senator Crapo appears in the 
appendix.]
    The Chairman. Thank you, Senator Crapo.
    Our nominees have the good fortune of being introduced by 
two Senators with a long history of health-care advocacy, and 
we will start with Senator Baldwin, who will introduce Ms. 
Palm; then we will go with Senator Menendez, who will introduce 
Ms. Brooks-LaSure.
    Senator Baldwin?

               STATEMENT OF HON. TAMMY BALDWIN, 
                 A U.S. SENATOR FROM WISCONSIN

    Senator Baldwin. Thank you, Chairman Wyden and Ranking 
Member Crapo, for holding this hearing, and I am honored to be 
here today to introduce Andrea Palm, President Biden's nominee 
for Deputy Secretary of Health and Human Services.
    More than 2 years ago, Governor Tony Evers selected Andrea 
Palm to serve as Secretary of the Wisconsin Department of 
Health Services. I met with her very soon after that 
announcement and was immediately struck with her expert 
understanding of the health policy landscape, as well as her 
keen interest in building relationships with stakeholders from 
across our State.
    Her prior experience, as a Senior Counselor to HHS 
Secretary Burwell and as a Senior Advisor on the White House 
Domestic Policy Council, provided her with strong 
qualifications to serve our State. With this foundation of 
experience, Andrea Palm delivered leadership to Wisconsin 
during the COVID-19 pandemic, and she built an effective 
response to the public health crisis we faced in our State, 
including her efforts to build a testing, contact tracing, and 
vaccination infrastructure in the State of Wisconsin.
    Andrea's nomination as Wisconsin DHS Secretary, like other 
nominations from our Governor, was politicized from the 
beginning by the Republican-controlled Wisconsin State 
legislature. It is true they held up her nomination for months 
during an unprecedented global health crisis. It is also true 
that the State legislature refused to convene for more than 9 
months, and instead sought to limit the power of the Governor 
and other public health leaders even as Wisconsin was 
experiencing one of the worst COVID-19 outbreaks in the 
country.
    Despite these barriers, Andrea Palm led and put the people 
of Wisconsin ahead of State capital politics. In the face of 
consistent and constant political bickering and obstruction, 
Andrea Palm stayed the course and lived up to our State motto: 
``Forward.'' She made every possible effort to collaborate with 
stakeholders and trusted messengers throughout the State to 
protect Wisconsinites and provide them with the information 
needed to protect themselves and their families. And most 
importantly, Andrea provided leadership in Wisconsin that was 
always focused on science, public health, and the idea that we 
are all in this together.
    Because of Andrea's leadership, Wisconsin has maintained 
one of the fastest vaccination rates in the country. She set us 
up for success in Wisconsin as a national leader in getting 
people vaccinated quickly, and I give her a tremendous amount 
of credit for where we today, because she helped put the 
partnerships in place that we have used to get shots in 
people's arms and to protect public health.
    She also worked to ensure robust data transparency since 
the very beginning of the pandemic, which continues to inform 
our vaccine roll-out and help us reach underserved communities. 
And in rural areas of Wisconsin, residents are getting 
vaccinated as quickly and as easily as residents in urban 
areas, a direct result of her focus on building relationships 
with stakeholders across our State.
    Having Andrea back at HHS will be a tremendous benefit for 
the Department and all of our States, because she understands 
the urgent need to beat this pandemic and ensure the health and 
safety of all Americans.
    Andrea, welcome back to the Senate, and thank you for your 
service to the State of Wisconsin. Your hard work has always 
enabled you to meet and overcome challenges, and I look forward 
to seeing you confirmed as Deputy Secretary of Health and Human 
Services.
    The Chairman. Senior Baldwin, thank you, and you are always 
welcome in this committee.
    Senator Menendez?

          OPENING STATEMENT OF HON. ROBERT MENENDEZ, 
                 A U.S. SENATOR FROM NEW JERSEY

    Senator Menendez. Well, thank you, Mr. Chairman. And there 
are many reasons we want to finally beat this pandemic: the 
health and welfare of our families, our neighbors, and our 
fellow Americans. And because, after 16 years, I had finally 
worked my way down this dais close to Senator Stabenow, I am 
hoping that we can get to that point--that we can get there 
again.
    Mr. Chairman, Ranking Member Crapo, and fellow members of 
the Senate Finance Committee, today I have the pleasure of 
introducing you to Ms. Chiquita Brooks-LaSure, President 
Biden's nominee to lead the Center for Medicare and Medicaid 
Services. And I must admit, I was thrilled to learn of Ms. 
Brooks-LaSure's nomination to serve as CMS Administrator.
    A native of Willingboro, NJ, Ms. Brooks-LaSure graduated 
from Princeton University, earned a master's in public policy 
from Georgetown, and embarked on an impressive career in 
Federal health policy.
    To say Ms. Brooks-LaSure understands the U.S. health-care 
system would be an understatement. Over the course of more than 
2 decades, she has amassed a deep working knowledge of Federal 
health-care policy and the vital role that programs like 
Medicare, Medicaid, and the Affordable Care Act play in the 
lives of patients and consumers, especially those who are from 
low-income communities and communities of color.
    CMS is sure to benefit from Ms. Brooks-LaSure's extensive 
experience, from her early days coordinating Medicaid policy in 
the Office of Management and Budget; to her work with the House 
Ways and Means Committee, passing signature legislation like 
the Affordable Care Act; to her service as Director of Coverage 
Policy at the Department of Health and Human Services; as well 
as deputy director for policy at the Center for Consumer 
Information and Insurance Oversight.
    Most recently in the private sector, Ms. Brooks-LaSure 
worked at the firm of Manatt, Phelps, and Phillips, helping 
clients in the health-care space navigate regulatory issues 
often involving Medicaid and Medicare.
    Simply put, her credentials are impeccable. And her 
commitment to building a more equitable and accessible health-
care system is unshakable. If confirmed, Ms. Brooks-LaSure will 
be the first 
African-American woman ever to serve as CMS Administrator, and 
her historic nomination comes at a historic moment for our 
country.
    The COVID-19 pandemic has exposed and aggravated the long-
standing racial inequalities and inequities in our country, 
that even in good times, leave people of color more vulnerable 
to poor access, financial hardship, disease, and death. As we 
emerge from this crisis, I can think of no one better 
positioned or more committed to rooting out the disparities in 
our health-care system than today's nominee, Ms. Brooks-LaSure.
    And I know my colleague from New Jersey, Senator Booker, 
asked as well to join in our enthusiasm for her historic 
nomination.
    Thank you, Mr. Chairman.
    The Chairman. I thank our colleague, and our colleague has 
been heavily involved on health-care issues here today, so we 
are glad to hear his ringing support for the nominee.
    I am also at this point going to introduce a letter of 
support, and a statement for the record.
    Without objection, I will make these a part of today's 
hearing record.
    [The letter and statement appear in the appendix beginning 
on p. 138.]
    The Chairman. We will now have opening statements for Ms. 
Palm and Ms. Brooks-LaSure, and then we have some formalities 
we have to deal with. I thank our colleagues for being here.
    Ms. Palm?

     STATEMENT OF ANDREA JOAN PALM, NOMINATED TO BE DEPUTY 
SECRETARY, DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, 
                               DC

    Ms. Palm. Thank you, Chairman Wyden, Ranking Member Crapo. 
Good to see you both this morning. I'm grateful for the 
opportunity to testify before you today as President Biden's 
nominee for Deputy Secretary of the United States Department of 
Health and Human Services.
    I want to thank Senator Tammy Baldwin for the kind 
introduction and for her work on behalf of the people of 
Wisconsin. I'd also like to acknowledge and thank my husband 
Dan, who is here with me today. And thank you to the members of 
this committee for considering my nomination. I have enjoyed 
the opportunity to speak with many of you individually 
throughout this process.
    I was born and raised in Star Lake, NY, a town of about 
1,000 people. When you grow up in a small town, you understand 
from a young age that together is the only way to get things 
done. That sense of community was formative and is what led me 
to become a social worker. I spent my twenties as a caseworker, 
finding safe homes for children in crisis and working with 
people in behavioral health crises.
    These experiences shaped the rest of my career. It was the 
children and families I worked with during this time that made 
me want to change the system, and drew me to public service and 
to public policy. The memories of these kids are what still 
motivates me today.
    I have spent my entire career focused on health and human 
services policy and lifting our most vulnerable communities, 
from my time in the Senate working on the HITECH Act to serving 
at HHS, where I played a key role in implementing the 
Affordable Care Act and negotiating bipartisan policies with 
Congress like the 21st Century Cures Act.
    Most recently, I had the privilege of leading Wisconsin's 
Department of Health Services. I am proud of the work we were 
able to accomplish in Wisconsin. There, we found ways to make 
progress on a bipartisan basis, expanding access to telehealth 
services, our innovative children's health insurance program to 
tackle childhood lead poisoning, and improving delivery of the 
programs at the Department more broadly to better serve the 
people of Wisconsin.
    And when the pandemic hit, we led with fact, science, and 
transparency to protect our communities. As every single State 
did, we faced challenges in Wisconsin. But we built a strong, 
State-wide response, leveraging government assets and the 
expertise of our 
private-sector partners to build a stable testing and contact 
tracing system, reaching our rural communities, and vaccinating 
Wisconsinites. And it is working. As Senator Baldwin noted, 
Wisconsin is among the top States in vaccinating our residents.
    When I was previously at HHS, then-Secretary Burwell would 
joke that if there was an issue that was going to require 
bipartisan cooperation, the team should give it to me. She 
called my portfolio the ``common ground agenda.'' And if I have 
the honor of being confirmed and returning to HHS, that is what 
I am bringing with me: a common ground agenda.
    First, we must end the COVID pandemic. I know we can all 
agree that we have lost far too many Americans to this virus. 
President Biden put forward ambitious goals, and Congress has 
followed through, providing the resources to get the job done.
    If confirmed, I look forward to implementing the American 
Rescue Plan, getting vaccines in arms, rebuilding the public 
health workforce, and securing the Nation's supply chain.
    Second, we must expand access to high-quality, affordable 
health care. The American Rescue Plan took a major step in 
bringing down the cost of health care for working families, but 
we cannot stop there. We must strengthen our Medicare and 
Medicaid lifelines, reduce the cost of prescription drugs, 
better integrate mental health and substance use disorder 
treatment into our health-care system, and ensure our global 
leadership in research, development, and innovation.
    And finally, we must prioritize human services. HHS has an 
important role to play, from caring for children to advancing 
the health and well-being of people with disabilities. We must 
not lose sight of those core missions.
    HHS faces big challenges. And it is our responsibility to 
be tireless stewards of an agency that touches nearly every 
aspect of American life. To me, that is what public service is 
all about; making government work for the people it serves, and 
leaving the country better than we found it.
    I am ready for the task, and eager to continue serving. 
Thank you again for considering my nomination.
    The Chairman. Thank you very much, Ms. Palm. And we will 
have some questions here in a bit.
    [The prepared statement of Ms. Palm appears in the 
appendix.]
    The Chairman. Ms. Brooks-LaSure?

     STATEMENT OF CHIQUITA BROOKS-LaSURE, NOMINATED TO BE 
  ADMINISTRATOR, CENTERS FOR MEDICARE AND MEDICAID SERVICES, 
    DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC

    Ms. Brooks-LaSure. Chairman Wyden, Ranking Member Crapo, 
and members of the committee, thank you for considering my 
nomination to be the Administrator of the Centers for Medicare 
and Medicaid Services. It is humbling to be before you. And 
thank you to Senator Menendez for his kind introduction.
    My career in public service started at the Office of 
Management and Budget, working on CMS's budget, Medicaid, and 
CHIP. But after 9/11, everything changed. It did for the 
victims of that terrible tragedy, their families, and for first 
responders. It also changed for many of you and for all of us 
in government service.
    For me, my work shifted to finding coverage for dislocated 
workers in the wake of the attack. I worked closely with the 
Treasury Department and key members of the Bush administration 
to ensure that those impacted by this senseless attack had the 
health coverage they needed for such a vulnerable time in their 
lives.
    It was inspiring to be part of a bipartisan effort to 
ensure that people who lost their jobs as a result of the 
attack and the economic aftermath were able to get the health 
care they needed. I took that philosophy and sense of mission 
with me to the Ways and Means Committee and then to HHS and 
CMS, where I led the development of policies that expanded 
coverage to more than 20 million Americans.
    I have approached my work in the private sector with the 
same philosophy, working with States and stakeholders to expand 
coverage options, especially for those living in rural parts of 
the country and for traditionally marginalized communities.
    Today, as we navigate this public health crisis and its 
aftermath, that philosophy guides me yet again, and if 
confirmed, that is the collaborative, common-sense, results-
oriented philosophy I will take to CMS to address the complex 
challenges we face.
    First, we must get the pandemic under control. COVID-19 has 
put unbearable pressure on front-line health-care workers, put 
vulnerable seniors and those with disabilities at great risk, 
and unmasked inequities that persist in our health-care system. 
My own home town, a predominantly black community where my 
parents still live, experienced higher rates of COVID 
infections and deaths compared to many of our surrounding 
communities.
    I am committed to working with you and leaders across the 
government to ensure that CMS is supporting patients, their 
families, and providers, including communities of color, who 
have been hardest hit by this pandemic.
    If confirmed, I will work to make CMS programs work 
together better and remain the pillars of our health-care 
system. This includes addressing Medicare solvency to protect 
Medicare for current and future beneficiaries. There is much we 
can do to strengthen these programs, to improve quality, lower 
cost, and expand access, including implementing the critical 
reforms in last December's appropriations bill and the American 
Rescue Plan.
    If confirmed, I am also committed to working with you to 
expand access to innovative therapies, procedures, and models 
of care. We are living in an era of incredible change, as 
researchers find new ways to conquer disease and improve our 
quality of life. We must bear in mind, though, that innovation 
is only effective if patients can actually afford it. So I will 
work with you to reign in health-care costs, including for 
prescription drugs.
    I realize we may not always agree on the best approaches to 
solve these challenges, but I pledge to work closely with all 
of you to ensure that our decisions are transparent, our team 
is accessible, and that CMS is listening to your views.
    Before I close, I would be remiss if I did not acknowledge 
the outpouring of support I have received from women of color 
across this country. I am proud that, if I have the honor of 
being confirmed, I will be the first black woman to lead CMS. I 
would not be here without God and my family, my husband sitting 
behind me, my parents, my brother and sister, and the many 
strong, smart black women and men who came before me. Too often 
they were not given the opportunity to live up to their full 
God-given potential, but their selfless, often silent sacrifice 
paved the way for me and so many other women of color.
    Today, I am proud that my daughter can see her mother 
nominated by the President of the United States to lead such a 
critical agency and know that she can be anything she wants to 
be.
    Thank you for considering my nomination, and I look forward 
to answering your questions.
    The Chairman. Thank you very much, Ms. Brooks-LaSure. And 
let the record show that Ms. Brooks-LaSure was also an intern 
to the Senate Finance Committee, and so we are very proud of 
that.
    [The prepared statement of Ms. Brooks-LaSure appears in the 
appendix.]
    The Chairman. Now, we have some obligatory questions we are 
going to ask, and I am just going to ask the question and have 
a response from each of you, if that would be all right.
    First, is there anything that you are aware of in your 
background that might present a conflict of interest with the 
duties of the office to which you have been nominated?
    Ms. Palm?
    Ms. Palm. No.
    The Chairman. Ms. Brooks-LaSure?
    Ms. Brooks-LaSure. No.
    The Chairman. Second, do you know of any reason, personal 
or otherwise, that would in any way prevent you from fully and 
honorably discharging the responsibilities of the office to 
which you have been nominated?
    Ms. Palm?
    Ms. Palm. No.
    The Chairman. Ms. Brooks-LaSure?
    Ms. Brooks-LaSure. No.
    The Chairman. Third, do you agree, without reservation, to 
respond to any reasonable summons to appear and testify before 
any duly constituted committee of the Congress, if you are 
confirmed?
    Ms. Palm?
    Ms. Palm. Yes.
    The Chairman. Ms. Brooks-LaSure?
    Ms. Brooks-LaSure. Yes.
    The Chairman. Finally, do you commit to provide a prompt 
response in writing to any questions addressed to you by any 
Senator of the committee?
    Ms. Palm?
    Ms. Palm. Yes.
    The Chairman. Ms. Brooks-LaSure?
    Ms. Brooks-LaSure. Yes.
    The Chairman. Thank you both.
    All right. Let us go on now to members' questions. We are 
going to do this in 5-minute rounds. And let me start with 
questions for you, Ms. Brooks-LaSure, and it really speaks to 
this judgment that I have had--and I have had two colleagues 
sitting on my sides who have shared it with me over the years--
which is that I do not believe the Federal Government has a 
monopoly on good ideas. If the States can do better, they ought 
to be able to do it.
    That is why I wrote section 1332 of the Affordable Care 
Act. It allows States to get a waiver to put in place fresh and 
creative strategies as long as they meet--this is critical--the 
essential consumer protection guard rails that are embedded in 
the Affordable Care Act.
    So now, all over the country, there are States that would 
like to promote a public option, for example, to increase 
competition and hold down health-care costs, and there are some 
that are interested in aggregating Medicare and Medicaid 
dollars because they would like to move closer to a single-
payer approach at the State level. Conversely, there are States 
with conservative ideas that would like to advance what they 
believe is the right course, and they believe that they can 
advance those conservative ideas while meeting consumer 
protection guard rails.
    The reason I am asking you this question, Ms. Brooks-
LaSure, is you had years of experience working closely with the 
States. And if confirmed--I believe, when you are confirmed--
you will have authority to be involved in promulgating those 
kinds of guidance rules that will give a road map for the 
States on how to proceed.
    How are you looking at your authority with respect to the 
States, and particularly ensuring that both progressive States 
and conservative States will say they have been treated fairly, 
showing that they have good ideas but never fudging on the 
essential consumer protection guidelines? How do you see your 
job in that regard?
    Ms. Brooks-LaSure. Thank you, Chairman Wyden, for the 
question and for your leadership in ensuring that States had an 
option of applying for waivers to think about ways to improve 
upon the Affordable Care Act.
    As you said, the Federal Government does not have a 
monopoly on good ideas and, in fact, some of the best ideas 
that are eventually enacted in Washington start at the State 
level, through waivers, through demonstrations. And there are 
so many States that are looking for the best ways to cover 
their populations; there is so much variety in our great 
country.
    I see the role of the Federal Government in granting 
waivers as being a trusted partner with the States that have a 
great deal of responsibility across the Medicaid program, and 
in many States, their marketplaces and certainly their 
insurance markets. And I want States to understand what the 
rules are, to have consistent guidance, and to make sure they 
are meeting the standards that are set forth in the law.
    Certainly I agree, and I think that States want to use the 
1332 guidance to expand coverage and test different options in 
many ways. And if confirmed, CMS will certainly have an open 
door to States, to new ideas. And I really want to treat all 
the States with consistency and fairness, and then make sure 
they are meeting the guard rails.
    The Chairman. One last question on this. Would you make it 
a priority to get the guidance out so that States with 
different philosophical viewpoints would know how to proceed?
    Ms. Brooks-LaSure. Absolutely. States need certainty and 
are on important schedules, annual budgets, and that is 
absolutely important.
    The Chairman. We will have more conversations about the 
guidance, and I thank you for that.
    Ms. Palm, let us talk about this whole question of health-
care equity. I think you heard me in my opening statement say I 
think there are two health-care systems in America, plain and 
simple. The most affluent, and particularly those who live in 
suburbs, have a technology treasure trove in front of them in 
terms of how they can use telehealth and all kinds of services 
that are beneficial. Conversely, folks of modest means are just 
trying to figure out how to make their way through the maze of 
rules, even dealing with COVID services.
    So my question to you is, if confirmed--and I believe you 
will be confirmed--how would you actually lead at the 
Department to root out the significant racial, ethnic, and 
geographical health disparities? Because I think that is what 
this is going to be all about. We are going to need leadership 
that has a real agenda to root out these systematic inequities. 
Tell us what yours would be.
    Ms. Palm. Thank you, Chairman Wyden.
    From my perspective, as Deputy Secretary, should I be 
confirmed, I think about this sort of on two levels. One is how 
we are working to ensure, at the programmatic and policy 
development level, equity and that an equity lens is baked into 
the development and implementation of our programs.
    And then I lift up and think operationally about how we as 
a department are infusing, within our processes, the ways we 
need to do the work better, to bake equity in at the beginning 
so that we are not chasing it at the end. And so that, for me, 
is both programmatic and policy development, but then also 
operationally, we have the opportunity to really structurally 
change the way we do our work so that everybody is responsible 
for equity and making sure that the work that we do is 
equitable and that we are eliminating the systemic issues that 
have brought us to where we are today.
    The Chairman. I think your point about individual 
accountability--my time is up--is hugely important, because at 
the end of the day, these issues have just gotten short shrift. 
I mean, the country has known about them, people say that you 
ought to do something about it, but it is really time for the 
kind of accountability that you just mentioned.
    Senator Crapo?
    Senator Crapo. Thank you very much, Mr. Chairman. And I 
want to return in my questioning to the issue that the chairman 
dedicated his first question to: that of waivers.
    I appreciated the chairman highlighting this issue and the 
focus that he brought to it. Waivers are an essential tool for 
States, allowing them to tailor insurance programs to fit the 
needs of their patients. Across the country, States continue to 
prioritize flexibility and the use of innovative, local 
solutions to expand coverage.
    Unfortunately, this desire for flexibility has met Federal 
Government roadblocks, and this is especially true for Idaho. 
As I mentioned with both of you privately when we talked, Idaho 
has tried numerous creative approaches to expand and coordinate 
coverage between certain individual market and Medicaid 
populations. Medicaid 1115 waivers grant important 
flexibilities for States to improve benefits and to try new 
ideas in their Medicaid programs.
    Obamacare's 1332 waivers allow States to implement policies 
that stabilize the market, lower insurance costs, and incent 
competition, provided--as Senator Wyden mentioned--that the 
guard rails are protected.
    Yet when States try to merge the two waivers to coordinate 
and expand coverage, they are met with rejection and 
disappointment from the Federal Government far too often. This 
appears to be a statutory problem in many cases that prevents 
novel approaches to creating more seamless, harmonized 
insurance markets for patients. Without solving this issue, 
States must deal with population churn, inconsistent benefits, 
budget uncertainty, and the inability to advance changes that 
would improve care.
    I realize you cannot change the statutes, but I do believe 
that as much flexibility as possible to allow States to use 
these creative options should be utilized. And I just first 
want to ask--and I think you have already basically said this 
to Senator Wyden--but if confirmed, would you work with me and 
others interested in improving the 1115 and 1332 waiver 
coordination through statutes? It is just a ``yes'' or ``no'' 
for each of you.
    Ms. Palm. Yes.
    Ms. Brooks-LaSure. Yes.
    Senator Crapo. And I appreciate that.
    And while this waiver work is underway, do you commit to 
incorporating State perspectives and expertise in CMS and HHS 
decision-making to ensure that local solutions to address 
coverage are included in your work?
    Ms. Brooks-LaSure. Yes.
    Ms. Palm. Yes.
    Senator Crapo. Thank you.
    And finally on this, I am deeply concerned by the current 
administration's approach to Medicaid waivers that were granted 
in the last administration. In other words, what will be the 
approach to waivers that have already been granted? While we 
should work to improve evaluations and processes for all 
waivers and demonstrations, the changes that have occurred this 
year on Medicaid waivers necessitate more immediate action.
    Ms. Brooks-LaSure, do you believe revoking approved 
Medicaid waivers or portions of approved Medicaid waivers 
immediately following an election sends the wrong message to 
the States?
    Ms. Brooks-LaSure. Senator Crapo, thank you for raising the 
issue, and as I have mentioned, I do a lot of work with States 
and understand how much they want certainty from the Federal 
Government. That is something, if confirmed, I will really work 
on: to make sure that States understand decisions and, as you 
said, are part of the decision-making.
    Senator Crapo. All right; thank you.
    And in the little bit of time I have left, I want to go 
back to you, Ms. Brooks-LaSure, on the Medicare Advantage 
issue.
    I am a huge advocate for Medicare Advantage; I think it is 
one of the best-working pieces of Medicare, and we should do 
all we can to take advantage of it.
    During the COVID-19 pandemic, CMS provided Medicare 
Advantage plans with additional flexibilities, such as 
expanding telehealth services, providing beneficiaries with 
devices to use for telehealth and remote patient monitoring, 
and reducing cost sharing and premiums, and we found some 
things that really worked.
    Ms. Brooks-LaSure. Yes.
    Senator Crapo. How would you work with stakeholders and 
Congress to continue these certain enhanced benefits and 
flexibilities? What I am talking about is, why do we have to 
stop this when the pandemic ends? Could you respond to that.
    Ms. Brooks-LaSure. Absolutely. I think that this pandemic 
has given us an opportunity to take the lessons across a 
variety of issues, and telehealth has been something that has 
been discussed for more than a decade, and now we have been 
able to see what value it brings. My brother is a psychologist, 
and he has been able to see more patients during a difficult 
time as a result of it.
    I really want to work with all of you to look at what CMS's 
administrative authority is and what changes we may need 
congressionally to work on bringing the lessons that we have 
learned from COVID into our health-care system on a permanent 
basis.
    Senator Crapo. All right. Thank you very much.
    My time has expired so, Ms. Palm, I will have to probably 
send you some questions for the record.
    Ms. Palm. Thank you.
    The Chairman. Colleagues, here is where we are: Senator 
Stabenow will go next in person, then we will have Senator 
Grassley on the web, and then we will have Senator Cantwell in 
person.
    Senator Stabenow?
    Senator Stabenow. Thank you very much, Mr. Chairman, and 
welcome to Ms. Palm and to Ms. Brooks-LaSure. We are so lucky 
to have both of you willing to commit to public service at this 
very important time, and I am very impressed with your 
credentials, both of you--your experience and your credentials.
    I care about every part of the health-care system, as you 
know. I have worked for years--it was actually health care that 
got me in to my own public service, and I think it is probably 
no surprise that I would like to start talking about behavioral 
health.
    And so I would ask both of you--and I know, Ms. Palm, that 
you were at HHS when Senator Roy Blunt and I were able to pass 
the Excellence in Mental Health and Addiction Services 
Treatment Act, and that you were involved in the initial 
implementation and in establishing the quality standards. So I 
appreciate that very much, and I know you both have been 
involved in these issues.
    But as you know, so many people are living with mental 
health issues and addiction issues right now, even more because 
of COVID. In January, 41 percent of American adults reported 
that they were struggling with anxiety and depression, and that 
is up from 11 percent before the pandemic. So we have serious, 
serious issues.
    And more than one in four young people have reported 
suicidal thoughts. Meanwhile, communities are seeing more 
people overdose. Just yesterday the CDC reported that more than 
87,000 Americans died of drug overdoses over a 12-month period 
that ended in September, the most deaths in a year since the 
opioid epidemic began in the 1990s. Serious alarm.
    So long after the epidemic ends, these behavioral health 
issues will linger. And I have talked to both of you about--I 
believe strongly we need to treat health care above the neck 
the same as health care below the neck as part of the health-
care system.
    The good news is that, through Certified Community 
Behavioral Health Clinics that we now have in 41 States--and 
expanding now because of the American Rescue plan as well--we 
have a structure that allows clinics to truly meet the needs of 
the community. This has been a tremendous success, a model for 
the future, and I have to commend our chairman on the CAHOOTS 
program which this model also embraces as a partnership; so 
this is so, so important.
    And now we have the opportunity to expand it nationwide so 
that every State has the opportunity to meet quality standards 
and provide comprehensive services. And now is really the time 
to do that.
    So my question--I will start with Ms. Palm--is, could you 
talk about your experience working on behavioral health issues 
and how you will work with us to ensure high-quality 
comprehensive care, including through the CCBHC program?
    Ms. Palm. Yes. Thank you for the question, and thank you 
for your leadership on this issue.
    I think to your point, the bipartisan nature of the work 
that you and Senator Blunt have done on this, the bipartisan 
work that has happened around the opioid epidemic, really does 
afford us a critical opportunity at this moment to do 
additional work, to really, as I mentioned in my opening, 
integrate behavioral health into the health-care system. Your 
analogy of the neck-up and the neck-down is exactly right, and 
I think it is really time that we think about mental health, 
substance abuse, the behavioral health issues as chronic 
conditions that need to be managed and treated the way other 
health-care conditions are; and that the health and wellness of 
people and putting them at the center of their health care 
means that we have to do that for behavioral health.
    I have worked in behavioral health from direct service all 
the way to, as you mentioned, implementation of programs, and 
then most recently running them at the Department of Health 
Services in Wisconsin. And so I would look forward to the 
opportunity to work with you and others on this committee to 
really sort of turn the crank and take these next important 
steps in behavioral health.
    Senator Stabenow. Thank you.
    Ms. Brooks-LaSure?
    Ms. Brooks-LaSure. I join my colleague in thanking you for 
your bipartisan work in this area, and highlighting just how 
much of an issue this is and has been. And then as you have 
stated, with COVID-19, it has been an incredibly difficult time 
for a host of people, including children, for a number of 
reasons.
    I think that one of the important pieces is increasing 
providers, which is what the work of your clinic does by making 
more availability. We have seen telehealth help in this area. 
One of the things, if confirmed, I really want to focus on is 
helping CMS to coordinate better with the Department on these 
critical issues. States are doing some incredible things in 
their Medicaid programs and really coordinating that with the 
grants from SAMHSA to make sure that we are integrating 
behavioral health and substance abuse with physical health.
    And finally I mention, of course, mental health parity is 
an important part of CMS's role of enforcing and ensuring that 
mental services are treated equally.
    Senator Stabenow. Thank you.
    Mr. Chairman, I know my time is up, but I have just one 
other thing I want to mention--no question, though--and that is 
school-based health clinics. We have authorized school-based 
health clinics to the end of the year, bipartisan legislation, 
but they are not yet funded. And yet we know that children and 
young adults have been hit particularly hard by the pandemic, 
not only anxiety and depression and other issues, but routine 
vaccination rates are down, and many children have missed 
primary care doctor's appointments and dental visits.
    So Senator Capito and I are working together to secure 
funding for these clinics that have been authorized. We invite 
all of our colleagues to join us. I also want to work with each 
of you on these issues to make sure that school-based health 
centers are able to get the CHIP funding and Medicaid funding 
that will allow them again to be a permanent part of our 
health-care structure. This is very, very important for our 
children.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Stabenow.
    Senator Cantwell?
    Senator Cantwell. I thought Senator Grassley was next.
    The Chairman. Excuse me, he is not available right now.
    Senator Cantwell. Okay; thank you, Mr. Chairman. I just 
wanted to make sure we were not skipping ahead.
    Thank you to the witnesses, and congratulations on your 
nominations. I certainly support moving you forward.
    We have had a chance, at least our CMS nominee, Ms. Brooks-
LaSure, to talk about the basic health plan I mentioned to you; 
how in New York approximately 800,000 people are enrolled in a 
plan that costs $500--$500--$500 annually for a family of four 
buying coverage. That saves $1,000 compared to the silver 
exchange plans, and it saves the State billions of dollars as 
well. So I want to make sure that it also saves us federally if 
more States implement this.
    So I want to hear if both nominees are comfortable with 
States expanding this program, and if you would encourage them 
to do so. I do not mean to tell them to do so; I mean if they 
wanted to do so, would you be encouraging of that?
    Can I get it for the record so we can hear you?
    Ms. Brooks-LaSure. Yes, Senator. Absolutely.
    Senator Cantwell. Thank you.
    Also I want to make sure that the Department, Ms. Palm, 
would assist people in the implementation of that.
    Ms. Palm. Absolutely.
    Senator Cantwell. Okay; great.
    On Medicaid rebalancing, Senator Portman and I have been 
very big supporters. I just want to add that Senator Stabenow 
was also a big supporter of the basic health plan, and so I do 
not want to--she is very much appreciated, her efforts in 
getting that implemented; and we would like to continue to see 
the implementation.
    On the Money Follows the Person program, Senator Portman 
and I and several others have been continuing to push that, 
giving over 8,000 individuals in long-term care facilities the 
ability to go back into their homes, saving Medicaid dollars. 
We feel like this has been--and rebalancing in general--a big 
cost savings.
    So, Ms. Palm, will you work with States to implement the 
Money Follows the Person program to assure seniors and people 
with disabilities can avoid institutional living?
    Ms. Palm. Absolutely.
    Senator Cantwell. Thank you.
    And, Ms. Brooks-LaSure, do you support Federal incentives 
like those to help States move people from these high-cost 
institutional settings?
    Ms. Brooks-LaSure. Yes.
    Senator Cantwell. Okay; great.
    My colleague has covered mental health.
    So on my colleague from Idaho's conversation about 
telehealth, let's see if we can get a little more granular 
here.
    What do you think--how do you characterize where the 
reimbursement rate should be? I have had great conversations 
with the University of Washington, Paul Ramsey, the CEO of that 
institution's health-care system. So in the Northwest we 
definitely are going to support more broadband access; we 
definitely see how this worked--you mentioned your brother. I 
can tell you personally there are lots of indications in my 
State of how successful this has been. I think we got a real 
feel--a real feel for the medicine of the future.
    So what do we do about the reimbursement rate? Is it 100 
percent; is it the same? Is it slightly different for some 
reason? Where do you think we are? And I will start with you, 
Ms. Brooks-LaSure.
    Ms. Brooks-LaSure. Thank you for the question. I think it 
is an incredibly important issue, and one, as you said, that 
has been really critical in a number of States, in rural areas. 
And we need to think about how we continue to move this issue 
forward.
    Reimbursement, I would say, is something I, if confirmed, 
would be happy to talk with you about and think through. There 
are certainly safeguards that we need, to make sure, from a 
program integrity perspective, that we know that services are 
being delivered, but it is one that I think that we will have 
to titrate but figure out.
    Senator Cantwell. Okay. For somebody who is intellectually 
smart on this subject, I consider that a little bit of a punt, 
but----
    I think the issue--I am good with examining the savings, 
but I would say to people that this is just a new efficiency 
discovered in the information age, with COVID being the thing 
that prompted us here. But my guess is, we are going to see 
huge savings. So I would say you are at or close to the 
reimbursement rate that we are at today. It is almost something 
we want to incent, just like we have had pay follow the person, 
just like we have had these other things. Why? Because we are 
going to discover that there are probably savings here in the 
system overall.
    So anyway, I do not know if you have any comments, Ms. 
Palm.
    Ms. Palm. I would echo what my colleague said. I would also 
say we worked hard on a bipartisan bill in Wisconsin to bring 
telehealth into the Medicaid program, where we treated them the 
same for purposes of coverage and reimbursement, and we were 
really so grateful to put that statutory framework in place 
before the pandemic, and we used our flexibilities to really 
make sure we were ensuring access during the pandemic.
    But I would certainly welcome an opportunity to continue 
working with you on this issue.
    Senator Cantwell. Thank you.
    Well, Mr. Chairman and Senator Crapo, I think this is an 
incredibly important subject. We in the Commerce Committee with 
Senator Lujan will be working on a broadband piece for the 
medicine delivery system. And one thing we really like is that 
we do have, even in rural communities, rural hospitals 
everywhere. So they are a system of delivery, and I think it 
would be foolish not to try to pair the broadband investment 
with the right reimbursement rate, because otherwise we would 
be making this investment and giving us access but not having 
the utilization because physicians or the system would continue 
to defer to see people in person.
    So we have to get it right, and I so appreciate my 
colleagues. Thank you.
    The Chairman. Senator Cantwell, as always, you are out in 
front on these issues. And Senator Crapo and I have been 
talking about a bipartisan effort in this telehealth area and 
as part of the critical reimbursement issue you mention, 
because this committee really shoehorned the telehealth efforts 
into the first CARES package.
    I think it is going to be important to make sure that right 
now, as a result of the pandemic, we have removed some of the 
roadblocks for people to actually get to a telehealth provider. 
We are going to have to make those kinds of changes permanent, 
in addition to working on the critical reimbursement issue you 
have mentioned.
    And I want to thank Senator Crapo, because he has indicated 
that telehealth could be one of the real bipartisan priorities 
for the committee.
    Senator Cantwell. Well, I am pretty sure that the three of 
us, whether it is the panhandle of Idaho or eastern Oregon or 
the Okanagan in my State, we see a very dispersed rural health-
care delivery system where people have to drive hours. So I 
think this would be very helpful.
    Thank you, Mr. Chairman.
    The Chairman. Thank you for your leadership.
    We are now on to Senator Cassidy on the web, and then 
Senator Bennet. Colleagues have a hectic morning, so we are 
trying in a bipartisan way to make sure that everybody gets a 
chance to be heard as soon as possible.
    Senator Cassidy, I think you are out in cyberspace. So we 
would like to hear from you.
    Senator Cassidy. Yes, sir, Mr. Chairman.
    Ms. Brooks-LaSure, thanks for reaching out. I enjoyed our 
conversation. As I told you, I was going to follow up on dual 
eligibles, not as a ``got you'' question but rather just kind 
of to explore it. We both know that we spend a lot of money in 
this country on duals, and we get miserable outcomes.
    Now duals are a heterogeneous population, both in terms of 
who they are medically but also in terms of the method by which 
they are financed. But one thing you pointed out in our 
conversation is the difficulty in aligning the incentive for 
the State and the Federal Governments.
    The ACA attempted to address the duals, and I do not think 
it worked. Can you give a little bit of a kind of ``lessons 
learned'' from the ACA's attempt to address the lack of 
alignment among duals?
    Ms. Brooks-LaSure. Senator Cassidy, I very much appreciated 
our conversation and enjoyed the opportunity to talk. As we 
talked about, dual eligibles are sometimes the most vulnerable 
in our society in terms of comorbidities, and often very 
expensive for both the Medicare and the Medicaid programs.
    I think that, as we talked about, greater alignment is 
something that we are going to need to continue to work on. 
Some of that can be done by CMS administratively, with getting 
the programs----
    Senator Cassidy. But let me ask you particularly, what were 
the lessons learned from the ACA's effort? Because I think 
Minnesota may have been the only State in which their 
particular program worked. And so again I would like to build 
upon what we have learned. What have we learned?
    Ms. Brooks-LaSure. I would say--you know, when I look at 
the valuation, particularly around Minnesota, what I would say 
is, there still is a need to coordinate better on what we see 
in long-term care, and the nursing homes, and hospitalization. 
And some of that is going to take legislation and really 
thinking about how do we treat people on the continuum?
    So particularly in assisted living, PACE programs, I think 
there is more we can do to encourage that kind of coordination.
    Senator Cassidy. Ms. Palm, you have been kind of front and 
center on this in your jobs in Wisconsin. What thoughts do you 
have about the duals?
    Ms. Palm. I appreciate the question, and your point about 
the different financing, and States and the feds working 
together for us, we were very focused on the continuum of long-
term care services and providing the opportunity for patients, 
for seniors, people with disabilities, to choose care that best 
met their needs with the greatest amount of independence. And 
our ability to do that most effectively and efficiently would 
benefit from, as Ms. Brooks-LaSure mentioned, a greater 
alignment as you are sort of driving towards----
    Senator Cassidy. Let me stop you for a second. Let me just 
kind of stop you for a second. I think one of the things that 
happened in California was that there was an incredible amount 
of churn. People got assigned to a program, I think run by 
Medicaid, but with a Medicare--I may have this wrong, and you 
guys may know if I am correct. But this so-called patient 
choice ended up being churn where people were changing from 
program to program several times within a year, which of course 
destroyed continuity of care. And it begs the question as to 
whether or not the decision as to where to receive care was 
informed, or whether it was perhaps influenced by those who had 
other agendas.
    Any thoughts upon this? Is there a way to address that? I 
will start with you, Ms. Palm.
    Ms. Palm. Yes, I would say, Senator, we saw much more churn 
in our non-long-term care population in Wisconsin. I am not 
saying that what you are raising is not an issue----
    Senator Cassidy. I am saying among duals in general--duals 
in general.
    Ms. Palm. Yes, I think that, sort of to your fundamental 
point, continuity of care, care coordination, making sure that 
we are putting patients at the center of the care they are 
receiving, and doing what we can to do that----
    Senator Cassidy. I guess I am not making my point, Ms. 
Palm. Everything you are saying is true. What I am trying to 
get at is, how do we address the churn?
    Ms. Palm. Well, I think, Senator, from our perspective in 
Wisconsin, we wanted to make sure that the products that were 
available and the choices that seniors had were transparent on 
the front end, that they understood them, and that when they 
made their choice, they made a good choice for them so that 
there were not--there was not a need to change----
    Senator Cassidy. What was your rate of churn in Wisconsin? 
I am just curious; I do not know that answer.
    Ms. Palm. Again, I am not sure I can remember off the top 
of my head in long-term care versus in the regular population, 
but I would be happy to get that information back to you, 
Senator.
    Senator Cassidy. Okay. I yield back. Thank you.
    The Chairman. I thank my colleague.
    Senator Menendez is next.
    Senator Menendez. Thank you, Mr. Chairman.
    In March of last year, as COVID began to spread in States 
like mine, the shutdowns helped save lives. But at the same 
time, there were not systems in place to help individuals who 
rely on home and community-based services to continue to access 
care in such a situation.
    The scarcity of protective equipment meant many providers 
were not able to access necessary gear. Fortunately, the 
American Rescue Plan provided an enhanced FMAP for these 
services.
    My question to you is, will you commit to working with 
States to swiftly roll out information on how States can spend 
their increased FMAP for home and community-based services?
    Ms. Brooks-LaSure. Yes, sir.
    Senator Menendez. Okay.
    COVID-19 has disproportionately impacted black and Latino 
communities. I am pleased to see this administration is 
committed to improving health equity. However, even as we have 
seen record-breaking developments of diagnostic treatments and 
vaccines for COVID-19, members of the most heavily impacted 
communities do not have equal access to clinical trials for 
these innovations.
    And I believe we have to take active steps to remove these 
barriers. So, Ms. Brooks-LaSure, what role do you see for CMS 
to play in improving minority clinical trial participation?
    Ms. Brooks-LaSure. Thank you, Senator, for the question. 
This is such a crucial issue, and I am glad that Congress has 
made it so that Medicaid will be paying for covered services, 
to make sure that people can get into clinical trials. I think 
CMS can do more to integrate with NIH, as well as work with 
trusted partners.
    One of the things that I think we have learned with the 
pandemic is how important it is to have the medical community, 
community organizations, really making sure that communities of 
color build trust in these types of programs.
    Senator Menendez. So will you commit to working with me on 
improving clinical trial diversity?
    Ms. Brooks-LaSure. Absolutely.
    Senator Menendez. Ms. Palm, the same question to you.
    Ms. Palm. Yes, sir.
    Senator Menendez. Thank you.
    Now throughout the pandemic, Americans have deferred health 
care. An October 2020 study in JAMA found that primary care 
visits declined 21 percent during the second quarter of 2020 as 
compared to the same time frames in 2018 and 2019.
    In particular, I am deeply concerned that delays in cancer 
and other screenings will translate into an increase in 
advanced disease cases, and ultimately death as a result of 
millions of Americans avoiding routine preventative care over 
the past year. And once again, I feel these delays in care will 
disproportionately harm health-care outcomes for black and 
Latino communities, who already have less likely access to 
preventative care.
    So, Ms. Brooks-LaSure, what steps can the Centers for 
Medicare and Medicaid Services take to raise awareness and 
encourage Americans to seek important and necessary 
preventative screenings that have been delayed as a result of 
the pandemic?
    Ms. Brooks-LaSure. You are so right to raise this issue, 
with so many people being concerned about going back to their 
providers. Because of the Affordable Care Act, preventative 
services across several of the programs are free. Because of 
its importance, CMS needs to continue to educate providers, 
beneficiaries, patients, and families, and again, working with 
stakeholders who are trusted partners, to encourage people to 
get preventative care.
    Senator Menendez. Ms. Palm, what additional steps can HHS 
take to help raise awareness of this looming issue?
    Ms. Palm. It is a great question and really does lend 
itself to an opportunity across the Department, through our 
HRSA programs, to SAMHSA, to IHS, to the other avenues that we 
have, to reach the people that we serve with these messages 
encouraging folks to return for care, for the preventative 
treatment. So we should use all of our channels as well as our 
partners to reach people and encourage folks to return for care 
that they need.
    Senator Menendez. Finally, I worked on a bipartisan basis 
with members from both urban and rural areas at the end of the 
last Congress to secure 1,000 new Medicare-supported graduate 
medical education slots in the Consolidated Appropriations Act, 
the first increase in these positions in nearly 25 years.
    Senator Boozman and Leader Schumer joined me in 
reintroducing the Resident Physician Shortage Reduction Act, 
which would build upon our bipartisan success by further 
increasing Federal support for GME.
    Now that Congress has provided the slots, it will be up to 
the administration to determine their implementation, and it is 
important that they are distributed in a timely and efficient 
manner.
    How would you plan to ensure smooth implementation of these 
critical new GME slots, and how do you envision working with 
Congress to address physician shortages?
    Ms. Brooks-LaSure. Thank you, Senator, for your work on 
this critical issue. And I very much understand that the 
congressional intent is for these slots to go particularly to 
underserved areas. I, as we have talked about, want to make 
sure that we have an open dialogue, one with public notice and 
comment where stakeholders can engage, and certainly an open 
door to hear your views.
    Senator Menendez. I will look forward to working with you 
on that.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Menendez.
    Senator Bennet has to preside on the floor, so proceed.
    Senator Bennet. Thank you, Mr. Chairman, and I thank my 
colleagues for letting me jump in.
    Ms. Palm and Ms. Brooks-LaSure, thank you for your 
willingness to serve and for all the work you have done to pass 
and implement reforms such as the Affordable Care Act, which 
dramatically improved coverage and affordability for health 
care in this country.
    Despite the ACA's strides in coverage and affordability, 
many Coloradans and many Americans still face high costs and 
limited options. The American Rescue Plan expanded eligibility 
to the ACA premium tax credit. This capped how much Americans 
are paying for health plans on the exchange, which was, I 
think, very important, but still not enough.
    Separately, Senator Kaine and I have previously introduced 
the Medicare-X Choice Act. It would work within the Medicare 
framework to establish a public option for individuals, 
families, and small businesses. It would also make the American 
Rescue Plan caps permanent.
    As you know, President Biden ran on a public option as the 
answer to creating universal health care in this country, so I 
would ask that, if you are confirmed, that you--are both of you 
committed to working with me and others on the public option, 
and when it passes, implementing it to ensure that every single 
American has the health care that they need?
    Ms. Brooks-LaSure. Senator, thank you for your leadership 
on this issue, and for passing the American Rescue Plan which, 
as you have said, has significantly helped with affordability 
for middle-class families and given States options to expand 
the Medicaid program.
    Of course we will work with you, and really want to advance 
the President's agenda; and as you said, he is supportive of a 
public option.
    Senator Bennet. Ms. Palm?
    Ms. Palm. I would concur with my colleague. I look forward 
to working with you.
    Senator Bennet. I think this is something we should get 
done now. You mentioned it, Mr. Chairman, in your questions.
    The American people, coming through this pandemic, 
understand how critical it is for us to have, for everybody to 
have, access to primary care. And this was litigated 
extensively during the campaign, in both the Democratic primary 
and the general election.
    And so I hope the Biden administration will take us up on 
our offer to be helpful in fulfilling these commitments, and I 
look forward to working with the chairman as well.
    Children with complex medical needs may not be able to 
receive highly specialized care that they need in their home 
State. This requires families and State Medicaid officials to 
go through the difficult process of finding out-of-State 
providers. Senator Grassley and I worked hard to pass the ACE 
Kids Act, which will be implemented in October of 2022 and 
would enable better care coordination for these kids to make 
sure that they get the best services, no matter where they 
live.
    As a follow-up, last year we introduced the Accelerating 
Kids Access to Care Act. This bill would provide certainty for 
State Medicaid agencies to better determine who is responsible 
for paying and reduce regulatory burdens that can slow or 
prohibit access to care.
    If confirmed, will you commit to a timely implementation of 
the ACE Kids Act and work with us on the Accelerating Kids 
Access to Care Act so we can make sure we are taking care of 
the Nation's most sick kids.
    Ms. Brooks-LaSure?
    Ms. Brooks-LaSure. Yes.
    Senator Bennet. Thank you.
    Ms. Palm. Yes. I would welcome the opportunity, Senator.
    Senator Bennet. Thank you. I would welcome the opportunity 
too.
    I guess I have time for one more question, so I am going to 
ask one. In December we passed the No Surprises Act, which will 
end the practice of surprise billing. I think this was a major 
step to protect patients who are often taken advantage of in 
their most vulnerable state. I have been working on that effort 
for years with Senators Cassidy and Hassan and others on the 
committee, and I am grateful it was signed into law.
    Ms. Brooks-LaSure, in your written statement you mentioned 
you have the responsibility to implement the legislation when 
it goes into effect next year.
    Can you highlight your thoughts on eliminating surprise 
billing and reiterate your commitment to implement the 
legislation over the next year, should you be confirmed?
    Ms. Brooks-LaSure. Thank you, Senator, and thank you to 
this committee, which has done so much work. Surprise billing 
has been an incredibly difficult issue for patients. Several 
States, before you passed legislation, had legislation on the 
books, but thank goodness that you all were able to reach a 
bipartisan agreement and really make sure the protections are 
in place.
    If confirmed, I will absolutely work very hard to implement 
the regulations. I know we are on a very tight timeline, so I 
hope that I am so fortunate to be confirmed quickly to help 
with that effort.
    Senator Bennet. Great. Thank you very much for your 
testimony.
    Thank you, Mr. Chairman.
    The Chairman. I thank my colleague.
    Senator Carper is next.
    Senator Carper. Good morning. Great to see you both. I 
enjoyed talking with you by phone the other day. Thank you for 
joining us today, and congratulations on your nominations. We 
look forward to a swift confirmation, and the opportunity to 
work with you for any number of years.
    I have the opportunity--we have a bunch of caucuses here in 
the U.S. Senate, as you may know. One of those is called the 
Senate Community Health Center Caucus, and the last time I 
checked, we have about 1,400 federally qualified community 
health centers across the country.
    I think one of the smart things this administration has 
done early in its tenure is to make sure that people in 
neighborhoods across America can go to the federally qualified 
community health center and be vaccinated. I think that is a 
great move, and I think as we especially reach out to 
communities of color, folks who are frankly skeptical of taking 
the vaccine at all, it is a very wise move.
    Ms. Palm, can you think of any other areas where community 
health centers could be better leveraged to address rural and 
ethnic health disparities and our pandemic recovery?
    Ms. Palm. Thank you for those questions, Senator, and for 
your leadership on this issue.
    I think from my experience in Wisconsin, I can tell you our 
partnership with our community health centers was critical, 
both before the pandemic and during the pandemic. Areas like 
behavioral health and their ability to be providers in that 
space, particularly in rural communities, were critical assets 
they brought to the table. We have a shortage of dentists in 
the State of Wisconsin, so dental care in our community health 
centers is a critical access issue, again particularly in rural 
communities.
    But to your point, their ability to reach underserved and 
ethnic minority communities is really critical for us to tackle 
some of these health disparity issues and deal with those head-
on. So I think there are lots of opportunities for us to 
continue to work with those critical partners, and I look 
forward to doing that.
    Senator Carper. Good.
    Ms. LaSure--do people call you ``Ms. LaSure,'' or do they 
call you ``Ms. Brooks-LaSure''?
    Ms. Brooks-LaSure. They call me Chiquita. [Laughing.]
    Senator Carper. I want so badly to ask you who you are 
named after, but I am not going to go there.
    Ms. LaSure, as you know, we are not out of the woods yet on 
the pandemic. I think we are making some good progress; a lot 
still to be done, but it is incredibly important we keep the 
main thing the main thing--that is, to get as many people 
vaccinated as quickly as we can.
    When I was Governor, I was very active with the National 
Governors Association and helped stand up something called the 
American Legacy Foundation, which was very actively involved in 
messaging on youth smoking, trying to convince young people not 
to use tobacco, and those who were using it to stop. Hugely 
successful initiative--hugely successful initiative.
    And we are in a situation right now where we need a hugely 
successful messaging process on convincing people to accept 
vaccinations. And part of that is coming out of the private 
sector, part of it is coming out of like NYU, part of it is 
coming out of a coalition led by former Governors of, I think 
of Idaho and Massachusetts.
    But I think it is a shared responsibility, and just talk to 
us, if you will, about that shared responsibility, the role the 
Department of Health and Human Services plays in getting that 
message out and convincing people to take the vaccine.
    Ms. Brooks-LaSure. It is so important. Thank you for your 
leadership in this area, making sure that people know and are 
aware that they can get vaccines, that they do not have to pay 
for them.
    I, once again, want to talk about how what I really would 
like to see for CMS is to continue to partner with 
organizations. One of the things that I have heard over the 
last couple of months is how much people want to know, have 
their providers taken the vaccine? My brother-in-law, who sees 
many patients--he is a nephrologist--got vaccinated in part to 
make sure his patients knew he had taken the vaccine. And I 
think it is critical that we, if confirmed, at CMS are making 
sure that all the programs are encouraging this; that the plans 
are encouraging patients to know that this is an option.
    Senator Carper. One last quick question--and you can answer 
this for the record, but answer it a little bit while we are 
here--and that is, dealing with drugs, trying to rein in drug 
prices with the help of the Senate Finance Committee in 
Congress--and this would be for you, Ms. LaSure.
    In your testimony, I think you mentioned that, although 
research is finding new ways to conquer disease and improve our 
quality of life--and this is a quote, I believe, from you--``we 
must bear in mind, though, that innovation is only effective if 
patients can actually afford it,'' close quote.
    That being said, in the interest of reining in health-care 
costs in collaboration with the committee and Congress, as CMS 
Administrator, how do you plan to use your role to address 
prescription drug costs? Please.
    Ms. Brooks-LaSure. Thank you. This committee has done so 
much bipartisan work on prescription drugs. We have to address 
this issue and make sure that we are lowering costs for these 
innovative medicines; and as Ranking Member Crapo said, we have 
seen so much innovation, and we want to make sure that people 
have it available.
    I want to work with you all to make sure that we lower 
prescription drug costs--and am open to really working closely 
with you all on that.
    Senator Carper. Oh, you will have an opportunity in 
answering questions for the record to respond more fully, but I 
really was looking for, how do you plan to use your rulemaking 
authority to address prescription drug costs. I realize we are 
in this together, and we look forward to working towards that. 
Thank you.
    The Chairman. Thank you, Senator Carper.
    Senator Grassley?
    Senator Grassley. Thank you, Mr. Chairman. I want to take 
up where the Senator from Delaware just left off, because 
Senator Wyden and I have been working together for well over a 
year to lower prescription drug prices. Our bipartisan bill 
would cap out-of-pocket costs for seniors at $3,100. It slows 
the rate of growth of drug costs, saving the taxpayers $95 
billion. Some believe we should let the government do more than 
what our bill would do. I am not sure that CBO is very 
interested in giving us much cost savings on that, if any. And 
some people in CBO would say if you did more, you would have to 
limit consumer choice and access to lifesaving drugs.
    I believe that Congress must pass a bipartisan prescription 
drug bill if it is going to get done. I suppose if Democrats 
stuck together, then you could do it under reconciliation and 
that argument would not hold, but I hope that is not the course 
you go. And I think that a Wyden-Grassley bill could get 60 
votes very easily.
    The bill has meaningful provisions to lower drug prices. So 
is there any interest in the administration beyond what you 
told Senator Carper to working on enacting bipartisan 
prescription drug legislation?
    Ms. Brooks-LaSure. Senator Grassley, I so enjoyed our 
conversation and so appreciate your leadership with Chairman 
Wyden on this area and this issue, as I know you all care very 
deeply about making sure that we lower costs for patients and 
families. I have heard it from almost everyone--I think in all 
of my discussions--how much you all care about prescription 
drugs, and the administration certainly wants to work with 
Congress to come up with solutions for patients.
    Senator Grassley. And would I assume that that would be in 
a bipartisan effort?
    Ms. Brooks-LaSure. Absolutely, if people are interested--
which I know you are--in lowering costs. The importance is in 
making sure we get this right.
    Senator Grassley. On rural health care, this is a big item 
for me and even for the chairman, because Oregon has a lot 
rural areas as well. I led a charge to create a newly voluntary 
Medicare payment program called Rural Emergency Hospitals. It 
is a new voluntary Medicare designation; I suppose something 
specifically for critical access hospitals. It would let 
hospitals maintain essential medical services in their 
communities, like 24/7 emergency care, outpatient care, 
ambulance services, and obviously a lot more. It will also let 
certain rural hospitals right-size their health-care 
infrastructure, letting them provide services that better align 
with the needs of their community.
    Maybe this is something both of you should comment on; of 
course, you do not have to repeat the first person. But for 
both of you: can I have your commitment to implement the Rural 
Emergency Hospital program as quickly as possible--and I 
suppose as fairly as possible?
    Ms. Brooks-LaSure. Yes.
    Ms. Palm. Yes.
    Ms. Brooks-LaSure. You have my commitment, Senator.
    Senator Grassley. Okay. Thank you, and I appreciated that 
discussion we had in my office.
    This will probably have to be my last question. During the 
last 2 years as chairman of this committee, I worked to ensure 
that HHS's Office of National Security received access to 
intelligence community information. This included information 
involving threats to the Nation's health because of the virus. 
That office has gained access to some intelligence community 
elements, but more must be done.
    On March 8th, I wrote a follow-up letter to HHS and the 
Director of National Intelligence, asking what they have done 
to incorporate Federal health agencies into the intelligence 
community. HHS has failed to respond, so I hope you can help us 
get a full response to that letter.
    So let me go on to the second question. Do you agree that 
China is a significant and consistent bad actor when it comes 
to stealing U.S. taxpayer-funded intellectual property and 
academic research? If so, what will you do to protect American 
work products from the Communist Chinese Government's theft and 
espionage activities?
    And if you do not feel that way, why.
    Ms. Palm. Senator, I will take that one first.
    If I am lucky to be confirmed as Deputy Secretary, I think 
this just is a place where my office--and where I--will 
certainly play a role in making sure, to your point, that HHS 
is read into intelligence that pertains to our health-care 
system, our data privacy, and some of the cyber issues that we 
hold at the Department.
    To your point on intellectual property, I think it is a 
critical issue as we think about how we maintain and reassert 
our leadership in technology and innovation, and bringing our 
products to market in a way that continues to drive the health-
care system forward. And I would look forward to the 
opportunity to work with you on both of those issues, should I 
be confirmed.
    The Chairman. I thank my colleague.
    Senator Cardin----
    Senator Carper. Mr. Chairman, can I be recognized for 30 
seconds out of order, please?
    The Chairman. Sure.
    Senator Carper. To our witnesses I will say, I have the 
privilege of working along with Sheldon Whitehouse and Ben 
Cardin and others on this committee, and on the Environment and 
Public Works Committee. We spent a lot of time in the last 
Congress trying to come to agreement on water infrastructure, 
clean drinking water, that sort of thing; wastewater or 
sanitation stuff.
    We came close to getting it done; could not. We came back, 
and we were using that as a building block. To work on it, we 
are going to be on the floor next week with our water 
infrastructure legislation, all bipartisan.
    And the other thing is, we spent a lot of time in the last 
Congress trying to pass service transportation reauthorization, 
a 5-year bill, and which we have part of the jurisdiction for; 
could not get it done. We are coming back and using what we did 
last year as a building block.
    I just think you--and Mr. Chairman, you and Senator 
Grassley, before he leaves--you fellows did great work, 
absolutely great work. And we ought to be using your work as a 
building block in this Congress on drug pricing, and I would 
just urge us to do that. Thank you.
    The Chairman. I thank my colleague for his kind words. I 
know we are going to talk about that topic this afternoon.
    Our next member is Senator Cardin, who is on the web.
    Senator Cardin. Thank you, Mr. Chairman, and let me thank 
both of our nominees for their willingness to serve our 
country.
    Ms. Palm, I would like to start with a question following 
up on Chairman Wyden's point in regards to minority health and 
health disparities. I heard your answer, but I would like to at 
least call attention to the fact that we have offices within 
the Department of Health and Human Services that are devoted to 
minority health and health disparities. We have the National 
Institute of Minority Health and Health Disparities, and we 
have been talking about a commitment to really deal with the 
systemic challenges that we have in health care in America. It 
came out very clearly in COVID-19.
    So I would ask if you are committed to using every resource 
we have, including the direct involvement by your office in the 
minority health offices to develop a strategy to make 
fundamental changes in our health-care system to help the 
underserved communities. Your response?
    Ms. Palm. Sir, I appreciate your raising this, and for your 
leadership in the creation of those components at HHS. And 
certainly, we need to integrate them in our work, because I 
think the challenge is that we cannot allow those offices to be 
seen as the only places where that work happens.
    And so it is critical that they exist, but it is critical 
that we integrate them in a way that helps us all be 
accountable for the equity work that we need to do.
    Senator Cardin. I thank you for that. I agree completely 
with that. These offices are critically important, but they 
need to be integrated into the overall strategy on our health-
care policies.
    I also was listening to my colleagues talk about 
telehealth, and I certainly concur in their view that 
telehealth offers tremendous potential for access to care, 
particularly in underserved communities. We have talked about 
it being available for those who understand how to use 
telehealth and have the access to it, but we also need to make 
a priority of dealing with the underserved community, with 
access to telehealth as well as structural changes within the 
reimbursement structure, to allow the development of telehealth 
in so many different fields.
    We did that during COVID-19; we made some of those 
provisions permanent. We need to expand that, and I look 
forward to working with you and the other members of the 
committee as we expand telehealth.
    Ms. Brooks-LaSure, I want to ask you--we had a chance to 
talk about the fact that the Department has started the process 
of filling the position of Chief Dental Officer. I just really 
want to underscore the importance of getting that position 
filled as soon as possible. It was vacant during the Trump 
administration, but it demonstrates a priority within CMS to 
deal with the issues of oral health.
    So I hope that you will pay attention to getting that 
position filled when you are confirmed.
    Ms. Brooks-LaSure. Absolutely, Senator Cardin. You have my 
commitment on that, and I want to thank you for your leadership 
in keeping the memory alive of the young boy who died because 
of lack of dental coverage. It will be a priority of mine to 
make sure that the Medicaid and CHIP programs have a dental 
officer who is informing the work.
    Senator Cardin. Thank you. Deamonte Driver was that 
individual who died in my State in 2007, and it did change our 
understanding of the importance of oral health care, as policy-
makers, and I am pleased that we took action both in the CHIP 
program and in the Affordable Care Act program.
    My last point deals with the issue of prescription drugs, 
and one area which is totally unacceptable. In the wealthiest 
Nation in the world, we have relatively inexpensive drugs that 
are in drug shortage because drug manufacturers do not make the 
same amount of profit on those drugs as they do on others. In 
some cases, they are single-source manufactured drugs.
    And I would ask that there be a commitment by both of our 
nominees to make sure that that circumstance does not exist in 
this country, that we do not have drug shortages of inexpensive 
drugs that are not being made available solely because of the 
lack-of-profit motive to the private sector.
    And if I could have a commitment to work with us to deal 
with those drug shortages--let me start first, if I might, with 
Ms. Palm.
    Ms. Palm. Yes. It is a critical issue, Senator. You have my 
commitment.
    Senator Cardin. Thank you.
    Ms. Brooks-LaSure?
    Ms. Brooks-LaSure. And mine as well.
    Senator Cardin. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Cardin.
    The next member--and I believe he is on the web--would be 
Senator Thune. Is Senator Thune out there in cyberspace?
    [No response.]
    The Chairman. All right. Then Senator Brown is next, also 
on the web.
    Senator Brown. Thank you, Mr. Chairman. I just want to 
thank Senator Cardin for always raising oral health and dental 
health, and that is so, so important, both for Medicare, 
obviously, and Medicaid, but especially Medicaid and the work 
that he has done.
    Thank you for that.
    Thanks to both of the witnesses for their willingness to 
serve and for their commitment to reducing health disparities, 
prioritizing policies to address social determinants of health. 
The history of institutional racism within our health-care 
system continues to affect health outcomes for communities of 
color.
    I chair the Banking, Housing, and Urban Affairs Committee. 
We just had a hearing yesterday on, from the Black Codes to Jim 
Crow to redlining, to the Trump administration locking in 
discriminatory housing practices, what that has meant to health 
care and to wealth accumulation and inequality and all that. So 
what you are doing in health care is so very important.
    Ms. Brooks-LaSure, a question first for you. Medicaid and 
Medicare are not just payers; they are powerful tools to 
advance health-care quality and access to improve population 
health outcomes and act as economic drivers for workers in 
their communities.
    Will you commit to working with my staff and others on this 
committee to create and strengthen initiatives across CMS to 
address social determinants of health and reduce health 
disparities?
    Ms. Brooks-LaSure. Absolutely, Senator. And thank you for 
your leadership in this role, this critical issue. And it is 
certainly a priority of mine.
    Senator Brown. Thank you. We knew that; we wanted to hear 
you say it again. So thank you.
    One of the topics I raised with Secretary Becerra at his 
confirmation hearing was the growing gulf between traditional 
Medicare and Medicare Advantage. In recent years, both Congress 
and HHS have expanded the scope of benefits available to those 
enrolled in Medicare Advantage plans without doing so for those 
individuals who choose to remain in traditional Medicare. You 
have seen what has happened over 20 years of essentially 
privatization efforts.
    This question is for you both. If confirmed, will you work 
with me to ensure all Medicare beneficiaries, whether they are 
in traditional Medicare or enrolled in Medicare Advantage 
plans, have access to the same benefits and out-of-pocket 
protections?
    Ms. Brooks-LaSure. Yes, Senator.
    Ms. Palm. Yes, sir.
    Senator Brown. Thank you.
    One final issue for Ms. Palm. The Children's Hospitals 
Graduate Medical Education (CHGME) program is of critical 
importance to Ohio's six freestanding children's hospitals. 
Senator Casey and I have for years worked together on a number 
of children's issues where he has led, and especially with 
children's hospitals. Our States have some of the best 
children's hospitals in the country.
    Ms. Palm, will you commit to working with Senator Casey and 
me and the future head of HRSA to make sure that the Children's 
Hospitals Graduate Medical Education program and training for 
the next generation of pediatricians remains a priority for 
this administration?
    Ms. Palm. I would be happy to, Senator.
    Senator Brown. Thank you. It has never been easy with any 
administration, by budget time and other things, for GME, for 
Children's Hospitals GME. So we are counting on you to be a 
little bit different and a lot better than some of your 
predecessors, Ms. Palm. Thank you so much.
    Mr. Chairman, I yield back a minute and 40 seconds.
    The Chairman. Thank you, Senator Brown. Always leading, 
always leading.
    Senator Thune, are you available now?
    [No response.]
    The Chairman. All right. Then we have Senator Casey and 
Senator Whitehouse next.
    Senator Casey?
    Senator Casey. Mr. Chairman, yes, thank you very much. And 
thanks for your leadership on a number of the issues we are 
going to raise with our two nominees. Ms. Brooks-LaSure and Ms. 
Palm, we are grateful for your willingness to continue public 
service, especially at this time.
    I wanted to start by talking about an issue that, frankly, 
we have not spent enough time on over the last decade in terms 
of what the Federal Government does, and that is home and 
community-based services.
    President Biden's American Jobs plan calls for a bold 
investment in a great American idea, which is Medicaid-only 
community-based services. The President has acknowledged what 
every family in America already knows to be true: caregiving is 
part of our basic American infrastructure. It is part of who we 
are; it is how we function. It is part of our efforts to build 
back better with the emphasis on the word ``better.'' Not the 
old way, not the way it was in 2019, but better. And I would 
hope much better.
    Just as our society needs bridges, waterways, and roads to 
function, families need services and supports to care for older 
family members, to care for people with disabilities, and to 
care for children. The President's proposal builds on the $12.7 
billion of funding for home and community-based services that 
was made possible when Congress passed the American Rescue 
Plan.
    We know that investing in home and community-based services 
will, number one, improve the lives of both seniors and people 
with disabilities. It will at the same time increase wages and 
benefits for workers; and thirdly, it will create jobs, a lot 
of jobs across the country.
    A majority of these workers are low-income women of color 
who earn an average of just $12 an hour. An investment in their 
work is not only long overdue, it is consistent with American 
values. If we claim to be the greatest country in the world but 
our home and community-based services are not anywhere near the 
best in the world, we cannot say we are the country we claim to 
be. And for seniors and people with disabilities, access to 
these services is the difference between simply just surviving 
and indeed thriving.
    So I would ask both Ms. Brooks-LaSure and Ms. Palm one 
fundamental question, and I am going to ask you both the same 
question. I would ask for your commitment to work with us to 
secure funding for these services, the funding the President 
has outlined, and thereby realize the President's vision for 
home and community-based services.
    Ms. Brooks-LaSure, I will start with you.
    Ms. Brooks-LaSure. Yes; thank you, Senator, for your work 
on this issue, and so many of the members of this committee. 
Yes, I pledge to work with you on this.
    Senator Casey. Thank you.
    Ms. Palm. You have my commitment as well, Senator. This was 
a priority in Wisconsin as we looked at the whole continuum of 
the long-term care system and making sure that we were 
modernizing and preparing for the needs of the future in this 
system. And it would be my pleasure to work with you moving 
forward.
    Senator Casey. Thanks very much. I will stay with Ms. Palm 
for this question. I am holding a document which I think I have 
held up when we had a virtual engagement; it is called ``Five 
Freedoms for America's Children.'' This is a document that our 
staff worked on for a good long time; we are about to reissue 
it in an even more ambitious form.
    But when I proposed the ``Five Freedoms for America's 
Children''--borrowing directly from Franklin Roosevelt's ``Four 
Freedoms''--we were focused on, of course, this in a domestic 
context for children. But what we wanted to do was put in place 
a strategy for America's children. The good news is, in this 
long, 33-page, 136-footnote document that I am very proud of, 
some of the proposals in there were achieved in the American 
Rescue Plan: the great expansion of the Child Tax Credit, for 
example; the expansion of the Child and Dependent Care Credit.
    So I would just ask Ms. Palm if you would make a commitment 
to working with me--and obviously as one of the leaders of the 
Department--working with me to get as much of this, of these 
five freedoms implemented in the time that you serve.
    Ms. Palm. I appreciate the question, and certainly your 
leadership on this issue. I think to your point, if I am 
confirmed, the Deputy Secretary has the opportunity to leverage 
across the Department. We touch children in a whole variety of 
ways, in various programs at ACF, at SAMHSA, at HRSA, and 
across the board, and I would welcome the opportunity to work 
with you moving forward on these critical issues.
    Senator Casey. Thanks very much, and, Mr. Chairman, thank 
you for working with me on all these issues. We are grateful.
    The Chairman. Thank you.
    Senator Casey. I have one question for the record on 
nursing homes.
    The Chairman. Very good. Thank you for your outstanding 
work.
    The order now is Senator Thune next, followed by Senator 
Whitehouse and Senator Hassan.
    So, Senator Thune.
    Senator Thune. Thank you, Mr. Chairman.
    Ms. Palm, I raised this issue with Secretary Becerra when 
he was in front of the committee, but the topic of 340B is 
enormously important to hospitals all across South Dakota and 
across the region; we have three systems that serve the State 
but also overlap into Minnesota and Iowa and Wyoming and 
Nebraska--places like that.
    And that program has been dysfunctional, I would say, for 
some time now. And we have heard concerns recently from covered 
entities in my State about actions taken by manufacturers, not 
reimbursing contract pharmacies, all of a sudden deciding to 
dispense with that--which they have questionable authority to 
do--and now PBMs that are imposing conditions on hospitals in 
order to get reimbursed, to get payment. And that affects their 
ability to continue to provide a robust community benefit.
    So it is an issue that has been hanging around for a long 
time; it is a program, obviously, that Congress has expressed 
support for in law, and it seems like a lot of the entities 
that are designed to make it work are trying intentionally to 
undermine the program.
    So I am curious, if confirmed, how the Department would 
respond to ensure that covered entities are not harmed by these 
actions taken in that sort of supply chain, if you will, both 
manufacturers and PBMs.
    Ms. Palm. Thank you, Senator, for this question. And you 
are right. I recall from my previous time at HHS that the 340B 
program was often a topic of conversation, and a challenge. So 
you are right, there are things we can and need to be doing in 
this space.
    I think to your point, it is a critical program for our 
safety net providers and for the low-income folks who are able 
to access drugs through the program. And I, if confirmed, would 
look forward to the opportunity to make sure that the program 
is working as it is supposed to be working, and that the 
oversight and implementation are appropriate so that we really 
are implementing legislative intent and getting to our safety 
net providers in low-income communities the access that they 
need.
    Senator Thune. Thank you. And I am going to hold you to 
that and follow up with you. But thank you for that answer. You 
are absolutely right, it needs to be fixed, and I hope that, 
once confirmed, you will help us get on top of this issue as 
quickly as possible.
    Let me just ask you too, if confirmed: the Indian Health 
Service is one of the many operating divisions that would fall 
under your purview. As you may know, for several years IHS 
facilities in the Great Plains region have struggled with 
staffing and quality-of-care issues.
    Could you discuss your approach for how you would manage 
IHS, drive quality improvements, and ensure accountability to 
Congress? And maybe the follow-up to that, would you support 
legislation that would enable IHS to terminate poor-performing 
employees, and also to streamline the hiring process to enable 
the recruitment of talented health-care professionals?
    Ms. Palm. I really appreciate the question, Senator. I 
think that IHS is such a unique part of the Department of 
Health and Human Services, and when I served previously, I had 
the opportunity to visit an IHS facility in your State, and so 
I certainly understand firsthand the need for the work that is 
before us to make sure that our tribal communities are 
receiving the high-quality care that they need.
    So I would look forward--I really appreciate you 
prioritizing this, because there is important work that needs 
to be done here to meet our mission at HHS as it relates to 
IHS, and I would look forward to working with you, both through 
the work we can do at IHS, but then you mentioned legislation. 
I would be happy to work with you legislatively if there are 
things we need to do in that space as well.
    Senator Thune. Thank you.
    And very quickly, Ms. Brooks-LaSure, CMS plays a 
significant role with IHS as a payer and because of its 
involvement in accrediting facilities and assessing compliance 
with quality and safety measures.
    Over the years, multiple facilities in my State have lost 
or were in jeopardy of losing CMS accreditation because of 
quality issues. What can we do to improve coordination between 
IHS and CMS in holding facilities accountable for delivering 
the highest quality of care?
    Ms. Brooks-LaSure. This is a critical issue, and we have to 
maintain our commitment, as the government, to work with Indian 
populations to make sure they are getting the care that they 
need. I pledge to work with my colleague to make sure that IHS 
and CMS are coordinating well, and, whether it means that CMS 
needs to provide technical assistance or take other steps, we 
will work with you on this.
    Senator Thune. Thank you.
    And thank you, Mr. Chairman. I would just point out one 
thing I forgot to mention. North Dakota is also a State that is 
impacted by all these 340B issues; the regional systems that 
serve South Dakota also serve North Dakota.
    The Chairman. Thank you, Senator Thune.
    Senator Whitehouse?
    Senator Whitehouse. Thank you, Mr. Chairman. Welcome to 
both of you. I have 5 minutes to ask you four questions, so I 
will try to go quickly, macro to micro.
    We have trillions of dollars in debt. Now, 2024 is the 
first insolvency date for Medicare, and as my perennial graph 
that I have shown you before shows, something happened in here 
[pointing to graph] that has saved $6 trillion in Federal 
health-care spending predicted within the next decade. I think 
that what happened in here was delivery system reform.
    And I am asking that both of you agree that this needs to 
be a top priority for CMS and HHS, to figure out why that has 
happened and to do more of it. Do you agree?
    Ms. Brooks-LaSure. Yes, Senator. I think that delivery 
system reform is critical for addressing costs, making sure 
that we are delivering the care that people need, and CMS will 
continue to look at its authority, through the Innovation 
Center and through the Medicaid program, to continue to work on 
these issues.
    Ms. Palm. I would echo my colleague and would just suggest 
that it is also the opportunity to put patients at the center 
of care, as we are thinking about this.
    Senator Whitehouse. Second point: ACOs. We have a lot of 
really wonderful ACOs where I live. I have two of the best-
performing ACOs in the country, and it has been a constant 
battle to defend the ACOs from you guys trying to pick their 
pockets before they really get the reward of the investment 
that they have made. We are seeing ACO participation shrinking 
rather than growing. And you need to make sure that the ACO 
lead dogs who are crafting a new model of care actually get 
supported and encouraged so that that model of care can 
propagate.
    Ms. Palm. Senator, you have raised such an important issue, 
which is that we want to make sure that our private-sector 
stakeholders want to continue to innovate. And, if confirmed, I 
will work with you to make sure that our incentives continue to 
keep innovators wanting to innovate.
    Senator Whitehouse. Thank you. We have another project on 
end-of-life care where we will ask for waivers of some Medicare 
payment regulations that are frankly stupid when they are 
applied to this population. And I have been working on this now 
for 8 years, and every time we get close, there is an 
administration change or a personnel change or something, and 
it is imperative to get a CMMI waiver to make this happen.
    Will you promise that you will work with me to help me get 
this CMMI pilot and those requisite waivers?
    Ms. Brooks-LaSure. If confirmed, Senator, I am happy to 
understand this demo better and work with you on what we can do 
here.
    Senator Whitehouse. Yes; I come into this boiling with 
frustration because of 8 years of work--and it always falls off 
the ledge because of a change in the executive branch. And I am 
going to get this done.
    Then the last thing is, we are working with medication-
assisted treatment. We have seen telehealth be very helpful in 
this space. There is an ongoing conversation about the extent 
to which that telehealth engagement needs to be video 
conference and when it can be the audio conference. With people 
who do not have a home to go to, people who are in perilous 
circumstances of various kinds, the audio can be actually 
necessary, and often can be mediated by responsible groups that 
are serving that population.
    Can you help me understand the best practices for the video 
versus audio and also have somebody from HHS and CMS assigned 
to give me advice on where we should be fighting to draw that 
line: when is audio okay; when do you actually need it to be 
video for medication-assisted treatment in telehealth?
    Ms. Palm. Yes, Senator, this is a critical issue. So many 
underserved areas struggle with this distinction; and as much 
as we have seen telehealth improve care for some, we need to 
make sure that it really is available for all. I am happy to 
talk to you and learn more about this.
    Senator Whitehouse. I will wrap up with the observation 
that a lot of people, including our people in our national 
security establishment, have said that the biggest issues to 
America actually are the debt and deficits, and they go on to 
say that it appears that the biggest part in our debt and 
deficit area is this explosion of health-care expense. So that 
begs this question of how you draw down without taking benefits 
from people and making this really turgid system clear, fast, 
and efficient and provide people care early so they do not have 
the expensive care. That to me is just such an important 
priority. I hope you will see it that way. You may end up being 
the most important people in government, as I see it, in 
solving that problem. Thank you.
    The Chairman. Thank you, Senator Whitehouse.
    Senator Hassan?
    Senator Hassan. Well, thank you, Mr. Chair; and I want to 
thank you and our ranking member for this hearing. And to our 
nominees, thank you both for being here, for your willingness 
to serve, for the service you have already provided to your 
country and your State, and to your families too.
    And I want to associate myself with everything that Senator 
Whitehouse just asked you about; and I will just say that I 
know Senator Bennet asked about the elimination of surprise 
medical bills. I think that, the passage of that legislation to 
end that practice, was an example of really patient-focused 
policy-making. So I would look forward to working with you both 
as we implement that provision and find further ways to really 
look at our health-care system from the patient's perspective. 
And I appreciate very much your willingness to do that.
    Ms. Palm, I wanted to start with a question to you. As you 
know, the COVID-19 pandemic has exacerbated the ongoing 
substance use disorder crisis in the country. It is critical 
that Congress and HHS work together to ensure that States 
receive the funding that they need to support continued access 
to substance use disorder treatment and services.
    Over the past several years, State opioid response grant 
funding has allowed New Hampshire to dramatically expand access 
to opioid use disorder treatment and services for Granite 
Staters. But under the current funding formula, a significant 
portion of New Hampshire State opioid response grant funding is 
now at risk.
    I am working to ensure that States like New Hampshire do 
not face dramatic funding cuts that would devastate opioid use 
disorder treatment programs. Will you commit, Ms. Palm, to 
working with Congress to ensure that States do not face 
dramatic cuts in State opioid response grant funding?
    Ms. Palm. Senator, I am so grateful for your leadership on 
this issue, and considering what we have seen with the 
pandemic--we were making such good progress--we have to double 
down. And it is critical that States have the funding that they 
need to continue to provide treatment for opioid use disorders.
    Senator Hassan. Thank you very much.
    Ms. Brooks-LaSure, I want to turn to you, and I just want 
to say that I have two of the most eloquent colleagues in the 
world, Senators Menendez and Casey, when it comes to talking 
about home and community-based services.
    So I will associate myself with their comments about the 
importance of it. We know how important it is to individuals 
and families to have the choice to get their long-term care at 
home among familiar faces, in their community, and a chance to 
really interact with their loved ones and control their care 
that way.
    But I want to drill down on a couple of things. 
Unfortunately, many individuals who receive care in home and 
community-based settings have really faced unique challenges 
accessing, for instance, COVID-19 vaccines. And we know that 
home health workers have struggled to access the personal 
protective equipment and COVID-19 testing that they need to do 
their jobs safely. Just as we saw other disparities really 
highlighted by the pandemic, the disparity in terms of being 
either a home health-care patient or a home health-care worker 
has really been exacerbated too.
    So, following up on the commitment you made to Senators 
Menendez and Casey, as CMS Administrator, how would you work 
with States to better support home health-care workers and 
individuals who receive home and community-based care during 
the COVID-19 pandemic?
    Ms. Brooks-LaSure. Thank you, Senator. This issue you 
raised, and the other Senators have raised, is such a critical 
issue. We want to make sure that people are in the setting that 
makes the most sense for them. And if confirmed, you certainly 
have my commitment to make sure that CMS is doing everything it 
can do, whether it is approving waivers or working with States 
to address issues; and I would love to follow up with you on 
this particular point.
    Senator Hassan. Well, I would look forward to that as well, 
because it continues to be a really serious issue.
    I have one more question, and it is to Ms. Palm. As the 
Secretary of the Wisconsin Department of Health Services, you 
emphasized the importance of health data infrastructure in 
expanding access to COVID-19 testing.
    With the continued emergence of COVID-19 variants, ongoing 
surveillance and health data exchange will be essential for 
tracking emergent variants and mitigating community spread.
    If confirmed, how will you leverage the tools at CMS or 
throughout the Department to incentivize health data 
modernization and improve data exchange?
    Ms. Palm. It is such an important question. I think, more 
broadly, our data infrastructure, our technology, our 
modernization of the way we think about surveillance and data 
is critical, and it is a place where HHS can and should help be 
a leader, so that we are learning the lessons of what our data 
infrastructure could do and could not do; what we need it to 
do; where we could partner with the private sector to really 
maximize our ability to understand community spread in the 
example you gave; and how that helps us get in front of the 
next surge or the next community that is facing an outbreak.
    And so there is a lot of opportunity there, and I think we 
really have to be focused, learn the lessons, and drive that 
into the next iteration of how we work on data and the 
transparency of that data moving forward.
    Senator Hassan. Thank you very much. I look forward to 
working with you on that.
    Thank you, Mr. Chair.
    The Chairman. I thank my colleague.
    Next is Senator Daines.
    Senator Daines. Thank you, Mr. Chairman.
    Due to the open-border policies of this administration, we 
are experiencing a public health and, sadly, humanitarian 
crisis at our southern border. I saw it firsthand myself; other 
Senators on this committee in fact were there as well, 
including Senator Cornyn just a few weeks ago.
    We had a chance to talk face-to-face with the border patrol 
agents, who are overwhelmed by the influx of migrants at the 
border. The Donna, TX facility has a capacity of 1,000. With 
COVID, they reduced that number to 250. There were 4,200 
migrants in that facility the day we visited, about 2\1/2\ 
weeks ago.
    If confirmed, you will help oversee the agency that handles 
care for unaccompanied children.
    Ms. Palm, do you think the current situation at the 
southern border is a crisis?
    Ms. Palm. Senator, I am so grateful that you raised this. 
This is one of the most pressing issues that HHS is working on 
right now; and should I be fortunate enough to be confirmed, I 
look forward to being part of helping get these children 
through the system and placed in safe places with sponsors as 
quickly as possible.
    Senator Daines. Do you think it is a crisis?
    Ms. Palm. I think it is a very urgent need, and----
    Senator Daines. Have you seen it?
    Ms. Palm. I have not been to the border.
    Senator Daines. Have you seen the photos of the children in 
these overcrowded facilities with no COVID protocols in place? 
You know, I come from a northern border State. The northern 
border is still virtually shut down. The southern border had 
4,200, many of whom were children, in this facility with a 250-
person capacity. A high percentage of COVID transmission is 
going on, high positive COVID test rates.
    Have you seen those photos with really no COVID protocols 
in place?
    Ms. Palm. I have, Senator, and I can tell you as a social 
worker, the care and safety of those kids has to be our top 
priority at HHS, and if I am confirmed, I certainly will----
    Senator Daines. And you are aware of what is going on 
across the Mexican desert with the cartels and the coyotes, the 
human trafficking, the abuse of these children that is going on 
as a result of creating an incentive by the Biden 
administration for them to make that dangerous journey, give 
their life savings away to the cartels to come across 
illegally?
    Ms. Palm. I think one of the most important parts of the 
process for us in placing these children with sponsors is that 
screening, to make sure that those children are going to safe 
homes, trusted homes, so that we are--so that human trafficking 
and those abuse issues are screened out.
    Senator Daines. Yes, but once you get across the border, 
the trafficking issues and the abuse issues have already 
occurred. This becomes a question of, how do we prevent that 
and frankly stop it?
    Ms. Palm. Senator, I know that there are--my colleagues 
across the administration are looking at the broader issues at 
play here, at the root causes and other issues. What I can tell 
you is, should I be confirmed, our focus at HHS will be on the 
safety of those children's placement in safe homes and finding 
efficiencies in the system so that we are moving them quickly.
    Senator Daines. Thank you. Do you think that the Vice 
President, who the President has put in charge of resolving the 
issue at the southern border, do you think she should be 
visiting to see firsthand what is happening on the southern 
border and witness conditions that we all saw here 2\1/2\ weeks 
ago?
    Ms. Palm. I think the Vice President has been tasked with a 
great challenge, and I am sure she is doing everything she 
needs to do----
    Senator Daines. Why--we are just curious, why wouldn't she 
go down and see this firsthand? The President has given her 
explicit responsibilities. And that was 20 days ago. And she 
has yet to show any interest in actually visiting the southern 
border; has not shown up.
    Ms. Palm. Senator, what I can tell you is, should I be 
confirmed, I really want to emphasize the priority that we have 
on placing those children as safely and quickly as possible.
    Senator Daines. Throughout the pandemic, assisted living 
providers in my home State have cared for over 6,000 vulnerable 
Montanans, many of who are living with Alzheimer's or some form 
of dementia.
    Due to PPE needs, workforce needs, occupancy deadlines, 
many of these providers have suffered millions in losses 
throughout the pandemic and will struggle to sustain their 
operations without financial relief. There is about $23 billion 
remaining in the Provider Relief Fund to help support our 
health-care heroes, who are on the front line of the COVID 
response. I have urged Secretary Becerra to distribute more of 
the remaining PRF to assisted living facilities and other 
senior care centers.
    Ms. Palm, would you support that kind of request?
    Ms. Palm. Yes; to your point, our front-line health-care 
workers have borne the brunt of this pandemic. When I was in 
Wisconsin, we added additional dollars to what the feds were 
providing to help ease the workload and the burden that they 
were facing.
    Senator Daines. Thank you.
    One final question for Ms. Brooks-LaSure.
    I founded this pro-life caucus in the United States Senate. 
I am deeply committed to protecting the most vulnerable, and 
that is the unborn. That is why I was troubled to see the 
Democrats' $1.9-
trillion, quote ``rescue package'' include a taxpayer funding 
of abortion and numerous provisions, including through 
Obamacare.
    If confirmed, how will you ensure compliance with separate 
billing requirements for abortion under section 1303 of 
Obamacare?
    Ms. Brooks-LaSure. Senator, I will, if confirmed as CMS 
Administrator, absolutely follow the law. And Congress sets 
that, and whatever the requirements are, I will meet those.
    Senator Daines. And more specifically, will you require 
recipients of abortion-covering plans with zero-cost premiums 
due to the expanded tax credits to pay the required abortion 
coverage surcharge of at least a dollar a month?
    Ms. Brooks-LaSure. Senator, I will follow the law. So if 
that is the law, I will move forward with whatever you, as 
Congress, have passed for me to do. Those are my 
responsibilities.
    Senator Daines. Thank you.
    The Chairman. Thank you, Senator Daines.
    Next is Senator Cornyn.
    Senator Cornyn. Ms. Palm, as I think the chairman will back 
me up on this, China has risen to the top of everybody's 
agenda, out of concerns about cybersecurity, cyber-attacks, 
stealing intellectual property, espionage, obviously with vast 
national security implications.
    So I will ask you some specific questions in writing later 
on, but I want to follow up on some of the things that Senator 
Daines raised, because it has such a dramatic impact on my 
State and the country.
    So, if confirmed, you would oversee the Office of Refugee 
Resettlement, correct?
    Ms. Palm. Yes, as part of the Administration for Children 
and Families; yes.
    Senator Cornyn. And you mentioned that the goal, your goal, 
would be to place these children, unaccompanied children, with 
sponsors as soon as you could.
    Ms. Palm. Yes. Our mission is to find the sponsors, the 
families, the relatives to care for these kids while their 
immigration processes are proceeding.
    Senator Cornyn. And after you have placed them with 
sponsors, is the responsibility of the Office of Refugee 
Resettlement finished?
    Ms. Palm. As I understand it, Senator, yes.
    Senator Cornyn. Which government agency monitors the 
welfare of these children once they are placed with sponsors? 
Is there any government agency you are aware of that has that 
responsibility?
    Ms. Palm. It is my understanding--and I'm happy to follow 
up--that if there are concerns once they are placed, State 
child welfare agencies can become involved in those situations.
    Senator Cornyn. Are you aware of the fact that roughly 18 
percent of the wellness checks, telephone calls made to the 
sponsors' telephone number, go unanswered?
    Ms. Palm. I did not know that, sir.
    Senator Cornyn. Are you aware of the investigation--the 
Permanent Subcommittee on Investigations of the Homeland 
Security and Governmental Affairs Committee revealed that some 
unaccompanied children, once placed with sponsors, I believe in 
Ohio, were put into a forced labor condition. Have you heard of 
that?
    Ms. Palm. I have heard of that, sir, yes.
    Senator Cornyn. So do you share my concern for the welfare 
of these children once they are placed with these sponsors who 
may not even be American citizens, who may not even be related 
to the child?
    Ms. Palm. Senator, our mission at HHS is the safety and 
welfare of those children while they are in our custody; and it 
is our job to screen those sponsors before placement; and 
should I be confirmed, I certainly am committed to doing that 
work.
    Senator Cornyn. Well, after they have been placed with the 
sponsors, who is supposed to protect these children?
    Ms. Palm. Senator, as I mentioned, it is my understanding 
that, if there are concerns beyond the placement, our placement 
and the transfer of custody to those sponsors, child welfare 
agencies may get involved.
    Senator Cornyn. So there may or may not be a report to the 
child welfare agencies if these children are put into a forced 
labor situation or if they are being trafficked for sex or they 
are being recruited into gangs? We are supposed to wait on a 
report from somebody that alerts the child welfare system. Is 
that correct?
    Ms. Palm. Senator, it is my understanding that, if there 
are concerns post-placement by HHS, child welfare agencies may 
become involved.
    Senator Cornyn. Well, let us talk about while these 
children are still in the custody of HHS and the Office of 
Refugee Resettlement. Last week my Governor, Governor Abbot, 
sent a letter to Vice President Harris with regard to 
complaints of sexual assault while the young children, I think 
they are all males, were located at the Joe Freeman Coliseum in 
San Antonio in an HHS facility.
    The complaints outlined multiple allegations involving 
sexual assault, shortage of staff to supervise the children, 
and reports that the children were not receiving enough food. 
There were also complaints that the children who have been 
exposed to COVID were not properly isolated from other children 
who were not, had not been exposed.
    Obviously these allegations, if true, are extremely 
disturbing. What steps would you take, if confirmed, to address 
these sort of allegations?
    Ms. Palm. Senator, these are serious allegations and 
certainly ones that I take seriously. Should I be confirmed--I 
think there are a couple of things here. From my experience 
previously but also my priorities moving forward, there is a 
zero-tolerance policy for abuse in HHS facilities. There is an 
internal investigation and, because they are mandatory 
reporters, there also is an external investigation that comes 
forward. Staff are removed from the facility pending that 
investigation, and that speaks to the seriousness with which 
HHS takes allegations around abuse of children in our care.
    As it relates to COVID protocols, obviously that is a 
critical part of reducing the spread of COVID, and it is my 
understanding that CDC is both providing assistance in the 
development of those protocols but also that there are CDC 
folks on the ground at our facilities to help with 
implementation and to help make sure that what is necessary is 
being done. But if there are concerns that that is not 
happening, I would look forward to hearing about them and 
working with you to make sure that those COVID protocols are in 
place and implemented.
    The Chairman. The time of my colleague has expired, and we 
still have other Senators waiting.
    Senator Warner?
    Senator Warner. Thank you, Mr. Chairman.
    And again, Ms. Brooks-LaSure and Ms. Palm, thank you for 
your willingness to serve. I have a series of questions.
    Over the past decade, a hundred rural hospitals have 
closed; we have seen three of those in my State of Virginia. 
Obviously, the pandemic has particularly hit the rural 
communities extra hard, and rural hospitals extra hard. And it 
is no coincidence that the vast majority of these hospital 
closures occurred in areas with the lowest Medicare area wage 
index rates.
    In Virginia, for example, I have been working for 3 or 4 
years in one of our most rural far southwest counties, Lee 
County, to get a hospital facility reopened. And they have told 
me point-blank on the path to getting it reopened that fixing 
the Medicare area wage index would be a huge step in the right 
direction.
    To help solve this problem, we have bipartisan 
legislation--the Save Rural Hospitals Act of 2021, with 
Senators Blackburn, Cornyn, and Warnock--which would establish 
a reasonable match, no-
minimum Medicare wage index of .85, which would increase 
Medicare payments for rural hospitals in 22 States.
    Ms. Brooks-LaSure and Ms. Palm, obviously both HHS and CMS 
would play an incredibly important role. I would like you to 
both pledge to work with Congress, if you are confirmed, to 
support rural hospitals by addressing the problem in the 
Medicare area wage system, and any other comments you might 
have specifically on how we can guarantee the viability, long-
term, of our rural health system.
    Ms. Brooks-LaSure. Thank you, Senator Warner, for your 
leadership, and for other members of this committee, who I know 
very much care about your rural hospitals, which are in so many 
areas, backbones of their communities; and their issues can be 
different across the different States.
    We will absolutely work with you to make sure that we are 
supporting rural hospitals in the way that is appropriate, and 
I want to work with you on this topic.
    Senator Warner. And specifically on the--you know, the 
rubber hits the road on the Medicare area wage system. You will 
work with us on that issue specifically as well?
    Ms. Brooks-LaSure. Certainly.
    Senator Warner. Ms. Palm?
    Ms. Palm. I look forward to working with you, Senator, on 
this issue.
    Senator Warner. And both are very, very important. And I 
again think you are going to find broad-based bipartisan 
support for changing the ratio to the .85 we have suggested; 
and again, I look forward to working with you both on that.
    I want to raise another issue, which is the question around 
diabetes and diabetes education. I think we all know--you know, 
one in three Americans has diabetes. My home, in Virginia--we 
have 631,000 Virginians who have diabetes. To try to educate 
those individuals--life-style changes have been a bit of a 
challenge. That national diabetes prevention program, which 
again CMS has worked with, has shown, I think, great results. 
The problem has been that, for example in Virginia, we only 
have one in-person educator for the whole State.
    So with COVID coming, we have been able to show, through 
telehealth, that this is a much more efficient delivery model, 
oftentimes again to the rural communities we were just talking 
about. So I have legislation, bipartisan with Senator Scott of 
South Carolina, that would allow a virtual platform to be used. 
I do not know if this has come to your attention, Ms. LaSure, 
but again, it is for both nominees.
    I would hope you would be willing to take some of the 
lessons learned from COVID in delivery of telehealth, 
particularly on the education side with diabetes. I think this 
may be one of the areas where we have a better solution set 
now, and my hope would be that we could make that permanent.
    Ms. Brooks-LaSure. Thank you, Senator Warner. I certainly 
have heard, across this discussion, how important telehealth 
is, and what a great example of a clear area where it has been 
helpful. I really want to work with you and all the members of 
this committee to see what we can do certainly, if confirmed, 
administratively, as well as where we might need congressional 
help.
    Senator Warner. Ms. Palm?
    Ms. Palm. I would welcome the opportunity. I think we 
learned in Wisconsin that these flexibilities and the 
opportunities to be creative in this space provided us 
learnings and places where we ought to maintain those 
flexibilities; and I would look forward to working with you.
    Senator Warner. Mr. Chairman, this is an area I hope I 
could work with you on as well. I think getting diabetes 
education on a virtual platform really makes good sense.
    The Chairman. Absolutely, Senator Warner. I think it is 
hugely important. Thank you.
    Our next speaker is Senator Cortez Masto.
    Senator Cortez Masto. Thank you. Congratulations to both of 
you.
    Let me just say, in nearly every conversation I have with 
Nevadans about the pandemic, they mention the toll COVID-19 has 
taken on mental health and wellness, from students experiencing 
trauma to isolated seniors, to communities of color who have 
been hardest hit, and families experiencing severe economic 
hardship. No one has been spared in Nevada, and similarly 
across the country.
    In my view, addressing these impacts should be at the top 
of both of your lists. So let me start with--there has been a 
lot of discussion about telehealth and telemedicine. Count me 
in; that is something that I have seen in my State that should 
be permanent. It has brought essential services into our 
underserved communities.
    But one thing I do want to add, Ms. LaSure, is that 
utilization of telehealth services via telephone without any 
video is just as important. So I hope, as we look at maybe 
making this a permanent infrastructure, we recognize the 
benefits of both, whether it is video or just a telephone, 
working with a patient. Because that has brought essential 
services into my communities as well. And I just want to put 
that on your radar.
    Another area I want to focus on is that, unfortunately, we 
have seen high suicide rates in southern Nevada from some of 
our students. And recently, I wrote a letter to Secretary 
Becerra and Secretary Cardona about my concerns over students' 
mental health and behavioral health. And I asked the 
Secretaries to work together to ensure that schools are 
welcoming kids back to classrooms, and they have guidance and 
best practices at their fingertips that incorporate the wealth 
of knowledge at HHS on dealing with youth mental health.
    So let me ask, Ms. Palm, as the COO of HHS, how will you 
work to ensure that we are leveraging all of the expertise at 
the Department, from ACF's work with kids in the child welfare 
system to SAMHSA's experience in providing trauma-informed 
care, to make sure that we are spending the American Rescue 
Plan resources as effectively as possible?
    Ms. Palm. I really appreciate the question, Senator, and 
appreciate your leadership in this space. I think, as we talked 
about when we met and here today, it is--if I am fortunate 
enough to be confirmed, I think one of the places where the 
Deputy Secretary's office has a real opportunity is in making 
sure that the whole is greater than the sum of its parts; that 
we really are leveraging the assets and the expertise of the 
various programs in the Department to really put the people 
that we serve, the American people, at the center of what we do 
and the programs that we implement.
    And so, whether it is kids' mental health or other issues, 
we have a real opportunity, and I certainly would look forward 
to working with you on this issue and others where our 
coordination and our ability to work together really does 
better serve the people of this country.
    Senator Cortez Masto. Thank you.
    And staying on the same theme of behavioral health--crisis 
services. So last year, SAMHSA released national guidelines for 
behavioral health crisis care. This playbook is the product of 
years of work by the agency and draws from innovative projects 
in communities across the country that are going above and 
beyond to meet the needs of individuals experiencing behavioral 
health services.
    This tool is so important because it paints a picture of 
how we can build a sustainable continuum of crisis services 
that we do not have in Nevada. And similarly, I am hearing from 
some colleagues across the country.
    I started working with Senator Cornyn on legislation that 
would help States stand up crisis services and make them 
sustainable by integrating them into both public and commercial 
insurance plans.
    So Ms. Brooks-LaSure, these guidelines are a product of 
SAMHSA, but CMS will play an integral role in expanding crisis 
services to patients across the country. Can you speak to what 
you see as the need for behavioral health crisis services and 
how you would work with SAMHSA to make sure that those needs 
are met?
    Ms. Brooks-LaSure. Thank you for raising this issue and for 
your leadership in this area, as we have been talking about 
today. What we have seen across our country in terms of mental 
health is, we had an issue before COVID, and COVID has 
absolutely had such an effect on so many individuals, and 
particularly students, as you raise and point out.
    One of the things that, if confirmed, I want to make sure 
of, is that CMS is really integrating very closely with the 
other parts of HHS and with my colleagues. States in the 
Medicaid program have a very important role in behavioral 
health, and many of them are engaging and working in this area. 
I think certainly in the Medicaid program and others, we want 
CMS to integrate with SAMHSA to make sure we are tackling this 
issue holistically as opposed to one part of the agency.
    Senator Cortez Masto. Thank you. And I know my time is up. 
I just want to say, you have heard from the discussion, this is 
such an important topic for all of my colleagues; we have 
talked about this in a bipartisan way, as you can imagine. We 
look forward to working with you to really bring additional 
resources that are necessary to address behavioral health needs 
across this country.
    Thank you again, and congratulations on your nominations.
    Ms. Brooks-LaSure. Thank you.
    The Chairman. I thank my colleague.
    Senator Warren is next.
    Senator Warren. Thank you, Mr. Chairman, and 
congratulations to our nominees.
    It is no secret that our health insurance system, even in 
the best of times, leaves millions of people without the 
coverage that they need. But because most Americans still 
depend on their jobs to provide health coverage, our system 
performs even worse in a crisis like the one we are now living 
through.
    Heading into 2020, nearly 30 million people were uninsured. 
Then when the coronavirus hit, unemployment spiked, and up to 3 
million more people lost their employer-based insurance.
    Now President Biden has promised to expand health coverage, 
and public programs like Medicare that provide high-quality 
care at low cost will be the backbone of that expansion, not 
for-profit insurers that will find any opportunity to shift 
costs to patients while they line their own pockets.
    So, Ms. Brooks-LaSure, you have testified previously about 
the popularity of the Medicare program. Americans aged 65 and 
up, and some people with disabilities, are eligible for 
Medicare right now, but there are a lot of people, many just 
below the eligibility age, who struggle to get high-quality, 
affordable care through private insurance.
    Can you just say a word about what are the challenges 
facing older Americans who may want Medicare but have not hit 
their 65th birthday yet?
    Ms. Brooks-LaSure. Thank you, Senator Warren, for your 
leadership in making sure that policy-makers continue to focus 
on making sure coverage is affordable in this country. The 
Affordable Care Act was such an incredible, important first 
step in making sure that people had affordable care options. 
The Congress has just passed the American Rescue Plan--thank 
you for that--which is making such a difference to people on 
the ground right now who, as a result of the COVID pandemic, 
may be struggling to pay for their health insurance.
    Being right below the Medicare-eligible age can be an 
incredible challenge for people if they do not have affordable 
employer-
sponsored insurance. In many States, coverage through the 
marketplaces is available to them, and we need to continue to 
work to make sure that we have affordable options available for 
that population in particular, as they may want to make 
decisions about retirement, make decisions about job changes at 
that point in their lives.
    Senator Warren. Right. So we have this group of Americans 
who are not quite old enough yet for Medicare, but who are 
sometimes struggling to access health care right now, during 
the time in their lives when they start to need health-care 
coverage the most.
    As a candidate, President Biden promised to help this group 
of Americans by lowering the age of Medicare eligibility to 60 
years old. And doing so would expand Medicare coverage to 
roughly 23 million people.
    Ms. Brooks-LaSure, analysts have shown that lowering the 
Medicare eligibility age to 60 could ensure nearly 2 million 
previously uninsured people would get coverage, and it would 
help reduce premiums for the current Medicare population 
because it would add a younger, healthier population to the 
Medicare risk pool, benefiting the health system overall.
    Is that correct?
    Ms. Brooks-LaSure. I am not familiar with that particular 
study. I do know that the population you are talking about is 
absolutely one that--I have worked with States where 
eligibility for various programs could be higher, and we need 
to make sure that that population has coverage.
    Senator Warren. Well, let me just ask it slightly 
differently. I understand if you do not know this particular 
study, but the general principle makes sense.
    When we have fewer uninsured people, and when healthier, 
younger people join risk pools, that is a good thing, right?
    Ms. Brooks-LaSure. Yes, it is a good thing when healthier, 
younger people join this pool.
    Senator Warren. And more people get coverage.
    So, Ms. Brooks-LaSure, do you agree with President Biden 
that lowering the Medicare eligibility age could strengthen 
health-care coverage in America?
    Ms. Brooks-LaSure. I think that the President has outlined 
several important policies, including as you said, the lowering 
of the Medicare age; and if confirmed, I will work to implement 
the policies of the administration.
    Senator Warren. All right. And I appreciate your answer. I 
have to tell you, lowering the Medicare eligibility age to 
expand coverage and lower costs is a no-brainer. I know 
President Biden has talked about dropping the Medicare age from 
65 to 60, but frankly I think we should go even further. People 
need low-cost health-care options, particularly as they get 
older and need more health care.
    Dropping the age to 60 could expand Medicare for 23 million 
people, but dropping the age to 55 could expand it for an 
additional 14 million people. And doing so has the potential to 
lower premiums in the Medicare program, and depending on how we 
structure it, lower premiums for private health insurance too.
    So we have this opportunity to expand Medicare coverage to 
tens of millions of Americans, and we cannot waste it. We need 
to get this done.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren. And Senator Warren 
is raising an important point. I was director of the Gray 
Panthers for about 7 years before I was elected to Congress, 
and one of the things we always talked about is that Medicare, 
when it began in 1965, was just half a loaf. It did not cover 
so many crucial needs; dental care, for example, which we have 
seen during the pandemic being a particularly urgent priority.
    So I think these are critical issues that we are going to 
be digging into.
    I have a couple more questions, and then we will wrap up. 
On the chronic care question--apropos again to how Medicare has 
changed. Back in those Gray Panthers days, I taught gerontology 
as well. The first question on every exam I gave was, what was 
the difference between Medicare Part A and Medicare Part B? 
Because that was it. You had hospitals, you had doctors, and 
you were basically dealing with acute care.
    That is not it anymore. Now the program is overwhelmingly 
about chronic illness, and it is increasingly headed that way.
    So I have a very specific question. Our bill in 2017 
finally put a stake in the ground that we were going to update 
the Medicare guarantee. We did fairly well, in some key pieces. 
Telehealth would be one--the Trump administration, your 
predecessor, Ms. Brooks-LaSure, did not do much, but at least 
we got that position--Medicare Advantage.
    But my question to you is, what are the next steps in your 
view, because it seems to me that one of the next crucial 
priorities for chronic care is doing more to bring traditional 
Medicare, which still covers millions and millions of people, 
into this circle of better care for what is overwhelmingly 
going to be the future of the program.
    What are your thoughts on that?
    Ms. Brooks-LaSure. Thank you, Chairman Wyden, for your 
leadership in passing the CHRONIC Care Act, and I know that 
there has been so much analysis on how effective and helpful 
that is, including an article by the late Robert Pear. And 
Medicare Advantage has been able to take advantage of the 
legislation and the work that you have passed.
    I think, as Senator Brown mentioned, it is critically 
important that we bring some of the innovations and advantages 
to traditional fee-for-service and traditional Medicare. And 
whether that is something that we can, if confirmed, look at 
administratively or whether that is something we need to come 
back to Congress for, I am happy to work with you on this 
topic.
    The Chairman. Again, I put this in the context, not just if 
you are confirmed, but when you are confirmed, because we are 
deeply committed to that. I would very much like you all to 
assign some staff from the Department to work with us. We will 
work on a bipartisan basis. Then-chairman Hatch and I did that 
when we wrote the original bill.
    But I just think we have to do more to bring traditional 
Medicare into the update of what is, I think to the American 
people, a guarantee of Medicare.
    Now, a quick point about prescription drugs, because you 
have heard this back and forth and the like. I think we know 
why this is such an acutely important issue to millions of 
people; they just feel like they are getting mugged at the 
pharmacy counter.
    I mean, insulin prices went up 12-fold in a period of time 
that was not very long; the drug is not 12 times better. I 
mean, it is just plain old price gouging.
    So I want you to know that what I am in favor of is a 
policy that has Medicare negotiate on behalf of the more than 
60 million Medicare beneficiaries in order to get them a better 
deal. That is piece number one.
    And the second piece, which we focused on here in the 
Finance Committee, is when big pharma is price-gouging, they 
are going to lose subsidies. You know, they get subsidies from 
the Federal Government; if they price gouge on insulin, they 
are going to lose some of those subsidies.
    And so as you all in the administration, when confirmed, 
debate those issues, I want you to hear from me, we ought to be 
pursuing both policies: letting Medicare negotiate, because 
everybody tries to negotiate, it is just common sense; and we 
cut subsidies when there is price-gouging. That will produce 
more savings for the seniors and more savings for taxpayers.
    Last point, just to send you both off formally, I consider 
you both to be eminently qualified, and I think people who 
review this hearing and look at the record will see 
considerable bipartisanship. And, Ms. Palm, I noted that, if 
confirmed, you would advance the common-ground agenda. That is 
pretty conciliatory language. And, Ms. Brooks-LaSure, you 
indicated that you would work with Finance members on several 
bipartisan issues like the telehealth question and the 1332 
waivers which I talked about at some length; we do not need to 
do that again. But I appreciated your saying that that would be 
a priority for you when confirmed, in terms of getting the 
guidance out.
    So, we have had a long hearing today. I just want members 
to know I am going to support these two nominees strongly. The 
deadline for Senators to submit their questions for the record 
is 5 p.m., Friday, April 16th.
    And with that, the Finance Committee is adjourned.
    [Whereupon, at 1 p.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


     Prepared Statement of Chiquita Brooks-LaSure, Nominated to be 
 Administrator, Centers for Medicare and Medicaid Services, Department 
                      of Health and Human Services
    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
thank you for considering my nomination to be the Administrator of the 
Centers for Medicare and Medicaid Services. And thank you to Senators 
Booker and Menendez for their kind words.

    As a graduate student, one of my first internships was with the 
Senate Finance Committee. I remember being so awestruck the first time 
I saw the committee room and the important business being done on 
behalf of the American people. So, it's incredibly humbling to sit in 
front of this committee, this time to testify before you as President 
Biden's nominee to lead CMS.

    My career in public service started at the Office of Management and 
Budget. My portfolio included CMS's budget, the Children's Health 
Insurance Program, and coverage options for the uninsured.

    But after 9/11, everything changed. It did for the victims of that 
terrible tragedy, their families, and for first responders. It also 
changed for many of you, and for everyone in government service. For 
me, my work shifted toward finding coverage for dislocated workers in 
the wake of the attack. I worked closely with the Treasury Department 
and key members of the Bush administration to ensure that those 
impacted by this senseless attack had health coverage during such a 
vulnerable time in their lives.

    It was inspiring to be part of a bipartisan effort to ensure that 
people who lost jobs as a result of the attack and its impact on the 
economy were able to get the health care they needed. I took that 
philosophy of bipartisanship and sense of mission to improve health 
care for patients and families with me to the House Ways and Means 
Committee--where I was privileged to work for the members of that 
committee on five bills that eventually became law. It's the philosophy 
I took to HHS and CMS--where I led the development of policies needed 
to implement the Affordable Care Act and expand coverage to more than 
20 million Americans.

    I've approached my work in the private sector with the same 
philosophy--working with States and other stakeholders to expand 
coverage options, especially for those living in rural parts of the 
country and for traditionally marginalized communities. Today, as we 
navigate this public health crisis and its aftermath, that philosophy 
guides me yet again. If confirmed, that is the collaborative, common-
sense, results-oriented philosophy I'll take to CMS to address the 
complex challenges we face.

    I am excited by the many opportunities we have to work together to 
improve health-care quality, lower costs, and promote better access. I 
am committed to leading the agency in a way that ensures it acts with 
the utmost integrity and upholds its fiduciary responsibilities. This 
includes addressing Medicare solvency to protect Medicare for current 
and future beneficiaries.

    We must get the pandemic under control. COVID-19 has put unbearable 
pressure on front-line health-care workers, put vulnerable seniors and 
those with disabilities at great risk, and unmasked inequities that 
persist in our health-care system. I am committed to working with you 
and with leaders across government to ensure that CMS is supporting 
patients and providers, including communities of color who have been 
hardest hit by this pandemic.

    But we cannot wait to deliver better care to patients and families. 
If confirmed, I will work to make the programs overseen by CMS work 
better together to help the people they serve. Medicare, Medicaid, and 
coverage on the marketplaces remain the pillars of our health-care 
system, and there is much we can do to strengthen those programs to 
improve quality, lower costs, and expand access.

    That includes implementing the critical reforms in last December's 
appropriations bill and in the American Rescue Plan, particularly the 
prohibition on surprise medical bills, the new emergency rural hospital 
designation, and the expansion of financial help for working families 
to buy comprehensive coverage on the marketplaces.

    If confirmed, I am also committed to working with you to expand 
access to innovative therapies, procedures, and models of care. We are 
living in an era of incredible change as researchers find new ways to 
conquer disease and improve our quality of life. We must bear in mind 
though, that innovation is only effective if patients can actually 
afford it. I will also work with the committee and all of Congress to 
rein in health-care costs, including for prescription drugs.

    Finally, we must think broadly about health equity. During my 
career, I've seen how communities of color too often experience worse 
health outcomes, which we've seen so acutely during this pandemic. Last 
year in April, my own hometown, a predominately black community where 
my parents still live, experienced higher rates of COVID-19 infections 
and deaths compared to much of the surrounding communities. If 
confirmed, I look forward to working with each of you to expand access 
to quality care for all communities.

    I realize that members of this committee may not always agree on 
the best approaches to solve these challenges. While there may be 
disagreements on policy, I pledge to work closely with all members of 
this committee to ensure that our decisions are transparent, our team 
is accessible, and that CMS closely listens to and respects your views 
and ideas for how we can ensure that CMS's programs fulfill their 
mission to best serve patients, providers, and their communities.

    Before I close, I'd also be remiss if I did not acknowledge the 
outpouring of support I've received from women of color from across the 
country. I am proud that, if I have the honor of being confirmed, I 
will be the first black woman to lead CMS.

    And I wouldn't be here without my family--my husband sitting behind 
me, my parents and siblings, and the many strong, smart black women and 
men who came before me. Too often, they weren't given the opportunity 
to live up to their full God-given potential. But their selfless, often 
silent sacrifice paved the way for me and so many other women of color. 
Today, I'm proud that my daughter can see her mother nominated by the 
President of the United States to lead such a critical agency--and know 
that she can be anything she wants to be.

    Thank you for considering my nomination, and I look forward to 
answering your questions.

                                 ______
                                 

                        SENATE FINANCE COMMITTEE

                  STATEMENT OF INFORMATION REQUESTED 
                               OF NOMINEE

                      A. BIOGRAPHICAL INFORMATION

 1.  Name (include any former names used): Current: Chiquita White 
Brooks-LaSure; Former: Chiquita Lynn White.

 2.  Position to which nominated: Centers for Medicare and Medicaid 
Services Administrator.

 3.  Date of nomination: February 19, 2021.

 4.  Address (list current residence, office, and mailing addresses):

 5.  Date and place of birth: March 17, 1975; Philadelphia, PA.

 6.  Marital status (include maiden name of wife or husband's name):

 7.  Names and ages of children:

 8.  Education (list all secondary and higher education institutions, 
dates attended, degree received, and date degree granted):

        Georgetown University.
        Dates Attended: August 1997-June 1999.
        Degree Received: Master of Public Policy (MPP).
        Date Degree Granted: June 1999.

        Princeton University.
        Dates Attended: September 1992-June 1996.
        Degree Received: Bachelor of Arts Degree (AB).
        Date Degree Granted: June 1996.

        Willingboro High School.
        Dates Attended: 8th-12th grade--September 1987-June 1992.
        Degree Received: High School Diploma.
        Date Degree Granted: June 1992.

 9.  Employment record (list all jobs held since college, including the 
title or description of job, name of employer, location of work, and 
dates of employment for each job):

        Manatt Health Strategies, Manatt, Phelps, and Phillips, LLP.
        Managing Director.
        January 2016-present.
        Washington, DC.

        CapView Associates (Consulting).
        Senior Advisor.
        July-December 2015.
        Headquarters: Washington, DC; worked from Melbourne, Australia 
        and Falls Church, VA.

        Commonwealth Fund.
        Author.
        June-November 2015.
        Headquarters: New York, NY; worked from Melbourne, Australia 
        and Falls Church, VA.

        Deakin University.
        Visiting Scholar.
        May-August 2015.
        Melbourne, Australia.

        Breakaway Policy (Consulting).
        Senior Advisor.
        June 2014-January 2015.
        Headquarters: Washington, DC; worked from Melbourne, Australia.

        U.S. Department of Health and Human Services.
        Director of Coverage Policy, Office of Health Reform.
        April 2010-December 2012.
        Washington, DC.

        Centers for Consumer Information and Insurance Oversight 
        (CCIIO), Centers for Medicare and Medicaid Services (CMS).
        Deputy Center Director and Deputy Director for Policy and 
        Regulation.
        December 2012-May 2014.
        Washington, DC and Bethesda, MD.

        U.S. House of Representatives.
        Majority Professional Staff, Ways and Means Committee.
        November 2007-April 2010.
        Washington, DC.

        Avalere Health.
        Senior Manager/Manager (September 2003-September 2006).
        Director (October 2006-October 2007).
        Washington, DC.

        Office of Management and Budget.
        Program Examiner.
        July 1999-September 2003.
        Washington, DC.

        U.S. Senate.
        (Unpaid) Intern, Senate Finance Committee.
        January-June 1998 (Estimated).

        McCarter and English.
        Paralegal.
        July 1996-July 1997.
        Newark, NJ.

10.  Government experience (list any current and former advisory, 
consultative, honorary, or other part-time service or positions with 
Federal, State, or local governments held since college, including 
dates, other than those listed above):

        Advisory: Committee Member, Virginia Health Benefit Exchange 
        (September 2020-present). Upon confirmation, as outlined in my 
        Ethics Agreement, I will resign from this position. My role is 
        advisory; the committee provides advice to the Exchange 
        Executive Director and VA State officials as they develop their 
        State-based exchange in place of the federally facilitated 
        exchange.

        Volunteered as one of the two leads for the Biden-Harris 
        Transition Agency Review Team for HHS, October 2020-January 
        2021.

        Consultative: Authored reports for the States of Nevada 
        (January 2021), New Mexico (December 2018 and January 2019), 
        and Oregon (December 2020). Further detail included in response 
        to Question 15.

11.  Business relationships (list all current and former positions held 
as an officer, director, trustee, partner (e.g., limited partner, non-
voting, etc.), proprietor, agent, representative, or consultant of any 
corporation, company, firm, partnership, other business enterprise, or 
educational or other institution):

        The following are current positions. Upon confirmation, as 
        outlined in my Ethics Agreement, I will resign from these 
        positions:

        Board of directors, FAIR Health. I have served on the board of 
        directors since Spring 2018. The board of directors provides 
        input on the organization's strategic goals and activities and 
        approves the organization's budget and executive director's 
        salary. We receive regular updates on how the organization is 
        performing against its goals and budget and are updated on 
        personnel matters.

        Board of directors, Children's Law Center. I have served on the 
        board of directors since May 2019. The role of the board of 
        directors includes the activities and responsibilities listed 
        above for FAIR Health, with the additional responsibility of 
        fundraising. I am also on the Development Subcommittee which 
        assists with the organization's fundraising efforts, including 
        planning for the annual benefit.

        Managing Director, Manatt, Phelps, and Phillips, LLP (income, 
        but not equity, partner).

12.  Memberships (list all current and former memberships, as well as 
any current and former offices held in professional, fraternal, 
scholarly, civic, business, charitable, and other organizations dating 
back to college, including dates for these memberships and offices):

        Alfred Street Baptist Church.
        Member.
        2012-present.

        Thursday Network, Auxiliary of the National Urban League.
        Member.
        2001-2005 (Estimated).

        Princeton Evangelical Fellowship (now Princeton Christian 
        Fellowship).
        Social Chair: 1995-1996.
        Member: 1992-1996.

13.  Political affiliations and activities:

        a.  List all public offices for which you have been a candidate 
        dating back to the age of 18.

       None.

        b.  List all memberships and offices held in and services 
        rendered to all political parties or election committees, 
        currently and during the last 10 years prior to the date of 
        your nomination.

       Co-led the Coverage Subcommittee within the volunteer Health 
Policy Committee for the Biden Presidential Campaign, Summer 2020.

        c.  Itemize all political contributions to any individual, 
        campaign organization, political party, political action 
        committee, or similar entity of $50 or more for the past 10 
        years prior to the date of your nomination.

       See Table.


------------------------------------------------------------------------
      Contribution Description                  Date             Amount
------------------------------------------------------------------------
OBAMA FOR AMERICA                                  2012-08-31     $56.00
------------------------------------------------------------------------
OBAMA FOR AMERICA                                  2012-10-03     $56.00
------------------------------------------------------------------------
CALONE FOR CONGRESS                                2016-04-27    $250.00
------------------------------------------------------------------------
PEOPLE FOR DEREK KILMER                            2016-04-27    $250.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-07-06    $500.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-11-07    $120.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-11-07    $250.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2017-09-30    $100.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-04-30    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-05-29  $1,000.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-09-03    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-09-03    $100.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-09-30    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-09-30    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2019-06-10    $500.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-02-05    $100.00
------------------------------------------------------------------------
DSCC                                               2020-04-25    $125.00
------------------------------------------------------------------------
BIDEN FOR PRESIDENT                                2020-04-25    $125.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-04-25    $250.00
------------------------------------------------------------------------
BIDEN FOR PRESIDENT                                2020-04-29    $250.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-07-29    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-07-29    $100.00
------------------------------------------------------------------------
DNC SERVICES CORP/ DEMOCRATIC                      2020-10-11  $1,000.00
 NATIONAL COMMITTEE
------------------------------------------------------------------------
WARNOCK FOR GEORGIA                                2020-12-08    $250.00
------------------------------------------------------------------------


14.  Honors and awards (list all scholarships, fellowships, honorary 
degrees, honorary society memberships, military medals, and any other 
special recognitions for outstanding service or achievement received 
since the age of 18.):

        Recognition Award for Ten Years of Federal Service: 2013.

        OMB Performance Award: 2002 (Estimated).

        Campbell Award for Alumni (Georgetown University): May 2001.

        Merit Scholarship (Georgetown University): 1997-1999.

15.  Published writings (list the titles, publishers, dates and 
hyperlinks (as applicable) of all books, articles, reports, blog posts, 
or other published materials you have written):
Publications
        Co-author, Senate Concurrent Resolution No. 10 Study: 
        Evaluating Public Health Insurance Options for Nevada 
        Residents, Nevada Legislative Commission, January 2021.

        Co-author, ``Oregon Public Option Report: An Evaluation and 
        Comparison of Proposed Delivery Models,'' Oregon Health 
        Authority, December 17, 2020.

        Co-author, ``State Strategies for Overcoming Barriers to 
        Advance Health Equity,'' Robert Wood Johnson Foundation's State 
        Health and Value Strategies program, November 25, 2020.

        Co-author, ``The Federal Government's Response to the 
        Coronavirus (COVID-19) Pandemic: Questions and Answers,'' 
        Robert Wood Johnson Foundation's State Health and Value 
        Strategies program, April 22, 2020.

        Co-author, ``Building on the Gains of the ACA: Federal 
        Proposals to Improve Coverage and Affordability,'' Health 
        Affairs, March 2, 2020.

        Author, ``State Medicaid Buy-Ins: Key Questions to Consider,'' 
        Robert Wood Johnson Foundation's State Health and Value 
        Strategies program, April 25, 2019.

        Co-author, ``The Landscape of Federal and State Healthcare Buy-
        In Models: Considerations for Policymakers,'' Arnold Ventures, 
        February 2019.

        Co-author, ``Quantitative Evaluation of a Targeted Medicaid 
        Buy-In for New Mexico,'' Health Action New Mexico and the New 
        Mexico Center on Law and Poverty, January 31, 2019.

        Co-author, ``A Promising Strategy for an Affordable Medicaid 
        Buy-In Option in Colorado,'' Colorado Center on Law and Policy, 
        the Colorado Consumer Health Initiative, and the Bell Policy 
        Center, December 2018.

        Co-author, ``Evaluating Medicaid Buy-in Options for New 
        Mexico,'' Health Action New Mexico and the New Mexico Center on 
        Law and Poverty, December 7, 2018.

        Co-author, ``Medicaid Buy-in: State Options, Design 
        Considerations and 1332 Implications,'' Robert Wood Johnson 
        Foundation's State Health and Value Strategies program, May 16, 
        2018.

        Co-author, ``Manatt on Medicaid: 10 Trends to Watch in 2018,'' 
        February 7, 2018.

        Co-author, ``Understanding the Rules: Federal Legal 
        Considerations for State-Based Approaches to Expand Coverage in 
        California,'' California Health Care Foundation, February 2, 
        2018.

        Co-author, ``State Marketplace Stabilization Strategies,'' 
        American Hospital Association, January 22, 2018.

        Co-author, ``Liberating Data to Enable Healthcare Market 
        Transparency: A Guide for Regulators and Policymaker,'' Novo 
        Nordisk, March 22, 2016.

        Author, ``Increased Transparency and Consumer Protections for 
        2016 Marketplace Plans,'' The Commonwealth Fund, December 22, 
        2015.

        Co-author, ``The Insurance Commissioners,'' Morning Consult 
        Blog, September 2014.

        Co-author, ``Chapter Three: Quality of Care,'' The Healthcare 
        Delivery System: A Blueprint for Reform, Center for American 
        Progress, October 2008.

        Co-author, ``The Medicare Drug Benefit in California: Facts and 
        Figures,'' California HealthCare Foundation, September 2006.

        Co-author, ``The Medicare Drug Benefit: How Good Are the 
        Options?'' California HealthCare Foundation, March 2006.

        Co-author, ``The Impact of Enrollment in the Medicare 
        Prescription Drug Benefit on Premiums,'' Kaiser Family 
        Foundation, October 2005.

        Co-author, ``The Medicare Drug Benefit: Implications for 
        Chronic Disease Care,'' California HealthCare Foundation, 
        October 2005.

        Co-author, ``The Medicare Drug Benefit: Implications for 
        California,'' California HealthCare Foundation, April 26, 2005.

        Co-author, ``State Disease Medicaid Management: Lessons From 
        Florida,'' Avalere Health and Duke University, March 2005.
Newsletters
        Co-author, ``What a Supreme Court Vacancy Could Mean for the 
        ACA,'' Manatt on Health, October 21, 2020.

        Co-author, ``House Passes the Heroes Act,'' COVID-19 Update, 
        May 19, 2020.

        Co-author, ``ACA 10th Anniversary Infographic,'' Manatt on 
        Health, March 23, 2020.

        Co-author, ``Georgia Releases Section 1332 and 1115 Waivers,'' 
        Manatt on Health, November 20, 2019.

        Co-author, ``California Supreme Court: Unpaid Wages Are Not 
        Recoverable Under PAGA,'' Retail and Consumer Products Law 
        Roundup, October 11, 2019.

        Co-author, ``With 2020 in View, Democrats Outline Healthcare 
        Reform Positions,'' Manatt on Health, June 19, 2019.

        Co-author, ``Marketplace Roundup: Recent Federal Marketplace 
        Activity Promotes State-Level Policymaking,'' Manatt on Health, 
        May 2, 2019.

        Co-author, ``Medicaid Buy-In and Public Option: The State of 
        Play,'' Manatt on Health, February 26, 2019.

        Co-author, ``What's Ahead for Health Policy in 2019,'' Manatt 
        on Health, January 17, 2019.

        Co-author, ``Now on Demand: The Midterm Elections' Impact on 
        Healthcare--and Your Organization,'' Health Update, December 
        19, 2018.

        Co-author, ``CMS Promotes New 1332 Waiver Models, States Weigh 
        Options,'' Manatt on Health, December 19, 2018.

        Co-author, ``The Midterm Elections' Potential Impact on 
        Healthcare,'' Manatt on Health, October 24, 2018.

        Co-author, ``New Webinar Series: The Midterm Elections' Impact 
        on Healthcare,'' Health Update, October 23, 2018.

        Co-author, ``New Webinar: Are Medicaid Buy-In Proposals Gaining 
        Traction?'', Health Update, September 25, 2018.

        Co-author, ``State Action on Market Stabilization,'' Manatt on 
        Health, May 17, 2018.

        Co-author, ``States Choosing Divergent Paths for Individual 
        Market Coverage,'' Manatt on Health, April 11, 2018.

        Co-author, ``New Webinar: America's Multidimensional Opioid 
        Crisis,'' Manatt on Health: Medicaid Edition, March 28, 2018.

        Co-author, ``The President's Budget and Shifting Policy on 
        Prescription Drugs,'' Manatt on Health, February 26, 2018.

        Co-author, ``What's Ahead in 2018,'' Manatt on Health, January 
        10, 2018.

        Co-author, ``Next Steps on Healthcare Reform,'' Manatt on 
        Health, August 8, 2017.

        Co-author, ``Key BCRA Policy Concerns,'' Manatt on Health, July 
        25, 2017.

        Co-author, ``Special Edition: Key BCRA Policy Concerns,'' 
        Manatt on Health, July 21, 2017.

        Co-author, ``BCRA Implications: Affordability of Coverage,'' 
        Manatt on Health, July 11, 2017.

        Co-author, ``The Better Care Reconciliation Act of 2017,'' 
        Health Update, June 28, 2017.

        Co-author, ``Iowa Submits Sweeping 1332 Waiver Seeking 
        Emergency Relief,'' Manatt on 1332, June 21, 2017.

        Co-author, ``House Repeal and Replace Bill: The American Health 
        Care Act,'' Health Update, May 5, 2017.

        Co-author, ``New Manatt Webinar, Election 2016: Strategic 
        Implications for Healthcare,'' Health Update, January 23, 2017.

        Co-author, ``Special Edition: Comparison of Key Repeal and 
        Replace Proposals,'' Health Update, December 6, 2016.

        Co-author, ``The Election's Impact on Healthcare: Preparing for 
        Potential Scenarios,'' Health Update, September 22, 2016.

        Co-author, ``Transparency and Decision Support for Medicaid 
        Managed Care Consumers,'' Manatt on Health: Medicaid Edition, 
        June 30, 2016.

        Co-author, ``Despite Differences in Coverage Markets, 
        Regulatory Alignment Is Increasing,'' Health Update, June 23, 
        2016.

        Co-author, ``Now You Have a Second Chance to Benefit From What 
        Does the Medicare Part B Drug Payment Model Mean for Hospitals, 
        Physicians and Biopharmaceutical Companies?'', Health Update, 
        April 26, 2016.

        Co-author, ``Liberating Data to Enable Healthcare Market 
        Transparency: A Guide for Regulators and Policymakers,'' Health 
        Update, March 23, 2016.

16.  Speeches (list all formal speeches and presentations (e.g., 
PowerPoint) you have delivered during the past 5 years which are on 
topics relevant to the position for which you have been nominated, 
including dates):

        I delivered the following presentations but did not have formal 
        prepared remarks or slides for any of these presentations:

        Panelist, ``Solutions Over Politics: Improving Healthcare for 
        Every American Breakout Session,'' NEXT: Powered by the NewDem 
        Action Fund, October 14, 2020.

        Speaker, ``The Midterm Elections: How They May Impact Your 
        Business in 2018 and Beyond,'' Bloomberg Next Webinar, November 
        8, 2018.

        Panelist, ``Healthcare Exchanges,'' Democratic Attorneys 
        General Association Fall Policy Conference, Nashville 
        Tennessee, September 14, 2017.

        Speaker, ``The Future of Obamacare Individual Exchange 
        Marketplaces,'' Leerink Partners' 2017 Global Healthcare 
        Conference, New York, NY, February 16, 2017.

        Co-presenter, ``The Election's Impact on Healthcare: Preparing 
        for Potential Scenarios,'' PharmaVOICE podcast, September 15, 
        2016.

17.  Qualifications (state what, in your opinion, qualifies you to 
serve in the position to which you have been nominated):

        My professional background and health policy experience have 
        positioned me to serve as Centers for Medicare and Medicaid 
        Services (CMS) Administrator. I have extensive knowledge of 
        CMS, having worked at the agency as Deputy Director for Policy 
        in the Center for Consumer Information and Insurance Oversight 
        (CCIIO). In addition, I have a considerable amount of Federal 
        Government experience--including my time in Congress, at the 
        Office of Management and Budget (OMB), and the Department of 
        Health and Human Services (HHS)--and I am thoroughly familiar 
        with how these institutions work together to best serve the 
        American people.

        I have deep expertise across all of CMS's areas of 
        responsibility, including Medicare, Medicaid, and Affordable 
        Care Act (ACA) coverage. Since the beginning of my career at 
        OMB, I have worked extensively on Medicaid, the Children's 
        Health Insurance Program, and coverage for the uninsured. I 
        also have Medicare experience, most notably from my time at the 
        House Ways and Means Committee, working on Medicare Advantage 
        and Medicare Part D. I was fortunate to play a key role in the 
        passage and implementation of the ACA--first on the Ways and 
        Means Committee, and then in the Obama administration at HHS. 
        In this capacity, I focused primarily on expanding access for 
        the uninsured through the creation of marketplaces, consumer 
        protections for health coverage, and tax credits.

        In the private sector, I worked with States, consumer groups, 
        and other stakeholders on options to cover more of the 
        uninsured and underinsured--focusing on policies to expand 
        access to health insurance coverage and working on strategies 
        to address health equity. This work included exploring the role 
        that Medicaid programs can play in addressing maternal 
        mortality--a critical issue disproportionately affecting black 
        and brown women in America. This work has never been more 
        urgent as we have seen longstanding health disparities 
        illuminated during the COVID-19 pandemic.

        My role serving as one of the leads for the Biden-Harris 
        Transition Agency Review Team for HHS provided me a clear 
        picture of the work needed to rebuild HHS and CMS. Moreover, 
        this experience made clear the ways that CMS can work better 
        within HHS and across government to address inefficiencies in 
        our system, and also tackle public health crises such as COVID-
        19 and health inequities.

        If I have the honor of being confirmed, my priorities for CMS 
        are integrating--within CMS and between CMS and other parts of 
        HHS--to make coverage more affordable for people and make 
        programs work together for the people they serve. If our 
        health-care system is better integrated, we will not only be 
        better prepared for the next public health crisis, but also 
        better equipped to advance health equity and improve health-
        care access and coverage. If confirmed, I would seek to advance 
        payment reforms while promoting equity and health-care 
        coverage--and also working with Congress to reduce prescription 
        drug costs for seniors, people with disabilities, and other 
        consumers.

        It would be an honor and a privilege to be confirmed by the 
        Senate to lead CMS. And the significance of my nomination and 
        possibility that I would be the first black woman confirmed to 
        this role are not lost on me. After several decades working on 
        health policy on Capitol Hill, in the Obama administration, and 
        in the private sector, I believe I have the experience and 
        judgment needed to lead CMS during this critical time--not only 
        to recover from the pandemic, but to ensure that all Americans 
        have access to quality, affordable health care no matter their 
        zip code.

                   B. FUTURE EMPLOYMENT RELATIONSHIPS

 1.  Will you sever all connections (including participation in future 
benefit arrangements) with your present employers, business firms, 
associations, or organizations if you are confirmed by the Senate? If 
not, provide details.

        Upon consultation with and approval by my agency ethics 
        officials, I will receive a performance-based bonus for 
        calendar year 2020 in three installments and an additional 
        contribution to my Manatt, Phelps, and Phillips, LLP defined 
        contribution plan.

 2.  Do you have any plans, commitments, or agreements to pursue 
outside employment, with or without compensation, during your service 
with the government? If so, provide details.

        No.

 3.  Has any person or entity made a commitment or agreement to employ 
your services in any capacity after you leave government service? If 
so, provide details.

        No.

 4.  If you are confirmed by the Senate, do you expect to serve out 
your full term or until the next presidential election, whichever is 
applicable? If not, explain.

        Yes.

                   C. POTENTIAL CONFLICTS OF INTEREST

 1.  Indicate any current and former investments, obligations, 
liabilities, or other personal relationships, including spousal or 
family employment, which could involve potential conflicts of interest 
in the position to which you have been nominated.

        Any potential conflict of interest will be resolved in 
        accordance with the terms of my ethics agreement, which was 
        developed in consultation with ethics officials at the 
        Department of Health and Human Services and the Office of 
        Government Ethics. I understand that my ethics agreement has 
        been provided to the committee. I am not aware of any potential 
        conflict other than those addressed by my ethics agreement.

 2.  Describe any business relationship, dealing, or financial 
transaction which you have had during the last 10 years (prior to the 
date of your nomination), whether for yourself, on behalf of a client, 
or acting as an agent, that could in any way constitute or result in a 
possible conflict of interest in the position to which you have been 
nominated.

        Any potential conflict of interest will be resolved in 
        accordance with the terms of my ethics agreement, which was 
        developed in consultation with ethics officials at the 
        Department of Health and Human Services and the Office of 
        Government Ethics. I understand that my ethics agreement has 
        been provided to the committee. I am not aware of any potential 
        conflict other than those addressed by my ethics agreement.

 3.  Describe any activity during the past 10 years (prior to the date 
of your nomination) in which you have engaged for the purpose of 
directly or indirectly influencing the passage, defeat, or modification 
of any legislation or affecting the administration and execution of law 
or public policy. Activities performed as an employee of the Federal 
government need not be listed.

        In the last 5 years as a managing director at Manatt, I have 
        been involved in legislative and public policy issues at the 
        local and State level (as summarized in my list of publications 
        and discussed in my ethics agreement). I have testified one 
        time before Congress:

        On June 12, 2019, I testified before the U.S. House of 
        Representatives Ways and Means Committee regarding universal 
        health coverage. The hearing was titled, ``Pathways to 
        Universal Health Coverage.''

 4.  Explain how you will resolve any potential conflict of interest, 
including any that are disclosed by your responses to the above items.

        Any potential conflict of interest will be resolved in 
        accordance with the terms of my ethics agreement, which was 
        developed in consultation with ethics officials at the 
        Department of Health and Human Services and the Office of 
        Government Ethics. I understand that my ethics agreement has 
        been provided to the committee. I am not aware of any potential 
        conflict other than those addressed by my ethics agreement.

 5.  Two copies of written opinions should be provided directly to the 
committee by the designated agency ethics officer of the agency to 
which you have been nominated and by the Office of Government Ethics 
concerning potential conflicts of interest or any legal impediments to 
your serving in this position.

        I understand that my ethics agreement has been provided to the 
        committee.

                       D. LEGAL AND OTHER MATTERS

 1.  Have you ever been the subject of a complaint or been 
investigated, disciplined, or otherwise cited for a breach of ethics 
for unprofessional conduct before any court, administrative agency 
(e.g., an Inspector General's office), professional association, 
disciplinary committee, or other ethics enforcement entity at any time? 
Have you ever been interviewed regarding your own conduct as part of 
any such inquiry or investigation? If so, provide details, regardless 
of the outcome.

        No.

 2.  Have you ever been investigated, arrested, charged, or held by any 
Federal, State, or other law enforcement authority for a violation of 
any Federal, State, county, or municipal law, regulation, or ordinance, 
other than a minor traffic offense? Have you ever been interviewed 
regarding your own conduct as part of any such inquiry or 
investigation? If so, provide details.

        No.

 3.  Have you ever been involved as a party in interest in any 
administrative agency proceeding or civil litigation? If so, provide 
details.

        No.

 4.  Have you ever been convicted (including pleas of guilty or nolo 
contendere) of any criminal violation other than a minor traffic 
offense? If so, provide details.

        No.

 5.  Please advise the committee of any additional information, 
favorable or unfavorable, which you feel should be considered in 
connection with your nomination.

        N/A.

                     E. TESTIFYING BEFORE CONGRESS

 1.  If you are confirmed by the Senate, are you willing to appear and 
testify before any duly constituted committee of the Congress on such 
occasions as you may be reasonably requested to do so?

        Yes.

 2.  If you are confirmed by the Senate, are you willing to provide 
such information as is requested by such committees?

        Yes.

                                 ______
                                 
      Questions Submitted for the Record to Chiquita Brooks-LaSure
                 Questions Submitted by Hon. Ron Wyden
                          nursing home quality
    Question. The crisis of COVID-19 in nursing homes has been a 
collision of mismanagement at every level of the industry from 
government regulators to individual facilities. More than 175,000 
people living and working in the Nation's long-term care facilities 
have died of COVID-19, including more than 130,000 in nursing homes 
participating in Medicare and Medicaid. The Senate Finance Committee 
heard from witnesses during a hearing on March 17, 2021 about ongoing 
issues in nursing homes that negatively affect patient care like 
understaffing, poor infection control and inadequate emergency 
preparedness. These issues have persisted for decades and left 
facilities particularly ill-prepared for a public health crisis like 
the COVID-19 pandemic. If confirmed, what would you do to improve the 
care provided in our Nation's nursing homes?

    Answer. It has been heartbreaking to see how hard the COVID-19 
pandemic has hit the Nation's nursing homes, and as you noted, nursing 
home safety is not an issue newly created by the pandemic. Nursing 
homes' first obligation should be to their residents, and every nursing 
home that participates in Medicare and Medicaid must meet Federal 
health and safety standards. If confirmed, it will be a top priority 
for me to hold nursing homes accountable for providing high quality 
care to their residents. Thank you for your leadership on this critical 
issue.

    Question. Thorough and publicly available information on the health 
and safety of nursing homes is essential. I've worked closely with 
Senator Casey over the last year to push and prod CMS to collect and 
make public information about COVID-19's impact on nursing homes that 
participate in Medicare and Medicaid. More recently, Senator Casey and 
I were joined by Ranking Member Crapo and Senator Scott (South 
Carolina) to request that CMS begin collecting and disseminating 
information regarding facility-level vaccination data. I was pleased to 
see CMS recently take some important steps toward improving 
transparency--such as requiring reporting of staff vaccination rates--
but there is more work to do. For example, the Finance Committee has 
repeatedly received testimony about the shortcomings of the Five Star 
System, which was created to provide clear and meaningful information 
on the quality of nursing homes. Unfortunately, in many cases a ``five 
star'' facility may not provide any better care or protection for 
residents than a one-star home. This system needs to be fundamentally 
rethought.

    Broadly speaking, if confirmed as CMS Administrator, will you 
support efforts to improve transparency relating to COVID-19 in nursing 
homes and address the disproportionate impacts of COVID-19 on nursing 
home residents of color?

    And specifically in regard to vaccinations, will you support 
efforts to provide consumers and Congress facility-level data about the 
rate of COVID-19 vaccinations in nursing homes?

    Answer. If I am fortunate enough to be confirmed, it will be a top 
priority for CMS to work to address the disproportionate impact of the 
COVID-19 pandemic on nursing home residents, especially those of color. 
I will also work to improve transparency, evaluation and 
accountability, including increasing the available data regarding 
vaccinations in nursing homes.

    Question. For years, press reports and academic research have 
repeatedly shown the negative impact that private-equity ownership of 
nursing homes takes on patient care--an issue that has long been of 
interest to the Finance Committee. Most recently, a study published by 
the National Bureau of Economic Research found that private-equity 
ownership of nursing homes was associated with 10-percent higher short-
term mortality of Medicare patients, was ``accompanied by declines in 
other measures of patient well-being,'' and led to 11-percent higher 
taxpayer spending on a per-patient basis. Despite these issues, 
patients, families, and regulators are often hard-pressed to untangle 
when a nursing home is owned--or controlled through various 
subsidiaries--by a private equity firm. Section 6101 of the Affordable 
Care Act sought to address the black box of nursing home ownership by 
setting out statutory requirements to increase the amount of 
information made available to the public. CMS issued a proposed rule to 
implement the statute in 2011, but withdrew it in 2012 after receiving 
comments. At the time, the agency signaled its intention to reissue 
regulations that addressed the comments, but never did so.

    Does private equity's growing role in the nursing home industry, 
and its impact on care quality, concern you?

    Do you plan to increase the transparency of nursing home ownership 
information, either through implementation of section 6101, or other 
regulatory requirements and guidance?

    Answer. Nursing homes' first obligation should be to their 
residents, no matter what kind of ownership arrangements they have, and 
nursing homes participating in Medicare and Medicaid programs must meet 
required Federal health and safety standards. If confirmed, I am 
committed to working with you and your colleagues to ensure nursing 
homes provide high-quality care to their residents.

                                 ______
                                 
             Questions Submitted by Hon. Benjamin L. Cardin
                           dxa reimbursements
    Question. Hip fracture is the most devastating fracture that 
someone with osteoporosis can experience. In Maryland, there has been 
an 18.5-percent decline in DXA testing of Medicare women since 2008, 
resulting in too many unnecessary and avoidable hip fracture related 
deaths each year.

    Will you commit to working with me and Senator Collins to improve 
access to osteoporosis testing by restoring adequate reimbursement for 
screenings in the physician office?

    Answer. Thank you for bringing this issue to my attention. If 
confirmed, I am happy to work with you and Senator Collins to explore 
options to encourage osteoporosis screenings.
                            hospice payments
    Question. Hospices in Montgomery County, Maryland are at a long-
term competitive disadvantage due to a Medicare hospice Federal payment 
inequity imposed in 2006 by CMS involving the use of core-based 
statistical areas (CBSAs) when Metropolitan Divisions are present. 
Since CMS began using CBSAs to determine payment, hospices in 
Montgomery County have received lower payments than hospices in 
adjacent counties, or even those in more rural, low-cost parts of the 
tri-State area.

    Using CBSAs in this manner is flawed for the following reasons. 
Montgomery County has a similar cost of living compared to Washington, 
DC and shares the same labor market when competing for labor. As a 
result, hospices in Montgomery County are having difficulty providing 
the same level of services as hospices in DC, the three nearby Maryland 
counties, and the neighboring counties of Northern Virginia, all of 
which are paid a higher reimbursement.

    I sought an administration solution to this issue in two delegation 
letters to CMS in 2017 and 2018 and hospices in Montgomery County have 
commented on this problem to CMS annually since 2005.

    In your role as CMS Administrator, will you commit to work to 
resolve this problem?

    Answer. Thank you for raising this concern. I know you have been a 
leader in making sure Montgomery County, Maryland is treated fairly. I 
too want to make sure the Medicare program operates in an equitable and 
transparent way. If confirmed, I would be happy to work with you and 
others in the Maryland delegation on this issue to make sure your 
constituents have access to high quality hospice services.

                                 ______
                                 
               Questions Submitted by Hon. Sherrod Brown
                mental health services in child welfare
    Question. One of the ongoing challenges in child welfare is the 
greater need for mental health services including a greater supply of 
health professionals with knowledge and experience in child psychology. 
This is true in the need for post-adoption services as well as families 
we are trying to keep together.

    If confirmed, will you commit to working with States to improve 
coordination between State child welfare agencies and State Medicaid 
departments to streamline services and supports for children and young 
people? How would you work to increase the supply of health 
professionals to better meet children and young people's mental health 
needs?

    Answer. I share your commitment to making quality mental health 
services available to children and families involved in the child 
welfare system, including families who adopt children from the child 
welfare system. If confirmed, I will make it a priority for CMS to 
encourage better coordination between State Medicaid and child welfare 
agencies. The pandemic has created challenges for Americans' mental 
health, especially for children, and increasing the number of providers 
is an important step to address these challenges. If I have the 
privilege of being confirmed, I also want to focus on improved 
coordination with other Agencies in HHS, including SAMHSA, to make sure 
we are better integrating mental and behavioral health into the health-
care system.
                             hcbs workforce
    Question. In order to strengthen Medicaid's home and community-
based services (HCBS), it is essential that we prioritize policies to 
develop, support, and build our Nation's long-term care/HCBS workforce. 
We need to find ways to ensure higher wages for our home care workers 
and direct support professionals, and support their professional 
development.

    If confirmed, will you work with me and other members of Congress, 
the labor community, and other stakeholders on ways to provide more 
support for this essential workforce?

    Answer. I appreciate your leadership in this area, and I understand 
we still have a ways to go to make HCBS a reality for seniors and 
individuals with disabilities in need of long-term care. Developing, 
supporting and building the workforce is key to ensuring access to 
these important services. If confirmed, I look forward to working with 
you and our State partners to champion further progress to rebalance 
Medicaid's long-term care services and supports, including looking at 
what we can do together to help bolster the workforce.
                         continuous eligibility
    Question. Each year, millions of Medicaid and CHIP beneficiaries 
who enroll in coverage are at risk of losing that coverage as a result 
of taking on an extra shift or working overtime, simply because their 
income fluctuates slightly. As a result, these short-term changes set 
in motion bureaucratic snafus that cause taxpayers to be disenrolled 
from their insurance. This breakdown in coverage often disrupts 
treatment plans and undermines the progress of their care, but can also 
cause significant administrative challenges that result in higher costs 
for States, providers, and health plans. This can be particularly 
disruptive for Medicaid beneficiaries using care coordination and care 
management services, which are interrupted every time a beneficiary is 
disenrolled.

    The Stabilize Medicaid and CHIP Coverage Act--legislation I've 
introduced with two other members of this committee, Senators 
Whitehouse and Warren--would ease the burden caused by churn by 
ensuring beneficiaries can depend on their coverage for a continuous 
12-month period regardless of their age.

    Do you agree that we should work to minimize churn in health 
insurance coverage and eliminate disruptions in care that result when a 
beneficiary churns in and out of coverage?

    If confirmed, will you work with me and my colleagues to strengthen 
the Medicaid and CHIP programs to minimize churn and ensure continued 
access to care for beneficiaries?

    Answer. I agree that reducing churn in health-care coverage is 
critical to ensuring continuity of care and positive health outcomes. I 
look forward to working with you on solutions to ensure that 
beneficiaries have continued access to health-care coverage they can 
rely on.
                 medicare advantage/prior authorization
    Question. Thank you for your commitment to working with me to equal 
the playing field between traditional Medicare and the Medicare 
Advantage program. I look forward to collaborating on this effort.

    One area where we can create some parity lies in the prior 
authorization process. Last Congress, I introduced legislation with 
Senator Thune to establish an electronic prior authorization program in 
Medicare Advantage (MA) to better facilitate the prior authorization 
process in MA and improve the timeliness and efficacy of care delivery 
for beneficiaries and their providers. CMS has issued a notice of 
proposed rulemaking to establish similar programs in Medicaid, the 
Children's Health Insurance Program (CHIP), and insurers operating 
qualified health plans on the federally facilitated exchange under the 
Affordable Care Act (ACA). Beneficiaries and their providers should not 
have to jump through hoops in order to access medically necessary 
services.

    If confirmed, will you work with Senator Thune and me to provide 
additional technical assistance on our legislation so that we can 
advance improved prior authorization processes that put the patient 
back at the center of care and reduce barrier to timely access to 
essential services?

    CMS has the legal authority to implement some of the provisions 
included in the Improving Seniors' Timely Access to Care Act. As 
Administrator, will you consider regulatory action to move forward with 
the provisions of this legislation that are within your current 
authority to implement?

    Answer. I believe that ensuring Americans have timely access to 
health care is critical, and I agree with you that both providers and 
beneficiaries should not have to jump through unnecessary hoops for 
access to medically appropriate care. If confirmed, I look forward to 
working with you, Senator Thune, and other members of Congress on these 
important issues.
                            nursing schools
    Question. 42 U.S.C. 1395ww(l) provides an important source of 
support for 
hospital-based nursing schools across the country. Unfortunately, 
nearly a decade ago mistakes in the implementation of 42 U.S.C. 
1395ww(l) resulted in several hundred million dollars of CMS 
overpayments. After becoming aware of these prior overpayments, CMS 
issued Transmittal 10315, requiring the recoupment of funds from 
hospitals to correct for past program overpayments.

    Unfortunately, this has resulted in a situation where hospital-
based nursing schools in Ohio and across the country, due to no fault 
of their own, are required to pay back millions in funds that CMS 
mistakenly sent out in past years. While this claw-back of funding 
would be hard for hospital-based nursing schools to endure during 
normal times, this recoupment effort during the middle of a global 
pandemic that has decimated hospital revenues and highlighted the 
importance of our nursing workforce is both impossible and ironic.

    I have shared draft legislation with CMS that could help provide 
relief to these hospital-based nursing schools for the agency's 
technical assistance. If confirmed, will you help expedite the process 
for agency feedback on this proposed fix and work with me and my 
colleagues on a solution that will support our hospital-based nursing 
schools and their students?

    Answer. I am committed to supporting hospital-based nursing schools 
training the Nation's next generation of practitioners. If I am 
fortunate enough to be confirmed, I will look into this important issue 
and look forward to working with you.
                 direct and indirect remuneration fees
    Question. Community pharmacists are a critical player in our 
Nation's health-care workforce, extending essential services to 
underserved and disproportionately at-risk communities. Especially 
during the COVID-19 pandemic, pharmacists have been critical in our 
efforts to expand access to testing and vaccination services, including 
long-term care residents and other seniors and Part D beneficiaries.

    Unfortunately, the rapid growth of pharmacy direct and indirect 
remuneration (DIR) fees continues to create uncertainty for the 
community pharmacies Ohioans rely on for essential services. The use of 
DIR fees in Medicare Part D has exploded over the past several years, 
threatening the financial viability of pharmacies across Ohio and the 
health of the patients they serve. The Centers for Medicare and 
Medicaid Services (CMS) has estimated that pharmacy DIR fee reform 
could result in saving Medicare beneficiaries between $7.1 and $9.2 
billion in cost sharing burden over the next decade.

    If confirmed, will you commit to working with Congress on solutions 
to address the explosion of DIR fees and support stability for 
community pharmacies, while ensuring quality and low costs for Medicare 
beneficiaries?

    Answer. Small and rural pharmacies are critical to our Nation's 
health-care system and have been especially important during the 
pandemic. It can be hard for these pharmacies to predict retroactive 
DIR fees. We must do all we can to ensure that Americans can access 
important health-care services, including from local pharmacies in 
their communities. If confirmed, I look forward to working with 
Congress to ensure that community pharmacists have predictability and 
to lower drug prices for patients and families.
                     social determinants of health
    Question. As was discussed during Thursday's hearing, entities 
across the health-care and political spectrum are increasingly focused 
on ways to address the social determinants of health. The Centers for 
Medicare and Medicaid Services (CMS)--as both a payer and a policy 
driver--has many tools at its disposal to improve health and drive 
value by addressing social determinants.

    If confirmed, how will you use Federal payment policy--across 
Medicare and Medicaid and through the Center for Medicare and Medicaid 
Innovation (CMMI)--to address the social determinants of health, ensure 
our Federal programs and models address health-related social needs of 
patients, and support upstream investments in the social determinants 
of health?

    Answer. The COVID-19 pandemic has further exposed the disparities 
that exist in our society. I understand the CMS Innovation Center is 
currently testing the Accountable Health Communities Model, which 
evaluates whether systematically identifying and addressing the health-
related social needs of Medicare and Medicaid beneficiaries through 
screening, referral, and community navigation services will impact 
health-care costs and reduce health-care utilization. In addition, if 
confirmed, I intend to take a department-wide approach to the 
advancement of equity, consistent with President Biden's charge to 
Federal departments and agencies, and this would include examination of 
ways to address the social determinants of health.
                  reimbursements for new technologies
    Question. In January 2021, HHS released its Artificial Intelligence 
(AI) strategy, which reads, in part: together with its partners in 
academia, industry, and government, HHS will leverage AI to solve 
previously unsolvable problems by continuing to lead advances in the 
health and well-being of the American people, responding to the use of 
AI across the health and human services ecosystem, and scaling 
trustworthy AI adoption across the Department.

    While the growth of technology in health care has the potential to 
facilitate access to care and improve quality for beneficiaries, it is 
critical that any strategy to incorporate AI in HHS policy center 
consumers. As the Department works to leverage AI and incorporate AI 
applications and other advanced technologies across health care, HHS 
should use all existing tools, including payment systems, to support 
the adoption of technology that increases access to and quality of 
care.

    CMS payment policy has lagged behind when it comes to coverage of 
newer technologies that offer more personalized approaches to diagnosis 
and treatment, including those that utilize a form of AI. If confirmed, 
will you commit to reviewing CMS payment policies for disparities in 
coverage of AI and other new technologies and acting to update payment 
systems, where appropriate, to ensure access to those technologies that 
improve access to and quality of care?

    Answer. Thank you for raising this important issue. It is 
incredible what scientific progress has been made with innovative drugs 
and treatments, and we need to continue to modernize the Medicare and 
Medicaid programs to make sure beneficiaries have access to proven new 
treatments. I understand that in 2019, CMS launched the AI Health 
Outcomes Challenge, to engage with innovators with harness AI solutions 
to predict health outcomes for potential use in CMS Innovation Center 
innovative payment and service delivery models. If confirmed, I commit 
to continuing to review how CMS can harness new technologies that 
utilize AI to improve health outcomes for beneficiaries.

                                 ______
                                 
            Question Submitted by Hon. Robert P. Casey, Jr.
    Question. The COVID-19 pandemic has underscored the urgent need to 
enhance quality in our Nation's nursing homes. The profound loss of 
life we have experienced over the last year is a tragedy within the 
broader tragedy of this pandemic. More than 182,000 residents and 
workers have died of COVID-19 in nursing homes and other long-term care 
facilities. Well before the pandemic, I worked alongside Senator Toomey 
to shed light on cases of abuse and neglect in underperforming nursing 
homes. These nursing homes are part of what's known as the Special 
Focus Facility program.

    My 2019 investigation with Senator Toomey found that this subset of 
nursing homes consistently fails to provide quality care, and yet not 
every nursing home that needs it is receiving intervention. We have an 
obligation to use every tool available to ensure that the residents who 
live in these homes receive the highest standard of care.

    That is why, last month, Senator Toomey and I reintroduced our 
bill, the Nursing Home Reform Modernization Act (S. 782). Together, we 
have laid out a bipartisan path forward to strengthen, target and 
expand oversight and give help and assistance to nursing homes that 
need it.

    Ms. Brooks-LaSure, can I count on you to prioritize making 
improvements to nursing home quality and to work with me and Senator 
Toomey to identify how to enhance oversight for the poorest performing 
facilities?

    Answer. It has been heartbreaking to see how hard the COVID-19 
pandemic has hit the Nation's nursing homes, and this is not an issue 
newly created by the pandemic, as you noted. I agree that nursing homes 
must provide high-quality care to their residents. Nursing homes' first 
obligation should be to their residents, and every nursing home that 
participates in Medicare and Medicaid must meet Federal health and 
safety standards. If confirmed, it will be a top priority for me to 
hold nursing homes accountable for providing high quality of care to 
their residents.


    Thank you for your leadership on this critical issue. I know this 
has been a priority of yours, and I would be happy to work with you and 
Senator Toomey on this issue if I am fortunate enough to be confirmed.

               Questions Submitted by Hon. Mark R. Warner
    Question. The PACE (Program of All-Inclusive Care for the Elderly) 
was established by Federal statute to provide the full range of 
Medicare and Medicaid benefits to seniors who want to remain safely in 
their homes, rather than enter a nursing home setting. The COVID-19 
pandemic bolstered the attractiveness of the PACE program as these 
programs were able to pivot from providing services in PACE centers 
toward doing more telehealth and in-home visits, showing that PACE can 
help maintain seniors' well-being when it is dangerous for them to be 
in group settings.

    We have a number of large and successful PACE programs across 
Virginia. I have always been a fan of PACE, and Virginia is one of the 
more active and supportive States for PACE. PACE does have a big runway 
for growth, considering that more than two million people in the United 
States qualify for PACE, but only about 55,000 individuals are 
currently enrolled.

    How do you feel about PACE? Do you have a plan for promoting more 
PACE centers in the States?

    Answer. PACE is an important option that helps individuals in need 
of nursing home-level care to get health care at home or in community-
based settings. PACE provides Medicare and Medicaid services under a 
model of care that includes comprehensive care management. More can be 
done to encourage the kind of care coordination and alternative to 
institutional care seen in PACE. If I am fortunate enough to be 
confirmed, I will look forward to working with you on this important 
issue.

    Question. The American Federation of Government Employees (AFGE) 
Local 1923, the union that represents employees at the Centers for 
Medicare and Medicaid Services (CMS), has expressed concerns to my 
office about unfair labor practices enacted by the previous 
administration. Specifically, these dedicated public servants have 
expressed concern they were forced to accept an unfair collective 
bargaining agreement (CBA) due to the Trump administration's executive 
orders (EOs) of 2018 and the Federal Services Impasses Panel (FSIP).

    If confirmed, will you commit to reexamining this collective 
bargaining agreement (CBA) to ensure it is fair to the dedicated public 
servants you will oversee?

    Will you also ensure that CMS engages in good faith negotiations 
with AFGE and that the agency and its managers appropriately implement 
EO 14003?

    Answer. Thank you for raising this important issue. Our workforce 
is critical to the continued success of CMS's programs. If I am so 
fortunate to be confirmed, I would like to learn more about the issues 
that have been raised to your office, and I will look into this issue 
to make sure CMS employees have the protections they deserve.

                                 ______
                                 
             Questions Submitted by Hon. Sheldon Whitehouse
                        eleanor slater hospital
    Question. The Rhode Island Department of Behavioral Health, 
Developmental Disabilities and Hospitals stopped billing CMS for 
Medicaid claims in 2019 following a State audit that flagged the need 
for some technical fixes to the Rhode Island Medicaid State Plan. CMS 
recently approved an amendment to the State Plan, but the suspension of 
billing may amount to approximately $60 million of lost Medicaid 
dollars for my State. I have contacted CMS with number of questions 
regarding the suspension and the possibility of the State recouping 
some of the $60 million. Will you commit to providing me with detailed 
information regarding the billing suspension at Eleanor Slater Memorial 
Hospital and to working with me to recoup some of the funding that was 
lost?

    Answer. If confirmed, I would be happy to work with you on this 
issue. Responsiveness and communication with Congress will be a key 
priority for me, as I understand your important role in helping your 
constituents.
                   imputed rural floor implementation
    Question. As part of the American Rescue Plan, I championed a 
legislative fix to restore the imputed rural floor for Medicare 
hospital reimbursement rates. CMS is responsible for implementing the 
legislative fix and should include the imputed rural floor in the FY22 
Inpatient Prospective Payment System rule. Do you commit to restoring 
the imputed rural floor in the forthcoming IPPS rule?

    Answer. Thank you for your leadership on this issue. I want to make 
sure we operate the Medicare program in an equitable and transparent 
way. I know you worked very hard to make sure this was addressed in the 
American Rescue Plan Act, and I have every reason to anticipate that 
CMS is working hard to ensure that the provision will be implemented as 
quickly as possible. I would be very happy to stay in touch with you, 
if confirmed, on CMS's implementation of this provision.
                                medicaid
    Question. Rhode Island's Medicaid 1115 waiver will expire on 
December 31, 2023. The current 1115 waiver focuses on social 
determinants of health, long-term services and support rebalancing and 
alternative payment methodologies. How will CMS work with the State 
when it is time to renew the 1115 waiver?

    Answer. Medicaid is an important lifeline for many American 
families. Section 1115 demonstration projects, or waivers, are one 
available tool to States to help test new and innovative policies in 
Medicaid. I have worked closely with States throughout my career, so I 
know they face different challenges and need consistency and 
predictability. If confirmed, I will keep in mind what I have learned 
working on behalf of States to make sure waiver requests are 
appropriately evaluated while giving them consistent guidance. I will 
support State innovation and the ability of States to test out 
different models that meet the objectives of the Medicaid program. I 
look forward to seeing the ideas States bring to the table and will 
consider each one on its merits.

    Question. Rhode Island is committed to alternative payment 
methodologies, including Medicaid accountable care organizations but 
the Federal funding for this program is time-limited. What additional 
funding, policy support or technical assistance will CMS provide to 
advance alternative payment methodologies?

    Answer. Alternative payment methodologies and delivery reform, 
generally, are so important to moving our health-care system towards 
one that rewards value over volume. States, like Rhode Island, are 
often the leading innovators in this effort, and we should be learning 
from their successes. More integrated and coordinated care can help to 
improve care and lower costs. If confirmed, I want to work with you to 
make sure we are pursuing demonstration projects that achieve these 
goals, and I would be happy to work with you to support States' efforts 
to innovate in their Medicaid programs.
                               health it
    Question. CMS played a leading role in supporting significant HIT 
infrastructure under the HITECH Act. What resources does CMS need in 
order to fund new investments in HIT infrastructure that are compliant 
with interoperability standards?

    Answer. Interoperability of patient records is so critical to 
ensure appropriate coordination of care. We need to improve health 
information technology across our health-care system, particularly for 
behavioral health providers--an important issue I know you have worked 
to address. I look forward to working with you on this issue, including 
determining what additional resources might be needed, if confirmed.
                          affordable care act
    Question. How will CMS work with States like Rhode Island that 
fully embraced the ACA to reduce the remaining barriers to universal 
coverage?

    Answer. If I am fortunate enough to be confirmed, it will be a 
priority of mine to build on the successes of the Affordable Care Act 
(ACA). The ACA has extended coverage for millions of American families. 
It is so important that American patients and families be able to 
afford health insurance, and I appreciate Congress's leadership in 
taking action through the American Rescue Plan Act to bring down 
premiums during the pandemic. We need to continue to work on this issue 
to make health care more affordable. This includes working with States, 
like Rhode Island, that have been leaders in ACA implementation to 
learn from their successes and continue to move the ball forward.

                                 ______
                                 
           Questions Submitted by Hon. Catherine Cortez Masto
    Question. A noteworthy pattern over the course of the pandemic has 
been the high utilization of telehealth services via telephone, without 
any video. This flexibility has allowed physicians to keep their doors 
open and continue treating patients, and vulnerable individuals who 
don't have access to a smart phone or might struggle with technology 
are able to seek services.

    In your view, is it important that we maintain access to these 
services for both Medicare and Medicaid beneficiaries who are still 
unable to utilize in-person care?

    Answer. Telehealth has been invaluable during this pandemic to keep 
patients, their providers and their families safe. My brother is a 
psychologist, and telehealth has really helped his patients get the 
care they need. If I am fortunate enough to be confirmed, I will be 
taking a careful look at the telehealth flexibilities under Medicaid 
and Medicare before the Public Health Emergency ends. During that 
review, I will pay special attention to the issues of equity and 
access. I will look at what we can and should extend administratively 
and where we will need Congress's help to ensure that we bring the 
lessons learned about telehealth during the pandemic forward to 
modernize our health-care system.

    Question. Medicare Advantage plans serve more than 26 million 
vulnerable beneficiaries who have similarly benefited from this 
expansion in telehealth services. I'm concerned that current CMS risk 
adjustment policies that exclude audio-only diagnoses could hamper MA's 
ability to serve beneficiaries during this crucial period and 
negatively impact the program, its provider partners, and MA enrollees 
in the future.

    Will you further commit to reviewing this policy promptly to ensure 
that the policy does not negatively impact premiums, benefits, out-of-
pocket costs, or the availability of plans in 2022?

    Answer. Medicare Advantage serves millions of Americans and is an 
important option for Medicare beneficiaries. During the pandemic, we 
have been able to see the value telehealth brings for patients, 
including those enrolled in Medicare Advantage. If confirmed, I look 
forward to working with you to ensure that beneficiaries enrolled in 
Medicare Advantage plans can continue to benefit from these services.

                                 ______
                                 
              Questions Submitted by Hon. Elizabeth Warren
                       unique device identifiers
    Question. Although medical device failures are rare, when they do 
occur, they can create serious health problems and significant 
financial costs. A 2017 investigation by the Office of Inspector 
General at the Department of Health and Human Services found that 
recalls or premature failures of just seven faulty cardiac devices 
resulted in $1.5 billion in Medicare payments and $140 million in out-
of-pocket costs to beneficiaries. Furthermore, the Inspector General 
was not able to examine the total cost of all device failures because 
of the lack of information about specific devices in claims data. 
Instead, OIG examiners were forced to engage in a ``complex and labor-
intensive audit'' to assess the impact of the seven faulty devices. As 
a result, the OIG recommended that CMS add unique device identifiers 
(UDIs) to Medicare claims. Including device identifiers on claims 
transactions would greatly improve the health system's ability to 
identify risks and reach patients who may be affected by device 
failures.

    The process of adding UDIs to Medicare claims is a complex one, but 
ultimately will require CMS to agree to act on the recommendations of 
X12, an entity that establishes accredited standards for claims 
transactions. X12 recently recommended that the device identifier 
portion of a medical device's UDI be included on the electronic claims 
transaction. As the Administrator of CMS, will you commit to 
implementing X12's recommendation and adding UDIs to Medicare claims?

    Answer. Thank you for your bipartisan leadership on this issue. I 
understand that a revised claims form that includes the device 
identifier has made it through the first step in the consensus- based 
process and that the next step is for the National Committee on Vital 
and Health Statistics to make recommendations. If I am fortunate enough 
to be confirmed, I would be happy to look into this issue further and 
to stay in touch about it with you.
                     electronic visit verification
    Question. The 21st Century Cures Act of 2016 included a requirement 
that States implement electronic visit verification (EVV) systems for 
certain Medicaid services. EVV systems are designed to certify that 
personal care services and home health services in Medicaid are 
actually provided. They must verify the type of service provided, the 
date of service, the location of the service, the time the service 
begins and ends, and the identities of the patient and provider. States 
that fail to implement EVV programs are subject to a 1 percent, 
incremental FMAP reduction unless they can demonstrate that a ``good 
faith effort'' has been made to comply. States were required to begin 
implementing EVV for personal care services in January 2020, and they 
must begin doing so for home health services in January 2023.

    Since the 21st Century Cures Act was passed, advocates for workers, 
people with disabilities, older adults, and Medicaid patients have 
expressed concern about the lack of worker and patient privacy 
protections in EVV programs. Meanwhile, they have expressed concern 
about the possibility of States losing Medicaid funding in the midst of 
the COVID-19 pandemic. As the Administrator of CMS, will you commit to 
reviewing existing Federal EVV guidance to determine (1) whether worker 
and service recipient civil rights are adequately protected, 
particularly with regard to the use of biometric and GPS data and (2) 
whether existing EVV guidance contributes to workforce shortages, and 
what improvements could made to the guidance to mitigate those 
shortages? Will you commit to ensuring that States do not lose funding 
for critical services via an FMAP decrease during the COVID-19 
pandemic? Will you commit to improving existing Federal EVV guidance 
and considering the possibility of using the rulemaking process to 
ensure that worker and service recipient privacy and other rights are 
protected in EVV programs?

    Answer. Protecting the privacy of patients and our health-care 
workforce is critically important. If confirmed, I will fully examine 
these issues to determine the administrative or legislative actions 
that would be needed to make sure that these requirements are 
protecting privacy and not placing an undue burden on States and 
health-care workers.

                                 ______
                                 
                 Questions Submitted by Hon. Mike Crapo
                      medicare/medicare advantage
    Question. During the COVID-19 pandemic, CMS provided Medicare 
Advantage (MA) plans with additional flexibilities, such as expanding 
telehealth services, providing beneficiaries with devices to use 
telehealth and remote patient monitoring, and reducing cost sharing and 
premiums. How would you work with stakeholders and Congress to continue 
certain enhanced benefits and flexibilities, which could continue to 
further the MA program?

    Answer. Medicare Advantage serves millions of Americans and its 
enhanced benefits and plan flexibilities provide important options for 
beneficiaries who choose to enroll in it. I believe we have to take 
every approach we can in order to get people the health care they need 
at an affordable price, including through the appropriate use of 
telehealth services. Telehealth has been invaluable during this 
pandemic in helping to keep patients, their providers and their 
families safe. I want to be sure we take in the lessons from this 
pandemic, including the value of telehealth, and look at what 
flexibilities we can and should extend administratively, and where we 
may need to work with Congress. If confirmed as CMS Administrator, I 
look forward to working with you to achieve this important goal.
                           medicare solvency
    Question. Medicare is on a near-term path toward bankruptcy. The HI 
trust fund could be insolvent in anywhere from 4 to 5 years. Other than 
during the first few years of the Medicare program's existence, 
Congress has never allowed the HI trust fund to project less than 4 
years of solvency without acting in order to minimize the impact on 
health-care providers, taxpayers, and beneficiaries. Given the looming 
fiscal crisis, how soon can we expect a comprehensive legislative 
proposal from HHS that extends the life of the HI trust fund?

    Answer. Medicare solvency is an incredibly important, longstanding 
issue. I look forward to working with Congress on a bipartisan basis to 
address this. We will need both short-term and long-term strategies to 
make sure Medicare remains a bedrock of our health-care system. It is 
essential that we protect this program for Americans who have spent 
their lives paying into it.
                              drug prices
    Question. There is broad concern that establishing Medicare (or 
other) prescription drug payment amounts using foreign reference prices 
will harm patient access and stifle innovation. Do you support the use 
of foreign reference prices in Medicare? Do you view the use of a 
foreign reference price to set payment amounts as price setting or a 
form of negotiation?

    Answer. We all agree that too many Americans cannot afford their 
prescription drugs. Lowering prescription drug costs for American 
patients and families is a priority on both sides of the aisle, as is 
ensuring that the United States continues to allow for innovation in 
drug development. I want to work with you and other members of Congress 
to find ways to ensure patients have access to innovative drugs and 
bring down prescription drug prices.
                                  cmmi
    Question. The Affordable Care Act established the Center for 
Medicare and Medicaid Innovation (CMMI). There is significant 
bipartisan support for testing different ways to pay for services to 
figure out how patients can get better care at a lower cost. However, 
there is concern that Congress ceded too much authority to the 
executive branch by allowing CMMI to override statute, especially in 
Medicare, in the name of a payment change ``test.''

    What are your views on the appropriate use of CMMI authority?

    If confirmed, will you commit to ensuring that CMS would not use 
CMMI to avoid working with Congress?

    Considering that many CMMI tests have run for an extended period of 
time without meeting the criteria for expansion, is there a length of 
time sufficient to determine if a model works?

    With CMMI having a large budget of $10 billion for each decade and 
little accountability to Congress, what metrics would you use to 
determine whether CMMI is successful?

    Answer. The Innovation Center has been an important tool to test 
new models to move our system from one that rewards volume to one that 
rewards value. It will continue to be important, as we move forward, to 
test models that improve patient care, advance health equity, and lower 
patient costs. We have now had 10 years of experience to learn from at 
the Innovation Center. We need to look at what has worked and what 
hasn't, and I look forward to hearing from you about what you think is 
working well and what experiences you've seen in Idaho.
                                payments
    Question. There are concerns that the inclusion of calcimimetic 
medications in the Medicare End Stage Renal Disease (ESRD) bundled 
payment rate may harm beneficiaries' access to these treatments. There 
are anecdotal reports that some patients have had to change or 
otherwise stop using a medicine that has worked for them in response to 
this payment policy change. How would you ensure that ESRD patients 
have access to calcimimetic treatments and monitor patient outcomes in 
this area?

    Answer. I agree that is it important for Medicare beneficiaries, 
particularly patients with complex medical conditions such as ESRD, to 
have access to medically necessary treatments such as calcimimetics. If 
confirmed, I will work to preserve access to critical treatments and 
improve patient outcomes.

    Question. In the ``Medicare Hospital Outpatient Prospective Payment 
and Ambulatory Surgical Center Payment Systems'' proposed rule for 
2021, CMS solicited comments on the use of its ``equitable adjustment'' 
authority for pass-through products adversely impacted by the reduction 
in surgical procedures during the COVID-19 pandemic. Will CMS use this 
authority to ensure that products impacted by the pandemic receive 
pass-through payments for a length of time that enables adequate cost 
data collection that ensures reasonable payment once these products are 
bundled into an ambulatory payment classification (APC) group?

    Answer. The COVID pandemic is taking a toll on Americans in so many 
ways, including reducing and delaying surgeries. If confirmed, I will 
work with you and other members of Congress as we look for ways to help 
providers, suppliers, and other stakeholders recover from the financial 
impacts of the pandemic and maintain access for beneficiaries.
                             new treatments
    Question. The 21st Century Cures Act that was enacted in 2016 
created a home infusion therapy benefit to provide for the nursing 
services necessary to support drug administration in the home setting 
when patients are unable to self-
administer. To date, no new drugs requiring health-care professional 
administration have been able to get covered for home infusion. CMS 
issued a ``Durable Medical Equipment, Prosthetics, Orthotics, and 
Supplies (DMEPOS) Policy Issues and Level II of the Healthcare Common 
Procedure Coding System (HCPCS)'' proposed rule in 2020 that would 
create a pathway for drugs requiring healthcare professional 
administration to be covered for home infusion. This rule has not yet 
been finalized, even though many seniors would continue to benefit from 
being able to receive treatment at home during the COVID-19 pandemic. 
Will CMS prioritize the finalization of this DMEPOS proposed rule to 
expand seniors' access to the home infusion benefits?

    Answer. Thank you for raising this important issue. We share the 
goal of making sure people can receive care in their homes, when 
appropriate, especially during the pandemic. If confirmed, I am happy 
to make the review of this proposed rule a priority.

    Question. Cell and gene therapies present a paradigm shift in the 
treatment of disease, no longer just treating symptoms, but using 
cutting-edge technology to address the root cause of the disease 
itself. The FDA has previously predicted that it will be approving 10 
to 20 cell and gene therapies a year by 2025. Many of the initial 
diseases that these groundbreaking therapies aim to treat are 
disproportionately insured by Medicare and Medicaid. The cost of these 
potentially life-saving therapies has led to a national conversation on 
the use of value-based arrangements to ensure broader access for 
beneficiaries, especially for rare disease and cancer patients where 
the population that is eligible for the therapy could be in the 
hundreds or thousands.

    Would you agree that CMS should do all they can to ensure access to 
FDA-
approved cell and gene therapies when a doctor and a patient agree it 
is the best treatment option?

    As Administrator, would you commit to utilizing existing program 
flexibility and considering innovative demonstration programs to enable 
Medicare and Medicaid beneficiaries' timely access to innovative cell 
and gene therapies? Will you commit to working with Congress on a 
statutory solution that maximizes access without threatening future 
development of these innovative products?

    Answer. Thank you for raising this important issue. It is 
incredible what scientific progress has been made with innovative drugs 
and treatments, and we need to continue to modernize the Medicare and 
Medicaid programs to make sure beneficiaries have access to proven new 
treatments. I would be happy to work with you and other members of 
Congress on ways to spur innovation and facilitate beneficiary access 
to proven new advances in medicine.

                                 ______
                                 
               Questions Submitted by Hon. Chuck Grassley
    Question. American taxpayers expect us to be good stewards of 
Federal money. Under section 1903(u) of the Social Security Act, the 
Federal Government is required to recoup any improper Medicaid 
eligibility-related payments in excess of three percent made by States. 
The Centers for Medicare and Medicaid Services (CMS) has made little 
improvement since 1992 to recover any of these payments. In 2019, 
Congress passed the Payment Integrity Information Act requiring CMS to 
periodically review programs it administers, identify programs that may 
be susceptible to significant improper payments, estimate the amount of 
improper payments, and report on the improper payment estimates. The 
most recent annual reported improper payments figure across all 
Medicare and Medicaid/CHIP programs was $134.21 billion (2020 CMS 
estimated data) and $106 billion (2019 CMS data). The Medicaid improper 
payment rate for 2020 was 21.36 percent (or $84.49 billion) and the 
Medicare fee-for-service improper payment rate for 2020 was 6.27 
percent (or $25.74). This has been ongoing for decades. If confirmed, 
how will you as CMS administrator address the improper payment rate and 
the waste of taxpayer dollars?

    Answer. Medicaid is a critical lifeline for beneficiaries across 
the country and typically the largest expenditure for States. Reducing 
Medicaid improper payments is a priority because it helps ensure the 
fiscal health of the program. If confirmed, I will work with States and 
leaders in Congress to be responsible stewards of taxpayer dollars 
across both Medicaid and Medicare.

    Question. Ensuring access and protections for individuals with 
serious disabilities who rely on complex rehabilitative manual 
wheelchairs is important. In 2019, Congress provided 18-month relief 
for complex rehab technology (CRT) by including protections for complex 
rehab manual wheelchairs. On June 30, 2021, a temporary policy allowing 
users of complex rehabilitative manual wheelchairs the same benefits as 
complex rehabilitative power wheelchair users will expire. This policy 
has given equal access for the people with disabilities who depend on 
this new technology. If confirmed, would you support a permanent policy 
maintaining the equal access between manual and power wheelchairs?

    Answer. I agree that is important to make sure Medicare 
beneficiaries have access to the durable medical equipment they need. 
If confirmed, I will work with you on this issue.

    Question. In 2020, I cosponsored the Temporary Reauthorization and 
Study of the Emergency Scheduling of Fentanyl Analogues Act and it was 
signed into law. The law extended the Drug Enforcement Administration's 
temporary scheduling order to proactively control deadly fentanyl 
analogues. Fentanyl-related overdose deaths continue to rise and 
sophisticated drug trafficking organizations manipulate dangerous 
substances to skirt the law, so this critical law placed fentanyl 
substances in Schedule I so that they can be better detected and 
criminals can be held accountable for their actions. The law sunsets in 
May of 2021. In December 2019, 56 other State and territory attorneys 
general asked Congress to permanently codify a temporary emergency 
scheduling order keeping fentanyl-related substances classified as 
Schedule I drugs. If confirmed, do you support permanently codifying a 
temporary emergency scheduling order keeping fentanyl-related 
substances classified as Schedule I drugs?

    Answer. I recognize that fentanyl and fentanyl analogues pose a 
significant danger and are responsible for far too many deaths every 
year. While CMS does not have a role in the scheduling process, I 
understand that HHS plays a key role that effort.

    Question. Science tells us that an unborn child has many of the 
neural connections needed to feel pain, perhaps as early as eight weeks 
and most certainly by 20 weeks fetal age. Providing health care to 
unborn children and their mothers can help reduce infant mortality 
rates in low-income communities, research also suggests. Some States 
already offer prenatal care and other health services to unborn 
children through the Medicaid program. What is your view on whether 
unborn children should be entitled to Medicaid coverage, and do you 
believe that the Federal Government has a role to play in encouraging 
such coverage?

    Answer. Medicaid is an important source of pre- and post-natal 
care, and if I am confirmed, I will work to ensure that pregnant people 
have access to quality health care that improves their own health and 
the health of their babies. I was happy to see that Congress included 
incentives for States to expand Medicaid postpartum coverage in the 
American Rescue Plan and that CMS has approved section 1115 
demonstration projects to this effect. I look forward to working with 
members of this committee and Congress to expand access to affordable, 
quality care, including through the Medicaid program.

    Question. Congress's ability to acquire information from Federal 
agencies is critical to its constitutional responsibility of conducting 
oversight of the executive branch. If you are confirmed, will you 
commit to providing thorough, complete, and timely responses to 
requests for information from members of this committee, including 
requests from members of the minority?

    Answer. If confirmed, I will provide responses to requests from any 
members of this committee.

    Question. In 2019, Congress passed bipartisan the Advancing Care 
for Exceptional (ACE) Kids Act to improve health outcomes and care 
coordination for children with complex medical conditions in Medicaid. 
In 2020, I introduced the bipartisan Accelerating Kids' Access to Care 
Act to further help families gain access to life-saving care for 
children with complex medical conditions. The legislation aims to 
facilitate access to care while retaining program safeguards and 
reducing regulatory burdens on providers. If confirmed, what steps 
would you take to improve the system of care for children with complex 
medical conditions?

    Answer. Thank you for your leadership on the ACE Kids Act and your 
focus on access to care for children with complex medical needs. I 
agree that we should do all we can to remove barriers to care for these 
children. If I am fortunate enough to be confirmed, I will look forward 
to working with you on solutions to ensure children with complex 
medical needs get the best care possible.

    Question. In Iowa, transitional health plans (including 
grandmothered health plans) have enabled many middle class Iowans to 
keep the health plans and doctors they like at a reasonable price since 
the Affordable Care Act was implemented. For example, over 56,000 
Iowans are covered by grandmothered health plans. To put this in 
context, about 60,000 Iowans signed up for the Federal health insurance 
exchange in 2021. Iowans have chosen these grandmothered health plans 
that meet their individual needs. Currently, grandmothered health 
plans' existence is determined by the Department of Health and Human 
Services (HHS) through the Centers for Medicare and Medicaid Services 
(CMS) annually through non-enforcement extensions. If confirmed, are 
you committed to maintaining these affordable, 
consumer-chosen health plan options for Iowans by extending the non-
enforcement authority?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. If confirmed, I will examine rules and other policies to 
ensure all Americans can access the care that they need, and I look 
forward to learning more from you about what is working in Iowa.

    Question. Since this COVID-19 pandemic began, the Department of 
Health and Human Services (HHS) including within the Centers for 
Medicare and Medicaid Services (CMS) has provided health-care providers 
and patients many flexibilities under the public health emergency 
authority including over 80 services now furnished through telehealth 
for Medicare patients. A Centers for Disease Control and Prevention 
(CDC) Morbidity and Mortality Weekly Report found the use of telehealth 
increased 154 percent during the last week of March 2020 during the 
emergency of COVID-19 compared to the same period in 2019. We know the 
use of telehealth has continued throughout the COVID-19 pandemic. The 
data and response from patients and providers prove permitting 
telehealth services is a positive action to improve access and care. 
This last Congress, we provided permanent coverage for mental health 
telehealth visits under Medicare, which is helpful during the pandemic 
and will remain critical for many Americans afterwards. If confirmed, 
are you committed to working with Congress and in the executive branch 
to extend telehealth flexibilities in Medicare beyond the pandemic? 
Additionally, some providers, including community health centers, face 
regulatory barriers based on provider type or site of service. If 
confirmed, do you support removing those telehealth barriers for 
certain providers?

    Answer. Telehealth has been invaluable during this pandemic to keep 
patients, their providers and their families safe. My brother is a 
psychologist, and telehealth has really helped his patients get the 
care they need. If I am fortunate enough to be confirmed, I will take a 
careful look at the telehealth flexibilities under Medicaid and 
Medicare before the Public Health Emergency ends. During that review, I 
will pay special attention to the issues of equity and access. I will 
look at what we can and should extend administratively and where we 
will need Congress's help to ensure that we bring the lessons learned 
about telehealth during the pandemic forward to modernize our health-
care system.

    Question. As a direct result of the Affordable Care Act's one-size-
fits-all approach, many Iowans have been priced out of health 
insurance. To rectify this, the Trump administration and Iowa Insurance 
Division enabled Iowans more choice and competition in the health-care 
marketplace by enabling and expanding short-term 
limited-duration insurance (STLDI). This gives Iowans access to health 
insurance with consumer protections. If confirmed, will you work to 
maintain, modify, or rescind the current regulations enabling Americans 
to purchase STLDIs?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. If confirmed, I will examine rules and other policies to 
ensure that plans provide Americans access to the care that they need.

    Question. It is important to give people affordable options for 
health insurance. Small business owners, like Iowa farmers, want to be 
able to provide insurance for their employees. Association Health Plans 
are a way for these small businesses to band together to expand access 
to health insurance and drive down costs. I have introduced legislation 
and support efforts to expand the pathway to affordable and accessible 
health care remaining open to employees across America. Association 
Health Plans allow small businesses to join together to obtain 
affordable health insurance as though they were a single large 
employer. The coverage offered to association members is subject to the 
consumer protection requirements that apply to the nearly 160 million 
Americans who receive coverage from large employers. If confirmed, will 
you work to maintain, modify, or rescind current regulations enabling 
employers and employees access to Association Health Plans?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. If confirmed, I will examine all rules and policies to 
ensure all Americans can access the care that they need.

    Question. I support access to affordable health-care coverage for 
all Iowans, regardless of their health status or pre-existing 
conditions. Americans want to be in control of their own health care. 
National, single-payer health systems do not allow that. The Affordable 
Care Act took options away from people and adopting a single-payer 
system will make that worse. A national, single-payer health system 
would eliminate private health insurance for nearly 200 million 
Americans and require middle-class Americans to pay much more in taxes. 
Single-payer health care would also dramatically increase government 
spending substantially, fail to meet patient needs quickly, reduce 
provider payments rates and reduce quality of care, and the government 
would have more control over health care. It also threatens the 
benefits that current seniors on Medicare have paid into the system 
their entire working lives. If confirmed, do you intend to take 
administrative actions to implement the vision of a one- size-fits-all 
government-run health-care scheme like single-payer? If so, please 
describe what authority you believe you have to take such actions?

    Answer. President Biden has made it very clear that his goals for 
improving the American health-care system begin with building on the 
successes of the Affordable Care Act, and I am committed to working 
toward that goal.

    Question. If confirmed, will you take actions that stifles 
innovation and competition in health care?

    Answer. I believe it is important to foster innovation and 
competition in our health-care system. CMS has a critical role in 
promoting these goals and ensuring access to care. Americans should 
have access to health-care services and products at an affordable 
price.

    Question. In 2019, the Trump administration issued two rules 
requiring price transparency for hospitals and health plans. The rules 
took effect in January 2021. This effort shines a light on the health-
care industry that is all too often shrouded in secrecy. While Congress 
can build upon the rules, consumers can finally see sunshine in health-
care pricing. I have cosponsored legislation to codify the two health-
care price transparency rules. This transparency will bring more 
accountability and competition to the health-care industry. Consumers 
should have the ability to compare health-care prices online so they 
can make an informed choice about what's best for them and their 
families. If confirmed will you modify, rescind, or maintain the Trump 
administration's health-care price transparency regulations?

    Answer. I agree that the variation in pricing across hospitals is 
not always justified and ultimately can be bad for consumers. For 
transparency measures to work properly, patients and their families 
must be able to understand them in a meaningful way. If I am fortunate 
enough to be confirmed, I look forward to continuing to work on this 
issue.

    Question. Some States have lacked transparency in reporting their 
nursing home COVID-19 deaths data. For example, the State of New York 
undercounted nursing home deaths by as much as 50 percent and State 
officials intentionally withheld data for months. The New York Attorney 
General Letitia James released a report in January 2021 suggesting that 
many nursing home residents died from COVID-19 in hospitals after being 
transferred from their nursing homes. These figures were not reflected 
in the New York Department of Health's nursing home death figures for 
many months suggesting the State was undercounting by as much as 50 
percent. There are also reports finding New York State officials 
including members of New York Governor Andrew Cuomo's staff 
intentionally withheld data on COVID-19-
related deaths in the State's nursing homes. Following the release of 
the New York Attorney General report, the New York Department of Health 
reported 12,743 nursing home residents occurred. This included an 
additional 3,829 confirmed COVID-19 fatalities of those residents who 
had been transported to hospitals. I have warned President Biden that 
an across-the-board termination of 56 U.S. attorneys could imperil 
ongoing sensitive investigations. This concern has been expressed by 
Senate Democrats. Currently, Toni Bacon is serving as the U.S. attorney 
for the Northern District of New York. Ms. Bacon previously served as 
Justice Department's national elder justice coordinator and who 
currently has jurisdiction over Federal public corruption crimes in the 
State. Bacon is the obvious choice to continue a fair and unbiased 
investigation into possible violations of civil liberties of the 
elderly and the public corruption. Do you believe Department of Justice 
must have a fair, unbiased, and experienced U.S. Attorney in the 
Northern District of New York, such as Ms. Bacon?

    Answer. I defer to the Department of Justice on the selection of 
U.S. Attorneys.

    Question. I led an effort in the Senate making additional resources 
available to support elder justice initiatives that assist older 
Americans especially throughout the COVID-19 pandemic. During the 116th 
Congress as Senate Finance Committee chairman I convened two hearings 
on elder justice initiatives and gaps in nursing home oversight. In 
December 2020, I urged Senate leadership to make resources available 
for regional or statewide strike teams to support nursing homes in 
crisis during this pandemic. Through this work, the end-of-year COVID-
19 relief package included $100 million to support elder justice 
initiatives, including $50 million for State adult protective service 
agencies as they cope with unique challenges of serving vulnerable 
populations during the pandemic. This work includes nursing home strike 
teams who have provided needed support when an outbreak occurs at a 
nursing home or when additional resources are needed to meet the 
infection control or diagnostic testing requirements. Have State or 
Federal nursing home strike teams been effective at controlling 
outbreaks and protecting vulnerable Americans? If so, can you describe 
how their work slowed the spread and protected lives?

    Answer. It has been heartbreaking to see how hard the COVID-19 
pandemic has hit the Nation's nursing homes. Nursing homes and long 
term care facilities are the homes for some of our most vulnerable, and 
we must do everything we can to work to protect them. If confirmed, I 
look forward to reviewing the work of the Federal nursing home strike 
teams.

    Question. The global pandemic has exposed grave concerns our 
society must confront to protect the Nation's most vulnerable citizens. 
Approximately 1.4 million Americans live in about 15,000 nursing homes 
across the country. Many Iowans have a loved one who lives in a long-
term care facility. In 2019, as chairman of the Senate Finance 
Committee, I conducted a series of hearings to examine gaps in 
enforcement of nursing home abuse. A Government Accountability Office 
(GAO) investigation found a 103-percent increase in abuse deficiencies 
between 2013 and 2017. The GAO noted abuse in nursing homes is often 
underreported. The report documented physical, mental, verbal and 
sexual abuse perpetrated against residents. The number of nursing home 
deaths attributed to COVID-19 delivers a wake-up call we can't afford 
to ignore. The Federal Government needs to do a better job enforcing 
compliance with standards of care. When a loved one requires a long-
term care facility to deliver around-the-clock services, every family 
deserves peace of mind that every nursing home resident will receive 
high-quality, compassionate care and be treated with dignity and 
respect. If confirmed, how will you as administrator ensure nursing 
homes uphold the standard or care that is necessary while not placing 
onerous requirements and excessive administrative burdens on nursing 
home staff?

    Answer. Thank you for your longstanding leadership on this 
important issue of preventing elder abuse. This will be a focus of mine 
if confirmed. Nursing homes and long-term care facilities are the homes 
for some of our most vulnerable, and we must do everything we can to 
work to protect them.

                                 ______
                                 
                Questions Submitted by Hon. John Cornyn
                        end stage renal disease
    Question. Four hundred thousand Medicare beneficiaries are on 
dialysis, and those patients have not benefited from any meaningful 
innovation in their standard of care in decades. Over the last several 
years I have joined colleagues on both sides of the aisle and worked 
with CMS, the patient community and innovators to encourage adoption of 
a new policy to spur innovation in medical technology for Medicare 
patients under the ESRD bundled payment system. CMS has made 
significant progress, having created the TPNIES add-on payment for 
innovation in medical technology used in the provision of dialysis 
services. However, our work is not done. CMS should better align its 
metrics for innovation and clinical improvements over existing 
technologies with the lens FDA uses to evaluate such improvements and 
innovations. And CMS should also extend by another year the period of 
time during which the add-on payment can be made, having established an 
application and qualification process via rulemaking that essentially 
negates the first year of the add on payment window. I will again work 
with my colleagues on legislation to make these additional improvements 
to the work CMS has already done, and hope that you will commit to 
working with me to achieve full success on this policy for Medicare 
patients in whatever is the most expeditious and achievable path.

    Will you commit to working with Congress to implement these 
policies and bring long overdue innovation to this vulnerable group of 
patients?

    Answer. I agree that it is important to spur innovation in medical 
technology that improves health outcomes, particularly for patients 
with complex illnesses such as ESRD. I will always look for ways to 
improve access to innovative and effective treatments for ESRD 
patients, and I believe there is plenty of room for bipartisan work in 
this area. If confirmed, I will work with you and other members of 
Congress on ways to improve access to these innovative treatments.
                       medicare program integrity
    Question. I'm very concerned about the billions of Medicare funds 
lost to errors, waste, fraud, and abuse. Previously, CMS expressed the 
need to ``elevate program integrity, unleash the power of modern 
private sector innovation, prevent rather than chase fraud, waste, and 
abuse through smart, proactive measures, and unburden our provider 
partners so they can do what they do best--put patients first.'' Also, 
Congress included language in the Fiscal Year 2021 appropriations 
encouraging CMS ``to consider pilot programs using AI-enabled 
documentation and coding technology to address CMS's top program 
integrity priorities and reduce administrative burden.'' I think we can 
do more to harness the expertise used in the private sector to benefit 
our Medicare beneficiaries and safeguard the Medicare Trust Fund. I 
hope this is an area of policy that we can work on together.

    Will you commit to working with this committee to prioritize the 
use of artificial intelligence and other emerging technologies to 
bolster Medicare program integrity and protect the Medicare Trust Fund?

    Answer. Fighting fraud and abuse is important for maintaining a 
strong Medicare program. It is my understanding that CMS has taken 
steps to explore the possibilities of artificial intelligence for 
program integrity purposes in addition to a host of other tools it uses 
to detect waste, fraud and abuse. If confirmed, I will work with you to 
make sure that we are good stewards of the Medicare program and 
taxpayer dollars.
                            bundled payments
    Question. CMMI has recently expressed their commitment to value-
based payment programs but is no longer allowing new participants in 
the BPCI model and last week announced they won't take new applicants 
to the new direct contracting model. This is creating uncertainty about 
the agency's commitment. My constituents have made substantial 
investments in participating and/or preparing for these programs and 
strongly believe in their importance in driving value for Medicare 
beneficiaries and the trust fund.

    Can you assure me as CMS Administrator that you are indeed 
committed to these innovative models and that you will be open to 
stakeholder input to improve upon CMMI models before canceling them?"

    Answer. The Innovation Center has been an important tool to test 
new models to move our system from one that rewards volume to one that 
rewards value. It will continue to be important, as we move forward, to 
test models that improve patient care, advance health equity, and lower 
patient costs. We have now had 10 years of experience to learn from at 
the Innovation Center. We need to look at what has worked and what 
hasn't and chart a path forward from there. This absolutely includes 
getting stakeholder and congressional input. If confirmed, I will work 
with you to make sure we are pursuing models that recognize the strides 
providers have already made and improve our health-care system.
                   laboratory date of service policy
    Question. In 2017, CMS established regulations at 42 CFR 
Sec. 414.510(b)(5) to revise its date of service policy for clinical 
laboratory tests to allow a laboratory to bill Medicare directly for 
molecular pathology tests and certain Advanced Diagnostic Laboratory 
Tests (ADLTs) (as defined under section 1834A(d)(5)(A) of the Social 
Security Act) performed on specimens collected from hospital 
outpatients. These regulations eliminated access delays for Medicare 
beneficiaries that resulted from the previous requirement that the 
hospital at which the specimen was collected bill Medicare for these 
relatively uncommon tests. Under the current policy, hospitals and SNFs 
are similarly incentivized to delay submitting samples which can have 
an impact on patient care and time to treatment.

    Can you commit to working in future rulemaking to address this 
payment policy for skilled nursing facilities and inpatient hospitals 
as the agency has already done in the outpatient setting?

    Answer. I share your desire to protect Medicare beneficiaries' 
access to laboratory testing services. My understanding is that payment 
to a hospital or skilled nursing facility for laboratory tests 
furnished to an inpatient whose stay is covered under Part A is 
generally included in the prospective payment system rate for the 
facility. If I am fortunate enough to be confirmed, I would be happy to 
hear more from you on this important issue and work with you to improve 
beneficiary access to laboratory testing.
                            surprise billing
    Question. Complex molecular diagnostic tests for advanced cancer 
have tremendous benefit for patients and oncologists hoping to identify 
the best treatments. Many of these tests are viewed as out-of-network 
and have limited comparable tests for setting benchmarks.

    Can you commit to working with my office to make sure that access 
to these important tests is not delayed due to surprise billing 
regulations promulgated under the No Surprises Act?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. I know that there will be a lot of work to do to implement 
the No Surprises Act. If confirmed, I look forward to working with you 
and other members of Congress to make sure that consumers are protected 
from surprise bills while ensuring they have access to the care that 
they need.
               disproportionate share hospitals payments
    Question. Disproportionate Share Hospitals (DSH) are owed more than 
$10 billion in reimbursements going back to 2005. CMS has challenged 
these payments based on a formula that defied congressional intent. The 
court have consistently ruled that CMS's interpretation is wrong and 
therefore its rule making is invalid. The agency continues to fight and 
is planning to issue yet one more rule despite a loss on this issue at 
the Supreme Court.

    Will you commit to working to ensure DSH hospitals receive the DSH 
payments they are owed.

    Answer. Disproportionate Share Hospitals are critical to our 
Nation's health-care system, providing care to low-income patients and 
the uninsured, and I know that this pandemic has placed significant 
pressure on these health-care providers. If confirmed, I look forward 
to working with you and other members of Congress to ensure CMS is 
using taxpayer dollars appropriately while supporting these providers 
and the work they do on behalf of their patients. I will also ensure 
that States and providers have the guidance they need to administer and 
participate in the Medicaid program.
                      dialysis-related amyloidosis
    Question. We have watched for years as the Medicare program has 
delayed coverage for important medical breakthroughs offered by both 
prescription drugs and medical devices. Although we are aware of 
certain improvements over the past 2 years in the coding process for 
new drugs and devices, the coverage process lags far behind. The result 
is that patients are not receiving the care they need.

    One recent example involves Dialysis-Related Amyloidosis (DRA), a 
disease that affects an estimated 3,000-5,000 patients who have been 
receiving dialysis treatment for 5 or more years. DRA results from the 
failure of the kidneys to filter and remove a protein called ``beta-2 
microglobulin,'' cause cysts across the body, from joints to internal 
organs. These cysts can be extremely painful, and sometimes fatal, for 
those with DRA. Although for years there was no treatment available in 
the United States, a treatment was approved in 2015. Unfortunately, the 
Medicare program does not cover the treatment, which is of great 
concern to me and my constituents.

    In March of 2015 the FDA approved a new treatment for DRA using a 
special apheresis ``column'' in which blood is taken from the patient, 
processed to remove an accumulation of the bad protein (beta-2 
microglobulin) and returned to the patient. Because the patient 
population is so small and the treatment was sufficiently safe, the FDA 
approved the treatment as a Humanitarian Use Device. Yet, despite being 
approved 6 years ago, I am told the Medicare program is still 
evaluating the appropriate coverage pathway for the treatment. Until 
Medicare reaches a decision, Medicare beneficiaries continue to be 
denied access to the only FDA approved treatment for DRA.

    Can you commit to work expeditiously to apply an appropriate 
Medicare benefit category and finally decide coverage for this DRA 
treatment, and any other Humanitarian Use Devices approved by FDA but 
not yet covered by the Medicare program?

    Answer. I agree that is it important for Medicare beneficiaries, 
particularly patients with complex medical conditions such as ESRD, to 
have access to medically necessary treatments. If confirmed, I am happy 
to look into this further and work with you on this issue.
                                hospice
    Question. The COVID-19 pandemic has brought telehealth to the 
forefront of care, dramatically increasing accessibility and making 
strides toward health equity. The hospice community has rapidly 
expanded its telehealth services for the entire Interdisciplinary Team, 
from nursing to chaplains. However, CMS does not appropriately capture 
telehealth claims and therefore lacks visibility into a critical aspect 
of hospice care delivery. The 2021 shift by CMS to only claims based 
hospice quality measurement, exacerbates this gap in essential care 
delivered. Creating telehealth codes for the entire hospice 
Interdisciplinary Team including the required chaplains' visits, would 
give CMS proper visibility into the hospice landscape.

    Will CMS commit to implementing appropriate codes for hospice's 
telehealth services for every IDT discipline, including chaplain 
visits?

    Answer. Improving the safety and quality of end-of-life care is 
important, and telehealth has been and continues to be an important 
tool during the pandemic. While often at end of life, hands-on care is 
needed to manage symptoms, sometimes telehealth may be an appropriate 
and safe way to receive hospice care. If I am fortunate enough to be 
confirmed, I look forward to learning more from you about this issue 
and working to ensure that hospice patients have access to the highest 
quality care.
              ma plan treatment of new technology in esrd
    Question. As you know, Medicare Advantage plans are required to 
ensure coverage equal to that offered under fee-for-service. However, 
patient groups and other stakeholders have noted that Medicare 
Advantage plans may not have, or may not plan to, appropriately 
reimburse for End Stage Renal Disease (ESRD) drugs that are under the 
transitional drug add-on payment adjustment (TDAPA) through their 
negotiated monthly rates. Under certain circumstances this may just be 
a failing of timing, but what happens when new technologies appear 
after plans have already negotiated their rates? Failing to 
appropriately account for TDAPA payments puts a strain on dialysis 
organizations and hurts patient access to top of the line therapies. 
Additionally, many stakeholders continue to be concerned about the 
TDAPA ``cliff.'' After 2 years of additional payment for these 
innovative therapies, drugs which fall into minimally funded categories 
represent undue financial pressure for providers when the transitional 
payment goes away. This cliff can result in providers having to make 
difficult choices about how to continue to provide innovative products 
to their patients.

    While CMS does not interfere in direct negotiations between 
Medicare Advantage plans and their contracted providers, it does bear 
responsibility for upholding parity of coverage. How will CMS rectify 
this patient access issue?

    Can you commit to patients that this and other over-arching issues 
with TDAPA will be something that you have CMS look at so that we can 
feel comfortable knowing that the sickest patients will have access to 
all of these innovative therapies in the pipeline?

    Answer. It is important for Medicare beneficiaries with ESRD to 
have access to the ESRD therapies they need. Given that people with 
ESRD had the new option to enroll in Medicare Advantage plans for 
coverage beginning this year, Medicare Advantage now has a crucial role 
in providing access to ESRD therapies for Medicare beneficiaries. If 
confirmed, I will work to ensure that beneficiaries have access to ESRD 
therapies under Medicare Advantage plans. I will also work to ensure 
that Medicare beneficiaries continue to have access to innovative 
therapies and to improve patient outcomes.
            global and professional direct contracting model
    Question. Recently CMS announced that it would not be allowing a 
second round of applications for the Global and Professional Direct 
Contracting Model. However based on multiple polls, letters to the 
agency, and media reports, there is a significant coalition of 
providers, including Baylor Scott and White in Texas, that were 
interested in participating in the second application cohort. Many 
providers apparently delayed participating in the program because of 
the pandemic.

    What will you be doing to ensure that those providers are given an 
opportunity participate if they want to take on risk in the Global and 
Professional Direct Contracting Model and what are the administration's 
plans for this model and other models like it?

    Answer. The Innovation Center has been an important tool to test 
new models to move our system from one that rewards volume to one that 
rewards value. It will continue to be important, as we move forward, to 
test models that improve patient care, advance health equity, and lower 
patient costs. We have now had 10 years of experience to learn from at 
the Innovation Center. We need to look at what has worked and what 
hasn't and chart a path forward from there. This absolutely includes 
getting stakeholder and congressional input. If confirmed, I will work 
with you to make sure we are pursuing models that recognize the strides 
providers have already made and improve our health-care system.
                             allina ruling
    Question. As CMS Administrator, would you respect the ruling of the 
Supreme Court in the Allina case with regard to calculating DSH 
payments by including Medicare Advantage enrollees inpatient days who 
are also eligible for Medicaid?

    Answer. If confirmed, I will absolutely respect the Supreme Court 
rulings and follow the law.

                           children's health
    Question. As CMS Administrator, you will oversee a number of 
programs and agencies important to children from health coverage 
programs vital to children's health such as Medicaid and the Children's 
Health Insurance Program (CHIP) to programs responsible for training 
the pediatric health-care workforce like the Children's Hospital 
Graduate Medical Education Program (CHGME) to pediatric research 
initiatives at the National Institutes of Health.

    What are your priorities for child health, if confirmed?

    Answer. Programs such as Medicaid and the Children's Health 
Insurance Program (CHIP) are critical programs that help ensure that 
children have adequate access to quality health care. If confirmed, I 
would work to ensure children are receiving necessary health care 
through both programs. I would also look to better ensure access to 
oral health and vision care for children, as both are necessary for 
children to thrive in school. And we cannot forget that improving child 
health begins with ensuring maternal health. I will work tirelessly to 
reduce maternal and infant mortality and morbidity, using the expertise 
and resources across CMS and working collaboratively with colleagues 
across HHS. I look forward to working with Congress, and with State and 
local partners to make sure that we are doing all we can to improve 
child health in this country.

    Medicaid and CHIP are critical programs for children, providing 
coverage for over 40 million children. Medicaid is also the backbone of 
the pediatric health-care system providing care across the continuum 
from screenings and preventive to highly specialized diagnoses and 
treatments.

    Question. What are your plans to strengthen this safety net for 
children and the providers who care for them?

    Answer. If confirmed, I would work to support and strengthen 
Medicaid and CHIP to ensure that children have adequate access to 
quality health care. In particular, I would look to better ensure 
access to oral health and vision care for children, while working to 
reduce maternal and infant mortality and morbidity. If confirmed, I 
look forward to working with you to make sure our children have access 
to quality care.

    The pandemic is having a profound impact on children's health and 
the providers who care for them.

    Question. What are your immediate plans to address the current 
crisis in the increasing number of children facing severe mental, 
emotional and behavioral health challenges due to social isolation and 
the serious impact of the pandemic on the health of their families and 
caregivers?

    Answer. I am deeply concerned about the impact of the COVID-19 
pandemic on the mental, emotional, and other behavioral health outcomes 
of our children, their families and caregivers. I agree this must be an 
urgent national priority. If confirmed, I commit to working on this 
issue. In particular, we must ensure that we are fully leveraging 
Medicaid and CHIP to connect children to the behavioral health care 
they need to navigate this unprecedented time, and to work toward 
better integration of physical and behavioral health care. If 
confirmed, I would seek to collaborate with other HHS agencies, 
including SAMHSA, to do a better job of tackling this important issue.

    Question. The pediatric health-care safety net has been affected by 
the pandemic in different ways then the adult health-care system, with 
less direct Federal financial support because they are not eligible for 
Medicare funding streams. What are your plans to sustain a stable 
pediatric health-care system now and beyond the pandemic?

    Answer. Medicaid and CHIP are lifelines to children and help form 
the fabric of the pediatric health-care safety net. Over 77 million 
individuals are enrolled in those programs, and about half are 
children. It is critical that we work to support our pediatric health-
care safety net and pediatric health-care providers during the COVID-19 
pandemic and beyond. If confirmed, I would make it a priority to work 
within CMS and with my HHS partners and State Medicaid agencies, to 
provide necessary support to pediatric providers.

    Question. The Children's Hospital Graduate Medical Education 
Program (CHGME) provides significant support for the training of 
pediatricians and pediatric specialists. But unfortunately, the funding 
for this program still lags far behind the Medicare GME program--
funding only half of what Medicare GME provides per resident.

    What are your plans to address this gap in training support for our 
Nation's pediatric workforce?

    Answer. If confirmed, I will work with the resources within CMS and 
partner with State Medicaid agencies to support the health-care 
workforce, including those who work with pediatric populations. I would 
look forward to working with HHS partners as well, including HRSA, on 
ensuring access to needed health care for our Nation's children.

    Question. During the pandemic telehealth has played a major role in 
providing access to care for Medicaid beneficiaries, including 
children.

    How will HHS support the continued use and enhancements needed 
under Medicaid to ensure telehealth continues to enable access to care 
for children?

    Answer. Telehealth is an important tool to improve health equity 
and improve access to health care. Health care should be accessible, no 
matter where you live. Under current law, States have a great deal of 
flexibility with respect to delivering Medicaid services via 
telehealth. Medicaid has made great strides in expanding services 
available through telehealth, including pediatric services, during the 
public health emergency. If confirmed, I will look at the telehealth 
flexibilities under Medicaid and determine how we can build on this 
work to improve health equity and improve access to health care for 
children.

    Question. As you know, pediatric health care is organized 
differently than adult health care. Pediatric care is more regionalized 
and often results in children, especially those with complex health 
needs, having to travel across State lines for care. Under Medicaid, 
this can be challenging for them and their providers with different 
policies State to State. The ACE Kids Act passed in 2019 and is 
effective next year, is one step in addressing these inconsistencies 
and getting much needed national data to inform care improvements.

    If confirmed, how would you approach these cross-State challenges 
that children with complex needs face when traveling for needed care?

    Answer. Medicaid and CHIP are crucial to ensuring children have 
adequate access to quality health care, especially those with complex 
needs. If confirmed, I will work to ensure children are receiving 
necessary health care under both Medicaid and CHIP. I look forward to 
working across the administration and with Congress to make informed 
decisions that address the specific needs of children with complex 
medical conditions.

    Question. Oftentimes, changes in the larger health-care landscape 
take place, for example in the Medicare program, without a full 
examination of how these changes could potentially impact children, 
even inadvertently. At times, Medicare policies designed with the 
elderly population in mind have been applied to Medicaid or adopted by 
State Medicaid programs and private payers.

    As you look at health-care changes at the national level as HHS 
Secretary, how will you ensure that children's unique health-care needs 
are taken into account?

    Answer. If confirmed, I will work with Congress and States to spur 
and encourage innovation in these important programs. Innovative 
delivery system and payment models are vital to ensuring that Medicaid 
and CHIP are equipped to address emerging pediatric health issues and 
can continue to provide children with access to quality health care.

    Question. A major focus in health care among policy-makers has been 
on pursuing delivery system reforms that improve quality and reduce 
costs. The Federal Government has traditionally focused more on adult 
populations rather than the needs of children in these reforms. As a 
result, Medicaid for children still lags behind Medicare in supporting 
improvements in care and innovative payment models.

    What steps will you take to promote increased emphasis on these 
types of innovations in Medicaid targeting the unique needs of 
children?

    Answer. If confirmed, I will work with Congress and States to spur 
and encourage innovation in these important programs. Innovative 
delivery system and payment models are vital to ensuring that Medicaid 
and CHIP are equipped to address emerging pediatric health issues and 
can continue to provide children with access to quality health care.

                   follow-up questions for the record
    Question. Recently, CMS announced it was withdrawing the 10-year 
renewal of Texas's 1115 Medicaid waiver. The State negotiated 
intensively and in good faith with CMS to achieve approval of the 
renewal.

    If confirmed, how will you advise CMS to view the previous 
agreement reached on the budget neutrality calculation which impacts 
the amount of Federal Medicaid funding the State can expect to receive?

    Answer. Based on my experience working with many State officials 
throughout my career, I appreciate what is required for States to 
develop and submit waiver applications to CMS for consideration and 
approval. Additionally, I understand the challenges many States face in 
formulating waiver requests given their distinct budgetary processes 
and legislative calendars. With this in mind, if I am fortunate enough 
to be confirmed, I will make sure that CMS provides clear guidance and 
works closely with each State, including Texas, on its ideas to 
innovate in the Medicaid program.

    Question. The waiver recession would prevent billions of dollars 
from flowing to Texans in need and would threaten numerous aspects of 
Texas's health-care system, given Texas's reliance for months on the 
extension approval. This could begin having dramatic impacts on Texas 
as soon as September.

    If confirmed, will you work with Texas to ensure that the State can 
continue to provide safety-net programs notwithstanding the unique 
challenges that the State faces?

    Answer. If I am fortunate enough to be confirmed, I will be happy 
to work with you and State officials in Texas on this issue.

    Question. The decision to rescind the extension comes at a time 
when the Biden-Harris administration continues to urge that COVID-19 is 
a public health emergency.

    How do you reconcile an action undermining the health care of many 
needy Texans with the urgency of COVID-19, and if confirmed, what steps 
would you take to provide Texans facing potential funding losses with 
the care needed in light of COVID-19?

    Answer. While I am not an official at CMS, it is my understanding 
that this extension was rescinded because the agency determined that 
the appropriate notice and public comment requirements were not met. I 
appreciate Congress's leadership in making sure that patients suffering 
from COVID-19 have been able to get the care they need during the 
public health emergency, and if I am fortunate enough to be confirmed, 
I would look forward to working with you on this issue.

    Question. The letter purporting to rescind the extension would 
effectively overturn a discretionary decision by the former Secretary, 
on which Texas relied for months in planning and implementing health-
care programs. This causes serious concern for Texas and other States 
considering whether they can rely on these types of discretionary 
decisions.

    If confirmed, what steps will you take to restore trust with States 
that are relying on such decisions in structuring their health-care 
systems?

    Answer. I have worked closely with States throughout my career, and 
I understand the relationship with CMS as States' Federal partner is 
crucial. If confirmed, I will keep in mind what I have learned working 
on behalf of States to make sure waiver requests are appropriately 
evaluated while giving the States clear guidance.

    Question. It has been reported that waivers like Texas's that 
support uncompensated care pools are viewed as a roadblock to Medicaid 
expansion, and that they run counter to the Biden administration push 
for States to expand.

    Do you believe Medicaid expansion is the only way for States to 
provide care for uninsured individuals?

    If not, what other options are being considered by the 
administration?

    Answer. I support State innovation and the ability of States to 
test different models that meet the objectives of the Medicaid program. 
No two Medicaid programs are exactly alike, just like no two States are 
alike. If I am so fortunate as to be confirmed, I look forward to 
engaging with any State that seeks to meet their population's unique 
needs, including those of the most vulnerable.

    Question. It has also been reported that the decision to rescind 
the waiver was done to push State officials to accept Medicaid 
expansion.\1\
---------------------------------------------------------------------------
    \1\ ``The decision was characterized as an effort to push State 
officials toward accepting the Affordable Care Act's Medicaid 
expansion, which would cover more low-income residents, said two 
Federal health officials, who spoke on the condition of anonymity to 
discuss private conversations.'' https://www.washingtonpost.com/health/
2021/04/16/biden-rejects-texas-medicaid-plan/.

    Do you believe the 1115 waiver extension was rescinded in order to 
---------------------------------------------------------------------------
force Texas to expand their Medicaid program?

    Answer. It is my understanding that this extension was rescinded 
because CMS determined that the appropriate notice and public comment 
requirements were not met. If I am fortunate enough to be confirmed, I 
look forward to working with you and State officials in Texas if the 
State decides to resubmit a section 1115 demonstration extension 
application.

                                 ______
                                 
                Questions Submitted by Hon. Richard Burr
                          cms-fda coordination
    Question. I often hear from constituents about the reluctance of 
the Medicare program to cover new and innovative therapies. Even as the 
commercial market recognizes the benefits of breakthrough technologies 
and medicines, the Medicare program lags behind in covering novel 
products that can save and improve lives.

    A recent CBO report on pharmaceutical R&D provided a stark reminder 
of just how difficult it is to develop these new medicines. The costs 
of bringing a new drug to market have been estimated to top $2 
billion.\2\ Given this immense cost, the Federal Government should 
ensure a clear pathway to coverage for companies that work to meet the 
FDA's gold standard of safety and efficacy and bring new treatments to 
patients.
---------------------------------------------------------------------------
    \2\ https://www.cbo.gov/system/files/2021-04/57025-Rx-RnD.pdf.

    If confirmed, you will lead the agency at a time when innovative 
therapies and technologies are changing the way care is delivered. To 
meet this moment, Medicare must also adapt. I have long been a 
proponent of increasing the coordination between CMS and FDA to ensure 
that our Federal health programs--and the Americans that rely on them--
---------------------------------------------------------------------------
are prepared for the upcoming pipeline of novel technologies.

    Will you commit to working with my office to further the goal of 
enhanced coordination between CMS and FDA to bring innovative medical 
products to Americans in as timely a manner as possible?

    If so, what are some of the ways in which CMS could work with FDA 
in order to reduce the time patients wait for new treatments and 
therapies?

    Currently, there is a therapy under review at FDA that, if 
approved, would be indicated for the treatment of Alzheimer's disease--
a uniquely devastating illness in terms of its breadth and lethality. 
The action date for this therapy under the Prescription Drug User Fee 
Act is June 7, 2021. To date, FDA has only approved one method of 
diagnosis for Alzheimer's disease--a PET scan. CMS has denied Medicare 
coverage of PET scans for Alzheimer's pathologies, however. If this 
therapy is approved, Medicare's decision to forego coverage of this 
diagnostic could present a barrier to access for patients with no other 
effective therapeutic options. This specific situation is just one that 
demonstrates the broader need for FDA and CMS coordination. Will you 
commit to working with me on ensuring appropriate Medicare coverage of 
PET scans and other diagnostics that may benefit patients with 
Alzheimer's disease?

    Answer. Thank you for your leadership on the issue of expanding 
access to the benefits of innovative medical technologies to American 
patients and families. It is incredible what science has been able to 
do with innovative drugs and treatments in recent years. We need to 
make sure we're looking at modernizing the Medicare program to make 
sure beneficiaries have access to proven new treatments. I also think 
it is important for CMS to be collaborating with other agencies, 
including the FDA, to make sure we work better together. If I have the 
honor of being confirmed, I would be happy to work with you on this 
important issue.

    Question. In 2019, now-Acting FDA Commissioner Janet Woodcock 
testified before the House Energy and Commerce Committee that advanced 
manufacturing technologies could enable domestic drug producers to 
compete with China's lower labor, supply, and operating costs.\3\
---------------------------------------------------------------------------
    \3\ https://www.fda.gov/news-events/congressional-testimony/
safeguarding-pharmaceutical-supply-chains-global-economy-10302019.

    How can the programs administered by CMS play a role in 
strengthening the security of supply chains, both broadly and for 
---------------------------------------------------------------------------
specific fields, like synthetic biology?

    Do you agree that if CMS is to play a role in addressing supply 
chain issues that it needs to coordinate with FDA to better understand 
the nuance and complexities of global supply chains?

    Answer. America continues to be a leader in medical innovation. 
This has been crucial during the pandemic. I agree that the Nation's 
supply chain must be secure. If confirmed, I will make sure CMS is a 
helpful partner to FDA in this effort.
                             hi trust fund
    Question. Medicare Part A has a longstanding insolvency problem. 
The Hospital Insurance (HI) Trust Fund that finances Part A is funded 
by payroll taxes and as program spending has outpaced payroll tax 
revenues, the balance of the trust fund has steadily declined. In 
February, the Congressional Budget Office (CBO) projected that the HI 
Trust Fund will run out of money by 2026. CBO also estimates that 
expenditures will continue to outpace payroll tax revenue after the 
trust fund has been depleted.

    Addressing Medicare's finances sooner rather than later would allow 
for subtle, gradual changes that protect seniors' access to high-
quality care while ensuring sustainability for future generations. The 
alternative would threaten sudden and steep benefit cuts for tens of 
millions of senior citizens.

    As Administrator of CMS, if confirmed, you will be looked to by the 
President and Congress for leadership and assistance on reform 
proposals small and large. What specific experience do you have in 
crafting or evaluating proposals to reform the Medicare program?

    Answer. Medicare solvency is an incredibly important, longstanding 
issue. We will need both short-term and long-term strategies to make 
sure Medicare remains a bedrock of our health-care system, and I look 
forward to working with Congress on a bipartisan basis to address this. 
I look forward to working with you on ways to improve the solvency of 
the Medicare program.
                           price transparency
    Question. Empowering consumers with health-care price information 
so they can make informed health-care decisions has long been a 
bipartisan priority. If confirmed as Administrator, are you committed 
to ensuring full implementation of the Transparency in Coverage final 
rule?

    Answer. I agree that empowering consumers with health-care price 
information is important. For transparency measures to work properly, 
patients and their families must be able to understand them in a 
meaningful way. If I am fortunate enough to be confirmed, I look 
forward to continuing to work on this issue.
                              foster care
    Question. The Family First Prevention Services Act created a new 
Federal category for settings that deliver trauma-informed treatment 
for foster children with serious emotional or behavioral issues in a 
residential setting, known as Qualified Residential Treatment Programs 
(QRTPs). QRTPs are one of the few residential settings that are 
eligible for title IV-E reimbursement. Recently, however, the Centers 
for Medicare and Medicaid Services (CMS) indicated QRTPs with more than 
16 beds may meet the definition of an Institutions for Mental Diseases 
(IMDs), preventing Medicaid reimbursement for care in these 
circumstances. This interpretation is not consistent with congressional 
intent.

    Do you believe that QRTPs should be exempted from the IMD payment 
exclusion, allowing children in foster care to have Medicaid coverage 
in these placements?

    Answer. This is an important and complex question that I am 
committed to addressing if I am confirmed as CMS Administrator. I share 
your conviction that children in foster care should receive necessary 
medical care without disruption. If I am fortunate enough to be 
confirmed, I will be happy to work with you on this critical issue.
                            macpac proposal
    Question. As you know, the statutory Medicaid Drug Rebate Program 
(MDRP) requires drug manufacturers to provide rebates on drugs to State 
Medicaid programs rebates to ensure Medicaid receives the lowest price 
relative to private payers. There is an additional mandatory rebate on 
drugs calculated according to increases in price that exceed inflation. 
Earlier this month, the Congressional Budget Office cited research 
showing that the MDRP contributes to higher prices paid by private 
payers, as offering additional discounts in the private markets would 
result in lower Medicaid revenues.\4\
---------------------------------------------------------------------------
    \4\ https://www.cbo.gov/system/files/2021-04/57020-Public-
Option.pdf.

    The Medicaid and Chip Payment and Access Commission (MACPAC) 
recently voted on recommendations to increase the amount of rebates 
manufacturers must pay for drugs brought to market under the 
---------------------------------------------------------------------------
accelerated approval pathway at FDA.

    Do you think this recommendation is appropriate?

    If so, what are your reasons for supporting this unprecedented 
approach to tying rebates to FDA approval pathways?

    MACPAC has acknowledged that this policy could create access issues 
for the Medicaid population. How would you ensure equitable access to 
these treatments and therapies if this policy were to be adopted?

    Answer. We can all agree that prescription drug costs are too high 
for American patients and families. From my many meetings with Senators 
in the last few weeks, I have seen that addressing this is a priority 
on both sides of the aisle. I think there is an opportunity for real 
impact here to lower costs for American patients and families, while 
making sure to continue to support innovation.

    Prescription drug costs, including in the Medicaid program, are 
very complex. Ultimately, we need solutions that produce real results 
to bring down overall costs for American patients and families while 
avoiding barriers to access. I would be happy to examine this 
particular MACPAC proposal in more detail. If confirmed, I look forward 
to working with you and your colleagues to find solutions to the high 
cost of prescription drugs without reducing access to necessary 
treatments.
                            clinical trials
    Question. Late last year, the Clinical Treatment Act, was signed 
into law. Senator Cardin and I crafted this legislation to ensure 
Medicaid beneficiaries have access to clinical trials by requiring 
State Medicaid programs to provide coverage of routine medical care 
associated with the trial--a benefit already provided by Medicare. This 
law will improve access to potentially life-saving therapies for sick 
Americans as well as broaden the base of clinical trial participants, 
which will improve the ability of manufacturers to conduct these 
trials.

    How will you ensure that this important benefit is available to 
Medicaid beneficiaries as expeditiously as possible?

    Answer. If I am fortunate enough to be confirmed, I will work with 
the National Institutes of Health and with trusted partners in the 
community to help to encourage participation in clinical trials, 
which--as you noted--can offer potentially life-saving treatment 
opportunities to patients. One barrier to participation in these trials 
can be payment for routine medical care associated with the trial, so I 
think it is so important that Medicaid will pay for covered items and 
services provided as part of qualifying clinical trials starting 
January 1, 2022. If confirmed, I would look forward to working with 
you, Senator Cardin and other members of Congress on this issue as we 
work to implement this important benefit in a timely manner.
                                  cmmi
    Question. The Patient Protection and Affordable Care Act (PPACA) 
created the Centers for Medicare and Medicaid Innovation (CMMI) and 
afforded it broad authority to test new payment models. The law 
requires the termination or modification of any model that does not 
improve quality of care without increasing spending; reduce spending 
without reducing quality of care; or improve quality of care while also 
reducing spending. Shockingly, the PPACA also included a clause 
attempting to block any administrative or judicial review of CMMI 
demonstration models, leaving the Administrator as a key, potentially 
unaccountable, arbiter of whether or not the law's requirements are 
being followed.

    How specifically will you ensure that statutory requirements for 
CMMI models are stringently adhered to? Will you commit to working with 
members of this committee to establishing a permanent mechanism for 
congressional input and oversight?

    Answer. The Innovation Center has been an important tool to test 
new models to move our health-care system from one that rewards volume 
to one that rewards value. It will continue to be important, as we move 
forward, to test models that improve patient care, advance health 
equity, and lower patient costs. We have now had 10 years of experience 
to learn from at the Innovation Center. We need to look at what has 
worked and what hasn't and chart a path forward from there. If I am 
fortunate enough to be confirmed, I want to have open lines of 
communication with Congress, and I look forward to hearing from you 
about CMMI models.
                    clinical laboratory fee schedule
    Question. The Medicare Clinical Lab Fee Schedule (CLFS) payment 
rates for antigen testing that use visual interpretation for results 
have traditionally been the same as the tests that utilize instruments 
to interpret results. However, CMS has recently changed this practice 
for COVID-19 testing, bifurcating the rates for these types of tests. 
This bifurcation occurred in June 2020.

    Why does CMS believe that a bifurcation in reimbursement rates was 
warranted in the case of SARS-CoV-2 antigen testing?

    Under your leadership, how would CMS incentivize the development of 
digital health technologies that make diagnostic test results accurate 
and reliable?

    Answer. Access to safe and reliable testing is key to combating the 
COVID-19 pandemic. If I am fortunate enough to be confirmed, I look 
forward to hearing from you about Medicare's clinical laboratory fee 
schedule rates and protecting beneficiary access to laboratory testing 
services, including digital technologies where appropriate.

                                 ______
                                 
             Questions Submitted by Hon. Patrick J. Toomey
    Question. As part of the American Rescue Plan Act (ARPA; Pub. L. 
117-2), approximately $35 billion is estimated to be spent to 
temporarily expand Obamacare subsidies to current marketplace enrollees 
and individuals making over 400 percent of the Federal poverty level, 
including high-income earners or those making over six-figure salaries. 
The majority of these subsidies will go to individuals who already have 
health insurance. Furthermore, taxpayers are expected to spend an 
additional $6 billion to temporarily pause premium tax credit 
reconciliation for plan year 2020--meaning individuals who received 
more than they should will not be asked by the Federal Government to 
repay taxpayers for those improper subsidies. In the past, multiple 
government watchdogs have concluded that these taxpayer subsidies are 
susceptible to significant improper payments. As the Federal deficit 
hits records highs, more must be done to ensure our taxpayer dollars 
are spent wisely.

    You have extensive programmatic experience with the Federal 
marketplace and Virginia's State marketplace. If confirmed, how will 
you work with the Internal Revenue Service to reduce the advance 
premium tax credit program's susceptibility to improper payments? 
Please be specific.

    Answer. Advance payments of premium tax credits have helped make 
health insurance more affordable for millions of Americans and improved 
their access to care. This has been especially important during the 
pandemic when access to affordable health care has been more critical 
than ever. If confirmed, I will take seriously these responsibilities, 
including working with the Internal Revenue Service to make sure that 
we are good stewards of Federal dollars.

    Question. Over the years, the Medicare improper payment rate has 
dropped well below 10 percent. In fact, the improper payment rate for 
FY2020 dropped to 6.27 percent from 7.25 percent in FY 2019--its lowest 
rate in more than a decade. Further, over the past decade, the Medicare 
Advantage and Part D improper payment rates at their highest reached 11 
percent and 3.7 percent respectively. In FY2020, the Medicare Advantage 
and Part D improper payment rates dropped to 6.78 percent and 1.15 
percent respectively. Unlike the Medicare program, however, the 
Medicaid improper payment rate has ballooned. Most recently, the 
national improper payment rate in Medicaid was 21.36 percent, or $86.49 
billion. Not only has the Medicaid improper payment rate doubled since 
2010, but it is now more than triple the improper payment rate of the 
Medicare program.

    If confirmed, what actions will you take to bring the improper 
payment rate in the Medicaid program under 10 percent? Please be 
specific.

    Answer. Medicaid is a critical lifeline for beneficiaries across 
the country. Reducing Medicaid improper payments is a priority because 
it helps ensure the fiscal health of the program. If confirmed, I will 
work with States and leaders in Congress to be responsible stewards of 
taxpayer dollars.

    Question. Last fall, Senator Stabenow and I sent the Department of 
Health and Human Services a detailed letter recommending specific 
regulatory actions to improve our Federal health-care programs for 
beneficiaries with Alzheimer's disease. These recommendations were 
formed with input from more than 30 organizations that responded to a 
request for information as well as hearings and briefings led by 
Senator Stabenow and myself. Recently, the Biden administration took 
action on one of our recommendations and finalized a centralized 
website for patients and their caregivers to access information 
regarding their care options and clinical trial enrollment. However, 
other recommendations remain unimplemented.

    If confirmed, how will you help increase access to innovative 
diagnostic tools and/or make improvements to existing methods of 
assessing cognitive impairment, such as direct observation, in the 
Medicare program to improve early detection of Alzheimer's disease? 
Additionally, with the potential for the first disease modifying drug 
to be approved by the U.S. Food and Drug Administration, existing tools 
like the amyloid PET scan are the only option for confirmatory 
diagnosis until a noninvasive, affordable, and rapid diagnostic tool, 
such as a blood test, is made available to the public. Coverage 
determinations play a large role in diagnosing, treating, connecting to 
wrap-around services, and clinical trial enrollment. If confirmed, will 
you examine existing CMS coverage policies to ensure the Medicare 
program provides seamless access to the best diagnostic tool(s) 
available to this patient population and other similarly situated 
disease groups?

    How can the Medicare Advantage program play a role in strengthening 
care coordination among this population?

    What other policies will you prioritize to improve the lives of 
Medicare and Medicaid beneficiaries living with Alzheimer's disease?

    Answer. Alzheimer's disease is a devastating condition for patients 
and families. Early detection is critical to improve care, and I agree 
that CMS should work to improve coverage of proven diagnostics. I also 
agree that better coordinating health-care benefits patients, and we 
should strive to improve care coordination across programs. Medicaid 
and Medicare, including Medicare Advantage, have an important role to 
play in providing this type of quality care, including to those living 
with complex conditions like Alzheimer's disease. I would be happy to 
work with you on this important issue should I be confirmed.

    Question. Through section 1115 waiver authority, State Medicaid 
programs can waive certain programmatic requirements to implement 
greater flexibilities with their eligibility, benefit, and delivery 
systems. CMS plays an instrumental role in the implementation of 
section 1115 waivers through the negotiation process and oversight of 
their financial performance.

    If confirmed, how would you work to uphold and enforce the 
longstanding policy of budget-neutrality for section 1115 waivers and 
ensure the integrity of their financial performance?

    Answer. Each State is unique, and innovation is critical to 
improving the health-care system. Section 1115 demonstration projects, 
or waivers, are one available tool to States to help test new and 
innovative policies in Medicaid. I agree that it is important that we 
are good stewards of taxpayer dollars while pursuing innovation. If 
confirmed, I will support State innovation and the ability of States to 
test out different models that meet the objectives of the Medicaid 
program.

                                 ______
                                 
                 Questions Submitted by Hon. Tim Scott
        on leveraging virtual health technology and telehealth 
                        to expand access to care
On Enhancing Telehealth Access
    Question. Earlier this Congress, joined by Senator Schatz and a 
bipartisan group of my Senate colleagues, I introduced the Telehealth 
Modernization Act, legislation aimed at increasing access to high-
quality health-care services, particularly for our Nation's seniors, by 
codifying crucial flexibilities for telehealth coverage.

    Long before the pandemic began, South Carolina had emerged as a 
leader in telehealth innovation, hosting one of just two federally 
recognized Telehealth Centers of Excellence in the Nation. High-quality 
telehealth services and networks spearheaded by cutting-edge providers 
like the Medical University of South Carolina have transformed the 
Palmetto State's health-care landscape. Unfortunately, however, for the 
majority of the State's roughly 1 million Medicare beneficiaries, 
outdated coverage restrictions have long inhibited access to telehealth 
services.

    For years, rigid rules around patient location (geographic and site 
of service), eligible services and provider sites, and other components 
of care have created substantial barriers to telehealth utilization. In 
February 2020, for instance, just prior to the COVID-19 public health 
emergency (PHE), only 0.1 percent of Medicare fee-for-service (FFS) 
primary care visits were delivered via telehealth. In any given week 
before the PHE, an average of just 14,000 Medicare beneficiaries 
received a telehealth service.

    Congress took decisive steps towards expanding telehealth access 
through the CHRONIC Care Act, particularly for the roughly 36 percent 
of Medicare beneficiaries nationwide who have chosen to enroll in 
Medicare Advantage (MA) plans, more than three-quarters of which 
provided extra telehealth benefits, even before the pandemic struck. 
For South Carolina, however, MA penetration remained below 30 percent 
last year. For the 72 percent of SC's Medicare beneficiaries enrolled 
in FFS coverage, substantial restrictions have remained.

    While these Medicare access gaps predated the pandemic, the spread 
of COVID-19 highlighted the urgency of updating telehealth coverage 
rules, prompting Congress to provide authority for pivotal emergency 
waivers designed to ensure safe access to care for seniors and other 
vulnerable populations. As the pandemic raged, Medicare beneficiaries 
turned to telehealth services to minimize viral exposure risk and 
receive medically necessary care in safe and accessible settings. In 
April 2020, more than two-fifths (43.5 percent) of Medicare FFS primary 
care visits were provided through telehealth, and from mid-March 
through early July of that year, more than 10.1 million beneficiaries 
accessed telehealth services.

    Without congressional action, however, these emergency 
flexibilities will expire at the end of the PHE, creating an access 
cliff for tens of millions of Medicare beneficiaries, including many 
who have come to rely on telehealth for critically needed care.

    If confirmed, can you commit to making the expansion of telehealth 
access, particularly for seniors and vulnerable populations, a priority 
for the Centers for Medicare and Medicaid Services (CMS)?

    The Telehealth Modernization Act would eliminate a number of 
outdated restrictions on Medicare coverage for telehealth services, 
including by removing geographic and originating site restrictions and 
ensuring that federally qualified health centers and rural health 
clinics can continue to serve as distant sites, even after the pandemic 
subsides. Would you support these types of policy proposals as a means 
of expanding access to care?

    Can you commit, if confirmed, to working with my office, Sen. 
Schatz's office, and the offices of other telehealth access supporters 
to ensure that the tens of millions of Medicare beneficiaries enrolled 
in FFS do not face a coverage cliff when the public health emergency 
expires?

    In the absence of the emergency waivers, what would you cite as 
some of the most significant barriers to telehealth access, 
particularly for seniors and those with serious health conditions, and 
what steps would you take as CMS Administrator, if confirmed, to 
address some of these barriers?

    What role or roles do you see telehealth and other virtual health 
technologies in playing within the administration's broader goal of 
combating health disparities?

    I see our digital infrastructure as a powerful tool in addressing 
health disparities. If confirmed, how would you work with other Federal 
agencies and officials to bolster broadband access and bridge the 
digital divide?

    Answer. Telehealth has been invaluable during this pandemic to keep 
patients, their providers, and their families safe. My brother is a 
psychologist, and telehealth has helped his patients get the care they 
need. Additionally, I agree that telehealth services have improved 
health equity as beneficiaries have used telehealth to access care 
during the COVID-19 pandemic. Broadband access is a challenge for many 
patients, however, and I agree that digital infrastructure is an 
important issue to consider in the context of addressing health 
disparities. If confirmed, I want to be sure we learn lessons from this 
pandemic on telehealth about what we can and should extend 
administratively and what will need congressional action.
On Improving the Medicare Diabetes Prevention Program (MDPP) Expanded 
        Model
    Question. The Medicare Diabetes Prevention Program (MDPP) Expanded 
Model (EM) leverages proven interventions to prevent the onset of type 
2 diabetes in Medicare beneficiaries with prediabetes. In 2016, the 
Chief Actuary of CMS certified that ``beneficiaries participating in 
diabetes prevention programs have achieved success with losing weight 
and reducing the incidence of diabetes'' and that the expansion was 
``expected to reduce Medicare expenditures.'' According to CMS, the 
program at the core of the expanded model ``has been shown to reduce 
the incidence of diabetes by 71 percent in persons age 60 years or 
older.''

    Unfortunately, the exclusion of innovative virtual suppliers from 
the MDPP EM has impeded the program's reach and created substantial 
access gaps, particularly for older Americans living in rural and 
underserved urban communities. Politico reported that only 202 
beneficiaries had used the program in 2018, and an American Journal of 
Managed Care study published in June 2020 concluded that ``inadequate 
MDPP access'' stemmed in part from ``severe shortages'' of suppliers, 
particularly in States with large populations of Medicare beneficiaries 
of color. The COVID-19 pandemic has highlighted and exacerbated these 
access barriers, but regulatory flexibilities remain limited.

    In order to address these access gaps, last Congress, I partnered 
with Senator Warner in leading a number of letters to HHS and CMS 
leaders, urging them to take administrative action to enable the 
participation of CDC-recognized virtual suppliers in the MDPP EM. We 
also introduced the bipartisan, bicameral PREVENT DIABETES Act, which 
would accomplish the same goal legislatively. Unfortunately, virtual 
suppliers remain excluded from the program, and even the flexibilities 
provided for the pandemic emergency period have proven unable to 
improve access for beneficiaries in need.

    The Biden administration has cited combating health disparities as 
a key policy priority. According to the CDC, 13 percent of American 
adults have diabetes, including 26.8 percent of those aged 65 or older. 
Diabetes prevalence varies substantially by race/ethnicity, affecting 
16.4 percent of black adults, 14.9 percent of Asian adults, and 14.7 
percent of Hispanic adults, versus 11.9 percent of white adults. A 2018 
study that focused specifically on the provision of DPP services 
through virtual providers found statistically significant evidence of 
reduced costs and utilization pattern changes for a Medicare 
population, suggesting that the inclusion of virtual suppliers in MDPP, 
among other actions to strengthen the program, could help to address 
disparities, reduce costs, and improve outcomes for older Americans 
across the board.

    If confirmed, can you commit to working, in consultation with my 
office, Senator Warner's office, and other policy-makers, to enhance 
access to the Medicare Diabetes Prevention Program?

    Can you commit to reviewing the robust evidence base and giving due 
consideration to the bipartisan and bicameral requests that I have led, 
in partnership with Senator Warner and others, to secure the inclusion 
of CDC-recognized virtual suppliers in the MDPP EM?

    Beyond the MDPP EM, how do you envision CMMI's role in terms of 
facilitating the demonstration and evaluation of virtual care solutions 
and digital health tools?

    More broadly, can you speak to the administration's efforts to 
enable Medicare beneficiaries to leverage digital health tools for the 
prevention and treatment of disease? Are their limitations in your 
ability to expand access to these valuable resources for those that 
want to use them within Medicare?

    Answer. The Medicare Diabetes Prevention Program is an important 
model, and I appreciate your leadership in supporting patients with 
diabetes. I absolutely want to look at all options to help prevent 
diabetes, and I look forward to hearing more from you, Senator Warner, 
and other members of Congress on ways we can improve the program for 
Medicare beneficiaries.

    The Innovation Center has been an important tool to test new models 
to move our system from one that rewards volume to one that rewards 
value. It will continue to be important, as we move forward, to test 
models that improve patient care, advance health equity, and lower 
patient costs. We have now had 10 years of experience to learn from at 
the Innovation Center. We need to look at what has worked and chart a 
path forward from there. I look forward to hearing more of your 
thoughts on the direction of CMMI.
                   on enhancing access to innovation
    Question. As co-chair of the bipartisan, bicameral Personalized 
Medicine Caucus, I have long championed the potential for cutting-edge 
innovations like gene and cell therapies to transform the treatment 
landscape. In recent years, the pace of development on these fronts has 
accelerated, with a report from last Spring suggesting that more than 
360 gene and cell therapies were in the United States' clinical 
pipeline, versus fewer than 300 just 2 years earlier. More than one-
third of these therapies aim to treat rare diseases, providing cause 
for optimism to patients across the country, as 95 percent of the 7,000 
known rare diseases currently lack an FDA-
approved treatment option. Individuals with sickle cell disease, for 
instance, which affects an estimated 100,000 Americans, could feasibly 
see a cure on the horizon.

    According to a 2019 statement by key FDA leaders, the agency 
anticipated, at that point, approving 10 to 20 new gene and cell 
therapies every year by 2025, in addition to receiving a projected 200 
investigational new drug applications for gene and cell therapy 
candidates annually, beginning in 2020.

    I appreciate the emphasis that you placed, in your testimony, on 
advancing innovation.

    That said, even in the face of these potentially lifesaving 
developments, hurdles remain, even for gene and cell therapies that 
successfully gain FDA approval. A number of laws and regulations around 
Medicaid ``best price,'' the Anti-Kickback Statute (AKS), and the Stark 
Law, among other relevant statutes, understandably failed to 
contemplate this new generation of gene and cell therapies, which have 
only recently begun to come to market.

    A disproportionate share of the patients affected by the diseases 
most likely to be treated by the early waves of gene and cell therapies 
receive health-care coverage through Medicare or Medicaid. With that in 
mind, would you agree that HHS should do all that it can to ensure 
access to FDA-approved cell and gene therapies when a doctor and a 
patient agree that it is the most appropriate treatment option?

    The current Medicaid reimbursement structure was not designed with 
curative therapy payments in mind. For the roughly 100,000 Americans 
affected by SCD and other painful and debilitating conditions, these 
outdated rules risk delaying patient access and hinder Medicaid's 
ability to pay for innovative therapies based on their value. How will 
HHS overcome barriers in the current Medicaid reimbursement structure 
for cell and gene therapies, giving patients access to cures and not 
just treatments?

    In December, HHS finalized the ``Establishing Minimum Standards in 
Medicaid State Drug Utilization Review (DUR) and Supporting Value-Based 
Purchasing (VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug 
Rebate and Third Party Liability (TPL) Requirements (CMS 2482-F)'' 
rule, which took important steps towards ensuring that State Medicaid 
programs have the flexibility they need to hold manufacturers 
accountable for the performance of their therapies. Will CMS commit to 
implementing the VBP components of this rule and ensuring that patients 
have timely access to lifesaving cell and gene therapies?

    If and when CMS implements this rule, barriers to value-based 
arrangements will remain, both within the Federal health-care programs 
and in the private sector. Can you commit, if confirmed, to working 
with my office to develop the additional legislative and regulatory 
solutions needed to facilitate meaningful value-based arrangements for 
drugs, biologics, devices, and other innovative medical products?

    The prior administration issued new AKS safe harbors to protect 
value-based arrangements among health-care providers and other industry 
stakeholders, but value-based arrangements for drugs and biologics 
received no such protections, inhibiting the development of these types 
of agreements and jeopardizing patient access to innovation. Will you 
commit to developing a safe harbor that would help promote greater 
innovation in the pricing of drugs and biologics?

    Generally speaking, what changes do you envision to CMS's policies 
that would promote the development of curative medicines to ensure that 
they are available to Americans as soon as possible?

    With respect to sickle cell disease (SCD) in particular, can you 
commit to making efforts to combat SCD, both through novel gene 
therapies and through other innovative treatments and care models, a 
priority for CMS?

    While surveillance data on the SCD patient population remains 
limited in many ways, research suggests that the majority of 
individuals affected by SCD may receive health-care coverage through 
Medicaid, giving CMS an especially significant role in ensuring access 
to care for these Americans. Would you be willing to consider pilot 
programs, demonstration projects, or other innovative models to drive 
care improvement for those affected by SCD?

    Answer. It is incredible what scientific progress has been made 
with innovative drugs and treatments in recent years. We need to make 
sure we are looking at modernizing the Medicare and Medicaid programs 
to foster innovation and to make sure beneficiaries have access to 
proven new treatments. Thank you for your leadership on Sickle Cell 
Disease.

    If confirmed, I look forward to working with you and other members 
to find solutions to improve treatments, care models, and access to new 
therapies, including for Sickle Cell Disease.

    Question. FDA has testified ``that advanced manufacturing 
technologies could enable U.S.-based pharmaceutical manufacturing to 
regain its competitiveness with China.''

    How can CMS leverage and advance the U.S. advantage in synthetic 
biology to solidify our domestic drug supply chain security?

    Answer. America continues to be a leader in medical innovation. 
This has been crucial during the pandemic. I agree that the Nation's 
supply chain must be secure. If confirmed, I will make sure CMS is a 
helpful partner to the FDA in this effort.
On Coverage and Payment for Products Approved via Accelerated Approval
    Question. As described by FDA, the Accelerated Approval Program 
``allow[s] for earlier approval of drugs that treat serious conditions, 
and that fill an unmet medical need based on a surrogate endpoint,'' 
meaning ``a marker, such as a laboratory measurement, radiographic 
image, physical sign or other measure that is thought to predict 
clinical benefit, but is not itself a measure of clinical benefit.'' 
Furthermore, as explained by the agency, ``[t]he FDA bases its decision 
on whether to accept the proposed surrogate or intermediate clinical 
endpoint on the scientific support for that endpoint'' (emphasis mine).

    In explaining the rationale for the creation of Accelerated 
Approval, FDA has noted that the use of intermediate or surrogate 
endpoints ``can save valuable time in the drug approval process.'' In 
the example of cancer survival, for instance, the agency points out 
that measuring the extension of survival for cancer patients could take 
many years, whereas trials can assess tumor shrinkage, which is 
reasonably likely to predict the desired endpoint, much more 
efficiently. In this broad example, the use of accelerated approval 
could result in patient access to a life-saving product literally years 
earlier than might have been possible otherwise. For countless 
Americans, from children suffering from debilitating cancers to adults 
afflicted by rare blood disorders, access to drugs and biologics 
cleared through the Accelerated Approval pathway have been the 
difference between life and death.

    As we look towards the months and years ahead, scores of patients 
can look to Accelerated Approval and other innovative, evidence-based 
pathways as a source of hope, recognizing that a new generation of 
game-changing therapeutics could feasibly cure conditions like sickle 
cell disease.

    In 2018, CMS wrote to States affirming that drugs approved via the 
Accelerated Approval pathway ``must be covered by State Medicaid 
programs, if the drug meets the definition of `covered outpatient 
drug,' noting that said products ``must meet the same statutory 
evidentiary standards for safety and effectiveness as those granted 
traditional approvals.'' Can you commit to ensuring, if confirmed, that 
every State Medicaid program covers all covered outpatient drugs 
approved via the Accelerated Approval Program, with no difference in 
treatment between these products and products approved via the 
traditional approval pathway?

    Despite substantial pushback from patient advocates and 
policymakers, the Medicaid and CHIP Payment and Access Commission 
(MACPAC) has moved to advance a proposal that would create a 
differential rebate structure for products approved via the Accelerated 
Approval Program, essentially penalizing drugs and biologics for moving 
to market and serving patients more quickly. In addition to 
disincentivizing the use of the Accelerated Approval pathway and thus 
denying scores of Americans, including many childhood cancer patients, 
with timely access to potentially lifesaving medications, this policy 
risks deterring, chilling, or otherwise redirecting investment in 
products that do not lend themselves to efficient trials with easily 
and expeditiously measured primary endpoints. Moreover, the framing of 
the proposal itself suggests a misunderstanding of the scientific 
integrity and underlying purpose of the Accelerated Approval Program. 
Before advocating for or otherwise seeking to advance any policy 
proposals that might weaken, penalize, or otherwise chill the use of 
the Accelerated Approval Program, can you commit to engaging with FDA 
officials and experts, patient advocates, manufacturers, policymakers 
on the Hill, and other relevant stakeholders to assess the potential 
consequences of such policies?

    Regardless of the administration in question, critics have often 
argued that FDA and CMS could and should work more collaboratively to 
ensure that safe and effective products can come to market as 
efficiently as possible. Can you commit to working with your 
counterparts at FDA to bolster collaboration and communication between 
the two agencies?

    Answer. Thank you for your leadership on the issue of expanding 
access to the benefits of innovative medical technologies to American 
patients and families. It is incredible what scientific progress has 
been made with innovative drugs and treatments in recent years. We need 
to make sure we're looking at modernizing the Medicare and Medicaid 
programs to make sure beneficiaries have access to proven new 
treatments. I also think it is important for CMS to be collaborating 
with other agencies, including the FDA, to make sure we are working 
together to serve patients. I would be happy to examine this particular 
MACPAC proposal in more detail. If confirmed, I look forward to working 
with you and your colleagues to find solutions to the high cost of 
prescription drugs without reducing access to necessary treatments.
On Payment for FFR/iFR Technologies
    Question. CMS has recently committed to reexamining the Medicare 
payment policy for specific procedures performed in an Ambulatory 
Surgical Center (ASC) to ensure that physicians can ``exercise their 
clinical judgement in making site-of service determinations.'' One such 
policy that warrants reexamination is the ASC payment for fractional 
flow reserve and instantaneous wave-free ratio (FFR/iFR), technologies 
that accurately measure blood pressure and flow through a specific part 
of the coronary artery which can be critical for physicians in making 
treatment decisions for their patients.

    Many doctors rely on these technologies to assess whether to 
perform percutaneous coronary intervention (PCI), driving improvements 
in quality of care and cost savings. However, the current Medicare ASC 
payment policy to package payment for FFR/iFR results in a payment rate 
that is three times lower than the outpatient hospital setting, where a 
complexity adjustment accounts for the cost of this important 
technology. The current ASC payment policy for FFR/iFR has made these 
procedures out-of-reach for physicians and Medicare beneficiaries in an 
ASC. Many stakeholders, including the Society for Cardiovascular 
Angiography and Interventions (SCAI) and the American College of 
Cardiology (ACC), have expressed concerns over this policy and have 
called for a change, whether by separately paying for FFR/iFR or 
providing a payment adjustment similar to the adjustment provided under 
the outpatient setting.

    If confirmed as Administrator, will you commit to reexamining this 
ASC policy in the upcoming rulemaking cycle and considering changes to 
the policy to make FFR/iFR a viable option for providers and patients 
in an ASC?

    Answer. As more and more services can be provided on an outpatient 
basis in various settings, we need to be thoughtful about the 
incentives Medicare payment policies have on utilization in these sites 
of care. If confirmed, I will make sure that CMS continues to examine 
how payment policies that vary by site of care impact quality of care 
and cost savings, especially for technologies that are critical for 
making treatment decisions.
                              on vaccines
On Seniors' Access to Preventive Care
    Question. While Medicare Part B covers a number of vaccines, 
including for influenza, pneumococcal, and hepatitis B, with no 
beneficiary cost-sharing, the majority of vaccines recommended for 
adults, including for older adults, are covered under Part D, where 
seniors can face substantial copays. While cost-sharing can serve as a 
useful and appropriate tool in other contexts, those rationales do not 
apply in the case of ACIP-recommended vaccinations, and studies have 
shown a direct correlation between cost-sharing and increased 
abandonment rates for vaccines.

    As a number of my colleagues and I noted in a letter we sent to CMS 
on this subject last summer, ``A 2017 report by Avalere Health found 
between 47 and 72 percent of the 24 million Medicare beneficiaries with 
Part D coverage had some level of cost sharing for vaccines, ranging 
from $35 to $70 in 2015. Another study found that only 4 percent or 
less of Medicare Part D enrollees had access to vaccines with no cost 
sharing.''

    How can the Biden administration address the issue of ensuring 
medically necessary preventive care for all populations?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. I look forward to working with Congress to find ways to 
ensure preventive care, including recommended vaccinations, is 
accessible for all populations served by CMS programs. If confirmed, I 
will work with stakeholders and trusted partners to educate providers, 
beneficiaries, and families, and encourage individuals to seek 
preventive care.
                         on medicare advantage
    Question. A growing share of Medicare beneficiaries, rising from 
just one-quarter in 2010 to 39 percent in 2020, have chosen to enroll 
in Medicare Advantage (MA) plan, which enjoy a 94-percent satisfaction 
rate. MA has enjoyed increasingly strong bipartisan backing, with 64 
senators and 339 members of the House signing on to a letter of support 
for the program last year.

    MA plans cover an increasingly broad array of extra benefits, 
relative to the fee-for-service model. Of all MA plans, 88 percent 
cover hearing aids and 91 percent cover glasses and eye exams, while 92 
percent include dental benefits and 96 percent have a fitness benefit.

    Given the overwhelming bipartisan support and the additional 
benefits, as well as the growing competition in the MA market, what 
steps would you look to take, if confirmed, to continue increasing 
access to and education on MA options for seniors?

    Answer. Medicare Advantage serves millions of Americans and is an 
important option for all beneficiaries, including older Americans and 
people with disabilities. I believe that we have to take every approach 
we can to provide people access to quality health care. If confirmed as 
CMS Administrator, I look forward to working with Congress on this 
important issue.
On Integrating Certain Diagnoses Obtained via Audio-Only Telehealth 
        Visits for Risk Adjustment Purposes
    Question. South Carolina has seen substantial growth in MA market 
penetration in recent years. As a share of all Medicare beneficiaries 
across the State, MA enrollment has nearly doubled in the past decade, 
from 16 percent of total Medicare enrollment in 2010 to 31 percent in 
2020. We have also seen increased interest in Programs of All-Inclusive 
Care for the Elderly (PACE), another innovative model intended to drive 
value-based care, particularly for those dually eligible for Medicare 
and Medicaid. While PACE has a much smaller population of participants, 
more than 400 reside in SC, receiving care across three different 
programs, which enjoy a high satisfaction rate.

    Last spring, I was pleased to see the Centers for Medicare and 
Medicaid Services (CMS) relax previous telehealth restrictions in 
Medicare to allow high-risk individuals more options for care, 
including allowing diagnoses obtained via telehealth to be used for 
risk adjustment in MA and PACE. However, CMS's guidance requires a 
video component to validate any diagnosis for risk adjustment purposes, 
even though many beneficiaries and participants have received care via 
audio-only visits during the pandemic, due in part to broadband and 
technological access gaps. According to some surveys, the majority of 
seniors who have access to a cell phone lack smartphone capabilities, 
and for many older Americans living in rural areas, including more than 
27 percent of South Carolinians, broadband hurdles persist, making 
audio-visual visits challenging for many beneficiaries.

    I have heard from plans, providers, and researchers from across 
South Carolina that audio-only services have accounted for a 
substantial portion of telehealth services during the pandemic 
emergency, and lower-income patients disproportionately utilize audio-
only telehealth over both in-person and video telehealth services. 
According to CMS's data, only 65 percent of beneficiaries making less 
than $25,000 have access to any Internet service in their homes.

    Disqualifying diagnoses obtained via audio-only telehealth 
services, especially for chronic conditions that have been previously 
documented, will result in inaccurate and incomplete documentation for 
MA and PACE risk adjustment purposes, arbitrarily reducing risk scores. 
This could lead to unequal access, fewer choices, higher premiums, or 
reduced benefits for seniors and individuals with disabilities.

    Notably, CMS has taken the opposite approach for insurers 
participating in the Department of Health and Human Services (HHS)-
operated risk adjustment program in the commercial market. On April 
27th and August 3, 2020, the Center for Consumer Information and 
Insurance Oversight (CCIIO) published sets of frequently asked 
questions (FAQs) clarifying that HHS will allow diagnosis codes from 
audio-only telehealth services for risk adjustment purposes in 2020. On 
March 24, 2021, CCIIO issued updated FAQs stating that the policy would 
continue for 2021. The same logic underlying the exchange policy should 
justify the application of these flexibilities to MA and PACE risk 
adjustment as well.

    If confirmed, can you commit to thoroughly reviewing this policy 
within the agency to ensure consistency, parity, and alignment between 
departments and programs regarding audio-only telehealth and risk 
adjustment in the future?

    The deadline for plan bid submission for 2022 is less than 2 months 
away. Will you commit to working with my office and other interested 
offices on this issue to prevent adverse impacts for MA beneficiaries 
and PACE participants through reduced benefits, higher costs, or fewer 
choices next year?

    I understand and share potential concerns about beneficiary, 
participant, and taxpayer protections around fraud, waste, and abuse. 
For that reason, I have partnered with Senator Cortez Masto to 
introduce bipartisan legislation including numerous guardrails to 
prevent potential misuse. Will you commit to working with us on The 
Ensuring Parity in Medicare Advantage for Audio-Only Telehealth Act of 
2021 by providing technical assistance for congressional action or 
looking to it as a potential guide for implementing policy changes 
within the agency?

    Answer. Medicare Advantage serves millions of Americans and is an 
important option for Medicare beneficiaries. During the pandemic, we 
have been able to see the value telehealth brings for patients, 
including those enrolled in Medicare Advantage. If confirmed, I look 
forward to working with you to ensure that beneficiaries enrolled in 
Medicare Advantage plans can continue to benefit from these services.
                          on pending dme rule
    Question. Last year, CMS issued a Durable Medical Equipment (DME) 
proposed rule that would make the 50/50 blended rate for rural areas 
permanent. Rural access to services and care has been a longtime 
priority for me, given that more than one-fourth of South Carolinians 
live in rural areas. The proposed rule would also create a pathway for 
drugs requiring health-care professional administration to be covered 
for home infusion, helping to address an urgent challenge that the 
pandemic has exacerbated.

    I appreciate all of the work that CMS has undertaken thus far 
regarding the Medicare Durable Medical Equipment benefit, and we 
appreciate the agency's engagement with stakeholders regarding 
refinements to this and other rules.

    Can you commit, if confirmed, to working to finalize the DME rule 
as efficiently as practicable?

    Answer. I recognize that rural areas have unique needs and 
challenges, including access to durable medical equipment. If I am 
fortunate enough to be confirmed, I am happy to look into the status of 
this regulation and work with you and your office on this important 
issue.
                     on medicaid work requirements
    Question. A report on health equity that you co-authored last year 
criticized work requirements and the Trump administration's public 
charge rule, writing that both policies ``disproportionately impact 
people of color'' and ``perpetuate historic structural inequities and 
widen the health equity gap.'' The report described both as 
``discriminatory policies.''

    In 1996, bipartisan majorities in both chambers of Congress voted 
to pass the Personal Responsibility and Work Opportunity Reconciliation 
Act (PRWORA), which President Clinton signed into law, authorizing work 
requirements for a number of safety-net programs. As Democrats and 
Republicans who supported the legislation at the time explained, these 
requirements aimed to encourage self-sufficiency and promote 
opportunity. What did you mean, last year, when you described work 
requirements as ``discriminatory,'' and do you stand by that 
assessment?

    Do you believe in the core principle of welfare-to-work--namely, 
that workforce entry or reentry provides the ideal avenue out of 
poverty and dependency?

    Answer. Medicaid is an important lifeline for many American 
families. Section 1115 demonstration projects, or waivers, are one 
available tool to States to help test new and innovative policies in 
Medicaid. I have worked closely with States throughout my career, so I 
know they face different challenges and need consistency and 
predictability. If confirmed, I will keep in mind what I have learned 
working on behalf of States to make sure waiver requests are 
appropriately evaluated while giving them consistent guidance. I will 
support State innovation and the ability of States to test out 
different models that meet the objectives of the Medicaid program. I 
look forward to seeing the ideas States bring to the table and will 
consider each one on its merits.
                   on support for nursing home i-snps
    Question. As you know, Institutional Special Needs Plans (I-SNPs) 
are a type of Medicare Advantage plan where the only beneficiaries 
enrolled are seniors living in nursing homes. When nursing homes offer 
these plans, they are 100-percent at risk for all the care their 
residents need, either at their facilities or elsewhere. In the push 
towards value-based care, nursing homes taking on risk via I-SNPs are 
doing exactly what we want to see, but in 2020, being 100 percent at 
risk for a population exclusively made up of the individuals most 
vulnerable to COVID-19, and most likely to need high-cost 
hospitalization, created serious financial challenges for nursing homes 
with I-SNPs, including numerous communities in South Carolina. While 
nursing homes in general have received funds from the Provider Relief 
Fund (PRF), neither HHS nor CMS has provided relief to address the 
specific challenges nursing home I-SNPs have faced in order to ensure 
this model's continued viability.

    Will you commit to using administrative authority to support I-SNPs 
and to recognize the significant increased and unexpected costs that 
these plans have faced during the COVID-19 emergency?

    Answer. It has been heartbreaking to see how hard the COVID-19 
pandemic has affected the Nation's nursing home residents. Nursing home 
care will absolutely be a focus of mine if confirmed. Medicare 
Advantage serves millions of Americans, and Institutional Special Needs 
Plans provide important options for people in need of the level of care 
provided in nursing homes and long-term care facilities. This pandemic 
has given us the opportunity to take in lessons across a variety of 
issues. Moving forward, it is critical we examine every approach we can 
to improve affordability, quality, and access in long-term care. If 
confirmed as CMS Administrator, I look forward to working with you and 
other members of Congress to find ways to achieve this important goal.

                                 ______
                                 
               Questions Submitted by Hon. James Lankford
    Question. Biosimilar medicines are projected to save more than $100 
billion in the next 4 years and increase patient access to lifesaving 
medicines. Recent analysis found roughly 40 percent of first generics 
are not covered under Part D 3 years after launch. Over the last 10 
years, generic medicines have been increasingly placed on higher cost-
sharing tiers in Medicare Part D. I have been an advocate for the 
creation of a specialty tier to provide lower cost-sharing for 
biosimilars and specialty generics.

    What steps could CMS take to encourage the use of lower-cost 
biosimilars and generics?

    Will you work with Congress to ensure generics are covered soon 
after launch and seniors are provided rapid access to these lower-cost 
medicines?

    Will you work to reverse the trends of generics being placed on the 
inappropriate Part D tier in order to ensure patient access to low-cost 
generics with low cost sharing?

    Answer. Prescription drug costs are too high for American patients 
and families. From the meetings I have had with Senators in recent 
weeks, I have seen that lowering drug prices is a priority on both 
sides of the aisle. I agree that patient access to lower-cost generics 
and biosimilars is important. Competition in the market has helped 
control the growth in spending on prescription drugs, and generics 
biosimilars certainly have a role to play in creating competition for 
reference products. If I am fortunate enough to be confirmed, I look 
forward to working with you and other members of Congress to lower the 
cost of prescription drugs.

    Question. I recently sent a letter to GAO alongside many of my 
colleagues asking for an investigation into some recent reports on 
fraud in the Medicaid program.

    What holes in the system did you see when you worked as a program 
analyst for Medicaid, and what possible solutions do you look toward to 
help solve the problem?

    Answer. Fighting fraud and abuse is so important for maintaining a 
strong Medicaid program. Medicaid is a critical lifeline for 
beneficiaries across the country. If I am fortunate enough to be 
confirmed, I will be prepared to work with you, other members of 
Congress, and States to make sure that payments are made properly and 
we are good stewards of the Medicaid program and taxpayer dollars.

    Question. The pandemic has underscored the importance of managing 
and preventing chronic disease and removing health disparities. We also 
recognize that higher out-of-pocket costs correlate with less 
prescription drug access. To this end, we need to be proactive and 
address system challenges that inadvertently drive out-of-pocket costs 
up for seniors. For example, certain system fees, called DIR fees, lead 
to increased costs for seniors at the pharmacy counter, while also 
threatening the viability of pharmacies across the Nation, leading to 
gaps in care. As you are aware, the Centers for Medicare and Medicaid 
Services (CMS) has estimated that pharmacy DIR fee reform could result 
in saving Medicare beneficiaries between $7.1 and $9.2 billion in cost 
sharing burden over the next decade.

    To reduce out-of-pocket costs for seniors and safeguard access to 
care provided at local pharmacies, how will you commit to DIR fee claw-
back reform and the establishment of standardized performance measures 
for pharmacies in Part D to help drive quality for seniors and control 
rising costs?

    Answer. Small and rural pharmacies are critical to our Nation's 
health-care system and have been especially important during the 
pandemic. It can be hard for these pharmacies to predict retroactive 
DIR fees. We must do all we can to ensure that Americans can access 
important health-care services, including from local pharmacies in 
their communities. If confirmed, I look forward to working with 
Congress to ensure that pharmacies have predictability.

    Question. As you know, the Medicare Advantage institutional special 
needs program is an important source of personalized support for long-
term care residents. It has proven to deliver quality care with 
supplemental benefits at a lower cost. As a result, Congress has seen 
the value and made the I-SNP program permanent. Since I-SNPs only serve 
long-term care populations, they cannot shift the risks they may 
assume. One of these plans is currently servicing several of the long-
term care facilities in Oklahoma and, unsurprisingly, the COVID 
pandemic has had a particularly devastating effect on them, as nursing 
home residents continue to be on the front lines of those most 
negatively impacted. Special needs plans have fallen through the cracks 
of COVID support and have been subject to unintended consequences, 
leading to enrollment disincentives and further increasing the pressure 
on I-SNPs.

    Do you acknowledge that the I-SNPs are facing a significant 
problem?

    If so, will you commit to working with the struggling plans to 
address the disparities they currently face, ensuring there are 
equitable private options available for nursing home residents, and 
finding a solution?

    If not, please explain why.

    Answer. It has been heartbreaking to see how hard the COVID-19 
pandemic has affected the Nation's nursing home residents. Nursing home 
care will absolutely be a focus of mine, if confirmed. Medicare 
Advantage serves millions of Americans, and Institutional Special Needs 
Plans provide important options for people in need of the level of care 
provided in nursing homes and long-term care facilities. I agree that 
it is critical we examine every approach we can to improve 
affordability, quality, and access in long-term care. If confirmed as 
CMS Administrator,

    I look forward to working with you and other members of Congress to 
find ways to achieve this important goal.

    Question. Your career has focused on expanding health coverage for 
Americans.

    If confirmed, do you plan to increase the role of the Federal 
Government in health care by promoting a public option? Please detail 
your plans for expanded health coverage.

    Answer. President Biden has been clear that his goals for improving 
the American health-care system begin with building on the successes of 
the Affordable Care Act, and I am committed to working toward that 
goal. Ensuring that all Americans have access to affordable, quality 
health care will be a priority of mine. I want to work with States to 
expand coverage through Medicaid and the Marketplaces. I look forward 
to working with you to expand access to affordable, quality health 
care.

                                 ______
                                 
                Questions Submitted by Hon. Steve Daines
    Question. One of the silver linings of this pandemic has been the 
wide-spread adoption of technology to bring people together, whether it 
be families scattered across the Nation or patients and their 
providers. Telehealth has truly taken root, and we have seen 
exponential growth in telehealth adoption across Americans of all ages, 
locations and conditions. Much of the growth in usage among Medicare 
beneficiaries has been made possible by temporary flexibilities in 
place for the duration of the public health emergency. These include 
allowing Medicare beneficiaries to have telehealth visits from their 
home, regardless of where they live across the country. This has also 
allowed new types of providers, such as physical therapists and speech 
pathologists to practice via telehealth.

    Do you agree that the expanded access to telehealth services has 
been an important component in protecting patients and providers during 
the Nation's response to COVID-19?

    As Congress considers permanent telehealth reform, I hope you will 
be willing to work with us to ensure that telehealth is available to 
all of those that wish to use it. Do you believe that there are some 
telehealth regulatory restrictions that Congress and CMS can work 
together to address in the near term?

    Answer. Telehealth has been invaluable during this pandemic to keep 
patients, their providers and their families safe. My brother is a 
psychologist, and telehealth has really helped his patients get the 
care they need. If I am fortunate enough to be confirmed, I will be 
taking a careful look at the telehealth flexibilities under Medicaid 
and Medicare before the Public Health Emergency ends.

    I want to look at what we can and should extend administratively 
and what will need congressional action to ensure that we bring the 
lessons learned about telehealth during the pandemic into our health-
care system going forward. I look forward to hearing more from you 
about what existing flexibilities you view as especially important.

    Question. Emerging science indicates that addressing risk factors--
including cardiovascular disease, diabetes, obesity, and hypertension--
can delay the onset of dementia and Alzheimer's. However, we continue 
to see our health-care system, particularly Medicare, fail to pursue 
low-cost, effective policies to reduce the risk for chronic conditions, 
including Alzheimer's. Instead, our system waits until people are sick 
and treatment costs are significantly higher.

    If confirmed, how will CMS pursue wellness and early intervention 
policies that reduce the risk of chronic diseases like Alzheimer's?

    Answer. Alzheimer's disease is a devastating condition for patients 
and families. It is only going to be a growing challenge for the 
Medicare program and our aging population in coming years. Preventive 
care is crucial to improving health outcomes, and it is so important to 
catch the signs of cognitive impairment early. I'd be happy to work 
with you on this should I be confirmed.

    Question. Late last year, CMS issued a Durable Medical Equipment 
proposed rule, which would make the 50/50 blended rate for rural areas 
permanent. This rule has not been made final as of yet. I appreciate 
all the work HHS and CMS have done regarding the Medicare Durable 
Medical Equipment benefit.

    When will HHS and CMS issue the final DME rule?

    Answer. I recognize that rural areas have unique needs and 
challenges, including access to durable medical equipment. If I am 
fortunate enough to be confirmed, I am happy to look into the status of 
this regulation and work with you and your office on this important 
issue.

    Question. The coronavirus pandemic has underscored the value of 
vaccines for infectious diseases, including those that originate 
abroad. We all recognize that COVID-19 will not be the last time we 
have to respond to an outbreak for which vaccinations are necessary in 
order to stem an emerging public health threat.

    Public policy should make vaccines as accessible as possible for 
our citizens. That is why current law requires that insurers provide 
coverage without cost sharing for all recommended vaccines, without 
limitation.

    Yet, inexplicably, current HHS regulations implementing the law 
limit mandatory coverage to so-called ``routine'' vaccines on the 
Immunization Schedules. As a result, many vaccines for infectious 
diseases are not covered without cost-sharing, including those for 
current vaccines such as rabies, anthrax, Japanese Encephalitis, yellow 
fever and cholera, and those vaccines in the pipeline for malaria, 
chikungunya, dengue, and Zika.

    Last year, my colleagues and I worked on bipartisan legislation 
included in the CARES Act that ensures immediate coverage of COVID-19 
vaccines with no cost-sharing. As I said then, Montanans and Americans 
across the country need access to vaccines, and financial barriers 
should not stand in the way during a national emergency or otherwise.

    Congress should not have had to be reactive. A forward-looking, 
uniform approach is needed to ensure that we are prepared to move 
quickly on vaccinations when the next pandemic occurs.

    If confirmed, will you commit to quickly bringing agency 
regulations in line with the statute requiring no cost-sharing for all 
CDC recommended vaccines to maximize access to the best preventative 
measures against infectious diseases?

    Answer. I agree that the COVID-19 pandemic has underscored the 
importance of vaccines to preventing the spread of disease, and I agree 
that we should remove barriers for patients to get proven vaccines. We 
need to be prepared for any potential future outbreak, and I agree we 
cannot afford to be reactive on such an important issue. I am happy to 
work with you to ensure we are ready for the next public health 
emergency.

                                 ______
                                 
                 Questions Submitted by Hon. Todd Young
           center for medicare and medicaid innovation (cmmi)
    Question. The Center for Medicare and Medicaid Innovation (CMMI) is 
charged with testing and evaluating voluntary healthcare payment and 
service delivery models with the intent of increasing quality and 
efficiency while reducing program expenditures under Medicare, 
Medicaid, and the Children's Health Insurance Program (CHIP).

    As we discussed during our meeting, I feel there is absolute value 
in innovating with health-care payment and service delivery systems. We 
won't know if we're truly making a difference unless we test and 
evaluate--it's how we find out what works and what's most effective for 
patients and doctors alike.

    However, the actual experience of CMMI can too often be marked by a 
lack of transparency and little stakeholder engagement in the 
development and implementation of models.

    At times, models also seem to initiate wholesale policy changes 
rather than serve as true tests, circumventing Congress's role in 
establishing Medicare policy. I also want to ensure that proposed 
models sufficiently take into consideration the potential health-care 
access disparities for vulnerable populations.

    Will you work with the members of this committee on establishing 
protections to guarantee better transparency, stakeholder input, data 
sharing, and equity in the development of proposed models by CMMI?

    Will you commit to come back to this committee to share updates and 
release progress reports on CMMI actions and models?

    Answer. The Innovation Center has been an important tool to test 
new models to move our health-care system from one that rewards volume 
to one that rewards value. It will continue to be important, as we move 
forward, to test models that improve patient care, advance health 
equity, and lower patient costs. We have now had 10 years of experience 
to learn from at the Innovation Center. We need to look at what has 
worked and what hasn't and chart a path forward from there. This 
includes getting stakeholder input, and if I am fortunate enough to be 
confirmed, it will be a priority for me to have open lines of 
communication with Congress. I look forward to hearing from you about 
CMMI models.
                               telehealth
    Question. Even prior to the pandemic, I heard from my constituents 
in Indiana--particularly those in rural areas--about the ways in which 
telehealth can both increase access to underserved Americans and reduce 
health-care costs. Since the start of the public health emergency, 
telehealth flexibilities provided by Congress and HHS have been a 
lifeline for vulnerable seniors and others accessing care from the 
safety of their own homes.

    Currently, authorizations included in the CARES Act to create 
additional flexibility for patients and providers using telehealth only 
extend through the pandemic.

    We don't want to take a step back on telehealth. The Medicare 
Payment Advisory Commission (MedPAC) has recommended that we should 
``temporarily continue some of the telehealth expansions for a limited 
duration of time (e.g., 1 or 2 years after the public health emergency) 
to gather more evidence about the impact of telehealth on beneficiary 
access to care, quality of care, and program spending to inform any 
permanent changes.'' What data or evidence is CMS collecting now to 
determine what waivers should be made permanent?

    How should telehealth be used moving forward to expand access to 
mental and behavior health services for Medicare beneficiaries?

    Answer. Telehealth has been invaluable during this pandemic to keep 
patients, their providers and their families safe. My brother is a 
psychologist, and telehealth has really helped his patients get the 
care they need. If I am fortunate enough to be confirmed, I will be 
taking a careful look at the telehealth flexibilities under Medicaid 
and Medicare before the Public Health Emergency ends to determine what 
we can extend administratively and what we will need Congress's help on 
to ensure that we use the lessons learned about telehealth during the 
pandemic to modernize our health-care system.
                           organ procurement
    Question. Thirty-three Americans die every day waiting for a 
lifesaving organ transplant, and Medicare spends roughly $36 billion 
annually on care for dialysis patients because there are not enough 
kidney transplants available to meet the need. The problem is a network 
of unaccountable government monopoly contractors that run the organ 
donation system, called organ procurement organizations (OPOs), with a 
history of severe performance failure.

    Recently, CMS finalized a rule started in the previous 
administration that would allow HHS to replace failing OPOs with high 
performers, and is projected to save more than 7,000 additional lives 
every year, as well as over $1 billion annually to Medicare.

    This rule has broad bipartisan support, and is even more important 
since COVID-19 damages organs. As CMS Administrator, will you commit to 
its swift implementation?

    Answer. Thank you for bringing up this important issue. Federal law 
tasks CMS with conducting surveys of OPOs and recertifying them. As you 
noted, the rule replacing current OPO measures with new transparent, 
reliable, and objective outcome measures is now effective. My 
understanding is that the new outcome measures will be implemented on 
August 1, 2022, the start of the next recertification cycle. If 
confirmed, I will work to implement this rule in a timely way and 
ensure that all parts of the organ transplant system are as effective 
and efficient as possible in order to save as many lives as possible.
                           medicare advantage
    Question. We have seen a growth in the private/public partnership 
program in Medicare Advantage (MA). Over 40 percent of Medicare 
beneficiaries are choosing Medicare Advantage and they report high 
satisfaction with the provider networks, cost savings and coordinated 
care.

    What role do you see Medicare Advantage having in the future of 
Medicare as we work towards modernizing the program?

    Medicare Advantage is showing that it can provide lower consumer 
costs, offer additional benefits, and achieve better outcomes, like 
fewer avoidable hospitalizations including for high need, high risk 
patients for the same or lower cost as FFS Medicare.

    Research from UnitedHealth Group shows that Hoosiers enrolled in a 
Medicare Advantage plan spend nearly $1,800 less on premiums and out-
of-pocket costs than a Hoosier enrolled in traditional Medicare and a 
prescription drug plan; and, in addition to the dental, vision, and 
hearing benefits typically offered, the average MA beneficiary in 
Indiana receives $170 annually in additional benefits such as care 
coordination, meals, and non-emergency transportation not offered by 
traditional Medicare.

    Do you see Medicare Advantage as an important part of modernizing 
Medicare while getting better results for our taxpayer dollars?

    What will you do to protect this public/private partnership and 
keep the program strong?

    Answer. Medicare Advantage serves millions of Americans and is an 
important option for Medicare beneficiaries. I believe that we have to 
take every approach we can to provide people access to quality health 
care. If confirmed as CMS Administrator, I look forward to working with 
Congress on this important issue.
                    sepsis testing standard of care
    Question. More than 20 million Americans present with symptoms of 
sepsis in acute care hospitals annually, and are treated under a 
``sepsis protocol'' where blood culture tests are urgently drawn to 
diagnose bloodstream infections. However, approximately 40 percent of 
these blood culture tests are false positives. This results in patients 
being subjected to extended hospital stays and the unnecessary use of 
potent antibiotics, which have been proven to contribute to the spread 
of antibiotic resistance.

    What is CMS doing to ensure that hospitals across the country are 
working to reduce their false positive sepsis test rates to ensure 
patient safety?

    Answer. Thank you for raising this important issue. Timely 
diagnosis and treatment of sepsis is a critical issue as are actions 
that will enhance antibiotic stewardship. If confirmed, I look forward 
to working with you to continuously improve the quality of care that 
hospitals are providing to patients, including with respect to 
accurately diagnosing sepsis while avoiding unnecessary use of 
antibiotics.
                     end stage renal disease (esrd)
    Question. Last November, my staff shared some concerns we heard 
from representatives of the kidney care community about the proposed 
methodology to incorporate certain drugs into the ESRD bundle. There 
have been reports of dialysis patients on these therapies being forced 
off treatments that are working for them onto therapies that have not 
worked for the patient in the past.

    As CMS Administrator, how you will ensure patient quality of care 
is not being impacted--specifically for communities of color who are 
disproportionately impacted by kidney disease--so that patients can 
continue to access these medicines best suited for their treatment?

    Answer. I agree that is it important for Medicare beneficiaries, 
particularly patients with complex conditions such as ESRD, to have 
access to medically necessary treatments. Promoting health equity--
particularly for communities of color and rural areas--needs to be at 
the forefront of CMS decision making. If confirmed, I will work to 
preserve access to these treatments in Medicare and improve patient 
outcomes.

                                 ______
                                 
                 Questions Submitted by Hon. Ben Sasse
                               telehealth
    Question. While my colleagues have pointed out many of the ways 
COVID-19 has challenged our health-care system and exposed existing 
inequities, one bright spot in the pandemic has been increased access 
to telehealth services as a way for patients to maintain their health 
from the safety of their homes. This has been particularly important 
for States like Nebraska with large areas of rural population.

    We know that CMS has allowed expanded use of audio-only services 
during the pandemic, but how is CMS working to ensure that those 
without broadband access can utilize appropriate telehealth services in 
a post-pandemic world?

    Where do you stand on audio-only telehealth coverage? What about on 
payment parity between in-person and virtual services?

    How will you approach geographic restrictions, both in patient 
location and provider licensure?

    If confirmed, how do you plan to evaluate the use of telehealth 
over the last year and the places where it should--and potentially 
should not--be expanded beyond the end of the national emergency 
period?

    Answer. Telehealth has been invaluable during this pandemic to keep 
patients, their providers, and their families safe. My brother is a 
psychologist, and telehealth has really helped his patients get the 
care they need. If I am fortunate enough to be confirmed, I will take a 
careful look at the telehealth flexibilities under Medicaid and 
Medicare before the Public Health Emergency ends. During that review, I 
will pay special attention to the issues of equity and access. I will 
look at what we can and should extend administratively and where we 
will need Congress's help to ensure that we bring the lessons learned 
about telehealth during the pandemic forward to modernize our health-
care system.

    Question. Individuals with chronic disease place an immense strain 
on our health-care system and account for a huge percentage of the 
overall costs to taxpayers. I think you would agree that early 
identification and treatment is crucial not only among those with 
chronic diseases but in our health systems in general. Remote patient 
monitoring (RPM) can be beneficial in managing both acute and chronic 
conditions and identifying deteriorations in health as early as 
possible to allow for the best level of care. Issues with reimbursement 
continue to constrain Medicare recipients' access to this level of 
monitoring.

    Do you see value in increased access to remote patient monitoring 
and what are your views on the co-pay requirement for these services?

    Answer. Individuals with chronic disease benefit from access to 
comprehensive and coordinated care to manage and treat their chronic 
conditions and prevent the need for more costly care. Ensuring access 
to remote patient monitoring services, including through evaluating the 
adequacy of payments, will be important to beneficiaries who may 
benefit from these and other virtual services that allow their 
physicians to help manage and treat their health conditions outside of 
regular office visits.
                       most favored nation model
    Question. I have concerns with the Most Favored Nation model 
rulemaking, both with the policy of tying Medicare reimbursements to 
the prices foreign countries pay and with the creation of the expansive 
rule through the Center for Medicare and Medicaid Innovation (CMMI) 
under the guise of being a pilot program.

    If confirmed, how will you approach this policy? Do you support 
tying the prices of American drugs to foreign prices?

    Will you commit to ensuring that CMMI is used as intended rather 
than as a congressional workaround?

    Answer. Prescription drug costs are too high for American patients 
and families. From the meetings I have had with Senators in recent 
weeks, I have seen that this is a priority on both sides of the aisle. 
I think there is an opportunity for real impact here to lower 
prescription drug costs, and--if I am fortunate enough to be 
confirmed--I look forward to working with you and other members of 
Congress to achieve that goal.

    Regarding the Center for Medicare and Medicaid Innovation, the 
Innovation Center has been an important tool to test new models to move 
our system from one that rewards volume to one that rewards value. It 
will continue to be important, as we move forward, to test models that 
improve patient care, advance health equity, and lower patient costs. 
With 10 years of experience to learn from at the Innovation Center, we 
need to look at what has worked and what hasn't, and I look forward to 
hearing from you about what you think is working well and what 
experiences you've seen on the ground in Nebraska.
                                medicaid
    Question. Enrollment in the Medicaid program has exploded during 
the pandemic, partially due to problematic language in last year's 
relief bills where States have no choice but to provide services even 
to people who are not actually eligible for the program. The Families 
First Coronavirus Response Act (FFCRA) offered States an increased 
Federal Medical Assistance Percentage (FMAP) for their traditional 
Medicaid populations and in turn restricted them from maintaining 
control over their Medicaid programs via maintenance-of-effort 
requirements. Across the country there are millions of Medicaid 
enrollees whose redetermination has been delayed, and in just seven 
States where we have data we know that roughly half a million enrollees 
are receiving benefits who are ineligible for the program.

    Do you commit to working with States and Congress to actually 
identify which enrollees are eligible and which are not?

    Do you commit to making sure that the Medicaid program is able to 
serve those individuals who are truly in need?

    Do you believe States should have the right to remove ineligible 
enrollees, which is currently restricted by FFCRA?

    Answer. Medicaid is a critical lifeline for beneficiaries across 
the country. If I am fortunate enough to be confirmed, I will also be 
prepared to work with you, other members of Congress, and States to 
make sure that payments are made properly and we are good stewards of 
the Medicaid program and taxpayer dollars. The requirement related to 
enrollment at section 6008(b)(3) of the Families First Coronavirus 
Response Act for States receiving the Medicaid FMAP increase will be in 
effect until the end of the month in which the COVID-19 public health 
emergency ends. As that time grows nearer, it will be important for CMS 
to work closely with States to plan for the transition.
                       durable medical equipment
    Question. HHS and CMS have done a lot of work on the Medicare 
Durable Medical Equipment benefit, including issuing a proposed rule 
late last year that would have made the 50/50 blended rate for rural 
areas permanent.

    When does CMS plan to issue the final DME rule given the change of 
administrations?

    Answer. I recognize that rural areas have unique needs and 
challenges, including access to durable medical equipment. If I am 
fortunate enough to be confirmed, I am happy to look into the status of 
this regulation and work with you and your office on this important 
issue.

    Question. We know that some of our most vulnerable in society rely 
on ventilators for their care, yet access to new-generation, multi-
function ventilators can often be restricted by complicated payment 
policies that have not adapted for new technologies. This is 
particularly important in light of the pandemic, when ventilation in 
home care settings allows for more hospital space.

    If confirmed, will you work to update CMS payment regulations to 
account for advancements in ventilator technology, including adjusting 
irregularities in payment that impede patient access?

    Answer. We know that some of our most vulnerable patients rely on 
ventilators for their care, yet access to new-generation, multi-
function ventilators can often be impeded by statutory payment policies 
related to paying for equipment on a cap rental basis and the 
reasonable useful lifetime of the equipment. To help ensure access to 
ventilators in light of the COVID-19 public health emergency, I 
understand that CMS is allowing payment for multi-function ventilators 
even if separate devices have not met their reasonable useful lifetime.

    I agree that it is incredible what science has been able to do in 
recent years with innovative new drugs, treatments and devices. If I am 
fortunate enough to be confirmed, I will make sure we are looking at 
modernizing the Medicare program to make sure beneficiaries have access 
to proven new technology, and I would be happy to work with you on 
that.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. At the end of 2020, Congress provided relief from 
reductions in reimbursement to certain physicians which was included in 
last year's physician fee schedule final rule. This was the result of 
budget neutrality requirements within the fee schedule. With many 
physician practices experiencing substantial challenges as a result of 
the COVID-19 pandemic, it is important to ensure providers are able to 
continue caring for patients.

    Can you please discuss your approach regarding future changes to 
the physician fee schedule? In particular your feelings on reducing 
reimbursements to providers during the pandemic.

    Answer. I believe that ensuring adequate payments for primary care 
and specialty physicians is essential to maintain beneficiary access to 
high-quality and affordable health care. If confirmed, I will work to 
ensure that payments under the Medicare physician fee schedule are 
implemented in accordance with the law while preserving beneficiary 
access.

    Question. Current law requires zero cost sharing for COVID 
therapeutics. However, when the Public Health Emergency (PHE) is lifted 
many of these policies linked to the PHE declaration will no longer be 
in effect under the law and will potentially be subject to CMS' 
discretion.

    Please discuss your approach to reimbursement for COVID 
therapeutics. In particular your feelings on how this issue should be 
approach once the PHE is lifted.

    Answer. I appreciate Congress's leadership in making sure that 
patients suffering from COVID-19 have been able to get the care they 
need during the public health emergency. I think we need to look at the 
policies in place during the pandemic and determine what we should do 
after the pandemic is over, either administratively or with legislation 
from Congress. If confirmed, I will be happy to work with you and other 
members of Congress as we look beyond the pandemic.

    Question. Drugs approved via accelerated approval at the Food and 
Drug Administration (FDA) are novel treatments that address urgent and 
unmet medical needs involving serious and life-threatening diseases.

    As a doctor, I am particularly passionate about the new treatments 
approved through this pipeline to treat Duchenne Muscular Dystrophy. As 
you know, this is a deadly disease, which until very recently had no 
approved treatments. Today we have five treatments approved through 
this pathway with many more in development. While certainly not a cure, 
these therapies are an important step forward.

    Recently, the Medicaid and CHIP Payment and Access Commission 
(MACPAC) issued recommendations to increase the required Medicaid 
rebates for drugs specifically approved through the accelerated 
pathway.

    While I appreciate that MACPAC is a congressional advisory body, I 
believe their recommendation to single out these therapies is 
troubling. In particular, when you consider medications approved in 
this manner treat some of our most vulnerable patients and make up a 
very small percentage of total Medicaid spending.

    Can you discuss your views on Federal reimbursement policies on the 
development of new therapies for people with rare diseases?

    Answer. Thank you for raising this important issue. It is 
incredible what scientific progress has been made with innovative drugs 
and treatments, and we need to continue to modernize the Medicare and 
Medicaid programs to make sure beneficiaries, including those with rare 
diseases, have access to proven new treatments. If confirmed, I would 
be happy to examine this particular MACPAC proposal in more detail, and 
to work with you and other members of Congress on ways to spur 
innovation and facilitate beneficiary access to new advances in 
medicine.

    Question. Last year I led a bipartisan letter with Senate and House 
colleagues to CMS expressing concerns about cuts to hip and knee 
replacement in the Calendar Year 2021 (CY21) Physician Fee Schedule and 
the implications for value based care.

    Specifically, the letter urged CMS to recognize the patient 
preoptimization work physicians are doing in alternative payment 
models. The CY'21 rule substantially cut lower joint arthroplasty even 
though physicians performing those procedure are doing more work and 
saving the Medicare Trust Funds money through their record-high 
participation in alternative payment models (APMs).

    These cuts are concerning. This appears to be a disconnect between 
the legacy fee-for-service evaluation of procedures, and innovative 
care we are encouraging in APMs. However, the Final Rule indicated 
CMS's interest in capturing this patient preoptimization work.

    Would you please work with the stakeholders and I on the 
preoptimization issue?

    More broadly, can you discuss your feeling on alternative payment 
models and if there are specific areas where you wish to focus?

    Answer. I agree that we should continue efforts to further move our 
health-care system towards one that rewards value over volume. Delivery 
system reform efforts, including alternative payment models, can 
improve quality of care while reducing health-care costs. The 
Innovation Center has been an important tool to test new models to move 
our system from one that rewards volume to one that rewards value. It 
will continue to be important, as we move forward, to test models that 
improve patient care, advance health equity, and lower patient costs. 
We have now had 10 years of experience to learn from at the Innovation 
Center. We need to look at what has worked and what hasn't, and if 
confirmed, I will work with you to make sure we recognize the good work 
providers are doing to move our system in the right direction, improve 
care, and lower Medicare spending.

    Question. I support price transparency in the health-care system. 
The Trump administration made good progress on this problem with their 
hospital price transparency rule, which went into effect on January 1, 
2021.

    It appears from media reports that many hospitals are not following 
the rule. If confirmed, how will you address price transparency in 
health care, especially in terms of enforcement of the price 
transparency rule?

    Answer. I agree that the variation in pricing across hospitals is 
not always justified and ultimately can be bad for consumers. For 
transparency measures to work properly, patients and their families 
must be able to understand them in a meaningful way. If I am fortunate 
enough to be confirmed, I look forward to continuing to work on this 
issue.

                                 ______
                                 
                Prepared Statement of Hon. Mike Crapo, 
                       a U.S. Senator From Idaho
    When we held our hearing for Xavier Becerra to be the Secretary of 
Health and Human Services, I noted the size and importance of the 
Department he would lead. In normal times, HHS and its agencies provide 
health-care coverage to nearly 150 million people, and those agencies 
affect the lives of many more on a daily basis. The COVID-19 pandemic 
has raised the salience of the Department.

    The Department's leadership, including the Deputy Secretary, will 
continue to play a key role in bringing us out of the public health 
emergency. Similarly, Medicare and Medicaid are providing essential 
health care to patients who have suffered disproportionately from the 
COVID-19 pandemic.

    Looking to the future, the Secretary, the Deputy Secretary, and the 
CMS Administrator must carefully evaluate how best to use the resources 
available to them to promote the health care of our citizens. They must 
do so carefully, constructively, and creatively.

    Two months ago, I outlined several issues in the health-care space 
where I intend to focus my efforts as ranking member, including 
fostering innovation to improve patient care and make our health-care 
system more efficient. The COVID-19 pandemic has threatened Americans' 
physical and economic health, but it has also reinforced the value of 
innovation and provided an opportunity to test changes that foster it.

    HHS has used its authority under the public health emergency to 
waive numerous requirements to ensure Medicare and Medicaid 
beneficiaries and other patients receive care during the pandemic. 
Patients and providers have benefited from expanded access to 
telehealth and expedited approval of COVID-19 vaccines, diagnostics, 
and treatments. Going forward, Medicare and Medicaid patients must have 
the same access to innovative items and services as those with 
commercial insurance.

    We must carefully evaluate our response to the pandemic and 
implement appropriate reforms based on the lessons we have learned. HHS 
should partner with this committee in that effort. However, media 
reports about certain health-care policies that may come before 
Congress or be enacted through executive actions are concerning. Some 
of these policies, such as including additional benefits under 
Medicare, could experience bipartisan support if considered through a 
transparent, cooperative process.

    Unfortunately, reconciliation does not afford Congress the 
opportunity to work together to evaluate these changes and make 
necessary reforms to protect the long-term financial viability of the 
program. Other policies, such as expanding Obamacare's premium subsidy 
to everyone, regardless of income, would be incredibly expensive for 
taxpayers without taking appropriate steps to lower the cost of health 
insurance. Creative, bipartisan ideas to lower the cost of insurance in 
the individual market have been raised by States and my colleagues on 
this committee.

    I welcome the opportunity to work together on some of these ideas, 
such as allowing States to use waivers to their full potential, 
diversifying benefit designs, and incentivizing competition.

    Finally, I am concerned about paying for some of these policies 
through changes to our drug pricing system that could stifle 
innovation. We can see the end of the COVID-19 pandemic approaching, 
thanks to groundbreaking vaccines developed by pharmaceutical 
manufacturers. In this crisis, industry responded to the Nation's call 
to arms, code-named Project Warp Speed, developing powerful and 
effective vaccines in record time. This success was possible because of 
the private sector.

    I strongly agree with my colleagues that this innovation is only 
valuable if patients can afford it. We should establish an out-of-
pocket spending cap and reform Medicare Part D with the market-based 
principles of competition and transparency in mind.

    Ms. Palm and Ms. Brooks-LaSure, if you are confirmed, I look 
forward to working with you to improve our health-care system. I ask 
you to commit to careful assessments of the risks and considerations in 
every policy decision you make. Political pressures may make unilateral 
action seem attractive, but you should also consider how the market, 
individual choice, public policy, and incentives play vital roles in 
the development and delivery of health care.

    I look forward to hearing your testimony and your responses to 
questions. The positions to which you have been nominated have 
substantial influence over policy. The members of this committee need 
to understand how you will implement the administration's agenda.

    We expect your answers, here and in response to QFRs, to be 
detailed and candid.

                                 ______
                                 
    Prepared Statement of Andrea Joan Palm, Nominated to be Deputy 
           Secretary, Department of Health and Human Services
    Thank you, Chairman Wyden, Ranking Member Crapo. I am grateful for 
the opportunity to testify before you today as President Biden's 
nominee for Deputy Secretary of the United States Department of Health 
and Human Services. I want to thank Senator Tammy Baldwin for the kind 
introduction and for her work on behalf of the people of Wisconsin. And 
thank you to the members of this committee for considering my 
nomination. I've enjoyed the opportunity to speak with many of you 
individually.

    I was born and raised in Star Lake, NY--a town of about 1,000 
people. When you grow up in a small town, you understand from a young 
age that together is the only way to get things done. That sense of 
community was formative and is what led me to become a social worker. I 
spent my twenties as a caseworker, finding safe homes for children in 
crisis and working for people with behavioral health needs.

    These experiences shaped the rest of my career. It was the children 
and families I worked with during this time that made me want to change 
the system and drew me to public policy and public service. The 
memories of these kids still motivate me today.

    I've spent my entire career focused on health and human services 
policy and lifting up our most vulnerable communities, from my time in 
the Senate working on the HITECH Act to serving at HHS, where I played 
a key role implementing the Affordable Care Act and negotiating 
bipartisan policies like the 21st Century Cures Act.

    Most recently, I had the privilege of leading Wisconsin's 
Department of Health Services. I'm proud of the work I was able to 
accomplish in Wisconsin. There, we found ways to make progress on a 
bipartisan basis, expanding access to telehealth services and our 
innovative Children's Health Insurance Program, and improving delivery 
of the Departments' programs to better serve the people of Wisconsin.

    And when the pandemic hit, we led with facts, science, and 
transparency to protect our communities. As every single State did, we 
faced obstacles. But we built a strong State-wide response--leveraging 
government assets and the expertise of the private sector--to build 
stable testing and contact tracing programs, reach rural communities, 
and vaccinate Wisconsinites.

    And it's working. Wisconsin is among the top States in vaccinating 
its residents.

    When I was previously at HHS, then-Secretary Burwell would joke 
that if there was an issue that was going to require bipartisan 
cooperation, the team should give it to me. She called my portfolio the 
``common ground agenda.'' And if I have the honor of being confirmed 
and returning to HHS, that's what I'm bringing with me: a common-ground 
agenda.

    First, we must end the COVID-19 pandemic. I know we can all agree 
we have lost far too many Americans to this virus. President Biden put 
forward ambitious goals, and Congress has followed through, providing 
the resources to get the job done. If confirmed, I look forward to 
implementing the American Rescue Plan, getting vaccines in arms, 
rebuilding a public health workforce, and securing this Nation's supply 
chain.

    Second, we must expand access to high-quality, affordable health 
care. The American Rescue Plan took major steps to bring down the cost 
of health care for working families, but we can't stop there. We must 
strengthen our Medicare and Medicaid lifelines; reduce the cost of 
prescription drugs; better integrate mental health and substance use 
disorder treatment into our health-care system; maintain our global 
leadership in research, development and innovation; and ensure that all 
Americans have access to quality, affordable health care.

    Finally, we must prioritize human services. HHS has an important 
role to play. From caring for children, to advancing the health and 
well-being of people with disabilities, we must not lose sight of these 
core missions.

    HHS faces big challenges. And it's our responsibility to be 
tireless stewards of an agency that touches nearly every aspect of 
American life. To me, that's what public service is all about: making 
government work for the people, and leaving the country better than we 
found it.

    I am ready for the task, and eager to continue serving. Thank you 
for considering my nomination.

                                 ______
                                 

                        SENATE FINANCE COMMITTEE

                  STATEMENT OF INFORMATION REQUESTED 
                               OF NOMINEE

                      A. BIOGRAPHICAL INFORMATION

 1.  Name (include any former names used): Andrea Joan Palm.

 2.  Position to which nominated: Deputy Secretary, U.S. Department of 
Health and Human Services.

 3.  Date of nomination: January 18, 2021.

 4.  Address (list current residence, office, and mailing addresses):

 5.  Date and place of birth: October 5, 1972, Star Lake, NY.

 6.  Marital status (include maiden name of wife or husband's name):

 7.  Names and ages of children:

 8.  Education (list all secondary and higher education institutions, 
dates attended, degree received, and date degree granted):

        Washington University.
        Dates Attended: August 1994-May 1996.
        Degree Received: Master of Social Work.
        Date Degree Granted: May 1996.

        Cornell University.
        Dates Attended: August 1990-May 1994.
        Degree Received: Bachelor of Science.
        Date Degree Granted: May 1994.

        Clifton-Fine Central.
        Dates Attended: 7th-12th grade, September 1985-June 1990.
        Degree Received: High School Diploma.
        Date Degree Granted: June 1990.

 9.  Employment record (list all jobs held since college, including the 
title or description of job, name of employer, location of work, and 
dates of employment for each job):

        Wisconsin Department of Health Services.
        Secretary-designee.
        January 2019-January 2021.
        Madison, WI.

        U.S. Department of Health and Human Services.
        Senior Counselor to the Secretary (January 2015-January 2017).
        Chief of Staff (April 2013-December 2014).
        Counselor to the Secretary for Public Health (October 2011-
        April 2013).
        Senior Advisor to the White House Domestic Policy Council 
        (detailed from HHS; August 2010-October 2011).
        Acting Assistant Secretary for Legislation (August 2009-July 
        2010).
        Deputy Assistant Secretary for Public Health Legislation 
        (January 2009-July 2009).
        Washington, DC.

        Office of Senator Hillary Clinton.
        Senior Health Policy Advisor (January 2008-Janaury 2009).
        Legislative Assistant (June 2004-January 2008).
        Washington, DC.

        Office of Congressman Robert T. Matsui.
        Legislative Director (December 2003-May 2004).
        Senior Legislative Assistant (June 2001-December 2003).
        Washington, DC.

        Volunteers of America.
        Government Relations Manager (June 2000-May 2001).
        Public Policy Associate (October 1998-June 2000).
        Alexandria, VA.

        City of Phoenix.
        Policy Analyst, Human Services Department.
        June 1997-September 1998.
        Phoenix, AZ.

        Arizona Justice Institute.
        Equal Justice Fellow (Policy Analyst).
        October 1996-May 1997.
        Phoenix, AZ.

        ComCare.
        Crisis Counselor.
        January 1996-September 1996.
        Phoenix, AZ.

        Life Crisis Services.
        Development Director (part-time).
        August 1995-December 1995.
        St. Louis, MO.

        St. Louis Circuit Attorney's Office.
        Victim Services Caseworker (part-time).
        January 1995-December 1995.
        St. Louis, MO.

        Children's Home and Aid Society.
        Crisis Counselor.
        September 1994-December 1994.
        Mobile position; territory included the northern St. Louis, MO 
        suburbs.

10.  Government experience (list any current and former advisory, 
consultative, honorary, or other part-time service or positions with 
Federal, State, or local governments held since college, including 
dates, other than those listed above):

        None.

11.  Business relationships (list all current and former positions held 
as an officer, director, trustee, partner (e.g., limited partner, non-
voting, etc.), proprietor, agent, representative, or consultant of any 
corporation, company, firm, partnership, other business enterprise, or 
educational or other institution):

        None.

12.  Memberships (list all current and former memberships, as well as 
any current and former offices held in professional, fraternal, 
scholarly, civic, business, charitable, and other organizations dating 
back to college, including dates for these memberships and offices):

        Arizona Arts Chorale.
        President (1997-1998).
        Member (1996-1998).

        Chi Omega Sorority.
        Alumna (1994-present).
        President (1993-1994).
        Rush Chair (1992-1993).
        House Manager (1991-1992).

13.  Political affiliations and activities:

        a.  List all public offices for which you have been a candidate 
        dating back to the age of 18.

       None.

        b.  List all memberships and offices held in and services 
        rendered to all political parties or election committees, 
        currently and during the last 10 years prior to the date of 
        your nomination.

       None.

        c.  Itemize all political contributions to any individual, 
        campaign organization, political party, political action 
        committee, or similar entity of $50 or more for the past 10 
        years prior to the date of your nomination.

       See Table.


------------------------------------------------------------------------
      Contribution Description                  Date             Amount
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-07-24  $1,500.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-08-31     $50.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-09-21     $50.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-09-26     $50.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-10-19    $100.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-10-27     $50.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-10-29     $50.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-10-31     $50.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-11-01     $50.00
------------------------------------------------------------------------
HILLARY FOR AMERICA                                2016-11-03     $50.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-05-07    $250.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-09-22    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-09-22    $100.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2018-09-22    $250.00
------------------------------------------------------------------------
SINEMA FOR ARIZONA                                 2018-09-22    $100.00
------------------------------------------------------------------------
BREDESEN FOR SENATE                                2018-09-22    $100.00
------------------------------------------------------------------------
BETO FOR TEXAS                                     2018-09-22    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-09-29     $50.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-09-29     $50.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-09-30    $100.00
------------------------------------------------------------------------
SINEMA FOR ARIZONA                                 2018-09-30    $100.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2018-09-30    $100.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2018-09-30    $100.00
------------------------------------------------------------------------
HEIDI FOR SENATE                                   2018-09-30    $250.00
------------------------------------------------------------------------
BREDESEN FOR SENATE                                2018-09-30    $100.00
------------------------------------------------------------------------
DONNELLY FOR INDIANA                               2018-09-30    $250.00
------------------------------------------------------------------------
HEIDI FOR SENATE                                   2018-10-04    $250.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-10-05    $100.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-10-05    $100.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-10-08    $100.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-10-08    $100.00
------------------------------------------------------------------------
HEIDI FOR SENATE                                   2018-10-08    $100.00
------------------------------------------------------------------------
HEIDI FOR SENATE                                   2018-10-08    $100.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-10-17    $100.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-10-17    $100.00
------------------------------------------------------------------------
DONNELLY FOR INDIANA                               2018-10-18    $150.00
------------------------------------------------------------------------
DONNELLY FOR INDIANA                               2018-10-18    $150.00
------------------------------------------------------------------------
BREDESEN FOR SENATE                                2018-10-18    $100.00
------------------------------------------------------------------------
BREDESEN VICTORY FUND                              2018-10-18    $100.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2018-10-27     $50.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2018-10-27     $50.00
------------------------------------------------------------------------
DONNELLY FOR INDIANA                               2018-10-27    $100.00
------------------------------------------------------------------------
DONNELLY FOR INDIANA                               2018-10-27    $100.00
------------------------------------------------------------------------
BREDESEN FOR SENATE                                2018-10-27    $100.00
------------------------------------------------------------------------
BREDESEN FOR SENATE                                2018-10-27    $100.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-10-27    $100.00
------------------------------------------------------------------------
ROSEN FOR NEVADA                                   2018-10-27    $100.00
------------------------------------------------------------------------
SINEMA FOR ARIZONA                                 2018-10-27    $100.00
------------------------------------------------------------------------
HEIDI FOR SENATE                                   2018-10-27    $100.00
------------------------------------------------------------------------
STACEY ABRAMS                                      2018-10-27    $250.00
------------------------------------------------------------------------
ANDREW GILLUM                                      2018-10-27    $250.00
------------------------------------------------------------------------
RICHARD CORDRAY                                    2018-10-27    $250.00
------------------------------------------------------------------------
LAURA KELLY                                        2018-10-27    $250.00
------------------------------------------------------------------------
TONY EVERS                                         2018-10-27    $250.00
------------------------------------------------------------------------
STEVE SISOLAK                                      2018-10-27    $250.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-10-27    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2018-10-27    $100.00
------------------------------------------------------------------------
SINEMA FOR ARIZONA                                 2018-10-28    $100.00
------------------------------------------------------------------------
HEIDI FOR SENATE                                   2018-10-28    $100.00
------------------------------------------------------------------------
PHIL HERNANDEZ                                     2019-06-09    $250.00
------------------------------------------------------------------------
JOSH KAUL                                          2019-06-12    $250.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2019-06-25    $250.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2019-06-25    $250.00
------------------------------------------------------------------------
TONY EVERS                                         2019-06-29    $250.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2019-09-11    $100.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2019-09-11    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-01-14    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-01-14    $100.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2020-06-07    $100.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2020-06-07    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-06-07    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-06-07    $100.00
------------------------------------------------------------------------
MCGRATH FOR U.S. SENATE                            2020-06-07    $125.00
------------------------------------------------------------------------
DITCH FUND                                         2020-06-07    $125.00
------------------------------------------------------------------------
MARK KELLY FOR SENATE                              2020-06-07    $100.00
------------------------------------------------------------------------
THERESA GREENFIELD FOR IOWA                        2020-06-07    $100.00
------------------------------------------------------------------------
DOUG JONES FOR U.S. SENATE                         2020-06-07    $100.00
------------------------------------------------------------------------
HICKENLOOPER FOR COLORADO                          2020-06-07    $100.00
------------------------------------------------------------------------
CAL FOR NC                                         2020-06-07    $100.00
------------------------------------------------------------------------
SARA GIDEON FOR MAINE                              2020-06-07    $250.00
------------------------------------------------------------------------
JAIME HARRISON FOR U.S. SENATE                     2020-06-07    $250.00
------------------------------------------------------------------------
MONTANANS FOR BULLOCK                              2020-06-07    $250.00
------------------------------------------------------------------------
BIDEN FOR PRESIDENT                                2020-06-07    $250.00
------------------------------------------------------------------------
BIDEN FOR PRESIDENT                                2020-08-27    $250.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-08-27    $100.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2020-08-27    $100.00
------------------------------------------------------------------------
MONTANANS FOR BULLOCK                              2020-08-27    $250.00
------------------------------------------------------------------------
JAIME HARRISON FOR U.S. SENATE                     2020-08-27    $250.00
------------------------------------------------------------------------
SARA GIDEON FOR MAINE                              2020-08-27    $250.00
------------------------------------------------------------------------
CAL FOR NC                                         2020-08-27    $250.00
------------------------------------------------------------------------
DOUG JONES FOR U.S. SENATE                         2020-08-27    $100.00
------------------------------------------------------------------------
THERESA GREENFIELD FOR IOWA                        2020-08-27    $250.00
------------------------------------------------------------------------
MARK KELLY FOR SENATE                              2020-08-27    $100.00
------------------------------------------------------------------------
LAUREN UNDERWOOD FOR CONGRESS                      2020-08-27    $100.00
------------------------------------------------------------------------
HALEY STEVENS FOR CONGRESS                         2020-08-27    $100.00
------------------------------------------------------------------------
AMY MCGRATH FOR SENATE, INC.                       2020-08-27    $250.00
------------------------------------------------------------------------
HICKENLOOPER FOR COLORADO                          2020-08-27    $250.00
------------------------------------------------------------------------
JON OSSOFF FOR SENATE                              2020-08-27    $250.00
------------------------------------------------------------------------
JON OSSOFF FOR SENATE                              2020-12-06    $250.00
------------------------------------------------------------------------
WARNOCK FOR GEORGIA                                2020-12-06    $250.00
------------------------------------------------------------------------

14.  Honors and awards (list all scholarships, fellowships, honorary 
degrees, honorary society memberships, military medals, and any other 
special recognitions for outstanding service or achievement received 
since the age of 18):

        Brown School of Social Work Distinguished Alumni Award, 
        Washington University: 2016.

15.  Published writings (list the titles, publishers, dates, and 
hyperlinks (as applicable) of all books, articles, reports, blog posts, 
or other published materials you have written):

        None.

16.  Speeches (list all formal speeches and presentations (e.g., 
PowerPoint) you have delivered during the past 5 years which are on 
topics relevant to the position for which you have been nominated, 
including dates):

        Below is a list that covers my tenure as the Wisconsin 
        Department of Health Services Secretary-designee. In the 3 
        years prior to that, I did not deliver any speeches relevant to 
        the position for which I have been nominated.


------------------------------------------------------------------------
                     Speech Forum                             Date
------------------------------------------------------------------------
CCS Spring Conference                                         2019-04-16
------------------------------------------------------------------------
Wisconsin Assisted Living Association Conference              2019-04-30
------------------------------------------------------------------------
Doctor Day Conference                                         2019-05-01
------------------------------------------------------------------------
Wisconsin Public Health Association Conference                2019-05-23
------------------------------------------------------------------------
Surgical Collaborative of Wisconsin                           2019-05-29
------------------------------------------------------------------------
Bx Health Budget                                              2019-06-06
------------------------------------------------------------------------
SUD Prevention Conference                                     2019-06-11
------------------------------------------------------------------------
Drug Endangered Children Conference                           2019-07-16
------------------------------------------------------------------------
Wisconsin Personal Services Association Conference            2019-09-18
------------------------------------------------------------------------
Caregivers Taskforce Launch                                   2019-09-25
------------------------------------------------------------------------
Disability Service Provider Network Conference                2019-10-17
------------------------------------------------------------------------
Covering Wisconsin 211 Webinar                                2019-10-21
------------------------------------------------------------------------
DHS DQA FOCUS Conference                                      2019-11-21
------------------------------------------------------------------------
LeadingAge Conference                                         2020-02-18
------------------------------------------------------------------------
WAFCA Leadership Summit                                       2020-03-05
------------------------------------------------------------------------
Rep. Gallagher Teletownhall                                   2020-03-26
------------------------------------------------------------------------
Rep. Kind Teletownhall                                        2020-03-26
------------------------------------------------------------------------
Rep. Kind Teletownhall                                        2020-06-04
------------------------------------------------------------------------
Wisconsin Assisted Living Annual Conference                   2020-09-17
------------------------------------------------------------------------


17.  Qualifications (state what, in your opinion, qualifies you to 
serve in the position to which you have been nominated):

        I believe my public health and social services expertise and 
        extensive health care and management experience qualify me to 
        serve as the Deputy Secretary of the U.S. Department of Health 
        and Human Services (HHS).

        I have been in public service for the vast majority of my 
        career, from my earliest days as a caseworker for crime victims 
        to my time as a crisis counselor for individuals struggling 
        with serious mental health conditions and contemplating 
        suicide. I have broad experience in health care, behavioral 
        health, public health, and children and families issues--
        working for private, non-profit organizations, as well as 
        local, State, and Federal Government in direct service, 
        policy-making, and administrative roles.

        During my tenure at HHS during the Obama-Biden administration, 
        I worked on the legislative formulation and implementation of 
        major bipartisan efforts, including the Food Safety 
        Modernization Act, the Tobacco Control Act, reauthorization of 
        the Ryan White Act, and the 21st Century Cures Act, among 
        others. As a member of the HHS Budget Council, I helped craft 
        and implement each budget enacted during the Obama-Biden 
        administration.

        As the Chief of Staff at HHS, I oversaw the operations of the 
        Secretary's office, which includes a number of offices that 
        provide support to the work of the Department and the 
        Department's external partners, including communications, 
        legislative and external affairs, as well as the general 
        counsel, budget, and administrative functions, among others. In 
        my final role at HHS, I served as the lead for the Department's 
        agency-wide work to stem the tide of the opioid epidemic and 
        enact then-Vice President Biden's Cancer Moonshot Initiative.

        As the Department of Health Services (DHS) Secretary-designee, 
        I ran one of the largest State agencies in Wisconsin, with an 
        annual budget of $12 billion and more than 6,100 employees. I 
        was responsible for the State Medicaid program, the 
        Supplemental Nutrition Assistance Program (SNAP), and 
        behavioral health programs, among others. I was also 
        responsible for the health and safety of Wisconsinites living 
        at our seven 24/7 residential facilities. And as the public 
        health agency for the State of Wisconsin, I led the State's 
        response to the COVID-19 pandemic.

        During my tenure as Secretary-designee, I worked with the 
        Legislature to enact a bipartisan telehealth bill, which was 
        fundamental to our ability to expand access to care across the 
        State, particularly in Wisconsin's many rural communities. It 
        was also a critical springboard for the State's ability to 
        maintain and further expand access to care during the pandemic, 
        particularly for behavioral health care.

        I was also proud to secure bipartisan support for State funding 
        to allow the draw-down of additional Children's Health 
        Insurance Program dollars to support a Lead Safe Homes 
        Initiative. Wisconsin is one of just a handful of States to 
        take this innovative approach to address a critical public 
        health issue for children and families.

        As Secretary-designee, I launched the first-ever employee 
        engagement effort at DHS, including an annual employee 
        viewpoint survey to gauge the strengths of the organization and 
        identify areas for improvement in an effort to attract and 
        retain the best public servants at DHS.

        As we tackle the COVID-19 pandemic and help the American people 
        recover, the work of the U.S. Department of Health and Human 
        Services has never been more important than it is right now. I 
        believe my experiences and background qualify me for the role 
        of Deputy Secretary, and I am honored by President Biden's 
        nomination and ready for this responsibility. I would sincerely 
        look forward to the opportunity to work with the members of 
        this committee, should I be confirmed.

                   B. FUTURE EMPLOYMENT RELATIONSHIPS

 1.  Will you sever all connections (including participation in future 
benefit arrangements) with your present employers, business firms, 
associations, or organizations if you are confirmed by the Senate? If 
not, provide details.

        Yes.

 2.  Do you have any plans, commitments, or agreements to pursue 
outside employment, with or without compensation, during your service 
with the government? If so, provide details.

        No.

 3.  Has any person or entity made a commitment or agreement to employ 
your services in any capacity after you leave government service? If 
so, provide details.

        No.

 4.  If you are confirmed by the Senate, do you expect to serve out 
your full term or until the next presidential election, whichever is 
applicable? If not, explain.

        Yes.

                   C. POTENTIAL CONFLICTS OF INTEREST

 1.  Indicate any current and former investments, obligations, 
liabilities, or other personal relationships, including spousal or 
family employment, which could involve potential conflicts of interest 
in the position to which you have been nominated.

        Any potential conflict of interest will be resolved in 
        accordance with the terms of my ethics agreement, which was 
        developed in consultation with ethics officials at the 
        Department of Health and Human Services and the Office of 
        Government Ethics. I understand that my ethics agreement has 
        been provided to the committee. I am not aware of any potential 
        conflict other than those addressed by my ethics agreement.

 2.  Describe any business relationship, dealing, or financial 
transaction which you have had during the last 10 years (prior to the 
date of your nomination), whether for yourself, on behalf of a client, 
or acting as an agent, that could in any way constitute or result in a 
possible conflict of interest in the position to which you have been 
nominated.

        Any potential conflict of interest will be resolved in 
        accordance with the terms of my ethics agreement, which was 
        developed in consultation with ethics officials at the 
        Department of Health and Human Services and the Office of 
        Government Ethics. I understand that my ethics agreement has 
        been provided to the committee. I am not aware of any potential 
        conflict other than those addressed by my ethics agreement.

 3.  Describe any activity during the past 10 years (prior to the date 
of your nomination) in which you have engaged for the purpose of 
directly or indirectly influencing the passage, defeat, or modification 
of any legislation or affecting the administration and execution of law 
or public policy. Activities performed as an employee of the Federal 
Government need not be listed.

        In the last 2 years as Wisconsin Department of Health Services 
        Secretary-
        designee, I have been involved in a number of legislative and 
        public policy issues at the local and State level on behalf of 
        my Department and the Evers administration. Also in this role, 
        I have been involved in advocating at the Federal level on 
        health policies of concern to the State of Wisconsin. Prior to 
        that, I had no activity or was an employee of the Federal 
        government.

 4.  Explain how you will resolve any potential conflict of interest, 
including any that are disclosed by your responses to the above items.

        Any potential conflict of interest will be resolved in 
        accordance with the terms of my ethics agreement, which was 
        developed in consultation with ethics officials at the 
        Department of Health and Human Services and the Office of 
        Government Ethics. I understand that my ethics agreement has 
        been provided to the committee. I am not aware of any potential 
        conflict other than those addressed by my ethics agreement.

 5.  Two copies of written opinions should be provided directly to the 
committee by the designated agency ethics officer of the agency to 
which you have been nominated and by the Office of Government Ethics 
concerning potential conflicts of interest or any legal impediments to 
your serving in this position.

        I understand that my ethics agreement has been provided to the 
        committee.

                       D. LEGAL AND OTHER MATTERS

 1.  Have you ever been the subject of a complaint or been 
investigated, disciplined, or otherwise cited for a breach of ethics 
for unprofessional conduct before any court, administrative agency 
(e.g., an Inspector General's office), professional association, 
disciplinary committee, or other ethics enforcement entity at any time? 
Have you ever been interviewed regarding your own conduct as part of 
any such inquiry or investigation? If so, provide details, regardless 
of the outcome.

        No.

 2.  Have you ever been investigated, arrested, charged, or held by any 
Federal, State, or other law enforcement authority for a violation of 
any Federal, State, county, or municipal law, regulation, or ordinance, 
other than a minor traffic offense? Have you ever been interviewed 
regarding your own conduct as part of any such inquiry or 
investigation? If so, provide details.

        No.

 3.  Have you ever been involved as a party in interest in any 
administrative agency proceeding or civil litigation? If so, provide 
details.

        I have not been involved in any administrative proceedings or 
        civil litigation in my personal capacity. Supplemental 
        information: In my official capacity as former Wisconsin 
        Department of Health Services Secretary-designee, I was 
        sometimes named in litigation.

 4.  Have you ever been convicted (including pleas of guilty or nolo 
contendere) of any criminal violation other than a minor traffic 
offense? If so, provide details.

        No.

 5.  Please advise the committee of any additional information, 
favorable or unfavorable, which you feel should be considered in 
connection with your nomination.

        N/A.

                     E. TESTIFYING BEFORE CONGRESS

 1.  If you are confirmed by the Senate, are you willing to appear and 
testify before any duly constituted committee of the Congress on such 
occasions as you may be reasonably requested to do so?

        Yes.

 2.  If you are confirmed by the Senate, are you willing to provide 
such information as is requested by such committees?

        Yes.

                                 ______
                                 
         Questions Submitted for the Record to Andrea Joan Palm
                  Question Submitted by Hon. Ron Wyden
     racial and ethnic disparities within the child welfare system
    Question. The child welfare system is rife with racial, ethnic, and 
socioeconomic disparities. Black and American Indian children are over-
represented in the child welfare system, and there are clear 
disparities that children and families of color experience when 
interacting with the child welfare system. As you know, the Family 
First Prevention Services Act (FFPSA) is groundbreaking in its support 
and financing of evidence-based prevention services for children and 
parents to help them stay safely together and thrive.

    If confirmed, how will you ensure that FFPSA implementation lives 
up to its congressional intent?

    In particular, how will you ensure the prevention services 
allowable under FFPSA are as inclusive and expansive as possible to 
ensure that there are a range of services for States and tribes to 
utilize that are culturally sensitive and have demonstrated positive 
outcomes for underserved communities, including tribal nations, black, 
Latinx, LGBTQ+ communities, and older, aging-out foster youth?

    Answer. The Family First Prevention Services Act (FFPSA) is an 
important law that seeks to transform child welfare services by 
increasing support for evidence-based prevention services to strengthen 
families and keep children and youth safely at home and in their 
communities with their parents, other family members or kin whenever 
possible. If confirmed as Deputy Secretary, I will be committed to 
ensuring that the prevention services available are culturally 
appropriate and responsive to the needs of all people and communities, 
especially communities that have been traditionally underserved. As you 
know, the Biden administration and Secretary Becerra are committed to 
advancing racial equity and support for underserved communities, as 
reflected in the executive order the President signed on his first day 
in office, ``Advancing Racial Equity and Support for Underserved 
Communities Through the Federal Government.'' As Deputy Secretary, I 
will strive to advance this goal in all of our work.

                                 ______
                                 
               Questions Submitted by Hon. Sherrod Brown
                          provider relief fund
    Question. Throughout the past year, Congress has dedicated 
significant resources toward supporting hospitals and other health-care 
providers who have been negatively impacted by COVID-19. One of the 
largest sources of funding for provider relief has been through the 
Provider Relief Fund.

    If confirmed, will you commit to ensuring future distributions from 
the provider relief fund are equitable and transparent, and prioritize 
funding for those providers and facilities that continue to 
disproportionately struggle because of the pandemic?

    Answer. During the pandemic, while some providers have experienced 
challenges with overcapacity, many other providers have faced financial 
setbacks related to billing disruption, the suspension of non-essential 
surgeries and procedures, and health-care staff unable to work. HHS is 
committed to supporting providers who are taking care of patients 
during this pandemic and to making payments quickly while ensuring 
program integrity and effective oversight. If confirmed, I will work to 
ensure that the Provider Relief Fund is run transparently and 
equitably.
                        fda consumer protection
    Question. The Food and Drug Administration (FDA) is first and 
foremost a consumer protection agency; however, in the past there have 
been times when the FDA has served as little more than a rubber stamp 
for industry. It is time to rebuild consumer confidence in the FDA and 
give the FDA the tools, resources, and authorities it needs to help 
protect our health and safety.

    We have to be more aggressive on youth vaping and nicotine 
reduction. We must examine our drug supply chain and assess and correct 
vulnerabilities and gaps.

    If confirmed, how will you work with Secretary Becerra and the FDA 
Commissioner to ensure the consumer, the patient, remains at the center 
of all of the work HHS does--including the FDA?

    Answer. Patients and families should be at the heart of all of the 
work of HHS. It will be necessary for many agencies within HHS to work 
together in order to address this important issue. The work of FDA is 
critical for assuring consumer protections, including through tobacco 
regulation and ensuring the safety and security of our drug supply 
chain. If confirmed, I look forward to working on these issues.
                              biosimilars
    Question. Thank you for your commitment to lowering the high cost 
of prescription drugs. The robust uptake of biosimilars represents an 
opportunity to increase competition in the prescription drug 
marketplace and reduce costs for patients and taxpayers. I'd like to 
work with you on ways to maximize the uptake of biosimilars as they 
enter the market to ensure competition and reduce patient out-of-pocket 
cost.

    If confirmed, what additional steps should and will you take to 
build out a robust biosimilars market and ensure all patients who 
require treatment have immediate access to high quality, affordable 
biosimilar biologic medicines?

    Answer. Like President Biden and Secretary Becerra, I believe we 
must do all we can to lower the costs of prescription drugs and make 
them more accessible for Americans who depend on them. Competition in 
the market has helped control the growth in spending on prescription 
drugs. I believe that biosimilars have a role to play in containing the 
cost of expensive therapies by creating competition. I am committed to 
reducing drug prices and ensuring Americans have access to the drugs 
that they need. If confirmed, I look forward to working with you to 
find ways to achieve these important goals. I will also work across the 
government to address barriers to reducing drug prices.
                         antibiotic resistance
    Question. From the CDC to the World Health Organization, public 
health experts consider antibiotic resistance to be one of the top 
threats to global health security. The threat posed by superbugs 
demands swift action and a robust response.

    I urge you to commit to building on the National Action Plan for 
Combating
Antibiotic-Resistant Bacteria (CARB) and follow through on coordinated, 
strategic actions to address antibiotic resistance.

    What actions will you take, amidst and after this pandemic, to 
prioritize our Nation's fight against antibiotic resistance in addition 
to building out our antibiotic stewardship programs and curbing the 
overuse of antibiotics?

    Answer. It is clear that antimicrobial resistance (AMR) must be a 
top public health priority, not only for the United States but around 
the world. Even during this time, AMR remains a top HHS priority, and 
if confirmed, we will continue investing in key prevention strategies 
like early detection and containment, infection prevention, and 
ensuring the appropriate use of antibiotics in the U.S. and around the 
world. If confirmed, I will also support efforts to develop new 
antibiotics to treat infections that are becoming untreatable.

                                 ______
                                 
              Questions Submitted by Hon. Elizabeth Warren
                     over-the-counter hearing aids
    Question. In 2017, President Trump signed into law the Over-the-
Counter Hearing Aid Act, a bill that I introduced with Senator 
Grassley, Senator Hassan, and Senator Isakson. The bill requires the 
FDA to categorize certain hearing aids as over the counter (OTC). Under 
law, the FDA was required to issue regulations regarding OTC hearing 
aid safety and manufacturing by August 18, 2020--but the agency failed 
to issue the rules on time. As Deputy Secretary of Health and Human 
Services, will you commit to (1) identifying the reason(s) why the OTC 
hearing aid proposed rules have been delayed past their statutory 
deadline, (2) identifying the individual(s) responsible for developing 
and releasing the proposed rules, (3) requiring those individual(s) to 
release the proposed rules as soon as possible, and (4) requiring those 
individual(s) to communicate frequently with my office on the timeline 
for the rules' release?

    Answer. Thank you for your leadership on this issue. I commit that, 
if confirmed, I will support FDA in its rulemaking regarding over-the-
counter hearing aids and look forward to working closely with you on 
this issue. I recognize this is a public health priority as hearing 
loss can have a negative effect on communication, relationships, and 
other important aspects of life.
                  third-party medical device servicing
    Question. The Food and Drug Administration is responsible for 
ensuring the safety of medical devices. While some medical devices are 
disposable and are used only once, others are used repeatedly on 
multiple patients. Original equipment manufacturers and third-party 
entities often refurbish, repair, recondition, rebuild, remarket, or 
remanufacture these devices to ensure that they continue to operate 
safely and effectively after entering the market.

    Entities that perform maintenance activities are subject to 
different regulatory requirements depending on the type of maintenance 
being performed. Activities that ``significantly change'' the 
performance, safety specifications, or intended use of a device are 
considered ``remanufacturing'' activities, while activities that do not 
change the device are considered ``servicing.'' FDA has committed to 
issuing guidance clarifying the difference between ``remanufacturing'' 
and ``servicing.'' In a 2020 letter to me and Senator Cassidy, FDA 
stated that it ``intends to clarify the definitions of these activities 
so that entities can determine in which activities they are engaged, 
and with which regulatory requirements they should comply.'' The agency 
said it would issue the guidance during FY2020, but it has not yet done 
so. As Deputy Secretary of Health and Human Services, will you commit 
to (1) identifying the reason(s) why this guidance has been delayed, 
(2) identifying the individual(s) responsible for developing and 
releasing that guidance, and (3) requiring those individual(s) to 
communicate frequently with my office on the timeline for the 
guidance's release?

    Answer. Ensuring the appropriate consumer protections to keep 
patients and families safe is a top priority for the Biden-Harris 
administration. If confirmed, I commit to supporting FDA in their work 
issuing guidance related to third party medical device servicing. I 
recognize that this is a complicated issue and regulatory clarity is 
very important.

                                 ______
                                 
                 Questions Submitted by Hon. Mike Crapo
                       private insurance markets
    Question. How do you view HHS's role in the individual market, and 
what reforms would you propose that could affect the types of plans 
offered to consumers?

    Answer. The Affordable Care Act expanded critical consumer 
protections to millions of consumers enrolled in individual market 
plans across the country. HHS works together with States to make sure 
that consumers receive these important benefits. If confirmed, it will 
be a priority of mine to build on the successes of the ACA and to work 
with the Centers for Medicare and Medicaid Services to make sure 
American patients and their families continue to have access to 
quality, affordable health care.
                            medicaid waivers
    Question. What is your view of the appropriate role of incentives 
and disincentives in the Federal Government's partnership with State 
agencies?

    Answer. The partnership between States and the Federal Government 
is central to Medicaid. I know each State--including Idaho--is unique, 
and innovation is critical to improving the health-care system. If 
confirmed, I will support State innovation and the ability of States to 
test different models that meet the objectives of the Medicaid program. 
I look forward to working with colleagues at the Centers for Medicare 
and Medicaid Services on this issue and to hearing morefrom you about 
what ideas are working in Idaho.
                           medicare solvency
    Question. Medicare is on a near-term path toward bankruptcy. The HI 
trust fund could be insolvent in anywhere from 4 to 5 years. Other than 
during the first few years of the Medicare program's existence, 
Congress has never allowed the HI trust fund to project less than 4 
years of solvency without acting in order to minimize the impact on 
health-care providers, taxpayers, and beneficiaries. Given the looming 
fiscal crisis, how soon can we expect a comprehensive legislative 
proposal from HHS that extends the life of the HI trust fund?

    Answer. Medicare solvency is an incredibly important, longstanding 
issue. I look forward to working with Congress, and in concert with the 
Centers for Medicare and Medicaid Services, on a bipartisan basis to 
address this. We will need both short-term and long-term strategies to 
make sure Medicare remains a bedrock of our health-care system. It is 
essential that we protect and strengthen this program for Americans who 
have spent their lives paying into it.

               Questions Submitted by Hon. Chuck Grassley
    Question. The Family First Prevention Services Act allows States to 
receive Federal reimbursement for prevention services in order to keep 
children with their families whenever possible. In order to qualify for 
IV-E reimbursement, programs are required to be evidence-based. 
Currently, there are 29 programs that have been rated as promising, 
supported, or well-supported, and many programs are still awaiting 
evaluation on the Administration for Children and Families' (ACF) 
Clearinghouse. The COVID-19 pandemic has caused prevention service 
providers to alter their service models to comply with social 
distancing and other precautions. Additionally, some programs have 
faced decreased capacity or enrollment, leading to challenges in 
maintaining population sizes necessary for an evaluation. If confirmed, 
how will you work to ensure that ACF continues to add programs to the 
clearinghouse while maintaining the standards for evidence-based 
practices required by the Family First Prevention Services Act?

    Answer. The Family First Prevention Services Act (FFPSA) is a law 
that offers the promise to transform child welfare services by 
increasing the availability of 
evidence-based prevention services to strengthen families and keep 
children and youth safely at home and in their communities with their 
parents, or kin whenever possible. If confirmed as Deputy Secretary, I 
will work with the leadership of ACF to ensure that the Title IV-E 
Prevention Services Clearinghouse has adequate resources to be able to 
review and rate programs in a timely manner. I will also support the 
continued development of evidence-based practices through support of 
quality evaluation.

    Question. Many States, including my home State of Iowa, have faced 
a shortage of qualified foster parents in recent years. The COVID-19 
pandemic has exacerbated these shortages in many areas. In addition to 
getting new foster parents involved, there is a challenge in retaining 
foster parents for longer than 1 year. If confirmed, how would you work 
to improve foster parent recruitment and retention so that children are 
not placed in inappropriate settings due to a lack of available foster 
homes?

    Answer. I understand the important role that foster parents play in 
caring for children. As reflected in the policy goals of the Family 
First Prevention Services Act, when children must enter foster care, 
family foster homes--preferably kinship care--must be the preferred 
placement setting and institutional placements used only under limited 
circumstances. Whenever possible, child welfare systems must seek 
relatives and kin to care for children, to reduce the trauma children 
experience when they are separated from their parents. The COVID-19 
pandemic has placed great strain on all parents, including foster 
parents and kinship caregivers, and has had an impact on the ability to 
train and engage prospective foster parents and support existing foster 
parents. I think it is essential that child welfare agencies provide 
adequate support to foster parents, including relative caregivers and 
that they be proactive in recruiting diverse families to meet the needs 
of children who must come into foster care. If confirmed, I will work 
with leaders of the Administration for Children and Families to provide 
support for foster parent recruitment and retention.

    Question. The Adoption and Safe Families Act of 1997 required 
States to ensure that children in foster care did not languish in the 
system without permanency. It established that parental rights should 
be terminated if children have been in foster care for 15 out of the 
last 22 months. The law allows for exceptions if it is determined that 
there is a compelling reason that termination of parental rights is not 
in a child's best interest, or other limited reasons. States are not 
required to collect data on the enforcement of this law, and often do 
not provide a reason for granting an exception. If confirmed, will you 
work to improve oversight of this law to ensure that States are acting 
in the best interest of children?

    Answer. When children must enter into care, it is essential that we 
seek to ensure timely permanency. Whenever possible we should seek to 
support safe and timely reunification of children with their parents or 
extended family, but this is not always possible. As you note, the 
Adoption and Safe Families Act of 1997 established time frames for the 
filing of petitions to terminate parental rights, but allowed for 
certain exceptions. If confirmed, I will work with the Administration 
for Children and Families to review oversight of this provision and 
explore any additional steps that may be needed to promote the best 
interests of children.

    Question. In 2017, I sponsored the Over-the-Counter Hearing Aid Act 
with Senator Warren, which was included in the FDA Reauthorization Act 
of 2017. It required the Food and Drug Administration (FDA) to issue a 
regulation by August 2020 establishing the requirements for products in 
this category. This legislation was based on recommendations put forth 
by the Presidential Council of Advisors on Science and Technology and 
the National Academies of Science Engineering and Medicine to increase 
consumer access to hearing aid technology and decrease costs associated 
with hearing aids. The FDA has not completed rulemaking on this. If 
confirmed, will you work to prioritize rulemaking so consumers can 
access affordable help for hearing loss that Congress intended?

    Answer. Thank you for your leadership on this issue. I commit that, 
if confirmed, I will support FDA in its rulemaking and work to ensure 
availability of over-the-counter hearing aids. I recognize this is a 
public health priority as hearing loss can have a negative effect on 
communication, relationships, and other important aspects of life.

    Question. I support transparency in the 340B Drug Pricing Program. 
The previous administration finalized a 340B Drug Pricing Program 
Administrative Dispute Resolution regulation that went into effect in 
January 2021. This final rule sets forth the requirements and 
procedures for the 340B Program's administrative dispute resolution 
(ADR) process. The rule establishes a 340B Administrative Dispute 
Resolution Board to review claims. In addition, on December 30, 2020, 
the Department of Health and Human Services' Office of the General 
Counsel released an advisory opinion. If confirmed, are you committed 
to the continued implementation of the 340B Drug Pricing Program 
Administrative Dispute Resolution final rule and Office of General 
Counsel's advisory opinion? If confirmed, what detailed steps will the 
Biden administration take to ensure transparency in the 340B Drug 
Pricing Program?

    Answer. The 340B Drug Pricing Program is an indispensable program 
for our safety-net providers serving some of our neediest populations. 
If confirmed, I look forward to working with you and other members of 
Congress to uphold the law and ensure this vital program is able to 
continue supporting vulnerable communities.

    Question. During the last 2 years as chairman of the Senate Finance 
Committee, I've focused some of my oversight on what steps the 
Department of Health and Human Services has taken to detect and deter 
foreign threats to taxpayer-funded research. As part of my oversight, 
I've also worked to ensure that the Department's Office of National 
Security is given full, complete, and consistent access to all 
Intelligence Community information involving threats to the Nation's 
health care, such as COVID-19. That office has gained access to some 
Intelligence Community elements but more must be done. On March 8, 
2021, I wrote a follow-up letter to the Department of Health and Human 
Services and the Director of National Intelligence asking what they've 
done to incorporate Federal health agencies into the Intelligence 
Community. HHS has failed to respond. If confirmed, will you commit to 
answering that letter in full? If confirmed, will you commit to 
updating me on the functions of the Office of National Security and how 
it's interacting within the Intelligence Community?

    Answer. HHS is committed to working with Congress on its critical 
oversight work. As I noted in my hearing, if confirmed, I look forward 
to working with you on this issue.

    Question. In 2020, I cosponsored the Temporary Reauthorization and 
Study of the Emergency Scheduling of Fentanyl Analogues Act and it was 
signed into law. The law extended the Drug Enforcement Administration's 
temporary scheduling order to proactively control deadly fentanyl 
analogues. Fentanyl-related overdose deaths continue to rise and 
sophisticated drug trafficking organizations manipulate dangerous 
substances to skirt the law, so this critical law placed fentanyl 
substances in Schedule I so that they can be better detected and 
criminals can be held accountable for their actions. The law sunsets in 
May of 2021. In December 2019, 56 other State and territory Attorneys 
General asked Congress to permanently codify a temporary emergency 
scheduling order keeping fentanyl-related substances classified as 
Schedule I drugs. If confirmed, do you support permanently codifying a 
temporary emergency scheduling order keeping fentanyl-related 
substances classified as Schedule I drugs?

    Answer. If confirmed, I will work with you on legislation to ensure 
the appropriate scheduling of fentanyl and fentanyl analogues that pose 
a danger.

    Question. Science tells us that an unborn child has many of the 
neural connections needed to feel pain, perhaps as early as eight weeks 
and most certainly by 20 weeks fetal age. Providing health care to 
unborn children and their mothers can help reduce infant mortality 
rates in low-income communities, research also suggests. Some States 
already offer prenatal care and other health services to unborn 
children through the Medicaid program. What is your view on whether 
unborn children should be entitled to Medicaid coverage, and do you 
believe that the Federal Government has a role to play in encouraging 
such coverage?

    Answer. Medicaid is an important source of pre- and post-natal 
care, and if I am confirmed, I will work to ensure access to quality 
pregnancy care that improves their own health and the health of their 
babies. I was happy to see that Congress included incentives for States 
to expand Medicaid postpartum coverage in the American Rescue Plan and 
that CMS has approved section 1115 demonstration projects to this 
effect. I look forward to working with members of this committee and 
Congress to expand access to affordable, quality care, including 
through the Medicaid program.

    Question. Congress's ability to acquire information from Federal 
agencies is critical to its constitutional responsibility of conducting 
oversight of the executive branch. If you are confirmed, will you 
commit to providing thorough, complete, and timely responses to 
requests for information from members of this committee, including 
requests from members of the Minority?

    Answer. If confirmed, I will provide responses to requests from any 
members of this committee.

    Question. In 2019, Congress passed bipartisan the Advancing Care 
for Exceptional (ACE) Kids Act to improve health outcomes and care 
coordination for children with complex medical conditions in Medicaid. 
In 2020, I introduced the bipartisan Accelerating Kids' Access to Care 
Act to further help families gain access to life-saving care for 
children with complex medical conditions. The legislation aims to 
facilitate access to care while retaining program safeguards and 
reducing regulatory burdens on providers. If confirmed, what steps 
would you take to improve the system of care for children with complex 
medical conditions?

    Answer. Thank you for your leadership on the ACE Kids Act and your 
focus on access to care for children with complex medical needs. I 
agree that we should do all we can to remove barriers to care for these 
children. If I am fortunate enough to be confirmed, I will look forward 
to working with you on solutions to ensure children with complex 
medical needs get the best care possible.

    Question. In Iowa, transitional health plans (including 
grandmothered health plans) have enabled many middle-class Iowans to 
keep the health plans and doctors they like at a reasonable price since 
the Affordable Care Act was implemented. For example, over 56,000 
Iowans are covered by grandmothered health plans. To put this in 
context, about 60,000 Iowans signed up for the Federal health insurance 
exchange in 2021. Iowans have chosen these grandmothered health plans 
that meet their individual needs. Currently, grandmothered health 
plans' existence is determined by the Department of Health and Human 
Services (HHS) through the Centers for Medicare and Medicaid Services 
(CMS) annually through non-enforcement extensions. If confirmed, are 
you committed to maintaining these affordable, consumer-chosen health 
plan options for Iowans by extending the non-enforcement authority?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. If confirmed, I will examine rules and other policies to 
ensure all Americans can access the care that they need.

    Question. Since this COVID-19 pandemic began, the Department of 
Health and Human Services (HHS) including within the Centers for 
Medicare and Medicaid Services (CMS) has provided health-care providers 
and patients many flexibilities under the public health emergency 
authority including over 80 services now furnished through telehealth 
for Medicare patients. A Centers for Disease Control and Prevention 
(CDC) Morbidity and Mortality Weekly Report found the use of telehealth 
increased 154 percent during the last week of March 2020 during the 
emergency of COVID-19 compared to the same period in 2019. We know the 
use of telehealth has continued throughout the COVID-19 pandemic. The 
data and response from patients and providers prove permitting 
telehealth services is a positive action to improve access and care. 
This last Congress, we provided permanent coverage for mental health 
telehealth visits under Medicare, which is helpful during the pandemic 
and will remain critical for many Americans afterwards. If confirmed, 
are you committed to working with Congress and in the executive branch 
to extend telehealth flexibilities in Medicare beyond the pandemic? 
Additionally, some providers, including community health centers, face 
regulatory barriers based on provider type or site of service. If 
confirmed, do you support removing those telehealth barriers for 
certain providers?

    Answer. Telehealth is an important tool to improve health equity 
and access to health care. Health care should be accessible, no matter 
where you live. If confirmed, I would look forward to working with you 
and my colleagues at the Centers for Medicare and Medicaid Services on 
this issue.

    Question. As a direct result of the Affordable Care Act's one-size-
fits-all approach, many Iowans have been priced out of health 
insurance. To rectify this, the Trump administration and Iowa Insurance 
Division enabled Iowans more choice and competition in the health-care 
marketplace by enabling and expanding short-term 
limited-duration insurance (STLDI). This gives Iowans access to health 
insurance with consumer protections. If confirmed, will you work to 
maintain, modify, or rescind the current regulations enabling Americans 
to purchase STLDIs?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. If confirmed, I will examine rules and other policies to 
ensure that plans provide Americans access to the care that they need.

    Question. It is important to give people affordable options for 
health insurance. Small business owners, like Iowa farmers, want to be 
able to provide insurance for their employees. Association Health Plans 
are a way for these small businesses to band together to expand access 
to health insurance and drive down costs. I have introduced legislation 
and support efforts to expand the pathway to affordable and accessible 
health care remaining open to employees across America. Association 
Health Plans allow small businesses to join together to obtain 
affordable health insurance as though they were a single large 
employer. The coverage offered to association members is subject to the 
consumer protection requirements that apply to the nearly 160 million 
Americans who receive coverage from large employers. If confirmed, will 
you work to maintain, modify, or rescind current regulations enabling 
employers and employees access to Association Health Plans?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. If confirmed, I will examine all rules and policies to 
ensure all Americans can access the care that they need.

    Question. I support access to affordable health-care coverage for 
all Iowans, regardless of their health status or pre-existing 
conditions. Americans want to be in control of their own health care. 
National, single-payer health systems do not allow that. The Affordable 
Care Act took options away from people and adopting a single-payer 
system will make that worse. A national, single-payer health system 
would eliminate private health insurance for nearly 200 million 
Americans and require middle-class Americans to pay much more in taxes. 
Single-payer health care would also dramatically increase government 
spending substantially, fail to meet patient needs quickly, reduce 
provider payments rates and reduce quality of care, and the government 
would have more control over health care. It also threatens the 
benefits that current seniors on Medicare have paid into the system 
their entire working lives. If confirmed, do you intend to take 
administrative actions to implement the vision of a one-size-fits-all 
government-run health-care scheme like single-payer? If so, please 
describe what authority you believe you have to take such actions?

    Answer. President Biden has made it very clear that his goals for 
improving the American health-care system begin with building on the 
successes of the Affordable Care Act, and I am committed to working 
toward that goal.

    Question. If confirmed, will you take actions that stifle 
innovation and competition in health care?

    Answer. I believe it is important to foster innovation and 
competition in our health-care system. Americans should have access to 
health-care services and products at an affordable price.

    Question. In 2019, the Trump administration issued two rules 
requiring price transparency for hospitals and health plans. The rules 
took effect in January 2021. This effort shines a light on the health-
care industry that is all too often shrouded in secrecy. While Congress 
can build upon the rules, consumers can finally see sunshine in health-
care pricing. I have cosponsored legislation to codify the two health-
care price transparency rules. This transparency will bring more 
accountability and competition to the health-care industry. Consumers 
should have the ability to compare health-care prices online so they 
can make an informed choice about what's best for them and their 
families. If confirmed will you modify, rescind, or maintain the Trump 
administration's health-care price transparency regulations?

    Answer. If I am fortunate enough to be confirmed, I will ensure 
that the Department continues to take steps to improve price 
transparency, so consumers can look behind the curtain to understand 
how providers and insurers are operating.

    Question. Some States have lacked transparency in reporting their 
nursing home COVID-19 deaths data. For example, the State of New York 
undercounted nursing home deaths by as much as 50 percent and State 
officials intentionally withheld data for months. The New York Attorney 
General Letitia James released a report in January 2021 suggesting that 
many nursing home residents died from COVID-19 in hospitals after being 
transferred from their nursing homes. These figures were not reflected 
in the New York Department of Health's nursing home death figures for 
many months suggesting the State was undercounting by as much as 50 
percent. There are also reports finding New York State officials 
including members of New York Governor Andrew Cuomo's staff 
intentionally withheld data on COVID-19-related deaths in the State's 
nursing homes. Following the release of the New York Attorney General 
report, the New York Department of Health reported 12,743 nursing home 
residents occurred. This included an additional 3,829 confirmed COVID-
19 fatalities of those residents who had been transported to hospitals. 
I have warned President Biden that an across-the-board termination of 
56 U.S. attorneys could imperil ongoing sensitive investigations. This 
concern has been expressed by Senate Democrats. Currently, Toni Bacon 
is serving as the U.S. attorney for the Northern District of New York. 
Ms. Bacon previously served as Justice Department's national elder 
justice coordinator and who currently has jurisdiction over Federal 
public corruption crimes in the State. Bacon is the obvious choice to 
continue a fair and unbiased investigation into possible violations of 
civil liberties of the elderly and the public corruption. Do you 
believe Department of Justice must have a fair, unbiased, and 
experienced U.S. Attorney in the Northern District of New York, such as 
Ms. Bacon?

    Answer. I defer to the Department of Justice on the selection of 
U.S. attorneys.

    Question. I led an effort in the Senate making additional resources 
available to support elder justice initiatives that assist older 
Americans especially throughout the COVID-19 pandemic. During the 116th 
Congress, as Senate Finance Committee chairman, I convened two hearings 
on elder justice initiatives and gaps in nursing home oversight. In 
December 2020, I urged Senate leadership to make resources available 
for regional or statewide strike teams to support nursing homes in 
crisis during this pandemic. Through this work, the end-of-year COVID-
19 relief package included $100 million to support elder justice 
initiatives, including $50 million for State adult protective service 
agencies as they cope with unique challenges of serving vulnerable 
populations during the pandemic. This work includes nursing home strike 
teams who have provided needed support when an outbreak occurs at a 
nursing home or when additional resources are needed to meet the 
infection control or diagnostic testing requirements. Have State or 
Federal nursing home strike teams been effective at controlling 
outbreaks and protecting vulnerable Americans? If so, can you describe 
how their work slowed the spread and protected lives?

    Answer. It has been heartbreaking to see how hard the COVID-19 
pandemic has hit the Nation's nursing homes. Nursing homes and long-
term care facilities are the homes for some of our most vulnerable, and 
we must do everything we can to work to protect them and ensure that 
they are receiving high quality health care. In Wisconsin, we developed 
a variety of strategies, including surging staff and other resources to 
assist our skilled nursing facilities protect their residents from 
COVID-19. If I have the honor of being confirmed, I look forward to 
working on this issue and coordinating with the Centers for Medicare 
and Medicaid Services.

    Question. The global pandemic has exposed grave concerns our 
society must confront to protect the Nation's most vulnerable citizens. 
Approximately 1.4 million Americans live in about 15,000 nursing homes 
across the country. Many Iowans have a loved one who lives in a long-
term care facility. In 2019, as chairman of the Senate Finance 
Committee, I conducted a series of hearings to examine gaps in 
enforcement of nursing home abuse. A Government Accountability Office 
(GAO) investigation found a 103-percent increase in abuse deficiencies 
between 2013 and 2017. The GAO noted abuse in nursing homes is often 
underreported. The report documented physical, mental, verbal, and 
sexual abuse perpetrated against residents. The number of nursing home 
deaths attributed to COVID-19 delivers a wake-up call we can't afford 
to ignore. The Federal Government needs to do a better job enforcing 
compliance with standards of care. When a loved one requires a long-
term care facility to deliver around-the-clock services, every family 
deserves peace of mind that every nursing home resident will receive 
high-quality, compassionate care and be treated with dignity and 
respect. If confirmed, how will you, as Deputy Secretary, ensure 
nursing homes uphold the standard of care that is necessary while not 
placing onerous requirements and excessive administrative burdens on 
nursing home staff?

    Answer. Thank you for your longstanding leadership on this issue. 
Nursing homes and long-term care facilities are the homes for some of 
our most vulnerable, and we must do everything we can to work to 
protect them. If I have the honor of being confirmed, I look forward to 
coordinating with colleagues at the Centers for Medicare and Medicaid 
Services to improve the safety and quality of care for residents of 
nursing homes.

                                 ______
                                 
                Questions Submitted by Hon. John Cornyn
                      foreign threats to research
    Question. Ms. Palm, in 2019, this committee held a hearing on 
foreign threats to taxpayer-funded research after multiple reports of 
espionage by the People's Republic of China. We have seen attempts by 
foreign entities like North Korea to steal intellectual property 
related to COVID vaccine development and I continue to hear concerns 
from research institutions in Texas.

    Do you believe that NIH and other funders of public research should 
consider cybersecurity protocols that institutions have in place when 
evaluating applications for research grant funds?

    What additional initiatives are you considering to ensure taxpayer 
funded research is protected from foreign threats?

    Answer. Protecting the integrity of taxpayer funded biomedical 
research is a matter of great importance. I am committed to working 
with Congress, the NIH, and the HHS Office of National Security to 
ensure appropriate safeguards are in place to enhance and protect the 
security and the integrity of U.S. biomedical research.
                              supply chain
    Question. Regarding further distribution of personal protective 
equipment (PPE) and COVID-19 vaccines and ancillary products, how will 
government coordination with the private sector be managed? How will 
updates and information be communicated to the healthcare supply chain 
in a timely manner?

    Answer. The global pandemic has highlighted the vulnerabilities of 
the health-care supply chain for many products. In order to continue 
responding to the COVID-19 pandemic and better prepare the Federal 
Government to respond to any future public health emergencies, it is 
critical that HHS work to improve and expand health-care supply chain 
capabilities. If confirmed, I'm committed to working in coordination 
with the private sector on this urgent matter.

    Question. How does the new administration plan to coordinate with 
and leverage the expertise of the commercial healthcare supply chain to 
get product the last mile and get supplies into providers' hands across 
the care continuum?

    Answer. Coordination across departments, agencies, and industries 
is key to ensure the adequacy of the health-care supply chain. If 
confirmed, I'm committed to working on this urgent matter.

    Question. Once the COVID-19 pandemic is under control, how do you 
anticipate partnering with the commercial supply chain to ensure that 
the country is ready for the next public health emergency? Have you 
considered solutions such as a ``vendor managed inventory'' solution to 
help guarantee that non-expired product could be available on demand?

    Answer. As the Nation continues to turn the corner on the COVID-19 
pandemic, it is important to think ahead to the next public health 
emergency. If confirmed, I will work with the Assistant Secretary of 
Preparedness and Response (ASPR) to ensure these efforts can increase 
the Nation's ability to meet demand in future crises.

    Question. How does the Biden administration intend to use the DPA 
authority and will the administration do so with thoughtful 
consideration of those with expertise in the medical supply chain so 
the existing infrastructure and supply are augmented rather than 
duplicated?

    Answer. If confirmed, I commit to working closely with members of 
this committee on efforts related to the COVID-19 response, including 
the use of Defense Production Act and its potential impacts.
                                hospice
    Question. Within the Medicare program, State survey agencies (SAs) 
are overburdened and often lack the capacity to respond to survey 
complaints in a timely and appropriate manner. The ability to respond 
to and correct issues arising from complaints is imperative, 
particularly for terminally ill beneficiaries in hospice. Accreditation 
Organizations (AOs) are also authorized to conduct complaint surveys. 
Expanding the use of qualified AOs that are trained in hospice would 
alleviate State regulatory burden, while continuing to ensure that all 
complaints are addressed in timely coordination with the SAs and CMS. 
The expanded use of AOs would lead to increased transparency and 
emphasize savings in the hospice community.

    How does the administration plan to emphasize the services of 
Accreditation Organizations for hospice complaint surveys to relieve 
State regulatory burden and improve timely beneficiary safety and 
quality?

    Answer. Improving the safety and quality of care for American 
patients is critical, including in hospice settings. If confirmed I 
will work with my colleagues in the Centers for Medicare and Medicaid 
Services to make sure complaints are followed up on in a timely manner.

    Question. The Hospice Act brought attention to the need for 
Medicare surveyors, who are often State surveyors, to specifically be 
trained for the hospice population. Similar gaps in knowledge and 
judgement occur among the medical reviewers for OIG, MAC and Program 
Integrity hospice audits often driven by a similar hospice knowledge 
gap and compounded by a chart review that can never replicate the 
hospice program physician's real time medical prognostication of the 
patients at the end of life. When payment denials are appealed by the 
hospice provider, most are overturned on appeal, an expensive and time-
consuming process for both hospices and HHS.

    I understand the need for program integrity, but we cannot place so 
much of a burden that it creates an issue for providers that could turn 
into an access issue for these vulnerable beneficiaries. How will HHS 
address the gap in knowledge of Medicare medical reviewers, who 
frequently look past the certifying physician's medical judgment as 
reflected on the Certification of Terminal Illness (CTI); perhaps 
especially when the physician record entries as to the basis for 
prognostication are not as detailed as the Medicare reviewer believes 
was warranted.

    Answer. Thank you for bringing up this issue. If confirmed, I 
certainly want to look for any ways to be more efficient and improve 
processes, and I will work with my colleagues at the Centers for 
Medicare and Medicaid Services to find ways to improve the Medicare 
program.
                           children's health
    Question. As HHS Secretary, you will oversee a number of programs 
and agencies important to children from health coverage programs vital 
to children's health such as Medicaid and the Children's Health 
Insurance Program (CHIP) to programs responsible for training the 
pediatric health-care workforce like the Children's Hospital Graduate 
Medical Education Program (CHGME) to pediatric research initiatives at 
the National Institutes of Health.

    What are your priorities for child health if confirmed?

    Answer. Programs such as Medicaid and the Children's Health 
Insurance Program (CHIP) are critical programs that help ensure that 
children have adequate access to quality health care. If confirmed, I 
would work to ensure children are receiving necessary health care 
through both programs. I would also look to better ensure access to 
oral health and vision care for children, as both are necessary for 
children to thrive in school. And we cannot forget that improving child 
health begins with ensuring maternal health. I will work tirelessly to 
reduce maternal and infant mortality and morbidity, using the expertise 
and resources across HHS.

    Further, many other agencies of HHS work improve the lives of 
children in matters beyond that of health-care coverage. For example, 
the Children's Bureau partners with Federal, State, tribal, and local 
agencies to improve the overall health and well-being of our Nation's 
children and families. I look forward to working with Congress, and 
with State and local partners to make sure that we are doing all we can 
to improve child health in this country.

    Question. Medicaid and CHIP are critical programs for children, 
providing coverage for over 40 million children. Medicaid is also the 
backbone of the pediatric health-care system providing care across the 
continuum from screenings and preventive to highly specialized 
diagnoses and treatments.

    What are your plans to strengthen this safety net for children and 
the providers who care for them?

    Answer. If confirmed, I would work to support and strengthen 
Medicaid and CHIP, as well as other programs for children, to ensure 
that children have adequate access to quality health care. In 
particular, I would look to better ensure access to oral health and 
vision care for children, while working to reduce maternal and infant 
mortality and morbidity, as well as programs that ensure the safety of 
well-being for children and families. If confirmed, I lookforward to 
working with you to make sure our children have access to quality care 
and are able to thrive.

    Question. The pandemic is having a profound impact on children's 
health and the providers who care for them.

    What are your immediate plans to address the current crisis in the 
increasing number of children facing severe mental, emotional and 
behavioral health challenges due to social isolation and the serious 
impact of the pandemic on the health of their families and caregivers?

    Answer. I am deeply concerned about the impact of the COVID-19 
pandemic on the mental, emotional, and other behavioral health outcomes 
of our children, their families and caregivers. I agree this must be an 
urgent national priority. If confirmed, I commit to working on this 
issue and I would seek to ensure collaboration across HHS agencies, 
including CMS and SAMHSA, to ensure we are fully leveraging CHIP and 
Medicaid, and that we do a better job of tackling this important issue.

    Question. The pediatric health-care safety net has been affected by 
the pandemic in different ways then the adult health-care system, with 
less direct Federal financial support because they are not eligible for 
Medicare funding streams. What are your plans to sustain a stable 
pediatric health-care system now and beyond the pandemic?

    Answer. Medicaid and CHIP are lifelines to children and help form 
the fabric of the pediatric health-care safety net. Over 77 million 
individuals are enrolled in those programs, and about half are 
children. It is critical that we work to support our pediatric health-
care safety net and pediatric health-care providers during the COVID-19 
pandemic and beyond. If confirmed, I would make it a priority to work 
across HHS and with States to provide necessary support to pediatric 
providers.

    Question. The Children's Hospital Graduate Medical Education 
Program (CHGME) provides significant support for the training of 
pediatricians and pediatric specialists. But unfortunately, the funding 
for this program still lags far behind the Medicare GME program--
funding only half of what Medicare GME provides per resident.

    What are your plans to address this gap in training support for our 
Nation's pediatric workforce?

    Answer. If confirmed, I would work with the resources across the 
Department and with States to support the health-care workforce, 
including those who work with pediatric populations.

    Question. During the pandemic, telehealth has played a major role 
in providing access to care for Medicaid beneficiaries, including 
children.

    How will HHS support the continued use and enhancements needed 
under Medicaid to ensure telehealth continues to enable access to care 
for children?

    Answer. Telehealth is an important tool to improve health equity 
and improve access to health care. Health care should be accessible, no 
matter where you live. Under current law, States have a great deal of 
flexibility with respect to delivering Medicaid services via 
telehealth. Medicaid has made great strides in expanding services 
available through telehealth, including pediatric services, during the 
public health emergency. If confirmed, I will work with CMS to 
determine how we can build on this work to improve health equity and 
improve access to health care for children.

    Question. As you know, pediatric health care is organized 
differently than adult health care. Pediatric care is more regionalized 
and often results in children, especially those with complex health 
needs, having to travel across State lines for care. Under Medicaid, 
this can be challenging for them and their providers with different 
policies State to State. The ACE Kids Act passed in 2019 and is 
effective next year, is one step in addressing these inconsistencies 
and getting much needed national data to inform care improvements.

    If confirmed, how would you approach these cross-State challenges 
that children with complex needs face when traveling for needed care?

    Answer. Medicaid and CHIP are crucial to ensuring children have 
adequate access to quality health care, especially those with complex 
needs. If confirmed, I will work closely with CMS as well as across the 
Department to ensure children are receiving necessary health care. I 
look forward to working across the administration and with Congress to 
make informed decisions that address the specific needs of children 
with complex medical conditions.

    Question. Oftentimes, changes in the larger health-care landscape 
take place, for example in the Medicare program, without a full 
examination of how these changes could potentially impact children, 
even inadvertently. At times, Medicare policies designed with the 
elderly population in mind have been applied to Medicaid or adopted by 
State Medicaid programs and private payers.

    As you look at health-care changes at the national level as HHS 
Secretary, how will you ensure that children's unique health-care needs 
are taken into account?

    Answer. If confirmed, I will work with Congress and States to spur 
and encourage innovation in these important programs. Innovative 
delivery system and payment models are vital to ensuring that Medicaid 
and CHIP are equipped to address emerging pediatric health issues and 
can continue to provide children with access to quality health care.

    Question. A major focus in health care among policy makers has been 
on pursuing delivery system reforms that improve quality and reduce 
costs. The Federal Government has traditionally focused more on adult 
populations rather than the needs of children in these reforms. As a 
result, Medicaid for children still lags behind Medicare in supporting 
improvements in care and innovative payment models.

    What steps will you take to promote increased emphasis on these 
types of innovations in Medicaid targeting the unique needs of 
children?

    Answer. If confirmed, I will work with Congress and States to spur 
and encourage innovation in these important programs. Innovative 
delivery system and payment models are vital to ensuring that Medicaid 
and CHIP are equipped to address emerging pediatric health issues and 
can continue to provide children with access to quality health care.

                                 ______
                                 
                Questions Submitted by Hon. Richard Burr
                       countermeasure development
    Question. Platform technologies or innovative delivery platforms, 
such as a vaccine or therapeutic administered through a patch, that can 
deliver medicine to patients in certain circumstances, provide 
promising alternatives to traditional medical treatments. These 
platform technologies could provide a way to deliver vaccinations to 
patients. An innovation that provides a vaccine dose through a patch 
platform could replace or provide an alternative to vaccines injected 
via needles. A patch delivery platform does not need to be frozen, may 
require less ancillary medical supplies, and could be self-administered 
at home. If these characteristics were in place for a countermeasure, 
public health and health-care organizations could distribute vaccine or 
therapeutic doses more widely, improving access to underserved or hard 
to reach communities.

    How will this administration support the development of alternative 
delivery platforms for vaccines and other countermeasures, such as 
shelf-stable, self-applied patches during COVID-19?

    How will this administration support expanding the use of 
alternative vaccine delivery platforms for future pandemic needs?

    Answer. I agree that we must do all we can to improve vaccine 
technology and make vaccines easier to deliver. If confirmed, I will 
work with NIH and FDA, as well as our international partners, to ensure 
we take any steps needed to help facilitate the development, review, 
and approval of new vaccine technologies.
                           synthetic biology
    Question. President Biden, in his remarks on the American Jobs 
Plan, stated ``China . . . is racing ahead of us in the investments 
they have in the future.'' Synthetic biology is an emerging field 
which, with the appropriate regulatory oversight and investment, has 
the potential to provide high-paying U.S. jobs and supply chain 
security. How will HHS encourage the development of synthetic biology 
and appropriately evaluate the evolving science to ensure a regulatory 
approach that does not hamper innovation?

    Answer. Synthetic biology is an important, growing field and, if 
confirmed, I look forward working across HHS to support U.S. leadership 
in this space.

                                 ______
                                 
             Questions Submitted by Hon. Patrick J. Toomey
    Question. Over 2 months ago, my staff requested certain documents 
from the Department of Health and Human Services commonly referred to 
by the previous administration as ``weekly draw down reports.'' These 
reports provide some insight into the allocation of Federal funding and 
subsequent spending by the States as it relates to COVID-19 
supplemental appropriations. It is my understanding that these reports 
have been shared with other members of this chamber and are generally 
used for press inquiries. However, to date, my office has not received 
these reports despite repeated follow-ups with multiple staff members 
in the Department.

    I think we can both agree that transparency is a good thing--
particularly when it involves trillions of taxpayer dollars. If you are 
confirmed, will you commit to making public the funding appropriated, 
obligated, and spent on COVID-19 relief in a manner that is easily 
accessible and understood by the general public? Further, will you 
commit to providing weekly draw down reports with Congress on a weekly 
basis?

    Answer. If confirmed, I commit to reviewing your request and 
providing this committee with information relevant to its oversight 
functions.

    Question. During your time as Secretary-designee, on multiple 
occasions you attempted to bypass the Wisconsin State legislature or 
exceeded your authority to extend State-wide stay-at-home orders during 
the COVID-19 pandemic. In May 2020, the Wisconsin Supreme Court struck 
down Emergency Order #28 because you exceeded your statutory authority 
and you did not follow statutory emergency rule-
making procedures established by the State legislature. This order 
would have extended a previous executive order which confined all 
people to their homes, forbid travel, and closed businesses, but it 
also went a step further by establishing a criminal penalty for 
violators. Many months later, on October 6, 2020, you signed another 
emergency order to limit the number of people in certain public indoor 
businesses and private gatherings. The order would have also 
implemented a fine for violators. At a press conference on the same 
day, you even encouraged local governments to go further and offer more 
restrictive orders. The non-partisan Wisconsin Legislative Reference 
Bureau (WLRB) reviewed this order and determined it needed to be 
promulgated as a rule. A lawsuit was subsequently filed by the 
Wisconsin Tavern League on October 12, 2020, arguing that you once 
again exceeded your statutory authority and did not follow emergency 
rule making procedures established by the State legislature. On April 
14, 2020, the Wisconsin Supreme Court ruled the emergency order 
violated State law and was not validly enacted.

    If confirmed, how can I be assured of your compliance with Federal 
laws even if those laws are not popular within your own political 
party? Further, do you commit to abiding by the Administrative 
Procedure Act when enacting rules and regulations?

    Answer. If confirmed, I will follow the law.

    Question. Nearly 120,000 children enrolled in Medicaid across the 
Appalachian region received at least one opioid prescription in 2018. 
In some States, the share of child beneficiaries receiving at least one 
prescription opioid outpaced that of adult beneficiaries. This reckless 
prescribing puts Medicaid beneficiaries at risk of misuse and overdose. 
Despite research demonstrating nonfatal overdoses are among the most 
significant predictors of a future overdose, the Medicaid program has 
persistently failed to help enrollees in these circumstances. In fact, 
a study of 3,606 Medicaid enrolled adolescents (ages 13-22) who 
experienced an opioid-related overdose found that only one in 54 
received medication-assisted treatment, and less than one in three 
received any treatment whatsoever. Equally concerning, Medicaid 
beneficiaries often receive a legal opioid prescription even after 
suffering a nonfatal, opioid-related overdose.

    Senator Joe Manchin (D-WV) and I will be reintroducing the IMPROVE 
Addiction Care Act this Congress. This legislation fixes a problem in 
the Medicaid program that fails to identify victims of previous 
overdoses and ensure prescribers are notified of their patients' fatal 
overdoses. Our legislation is supported by a handful of advocacy and 
provider groups including Shatterproof, Faces and Voices of Recovery 
and the American Society of Addiction Medicine (to name a few).

    In your previous role as Secretary-designee, what efficiencies did 
you bring to Wisconsin's Medicaid program that directly benefited 
individuals suffering from substance use disorder (SUD)? How did you 
reduce the silos associated with their care to help connect enrollees 
to SUD treatment? Please be specific.

    Answer. This was a crisis before the pandemic. And now we know 
COVID-19 has taken a toll on Americans in so many different ways. Like 
President Biden, I am committed to addressing the substance use 
disorder epidemic and to making sure patients have access to 
prevention, treatment, and recovery services. In Wisconsin, I was proud 
to work with Republicans in the State legislature to enact telehealth 
legislation, that among other things, improved access to substance use 
disorder treatment in rural and underserved communities. In addition, 
we launched a hub and spoke model to better integrate behavioral health 
treatment within health care to reduce barriers to care, break down 
silos and better coordinate care for Medicaid beneficiaries. If I have 
the honor of being confirmed, I look forward to partnering with you to 
continue to work on this important issue.

    Question. In your testimony, you highlight bipartisan work in your 
role at the Department of Health and Human Services under the Obama 
administration. However, it does not specify bipartisan work performed 
in your most recent role at as Secretary-designee.

    What were some of your bipartisan accomplishments with the 
Republican-
controlled State legislature in Wisconsin? What major compromises have 
you had to make in order to improve Wisconsin's health-care system? 
Please be specific.

    Answer. I am proud of the work I was able to accomplish in 
Wisconsin. There, we secured bipartisan expansion and modernization of 
telehealth in the Medicaid program and bipartisan policy changes to 
Wisconsin's Children's Health Insurance Program (CHIP). We also worked 
in a bipartisan work manner to integrate a hub and spoke model of 
behavioral health treatment and stand up a residential treatment 
benefit--both of these initiatives improved access to substance use 
disorder treatment in Wisconsin. In all of my work, I prioritized 
judicious use of taxpayer dollars and working with members of both 
parties to improve health care for Wisconsin families.

    Question. In your testimony, you highlight reducing ``the cost of 
prescription drugs'' as one of your public health priorities.

    What policies do you support to reduce the cost of prescription 
drugs?

    Answer. I believe we must do all we can to lower the costs of 
prescription drugs and make them more accessible for Americans who 
depend on them. I am committed to finding ways to reduce drug prices 
and ensure Americans have access to the drugs that they need. If 
confirmed as Deputy Secretary of HHS, I look forward to working with 
you and others in Congress to achieve these important goals. I will 
also work across the government to address barriers to reducing drug 
prices.

                                 ______
                                 
                 Questions Submitted by Hon. Tim Scott
      on religious liberty, lockdown orders, and reopening schools
    Question. During your nomination hearing, you framed your 
priorities as part of a ``common-ground agenda.'' I appreciate this 
approach, and if you are confirmed, I look forward to working with you 
to advance a number of your stated goals, including, most immediately, 
a robust scale-up in vaccinations. Bipartisan collaboration has 
tremendous value as we seek to end the pandemic, bolster our economy, 
and increase access to health care. That said, some of my constituents 
have expressed serious concerns with your nomination, primarily focused 
on two key issues.

    First, with respect to religious liberty, you faced substantial 
pushback from conservatives and pro-life advocates during your tenure 
at Wisconsin's health department, based in part on your selection of a 
longtime Planned Parenthood lobbyist to serve as your deputy, as well 
as what some Wisconsin lawmakers have described as vague or 
noncommittal responses around the use of public funds for abortion. 
Early in the pandemic, a number of State legislators also took issue 
with the ability of abortion clinics to continue operating and using 
needed medical supplies, even as countless entities across the State 
were forced to shutter under your shelter-in-place order. Many South 
Carolinians have cited these controversies as significant cause for 
concern, particularly given HHS's role in overseeing a broad range of 
programs with profound implications for religious liberty and human 
life.

    Since long before I came to Congress, I have prioritized 
protections for religious liberty and freedom of conscience, one of our 
core constitutional rights. I have also been a committed defender of 
all human life, including the lives of the unborn.

    Prior to taking any actions with implications for people of faith, 
can you commit to consulting and engaging with religious liberty 
advocates, including those who disagree with your previously stated 
positions on the issues above?

    If confirmed, can you commit, through all of your actions as Deputy 
Secretary of HHS, to uphold religious liberty and freedom of conscience 
for all Americans, including those with deeply held religious 
convictions and beliefs?

    Answer. If confirmed, I commit to thoroughly consulting 
stakeholders and a diverse set of voices on all relevant issues. If 
confirmed, I will follow the law.

    Question. I have also heard from constituents across the Palmetto 
State with concerns regarding the shelter-in-place order that you 
issued in Wisconsin on April 16th of last year, which many have 
described as overreaching and arbitrary. In addition to banning non-
essential travel, extending a sweeping shutdown of diverse businesses, 
and placing severe restrictions on gatherings, the order in question 
adopted steep penalties for violations, with fines of $250 and 
imprisonment of up to 30 days on the table. The Wisconsin Supreme Court 
majority agreed with the order's critics, with Justice Roggensack 
writing, in enjoining the order, ``Rule-making exists precisely to 
ensure that kind of controlling, subjective judgment asserted by one 
unelected official, Palm, is not imposed on Wisconsin.'' The court's 
ruling caught the attention of The Wall Street Journal's editorial 
board, which celebrated the decision in an op-ed entitled ``Democracy 
Lives in Wisconsin,'' concluding that ``[d]emocracy and the rule of law 
don't end because there's a pandemic.''

    You were not alone, particularly among blue-State officials, in 
issuing and extending far-reaching lockdown orders, and the tumultuous 
early days of the pandemic triggered a number of bold decisions across 
the Nation, many of which look more rash or counterproductive in 
retrospect than they might have appeared at the time. At the same time, 
lockdowns have led to dire consequences for scores of Americans, 
particularly in the case of vulnerable communities. We have seen 
unprecedented learning losses for young people, along with spikes in 
suicide, deaths of despair, and economic insecurity.

    As you reflect on the past year, what are some of the areas where 
you might, in retrospect, have revised your approach to pandemic 
response, and what would you cite as some of the lessons learned?

    In a letter to the chairman and ranking member, two members of the 
House who served in Wisconsin's State government during your time as 
Secretary-designate alleged that you ``played a central role in the 
shuttering of Wisconsin schools for the final months of the 2019-2020 
school year and led many throughout the State to operate in a hybrid or 
virtual learning model for 2020-2021.'' How would you respond to these 
claims, and what steps do you believe that HHS should take, in concert 
with other Federal agencies and with State and local authorities, to 
accelerate the reopening of K-12 schools for in-person learning?

    Answer. I am proud of the work I was able to accomplish in 
Wisconsin. Every single day, I got up and worked tirelessly to protect 
the health and well-being of the people of Wisconsin, especially as we 
navigated a public health crisis. If confirmed, I commit to working 
with the CDC and State and local leaders to ensure everyone has the 
resources and support necessary to ensure children nationwide are able 
to attend school safely, which is a top priority of the Biden 
administration.
                    on vaccine technology innovation
    Question. Vaccine patches represent a promising alternative to 
traditional vaccines injected via needles. Vaccine patches do not need 
to be frozen, do not use needles, are single-dose, and can be self-
administered at home. By reducing logistical challenge, wastage, and 
vaccine hesitancy, they could play a major role in improving our 
Nation's response to the COVID-19 pandemic, as well as our preparedness 
for future pandemics.

    How will this administration support the development of alternative 
vaccine platforms, such as shelf-stable, self-applied patches?

    How will this administration support the expansion of use of 
alternative vaccine platforms for future pandemic needs?

    Answer. I agree that we must do all we can to improve vaccine 
technology and make vaccines easier to deliver. If confirmed, I will 
work with NIH and FDA, as well as our international partners, to ensure 
we take any steps needed to help facilitate the development, review, 
and approval of new vaccine technologies.
                       on supply chain resiliency
    Question. President Biden, in his remarks on the American Job Plan, 
stated ``China is racing ahead of us in the investments they have in 
the future.'' Synthetic biology is an emerging field which, with the 
proper regulatory regime and investment, will provide high-paying U.S. 
jobs and supply chain security.

    What legislative steps should Congress take to facilitate HHS 
development and support for the U.S. synthetic biology industry?

    Answer. I agree that synthetic biology is an area where the U.S. 
needs to be the world's leader. I commit to work with you to determine 
what legislative or resource needs there may be at HHS to help make 
this a reality.
                   on support for nursing home i-snps
    Question. As you know, Institutional Special Needs Plans (I-SNPs) 
are a type of Medicare Advantage plan where the only beneficiaries 
enrolled are seniors living in nursing homes. When nursing homes offer 
these plans, they are 100 percent at risk for all the care their 
residents need, either at their facilities or elsewhere. In the push 
towards value-based care, nursing homes taking on risk via I-SNPs are 
doing exactly what we want to see, but in 2020, being 100 percent at 
risk for a population exclusively made up of the individuals most 
vulnerable to COVID-19, and most likely to need high-cost 
hospitalization, created serious financial challenges for nursing homes 
with I-SNPs, including numerous communities in South Carolina. While 
nursing homes in general have received funds from the Provider Relief 
Fund (PRF), neither HHS nor CMS has provided relief to address the 
specific challenges nursing home I-SNPs have faced in order to ensure 
this model's continued viability.

    Will you commit to using administrative authority to support I-SNPs 
and to recognize the significant increased and unexpected costs that 
these plans have faced during the COVID-19 emergency?

    Answer. It has been heartbreaking to see how hard the COVID-19 
pandemic has affected the Nation's nursing home residents. Nursing home 
care will absolutely be a focus of mine if confirmed. Medicare 
Advantage serves millions of Americans, and I understand that 
Institutional Special Needs Plans provide important options for people 
in need of the level of care provided in nursing homes and long-term 
care facilities. If I have the honor of being confirmed as Deputy 
Secretary, I will be happy to work on this issue along with my 
colleagues at the Centers for Medicare and Medicaid Services.

                                 ______
                                 
               Questions Submitted by Hon. James Lankford
    Question. I am concerned regarding inequities in the distribution 
of the Provider Relief Fund. Assisted living providers care for the 
population most vulnerable to COVID, yet have received far too little 
relief to date. In my State of Oklahoma, assisted living providers care 
for over 18,000 seniors in 194 facilities across the State. 
Unfortunately, assisted living providers were allocated less than 2 
percent of the Provider Relief Fund (about $3 billion dollars) and have 
only received about a third of that. The average age of a resident in 
assisted living is 85. According to the CDC, this age group is 630 
times more likely to die from COVID than a 29-year-old. In assisted 
living, these vulnerable individuals need assistance with daily 
activities such as eating, using the restroom, taking medications, and 
dressing. Social distancing by their caregivers is not possible. Over 
40 percent of assisted living residents have Alzheimer's or some form 
of dementia. Due to PPE needs, workforce needs and occupancy declines, 
assisted living caregivers have incurred over $15 billion in losses. In 
Oklahoma, assisted living caregivers have suffered over $235 million in 
losses. Now, over half of assisted living facilities Nation-wide are 
operating at a loss, and 56 percent say they will not be able to 
sustain operations for another year.

    I recently signed a letter asking HHS Secretary Becerra to 
distribute more of the remaining PRF to assisted living facilities.

    Since you may be overseeing this distribution as well, will you 
commit to working with all long-term care providers to ensure our 
Nation's most vulnerable are properly cared for?

    Answer. If confirmed, I commit to working with all of our Nation's 
front-line workers to ensure they receive the support and resources 
they need to care for those who rely on them.

    Question. I know that your home State of Wisconsin has some 
similarities to my State of Oklahoma in that we were both hit 
exceptionally hard by the opioid epidemic.

    Please detail some of the solutions you will work on, if confirmed, 
to continue to combat the opioid epidemic.

    Answer. HHS has worked aggressively to address our Nation's opioid 
epidemic. Progress was being made to increase access to evidence-based 
treatment and reduced death by overdose until the pandemic hit. If 
confirmed, I will direct HHS agencies, including SAMHSA, HRSA, AHRQ, 
CDC, CMS, NIH, FDA and IHS, to work together and with ONDCP and other 
White House components, as well as with DOJ and other Federal entities, 
including VA and DOD, to increase access to prevention, early 
intervention, treatment, and recovery support programs. People with 
addiction to these powerful and tenacious drugs deserve access to the 
full range of 
evidence-based prevention, early intervention, treatment and ongoing 
recovery supports. Substance use is a treatable condition. Through 
access to evidence-based programs, people can and do recover.

                                 ______
                                 
                Questions Submitted by Hon. Steve Daines
    Question. Throughout the pandemic, assisted living providers in my 
home State have cared for over 6,000 vulnerable Montanans--many who are 
living with Alzheimer's or some form of dementia. Due to PPE needs, 
workforce needs, and occupancy declines, I continue to hear that many 
of these providers have suffered millions in losses throughout the 
pandemic and will struggle to sustain their operations without 
financial relief. There is roughly $23 billion remaining in the 
Provider Relief Fund to help support our healthcare heroes who are on 
the frontlines of the COVID response. I recently urged Secretary 
Becerra to distribute more of the remaining PRF to assisted living 
facilities and other senior care centers.

    Do you support this request?

    Answer. If confirmed, I commit to working with all of our Nation's 
front-line workers to ensure they receive the support and resources 
they need to care for those who rely on them.

    Question. For decades, the Federal Government has funded telehealth 
research grants. These grants have been administered by more than 10 
agencies and operating divisions across the Federal Government. 
Unfortunately, navigating the Federal grant process can be a challenge 
for the average provider and health system. Also, despite the Federal 
Government funding significant amounts of telehealth projects, we have 
very little data to point back to and it seems that grant programs can 
be duplicative or at odds with prior projects. Additionally, we know 
that there is still a learning curve for providers, patients and 
caregivers on telehealth. As we continue the shift toward a health-care 
system that will include virtual care permanently, I believe there is 
value in ensuring there is a function within HHS today to help with 
issues of digital literacy and education.

    Do you believe that we have a coordinated national telehealth 
strategy? Do you agree that a coordinated approach to telehealth 
investments and policies across at least HHS is important?

    Would it be beneficial for there to be an elevated presence within 
HHS leadership to coordinate telehealth investments and policy across 
the Federal Government?

    How can we improve digital health literacy for beneficiaries, 
caregivers and providers alike? Do you agree that this should be a 
focus for HHS as telehealth policies are adopted permanently?

    Answer. Telehealth has been invaluable during this pandemic to keep 
patients, their providers and their families safe, while maintaining 
critical access to care. If confirmed, I will take a careful look at 
those telehealth flexibilities along with my colleagues at HRSA, 
SAMHSA, and CMS. I look forward to hearing more from you about what 
existing flexibilities you view as especially important.

    Question. About 46 million Americans, nearly 15 percent of the U.S. 
population, live in rural areas like my home State of Montana. Those 
living in rural areas are more likely to die prematurely and face 
higher risks for chronic conditions like heart disease and diabetes. 
Americans living in rural communities face 17-percent higher prevalence 
of diabetes than those living in urban areas and may have to wait 
months before needing to travel great distances to see an 
endocrinologist to help manage their condition. This scenario is not 
uncommon and instead is the reality of rural Americans that routinely 
encounter not just a lack of specialty care but in many cases, primary 
care. Digital health tools, including telehealth and remote monitoring, 
have the potential to relieve some of the key healthcare challenges 
facing rural America.

    Can you speak to the promise of telehealth and digital health care 
more broadly for rural communities?

    Answer. I believe that we have to take every approach we can to 
provide Americans access to quality health care, especially in rural 
areas, and telehealth is an important tool to improve health equity and 
access to health care. Health care should be accessible, no matter 
where you live. If confirmed, I will look at how we can use telehealth 
to improve health equity and access to health care.

    Question. Virtual care can help address existing health disparities 
by eliminating the barriers of time, distance, and geography, while 
empowering patients to overcome the challenges of accessing in-person 
care, something Montanans know too well. One of the lessons learned 
from the COVID-19 pandemic is the value of leveraging telehealth to 
scale and meet rising demand for key health-care services. Health 
workforce shortages were at critical levels before COVID-19.

    I was pleased to lead the effort that resulted in section 3701 of 
the CARES Act, which created a temporary safe harbor that allows high-
deductible health plans (HDHPs) to cover telehealth and remote care 
services prior to a patient reaching their deductible. This important 
safe harbor ensures that high-deductible health plans can support 
patients that are leveraging virtual care to access a range of critical 
health-care services during the pandemic before the annual deductible 
is met. The CARES provision extended the safe harbor only through 
December 31, 2021.

    According to the Bureau of Labor Statistics (BLS), only 15 percent 
of workers employed in the private sector participated in an HDHP in 
2010. By 2018, that number had risen to 45 percent. Today, the number 
is estimated to be 54 percent. Importantly, participation in HDHPs is 
even across wage groups and in industries with a significant proportion 
of black and Hispanic workers.

    As the U.S. health-care system emerges from the pandemic, 
permanently extending the HDHP/HSA Telehealth Safe Harbor would allow 
half of American workers to continue accessing a range of clinically 
appropriate virtual services--for a range of common conditions--without 
the burden of first meeting a deductible. I look forward to working 
with my colleagues on this committee to support American workers and 
ensure this key policy continues beyond 2021.

    Do you agree that there is value in expanding access to telehealth 
regardless of your health plan design?

    Answer. Telehealth has been invaluable during this pandemic to keep 
patients, their providers and their families safe, while maintaining 
access to critical health care. If I have the honor of being confirmed, 
I would be happy to work with you on ways to continue to improve access 
to care, including through telehealth.

    Question. One of the silver linings of this pandemic has been the 
widespread adoption of technology to bring people together, whether it 
be families scattered across the Nation or patients and their 
providers. Telehealth has truly taken root and we have seen exponential 
growth in telehealth adoption across Americans of all ages, locations 
and conditions. Much of the growth in usage among Medicare 
beneficiaries has been made possible by temporary flexibilities in 
place for the duration of the public health emergency. These include 
allowing Medicare beneficiaries to have telehealth visits from their 
home, regardless of where they live across the country. This has also 
allowed new types of providers, such as physical therapists and speech 
pathologists to practice via telehealth.

    Do you agree that the expanded access to telehealth services has 
been an important component in protecting patients and providers during 
the Nation's response to COVID-19?

    As Congress considers permanent telehealth reform, I hope you will 
be willing to work with us to ensure that telehealth is available to 
all of those that wish to use it. Do you believe that there are some 
telehealth regulatory restrictions that Congress and HHS can work 
together to address in the near term?

    Answer. Telehealth has been invaluable during this pandemic to keep 
patients, their providers and their families safe, while maintaining 
access to critical health care. If I have the honor of being confirmed, 
I will be taking a careful look at telehealth along with my colleagues 
in the Centers for Medicare and Medicaid Services. I look forward to 
hearing more from you about what existing flexibilities you view as 
especially important.

    Question. The coronavirus pandemic has underscored the value of 
vaccines for infectious diseases, including those that originate 
abroad. We all recognize that COVID-19 will not be the last time we 
have to respond to an outbreak for which vaccinations are necessary in 
order to stem an emerging public health threat.

    Public policy should make vaccines as accessible as possible for 
our citizens. That is why current law requires that insurers provide 
coverage without cost sharing for all recommended vaccines, without 
limitation.

    Yet, inexplicably, current HHS regulations implementing the law 
limit mandatory coverage to so-called ``routine'' vaccines on the 
Immunization Schedules. As a result, many vaccines for infectious 
diseases are not covered without cost-sharing, including those for 
current vaccines such as rabies, anthrax, Japanese encephalitis, yellow 
fever, and cholera, and those vaccines in the pipeline for malaria, 
chikungunya, dengue, and Zika.

    Last year, my colleagues and I worked on bipartisan legislation 
included in the CARES Act that ensures immediate coverage of COVID-19 
vaccines with no cost-sharing. As I said then, Montanans and Americans 
across the country need access to vaccines, and financial barriers 
should not stand in the way during a national emergency or otherwise.

    Congress should not have had to be reactive. A forward-looking, 
uniform approach is needed to ensure that we are prepared to move 
quickly on vaccinations when the next pandemic occurs.

    If confirmed, will you commit to quickly bringing agency 
regulations in line with the statute requiring no cost-sharing for all 
CDC recommended vaccines to maximize access to the best preventative 
measures against infectious diseases?

    Answer. As we have seen over the past year, vaccines are a critical 
part of the public health system working to keep Americans safe. We 
need to be prepared for any potential future outbreak, and I agree we 
cannot afford to be reactive on this. If confirmed, I would be happy to 
work with you to ensure we are ready for the next public health 
emergency.

                                 ______
                                 
                 Questions Submitted by Hon. Todd Young
                             mental health
    Question. The coronavirus outbreak has created an unprecedented 
mental health challenge for our country. While we don't yet know the 
full impact of the coronavirus in this area, we do know it has forced 
Americans to isolate from their loved ones and other support systems--
causing a troubling spike in mental health and substance abuse 
problems. A Kaiser Family Foundation poll found that 45 percent of 
adults say the outbreak has affected their mental health, while a 
different study estimated that the pandemic could cause as many as 
150,000 additional ``deaths of despair'' from suicide and overdose.

    In Indiana, preliminary data show that compared with 2019, last 
year had nearly a 50-percent increase in overdoses seen in emergency 
departments, with an 18-
percent rise across the U.S. in just the first 4 months of the 
pandemic. In 2020, there was a 67-percent increase in the use of the 
opioid overdose reversal drug naloxone--further indicating a rise in 
overdoses.

    As HHS Deputy Secretary, how would you try to address this growing 
mental health crisis--both in the immediate aftermath of the public 
health emergency and in the long term?

    Given that mental health services cross many agencies, how will HHS 
coordinate efforts on this important issue? What programs or 
initiatives around mental health services would be your top priorities 
as Deputy Secretary?

    Answer. Unfortunately, the COVID-19 pandemic has dramatically 
impacted mental health and well-being for too many Americans. If 
confirmed, I am committed to working on this issue, including strong 
coordination among HHS agencies to support programs and initiatives 
across the continuum of prevention, intervention, treatment, and 
recovery support services as well as strengthening enforcement of this 
country's mental health parity laws.

                     social determinants of health
    Question. Social determinants of health are the economic and social 
conditions in which people live, learn, work, and play--such as access 
to reliable transportation and stable housing. Addressing these factors 
can positively impact the health and well-being of the most vulnerable 
Americans.

    Do you have specific plans to address the social determinants of 
health?

    How would you work within HHS to better leverage existing programs 
and address the barriers to coordination between health and social 
services programs?

    Answer. We need to be smarter about tackling our biggest health-
care challenges and understanding the many factors that affect outcomes 
is critical. Good data is critical in creating good policy, which can 
save money and lives, especially for our most vulnerable. If I have the 
honor of being confirmed, coordination across HHS programs would be 
instrumental to addressing social determinants of health. I look 
forward to working together with you on this important issue.

                                 ______
                                 
                 Questions Submitted by Hon. Ben Sasse
                               telehealth
    Question. While my colleagues have pointed out many of the ways 
COVID-19 has challenged our health-care system and exposed existing 
inequities, one bright spot in the pandemic has been increased access 
to telehealth services as a way for patients to maintain their health 
from the safety of their homes. This has been particularly important 
for States like Nebraska with large areas of rural population.

    We know that CMS has allowed expanded use of audio-only services 
during the pandemic, but how is CMS working to ensure that those 
without broadband access can utilize appropriate telehealth services in 
a post-pandemic world?

    Where do you stand on audio-only telehealth coverage? What about on 
payment parity between in-person and virtual services?

    How will you approach geographic restrictions, both in patient 
location and provider licensure?

    If confirmed, how do you plan to evaluate the use of telehealth 
over the last year and the places where it should--and potentially 
should not--be expanded beyond the end of the national emergency 
period?

    Answer. Telehealth is an important tool to improve health equity 
and access to health care. Health care should be accessible, no matter 
where you live. If confirmed, I would look forward to working with you 
and my colleagues at the Centers for Medicare and Medicaid Services on 
this issue.

    Question. Individuals with chronic disease place an immense strain 
on our health-care system and account for a huge percentage of the 
overall costs to taxpayers. I think you would agree that early 
identification and treatment is crucial not only among those with 
chronic diseases but in ourhealth systems in general. Remote patient 
monitoring (RPM) can be beneficial in managing both acute and chronic 
conditions and identifying deteriorations in health as early as 
possible to allow for the best level of care. Issues with reimbursement 
continue to constrain Medicare recipients' access to this level of 
monitoring.

    Do you see value in increased access to remote patient monitoring 
and what are your views on the co-pay requirement for these services?

    Answer. Individuals with chronic disease benefit from access to 
comprehensive and coordinated care to manage and treat their chronic 
conditions and prevent the need for more costly care. Ensuring access 
to remote patient monitoring services, including through evaluating the 
adequacy of payments, will be important to beneficiaries who may 
benefit from these and other virtual services that allow their 
physicians to help manage and treat their health conditions outside of 
regular office visits.
                       most-favored nation model
    Question. I have concerns with the Most-Favored Nation Model 
rulemaking, both with the policy of tying Medicare reimbursements to 
the prices foreign countries pay and with the creation of the expansive 
rule through the Center for Medicare and Medicaid Innovation (CMMI) 
under the guise of being a pilot program.

    If confirmed, how will you approach this policy? Do you support 
tying the prices of American drugs to foreign prices?

    Will you commit to ensuring that CMMI is used as intended rather 
than as a congressional workaround?

    Answer. We can all agree that bringing down the cost of 
prescription drugs needs to be a top priority. If confirmed, I will 
work to coordinate efforts across the Department to make sure we make 
progress toward this goal, and I look forward to working with Congress 
on ideas that will result in lower costs for American patients and 
families.
                            coverage options
    Question. As you have noted in the past, deductibles and premiums 
are often too high in the individual market for people who don't 
receive subsidies. This has been particularly true in Nebraska, where 
for years we had one provider on the market and where even today the 
cheapest plan available on the individual market has a premium of 
$1,700 per month for a family of four.

    We have too often ignored the fact that States like Nebraska 
actually lost health-care options as a result of the ACA. My State 
benefited tremendously from the previous administration's rules 
expanding Associations Health Plans and Short-Term Limited Duration 
Plans, and I'm concerned about the rules establishing these plans 
potentially being rescinded due to politics rather than actual data on 
their effectiveness or service coverage. These plans are very popular 
in my State and often cost less than half as much as ACA plans while 
providing more personalized coverage. Having fewer options in this case 
actually increases the number of uninsured.

    In addition to your support for expanding subsidies in the 
individual market, would you also support continued access to more 
affordable options, such as Association Health Plans, Short-Term 
Limited Duration Plans, and Health Sharing Ministries?

    If not, what data can you point to in recent years to say these 
plans haven't proven to be popular and affordable options while still 
protecting those with pre-existing conditions?

    Can you point to any actual evidence that these plans destabilized 
the market?

    Will you commit to working with Congress and other agencies to 
preserve these plan options for the millions of Americans who have 
enrolled?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. If confirmed, I will examine rules and other policies to 
ensure all Americans can access the care that they need.

    Question. Another popular and successful product in my State are 
Medicare Cost Plans, which offer a unique product in supplemental 
Medicare. These plans are particularly popular in Western and rural 
Nebraska, where beneficiaries typically only have a fee-for-service 
product available to them.

    Do you believe the rules prohibiting competition between Medicare 
Advantage and Medicare Cost Plans make sense in today's market, and 
does less competition benefit patients?

    Answer. Medicare Advantage and Medicare Cost Plans have an 
important role in giving people access to care. If confirmed, I would 
be happy to work with you on the unique needs and coverage options 
available to Nebraskans.

    Question. The previous administration worked on a rule to allow 
Direct Primary Care and Health Sharing Ministry expenses to be eligible 
expenses for use of health savings accounts under section 213 of the 
tax code. I believe strongly that Americans should be allowed to spend 
their health savings accounts on these services, and that more 
personalized choice in health markets leads to greater outcomes and 
higher quality care.

    Would you commit to working with me to explore this policy change 
and others like it that expand access to these care and coverage 
options?

    Answer. Making sure that all Americans have access to quality, 
affordable health care is one of the Biden administration's top 
priorities. As health-care costs have continued to rise, more burden 
has been shifted to consumers in the form of greater cost sharing. We 
must work to reduce barriers to access, including excessive cost 
sharing.
                       title x, conscience rules
    Question. The Department recently announced that it will replace 
the previous administration's Protect Life rule, which upheld the long-
time separation between abortion and health services by calling for 
title X grant recipients to ensure that abortion services were not co-
located with federally funded services. This policy has been affirmed 
previously by the Supreme Court, and I believe it protects the 
integrity of the title X program.

    If confirmed, how do you plan to amend this rule moving forward?

    While it will ultimately be a decision made by Congress, will you 
commit to supporting continued inclusion of the Hyde amendment in 
future appropriations packages, and if not, what is your justification 
for failing to protect the amendment, which has been the law of the 
land since 1976 and is supported by a majority of Americans?

    Will you commit to not reimpose the contraception mandate on 
religious ministries like Little Sisters of the Poor?

    Will you commit to ensuring that medical professionals are not 
forced to perform procedures, like abortion, that go against their 
religious convictions?

    Answer. I understand that there are different, deeply held views on 
this issue. During my time in the Obama administration, I followed the 
law. If confirmed as Deputy Secretary, I will continue to follow the 
law.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. As a doctor, I strongly support increasing access to 
mental health services, especially in rural communities. Senator 
Stabenow and I have previously introduced legislation for many years 
that would allow mental health counselors and marriage and family 
therapists to receive reimbursement from Medicare.

    Can you discuss how the Department of Health and Human Services can 
improve access for mental health services, especially for those on 
Medicare?

    In particular, can you comment on the merits of allowing licensed 
professional counselors and marriage and family therapists to receive 
reimbursements directly from Medicare?

    Answer. The COVID pandemic is taking a toll on Americans in so many 
ways, including their mental health. However, this Nation's mental 
health crisis did not begin and will not end with the pandemic. We have 
to address this challenge from every angle, including by bolstering our 
mental health workforce. Mental health counselors and marriage and 
family therapists have an important role to play in our health-care 
system. If confirmed, I will work with you and other members of 
Congress to better integrate mental health care into our health-care 
system.

    Question. Rural communities are facing significant challenges, 
especially during the COVID-19 pandemic.

    Can you please discuss your priorities for improving health in 
rural America?

    Answer. I recognize that rural areas have unique needs and 
challenges. I've seen how rural areas can vary both among different 
States and also within a State. Rural areas in Wyoming can face 
different challenges than rural areas in Virginia or Georgia.

    The COVID-19 pandemic has further exposed weaknesses in our health-
care system for both providers and patients in rural parts of the 
country. Rural hospitals and pharmacies are often the backbones of 
their communities, providing both necessary health care and employment. 
We should look at ways to bolster the rural health workforce, better 
utilize telehealth, and make sure these communities have the support 
they need. If confirmed, I look forward to working with you to ensure 
that rural communities are not left behind during the pandemic and 
beyond.

    Question. One of the most common challenges facing rural 
communities is recruiting enough health-care providers. These include 
doctors, but also nurse practitioners, physician assistants, nurses, 
and mental health providers, just to name a few.

    What are your general feelings on Federal health-care workforce 
policy?

    Answer. It is critically important to make sure we have enough 
providers to serve beneficiaries throughout the United States, 
including those in rural areas. This issue is becoming more acute as 
our population ages and doctors and other providers retire. If 
confirmed, I look forward to working with you and other members of 
Congress to find creative ways to bolster the health-care workforce.

    Question. As you know, Medicare is the single largest funder of 
graduate medical education. Several years ago George Washington 
University released a study which found New York State received 20 
percent of all Medicare's graduate medical education (GME) funding 
while 29 States, including places struggling with a severe shortage of 
physicians, got less than 1 percent.

    Do you believe major reforms to Federal GME funding policy are 
needed?

    Do you believe the current funding formulas exacerbate health-care 
disparities in underserved communities?

    Answer. I believe it's important to make sure we have enough 
providers, particularly as our population ages and doctors and other 
providers retire. I want to thank you for your work to add 1,000 new 
Medicare graduate medical education slots at the end of last year--the 
first increase to the program in nearly 25 years. I understand that 
Congress has prioritized these GME slots for teaching hospitals in 
underserved communities and other shortage areas, including rural 
areas. Prioritizing these communities for GME slots may help with 
provider shortages as doctors tend to want to stay where they trained. 
If confirmed, I want to work with you to make sure we have a robust 
health-care workforce across the country.

    Question. It is vital for the United States to learn from the 
COVID-19 pandemic and ensure we are better prepared for future public 
health emergencies. In particular, I am interested in addressing the 
supply chain for personal protective equipment (PPE).

    How do you anticipate HHS partnering with the private sector supply 
chain to ensure that the country is ready for the next public health 
emergency?

    Answer. The global pandemic has highlighted the vulnerabilities of 
the global supply chain for many products. In order to continue 
responding to the COVID-19 pandemic and better prepare the Federal 
Government to respond to any future public health emergencies, it is 
critical that HHS work to improve and expand domestic supply chain 
capabilities. If confirmed, I'm committed to working on this urgent 
matter.

                                 ______
                                 
                 Prepared Statement of Hon. Ron Wyden, 
                       a U.S. Senator From Oregon
    The Finance Committee meets this morning to discuss two key health-
care nominations. Chiquita Brooks-LaSure is nominated to serve as 
Administrator for the Centers for Medicare and Medicaid Services, and 
Andrea Palm is nominated to serve as Deputy Secretary of the Department 
of Health and Human Services.

    Ms. Brooks-LaSure has served at OMB, on staff at the Ways and Means 
Committee, at HHS, and in the private sector. She helped craft policies 
bringing down costs for seniors on Medicare. She helped to develop and 
pass key portions of the Affordable Care Act. At HHS she helped 
implement the law. She also worked hard to make sure that middle-class 
Americans shopping for private health insurance would get a fair shake 
thanks to strong consumer protections.

    The Trump administration later undermined a lot of those 
protections, which has created a lot of new challenges for this 
committee and the Biden administration to address.

    Ms. Brooks-LaSure is also well-versed in Medicaid policy. She's 
worked closely with everybody involved in Medicaid--the Federal 
Government, States, and private organizations--to try to expand 
coverage, improve care, and help people get ahead.

    Continuing on the theme of impeccable qualifications and 
experience, Andrea Palm is a proven health-care agency leader who knows 
exactly what it takes to run HHS smoothly. She previously served as the 
Department's Chief of Staff and senior counselor to the Secretary 
during the Obama administration. More recently, she served as 
Secretary-designee of the Wisconsin Department of Health Services, a 
$12-billion agency with 6,100 employees. She's been the point person 
when it comes to the COVID response in the State of Wisconsin. She's 
also led efforts to expand insurance coverage, improve mental health 
care, and reduce hunger.

    Bottom line, these are both highly qualified nominees who will be 
ready to go on Day 1 after they're confirmed by the Senate. There's a 
lot of work to be done at HHS in the months and years ahead, beginning 
with continuing the fight against COVID-19. Vaccinations are way up, 
but cases and deaths are still awfully high. There's a long way to go 
in this pandemic.

    This committee's also going to keep up its work on other health 
challenges facing the American people. For example, I've said that 
every time we discuss our Federal health programs, we're going to talk 
about the transformation of Medicare. Medicare used to be an acute care 
program--broken ankles and bouts of the flu. These days it's a chronic 
care program--cancer, Alzheimer's, diabetes. This committee led the 
passage of the CHRONIC Care Act in 2017. The Trump administration slow-
walked its implementation. I'm going to work with these nominees to 
turn that around.

    Second, in the American Rescue Plan the Congress made a big down 
payment for mental health services based on the CAHOOTS program. It's 
all about using health care, rather than law enforcement, to help 
people experiencing a mental health crisis. It's been a big success in 
Oregon, and I want to expand it even further.

    This committee is also putting a special focus on the issue of 
inequality in our Federal programs. Especially during the pandemic, the 
American people have seen the results of health-care disparities up 
close. Blacks, Latinos, and Native Americans have suffered and died 
from COVID-19 at much higher rates. However, it's not just about COVID-
19. It's also about maternal health, because women today are more 
likely to die in childbirth than their mothers were a generation ago.

    I also want to work closely with HHS on the issue of lowering 
prescription drug costs. That's because Americans get socked every time 
they walk up to the pharmacy window, and it's long past time for 
Congress to act.

    Finally, this country needs a revolution when it comes to access to 
mental health care. The law says that mental health care and physical 
health care are equally important, but in practice, mental health is 
often given short shrift. This is a major priority for members of this 
committee, so we'll continue working closely with these nominees on 
this issue--and all these issues I've raised--when they're confirmed.

    I want to thank Ms. Brooks-LaSure and Ms. Palm for their 
willingness to serve in these extraordinarily challenging and vital 
roles. I look forward to the discussion today.

                                 ______
                                 
                      National Association of ACOs

                  601 13th Street, NW, Suite 900 South

                          Washington, DC 20005

                              202-640-1985

                            [email protected]

                        https://www.naacos.com/

The National Association of ACOs (NAACOS) appreciates the opportunity 
to express our views on the nomination of Andrea Joan Palm to be Deputy 
Secretary of the Department of Health and Human Services (HHS) and 
Chiquita Brooks-LaSure to be Administrator of the Centers for Medicare 
and Medicaid Services (CMS). We strongly support the nominations of Ms. 
Palm and Ms. Brooks-LaSure and are hopeful that they and the Committee 
will consider the following issues in their work ahead.

NAACOS represents more than 12 million beneficiary lives through 
hundreds of organizations participating in population health-focused 
payment and delivery models in Medicare, Medicaid, and commercial 
insurance. Models include the Medicare Shared Savings Program (MSSP), 
the Next Generation Model, the Direct Contracting Model, and 
alternative payment models supported by a myriad of commercial health 
plans and Medicare Advantage. NAACOS is a member-led and member-owned 
nonprofit organization that works to improve quality of care, outcomes, 
and healthcare cost efficiency.

NAACOS looks forward to working collaboratively with the Committee and 
today's nominees on these topics. Mostly notably, we hope these 
appointments will bolster the shift to value following recent years of 
policies that have hampered that critical transition. The transition to 
value should not be taken for granted. While much progress has been 
made in the past decade, this transformation is threatened. For 
example, according to new data \1\ released by CMS, the number of 
participants in the largest and most successful value-based payment 
model, the MSSP, reached its lowest level since the Trump 
administration took office 4 years ago. As shown below, to start 2021, 
477 ACOs are participating in the MSSP, down from a high of 561 in 2018 
and the lowest since 480 participated in 2017, the Trump 
administration's first year in office.
---------------------------------------------------------------------------
    \1\ https://www.cms.gov/files/document/2021-shared-savings-program-
fast-facts.pdf.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


.epsIn contrast to the diminishing number of ACOs, the MSSP continued 
to produce greater savings every year and saw its best year yet in 
2019,\2\ the most recent year for which data is available. Serving 11.2 
million seniors in 2019, the MSSP saved Medicare $2.6 billion and $1.2 
billion after accounting for shared savings bonuses and collecting 
shared loss payments. Gross savings are shown below.
---------------------------------------------------------------------------
    \2\ https://www.naacos.com/press-release--py-2019-results.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

.epsThe Next Generation ACO Model, the premier accountable care model 
ran out of the CMS Innovation Center that emphasizes high risk and high 
reward, has also demonstrated great results. Serving 1.2 million 
patients in 2019, the model saved $559 million compared to the CMS-
generated benchmarks and netted $204 million to the Medicare Trust Fund 
after accounting for shared savings, shared losses, and discounts paid 
to CMS. NAACOS urges CMS to extend the Next Gen model through 2022, 
giving time to install it as a permanent option for ACOs, either as a 
stand-alone track or option within MSSP. The model is scheduled to 
sunset at the end of 2021. The above results should speak for 
---------------------------------------------------------------------------
themselves and substantiate permanentizing.

Given the success of the ACO program and need to strongly support the 
transition to value-based care and payment, we request HHS re-examine 
the balance of risk and reward for ACOs to bolster ACO growth and 
therefore savings to Medicare and to support high quality, coordinated 
patient care. Among those changes, we request that HHS and CMS reverse 
certain policies from a 2018 MSSP overhaul, which CMS called the ACO 
``Pathways to Success.'' That overhaul included some damaging 
provisions such as a cut to the share of savings most ACOs are eligible 
to keep and a push for ACOs to assume risk too quickly. These policies 
have chilled ACO growth and should be changed.

NAACOS also recommends that HHS focus the value transition on 
providers, keeping them at the center of payment models instead of 
implementing programs and policies to attract new players into 
traditional Medicare. As a telling example of CMS's recent approach, in 
2018 the agency released a model initially titled ``Direct Provider 
Contracting,'' only to later drop the word ``Provider.'' That name 
change went along with an emphasis on giving favorable treatment to 
entice new participants, such as payers, to the model at the expense of 
those who have been on the frontlines of the value transition for the 
past decade.

To support the ACO movement and recalibrate the value transition to 
center on and support healthcare providers, NAACOS recommends the 
following:

      Set a national goal to have a majority of traditional Medicare 
beneficiaries in an ACO by 2025.
      Deprioritize the rush to risk and build a population health 
infrastructure.
      Address overlap of competing payment models to prioritize total 
cost of care models.
      Strengthen incentives to attract new ACOs and retain existing 
ones.
      Provide meaningful funding to build infrastructure necessary to 
spur innovation and value through expanded advanced payments and 
grants.

To make progress on the broader goals listed above, NAACOS recommends 
enacting the following specific policy change this year:

      Adapt ACO and alternative payment model methodologies to account 
for COVID-19 anomalies.
      Halt implementation of the Geographic Option of the Direct 
Contracting Model and improve aspects of the Professional and Global 
Options to benefit legacy ACOs/providers.
      Improve the MSSP by increasing ACO shared savings rates, fixing 
key benchmarking and risk adjustment issues, allowing more time before 
requiring risk, and revisiting recently finalized quality policies.
      Make the Next Generation ACO Model permanent.
      Provide more timely and complete data to ACOs.

Ultimately, President Biden's administration inherits fewer ACOs than 
the Obama administration left at the start of 2017, which is a trend 
NAACOS hopes will be reversed under your leadership at HHS. We 
appreciate the work of the Committee on these topics and look forward 
to working with the nominees.

                                 ______
                                 
                      National Health Law Program

                     1444 I Street, NW, Suite 1105

                          Washington, DC 20005

                             (202) 289-7661

                         https://healthlaw.org/

April 15, 2021

The Honorable Ron Wyden             The Honorable Patty Murray
Chairman                            Chair
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Health, Education, 
                                    Labor, and Pensions
Washington, DC 20510                Washington DC 20510

The Honorable Mike Crapo            The Honorable Richard Burr
Ranking Member                      Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Health, Education 
                                    Labor, and Pensions
Washington, DC 20510                Washington, DC 20510

Dear Chairman Wyden, Ranking Member Crapo, Chair Murray, and Ranking 
Member Burr,

On behalf of the National Health Law Program, we write to urge you to 
support Chiquita Brooks-LaSure's confirmation as the next Administrator 
of the Department of Health and Human Services' Centers for Medicare 
and Medicaid Services (CMS). As a long-time thought leader and expert 
on access to health care for low-income people, particularly those most 
underserved by our health-care system, Brooks-LaSure has the expertise, 
experience, and dedication to advancing access to quality health care 
and health equity needed to guide CMS.

CMS provides vital health coverage to more than 100 million people 
through Medicaid, CHIP, Medicare, and the health insurance 
marketplaces. With over two decades of Medicaid and health-care reform 
leadership and expertise under her belt, as well as a demonstrated 
commitment to advancing health equity, Brooks-LaSure is an exceptional 
candidate to lead CMS.

Before her most recent work as a Managing Director at Manatt, Brooks-
LaSure served in key leadership roles advancing implementation of the 
Patient Protection and Affordable Care Act (ACA) within the Obama 
Administration. She served as Director of Coverage Policy in the White 
Home Office of Health Care Reform, and later as Deputy Director for 
Policy at CMS' Center for Consumer Information and Insurance Oversight. 
Before that, she served as staff on the House Ways and Means Committee, 
where she contributed to the ACA's passage.

Throughout her career, Brooks-LaSure has emphasized Medicaid and the 
ACA marketplaces' crucial roles in alleviating racial inequities in 
health outcomes. She has called out the role of the Trump 
administration's Medicaid work requirements and 2019 public charge rule 
in perpetuating health inequities, particularly for people of color. 
She has highlighted the importance of more robust data collection to 
better serve underserved populations and alleviate health inequities. 
Brooks-LaSure has stressed the importance of centering community voices 
in health policy development and priority-setting--an approach that is 
essential to fostering a healthier and more equitable country for all.

Brooks-LaSure has paid particular attention to our country's 
unconscionable Black maternal health crisis. She has underscored the 
importance of extending Medicaid and CHIP to 12 months postpartum--a 
reform now possible through the American Rescue Plan Act's new state 
plan amendment options. She has addressed the importance of efforts to 
expand access to doula care. Her testimony at a 2019 House Ways and 
Means Hearing on pathways to universal health coverage specifically 
highlighted racial injustices in maternal mortality.

The challenges facing this nation are multifold, both acute and long-
simmering. The pandemic has exposed flagrant flaws in our health-care 
system and painfully revealed the United States' entrenched health 
inequities. There is much to be done and undone to build a more robust 
and equitable health-care system. Our country desperately needs a CMS 
administrator who will center urgent health equity challenges and 
prioritize equitable solutions. We look forward to working with Brooks 
LaSure and the team at CMS to advance those solutions. We urge the 
Senate to confirm her nomination swiftly and resolutely.

If you have any questions, please contact Madeline Morcelle at 
morcelle@healthlaw.
org.

Sincerely,

Elizabeth Taylor                    Mara Youdelman
Executive Director                  Managing Attorney, Washington, DC 
                                    Office



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