Transcripts For CSPAN HHS Secretary Confirmation Hearing 20171204

Vote on the nomination. Senator murray and i will each have an Opening Statement and then former secretary and former governor Michael Leavitt who we welcome today good to see you and have you back and senator young, a member of this committee will introduce mr. Azar. After his testimony, each will have five minutes of questions. I anticipate a good, vigorous questioning time. Azar, you will be running a 1. 1 trillion organization. That almost equals the total of the 12 appropriation Bills Congress passes each year to find everything from National Parks to National Defense to national laboratories. You would be overseeing medicare and medicaid, our nations Insurance Programs for the poor and elderly. Mental health and substance abuse, where you will have to address the europe your crisis other issues. The National Institutes of health where with Francis Collins excellent leadership the United States is leading efforts to develop a cure for new treatmentd for cancer. The fda, where Scott Gottlieb has gotten off to an start speeding up the approval of generic drugs and working to spur innovation annexes to regenerate of messages medicines. And you will be subject to skyrocketing demands and Health Market that are currently a nightmare for americans who do not receive a government subsidy to help pay for their Health Insurance. You will also the opportunity to implement what the majority leader of the senate called the most important piece of last year. The 21st century cures act which senator murray and i and members of this committee agreed upon and gave broad new powers to the fdi, the National Institutes and included the first major senator murphy especially worked on that, of Mental Health programs in a decade as well as significant new funding for the open your crisis which virtually all of us support. I believe you are a nominee for this job. You have confirmed by the United States senate twice. You have offered to meet with every member of this committee and have met or spoken with 15 Committee Members. You served in the Judicial Branch as law clerk for Supreme Court justice scalia. You know the executive branch, having been hhs general counsel for four years and deputy secretary for two years will stop you spent a decade and a leadership position that one of the countrys major pharmaceutical companies, so you know the system of how drugs get from manufacturer to patient. From all of these perspectives, onthejobneed no training to take advantage of this exciting time in Biomedical Research to speed safe drugs to the system to patients more rapidly. I see your broad experience as one of your principal assets. Experience in health care to me is an obvious asset for someone going to lead the most Important Health care agency in the nation. Gottlieb, aty dr. The fda, has done so well is because he knows the agency having a Deputy Commissioner and he knows the private sector well, having worked in it. Knowledge dr. Collins of the nih and the human genome useful. Him especially im glad to know that people like you, dr. Gottlieb, and dr. Collins have the knowledge on the issues you will be dealing with every day. Are issues costs this committee has studied to better understand challenges and find solutions. We plan to hold a third hearing on how the but that is where we d most of our debate and discussion. As i mentioned, 9 million individual markets dont qualify for subsidy. They are really getting hammered by skyrocketing prices. Intimacy, premiums have increased 176 in four years and in addition in tennessee, premiums have increased 176 . Senator murray and i and members this committee worked on an agreement cosponsored by 11 other republicans and 11 other democrats which the Congressional Budget Office says will prevent a 25 price 2020 by in premiums by paying all sharing subsidies, decreasing dollars spent on a sea of premiums, and as result, lower the deficit. It will give the states authority to use the waiver in the law to find other ways to lower premiums. For example, alaska created a Reinsurance Program and lower no newby 20 with federal spending. Yesterday the president said he supported the Alexander Murray agreement becoming law but into the year. Our agreement has so much in it that appeals to so Many Democrats and independents. Its hard to imagine our not passing something that prevents a 25 increase in premiums by 2020 and offers states electability to further lower rates. The democratic leader called it a good compromise and said it has the support of all 48 democrats. The chairman of the Democratic National committee tweeted last , Alexander Murray has widespread bipartisan support. As secretary, there are many other steps you can take to lower premiums and stabilize the market. The Opioid Crisis that is ravaging this country is a priority for the president and every member of this committee. We are having estate perspective on Opioid Crisis tomorrow. Drug Overdose Deaths in tennessee went up by 12 from 2016. O it dramatically increase 74 in 2015 to pledged tos streamline programs and provide funding to states and communities on the frontline of this crisis, imprudent and putting preventing the comprehensive addiction and recovery act. We have included 860 million in the fiscal year 2018 appropriations bill. We stand ready to work where additional tools and authority is needed. Some say that we need an opioid czar. In tellingll join me the president that this is a bad idea. Once confirmed you need to be the one to take charge in leading the federal government response and letting us know how to help. Exciting opportunity to implement the 21st century i hope you will work with us to includingtage president obamas precision initiative, the Vice President s cancer moonshot. Fda gave you and the authority to hire the scientists it needs. I hope that you use these authorities to make sure we take full advantage of this exciting time. They will also provide oversight on the drug quality act. We will also try to figure out how to Lower Health Care costs including the cost to patients who pay for Prescription Drugs. Next to the committee will have to reauthorize the hand gimmick pandemic and all hazards preparedness act. Making sure our nation is prepared for and able to respond to such emergencies such as hurricanes, diseases like zika, and bioterror attacks. There is a lot to do. I look forward to working with you on this and hearing more about your priorities today. Mr. Azar, thank you and your family for being here and for your willingness to serve. Because these were recent challenges are what this committee and the congress are discussing was supposed to be focused on, i will start my remarks with a few stories i have been told. My constituent julie is a fourtime cancer survivor. She has said she would not be able to afford her medical expenses or even stay alive without Affordable Care act protections. Kim from allensburg talked about her addiction to opioids and the ability to overcome it. From marysville said before going to planned parenthood that she struggled to get Birth Control regularly. Given her unpredictable schedule in the fast food industry. Those are just some stories. There are many others and so many pressing Health Problems this administration could be solving. It seems it has been determined to create problems. The department has not attempted to help people get highquality affordable coverage. They made it harder by stopping payments for outofpocket cost reductions. By letting insurers cover fewer benefits. By cutting the open Enrollment Period and slashing funding for Consumer Outreach and more. Rather than allowing women to make their own health care choices, the department has tried to prevent them from wentng care, even if they to a provider they trust. President trump went to states like New Hampshire and ohio and said he would confront the Opioid Epidemic had on and called it a tremendous problem. This administration and its Health Department did the opposite. It proposed gutting medicaid which officers critical wrap around services and Substance Use Disorder Treatment to people who otherwise could not afford it. Experts say it would cripple response efforts. All it took was a meeting with a few pharmaceutical executives for President Trump to go dark, despite from us is of bringing down. Ices the department has proposed using Public Health funds to close near term budget caps rather than to prevent costly illness and disease down the road. They have utterly failed to see the urgency of the Public Health crisis is still going on in the wake of hurricane maria. The administration is rolling back protections that that prevent discrimination against people who have historically been denied access to health care. It shouldnt have to be said but the absolute last thing our nations Health Department should be spending time on is encouraging more discrimination in our Health Care System. That is wrong. You and i do have stark disagreements, but your nomination could be an andrtunity for hhs to reset put aside the extreme politics and start focusing on the department as ignition instead of President Trumps ideological agenda. People across the country would be far better off if you took this opportunity. , myazar, i have to say review of your record leaves me with serious doubts that you will. Eli lily is currently working to currently under investigation for working with other Drug Companies to needlessly raise the price of insula insulin. You made it clear on questions of Womens Health. Ideology over science and rightwing politicians over women. Although conservative experts, governors, and some members of congress have reject rejected have rejected President Trumps attempts to sabotage health care, you said that this legislation would not spike premiums or undermine protections for people with preexisting conditions, gutted medicaid, cost tens of millions of people their health care, defunded planned parenthood and more. You said it didnt go far enough. This leaves me very concerned about whether you would faithfully implement the bipartisan agreement that the chairman just talked about with us. Of President Trumps profoundly underwhelming followthrough on his Campaign Promises about tackling the Opioid Epidemic, it is deeply appointing that another hasnt supported committing the new resources we need for this effort. So i worry about your professional history and statements that point to a continuation of some of the extreme damaging and political driven approaches we have seen so far from this administration. Let me return to the stories i mentioned at the beginning of my remarks to make my final point. Right now, julie is traveling around the country raising awareness about open enrollment to help more people sign up. Kim is pursuing a masters in social work and helping people in Central Washington to get the necessary treatment and services so they can overcome their addiction. Christina has become a vocal advocate for helping women in washington and nationwide to get care that works for their needs. Christina ared doing more than their part to keep our communities healthy and well. My question is why isnt our nations Health Department doing the same . People should have a secretary of health who will work for and with patients and families not against them. And who is committed to making policy based on science and not ideology. Im looking forward to your thoughts on the many serious concerns i have raised and how you would be an appropriate choice for this position. Im concerned that President Trump has yet sent us an extreme ideologicallydriven nominee to pick up where secretary price has left off and women and families deserve a lot better. So im interested in your responses today. I hope i am pleasantly surprised and i do want to say if you are confirmed, i want to make it very clear i have not and will not let this administrations approach so far lower my expectations for any of the department this committee oversees, and i will continue doing everything i can to hold hhs to the highest of ethics andards service for people in my state and across the country. With that, thank you very much. Welcome dr. Azar. We also welcome your family and friends. We thank them all for being here. Theres pretty good group of them and you may want to introduce them when you begin. Mr. Azar will first be introduced by governor mike leavitt. Governor leavitt served as president george w. Bushs secretary of the department of health and Human Services from 2005 to 2009. He worked closely with mr. Azar then while he served as deputy secretary. Then the nominee will be introduced by his home state senator and member of this committee todd young. Governor leavitt, please introduce mr. Azar. Leavitt thank you, members of the committee. Senator alexander and senator murray have very ably described the complexity and the importance of this role. And therefore, its my privilege to introduce and to recommend he alex azar. He is up to the task and supremely well qualified to carry out this important work. As mentioned during my service as secretary of hhs, mr. Azar was deputy secretary. Chiefence, he was the operating officer of this large and complex department. Prior to his service, he served as the general counsel under sec i secretary thompson whom believe later will also introduce and robustly recommend him to the finance committee. That, plus his experience leads me to conclude that there may not have been a nominee to this office of secretary better prepared to hit the ground running than alex azar. It was mentioned that hhs is a large and complex place. While deputy secretary, alex azar was the manager of the daytoday operations of 90,000 employees and 1. 1 trillion budget. Just a brief example of what i think would illustrate his capability. President bush had a management agenda that laid out a criteria of several dozen different objectives, and then had a dashboard of green, yellow, red. Alex had an objective to have every criteria green. He was the first equity secretary in the entire federal government to achieve that. He was also delegated oversight of much of the regulatory process. In a very skillful and lawyerly managed tohe processy adjudicate the which is robust. Hes a world class policy thinker. Youll see that today. I can assure you, if he is confirmed as secretary, you can expect good communication on both sides of the aisle. He is an experienced diplomat. Experienced is a word that i think will be underscored here. I have seen him under fire. 911, he was part of the response. There was a point in time when , andna, pandemic influenza the rollout of Medicare Part b was happening at the same time. This is a personal with great experience in a complex department. Say,important, can i just he is an extraordinarily good human being. Hes got the kind of compassionate heart that i believe is required to serve to lead the mission of this important department. I commend him to urge the confirmation of the secretary of health and humanservices. Thank you, governor. Thank you for joining us again as you have before. Senator young . Sen. Young thank you, chairman and Ranking Member murray. And fellow members of this committee. I am grateful to introduce a , to behoosier, alex azar secretary of the department of health and Human Services. President trump made an outstand outstanding choice to lead this Critical Agency which happens to be the largest civilian Cabinet Agency in the entire u. S. Government. Alex, as has been said, is an extreme the qualified nominee and a well known expert in the health care industry. His previous leadership experience, and as deputy secretary of hhs, and as president of indiabased eli lilly incorporated, which is the largest affiliate of one of the Largest Health Care Companies in the world, will collectively be an effective combination as we work to solve our most Significant Health care challenges. Former hhs secretary Tommy Thompson said that azar is one of the most competent people i know. An experienced leader with deep , substantive health care knowledge. I agree. In addition to his impressive academic record, which includes degrees from dartmouth and yale, he clerked for the Supreme Court justice antonin scalia. He began his service in 2001, when the United States Senate Confirmed him to serve as the departments general counsel. Since then, alex has been a leading voice in Health Care Reform and Health Care Innovation with a reputation as an effective leader. He has been particularly outspoken on the need to lower the price of Prescription Drugs saying patients are paying too much. If anyone can help solve this problem, its alex azar. Hes the right person to reform care systemealth and can ensure the department succeeds in its mission to enhance and protect the well being of the American People. Alex was confirmed to both of hhsprevious positions at with unanimous bipartisan support. Confirmed twice by the United States senate for positions at hhs with unanimous bipartisan support. Im hopeful this time will be no different. I note alex is a good man with a heart for service. I have gotten to know him personally over the years. I look forward to supporting his nomination and working together to ensure all americans have access to high quality and Affordable Care. Thank you. Mr. Azar we invite you to , give your opening remarks. Your full statement will be incorporated into the record. Welcome. Dr. Azar if i could take a second to introduce my family that i have here today, im pleased to be joined today by my wife jennifer and my daughter claire, my son alex, my father dr. Alex azar, as well as my sister stacey, and her team. Her family. Unfortunately, my mother could not be here today, and most tragically my stepmother wilma died of cancer just in july. I am very said she could not be here for this moment. Having an opportunity such as this does not happen without a supportive family and their guidance. Thank you, mr. Chairman, members of the committee for the opportunity to appear before you today as the president s nominee to be thesecretary of health and Human Services. Senator young and governor leavitt, thank you for those kind words, for your friendship, your mentoring over the years. I also thank President Trump for the confidence that he has bestowed on me in nominating for this position. 97 years ago, my grandfather, and impoverished teenager who spoke no english stepped out on stepped out of steerage on , completing his long journey from lebanon to america. As he entered the receiving hall at ellis island, he met an individual in a military uniform. That person possessed the power to admit him or to send him back to poverty and uncertainty. That person was a member of the United States Public Health service. It is a testament to all that i love about this country that just 97 years after my grandfather went through his six second physical on ellis island with no discernible prospects other than the political, economic and religious freedom that america offers, his grandson might be. In charge of that very Public Health service as well as the other renowned components of the department of health and Human Services. The mission of hhs is to enhance and protect the health and well being of all americans through programs that touch every single american in some way, every single day. We are at an historic time in terms of delivering on that mission through innovation. Through its outstanding leaders and career staff, hhs is prime to meet thatchallenge. That challenge. This task is humbling. It requires marshaling a leading the incredible resources of that department require innovating, never being satisfied with the status quo and preparing for the future. I think i gained these skills in the dark days after 9 11. As we faced a health and human consequences of those attacks. Through the anthrax attacks and potential future biological, chemical, radiological, or nuclear attacks. In the implementation of our completely novel Prescription Drug benefit, by helping to build state and local pandemic preparedness programs and our response to threats is such as sars and our effort to reform welfare programs to make them as responsive and empowering as possible for the individualsand individuals and families that we serve. Through innovation and the private sector, to bring life improving therapies to ourpeople of the world and harnessing the power of big data and analytics to make us more capable of serving our fellow americans. With a department the size of hhs, it is often difficult to prioritize. Nonetheless, should i be confirmed, i do envision focusing my personal efforts in four critical areas. First, drug prices are too high. The president has made this clear, so have i. Through my experience helping to implement part d and with my Extensive Knowledge of how insurance manufactures, pharmacy and Government Programs Work Together, i believe i can bring the skills and experiences to the table that can help us address these issues while still encouraging discovery so americans have access to high quality care. Second, we must make health care more affordable, more available and more tailored to what individuals want and need in their care. Under the status quo, premiums have been skyrocketing and choices dwindling. We must address these challenges for those who have Insurance Coverage and those who have been left out of the Insurance Market by the Affordable Care act. Third, we must harness the power of medicare to shift the focus of our Health Care System from paying for procedures and sickness to paying for health and outcomes. We can better channel the power of Health Information technology and leverage what is best in our programs and in the private competitive marketplace to ensure the individual patient is the center of Decision Making and his or her needs are being met with Greater Transparency and accountability. Finally, we must heed President Trumps call to action and tackle the scourge of the Opioid Epidemic destroying so many individuals, families and communities. We need aggressive prevention, education, regulatory and enforcement efforts to stop overuse of these legal and illegal drugs. We need compassionate treatment for those suffering from dependence and addiction. These are serious challenges that require a serious minded sense of purpose. If confirmed i will work with the superb team at hhs to deliver results. I thank President Trump for this opportunity to serve the American People and thank you for your consideration of my nomination. I will just ask one question. Id like to reserve two minutes askhe end so i can questions later. During the nomination process for the secretary ofagriculture, of agriculture, there are concerns about his close ties to the agriculture industry. While moving treatments and cures through that agency. There was concern because he had worked with pharmaceutical companies. You have worked with a Major Pharmaceutical Company in a major position for ten years. My own view is that thats a big help. Having some familiarity with drug pricing as such a byzantine some a come inng who didnt know about it would be gone before they figured out 5 of how we might lower drug prices. What do you say to the skeptics who criticize you for that, especially those who criticize the increase in insulin prices while you were a leader at eli lilly over that tenyear period. Mr. Azar mr. Chairman, thank you for that question. As you and others have mentioned, i had the honor of serving general secretary of hhs for almost six years in the Senior Leadership there. So for me, if i were confirmed, this is returning home. This is my place that i want to be. After hhs, i did spend ten years at eli lilly where i was a senior leader. Eventually the president of the u. S. Affiliate directly leading the sales and marketing of all oncology drugsot nononcology drugs in the United States. As the geographic leader, i also supported operations for those other business units. I do believe, as the chairman mentioned, that these public and private sector experiences do prepare me very well for the role of secretary. This is especially true in the case of drug prices. The price of many drugs has risen substantially. In particular, insulin. The Current System of other medicines may meet the needs of many stake holders but that system is not working for the patients who have to pay out of pocket. We have to recognize that impact. Thats why the president and so many members of this committee on a bipartisan basis and i have talked about the need to fix this system. I do think through my experiences in the Public Sector and at lily my expenses in the private sector, understanding how the channel works, how the channel sees these issues, how manufacturers, payers, pharmacy benefit managers, all distributors all Work Together. I believe i can hit the ground running to work with you and others and we can work to identify solutions here. I will reserve the plans of my time. Thank you. Sen. Murray let me just follow up. I think the cost of drugs is something i hear about more than anything else. It affects somany people in a negative way. And im assuming that you agree with the overwhelming majority that drug costs are too high. Do you agree that congress and administrative actions are needed . Mr. Azar i absolutely do. Sen. Murray as we know you are president of a Major Pharmaceutical Company when it got worse. Tell us how you would approach this as secretary . Mr. Azar thank you to my senator murray. And i appreciate the chance we had to sit down together. I really enjoyed that discussion. Also in terms of your opening, i hope if im confirmed, i hope i can earn your trust and show you this is the job of a lifetime for me. I would approach this not for any industry or past affiliation, but to serve all americans to improve their health and wellbeing. I think there are constructive things we can do but id also like to hear ideas from the committee, from people at hhs, and elsewhere, but let me throw a couple things out that are worth focusing on. We need to crease generic and branded competition. The more drugs we get to the market, the more competition we have. That can bring down costs to the system. We have to fight gaming in the system of patents and exclusivity by Drug Companies. I have always been an opponent of abuse and gaming of the patent systems by Drug Companies. I led an effort to get rid of filing multiple patents to delay. The exclusivity saved 34 billion for consumers through the efforts that we pushed by reinterpreting. Why are americans paying more than those in europe and japan and is that fair that we are baring the cost ofother nations. Sen. Murray i am running out of time but i will say this. The skepticism comes from the world of pharmaceuticals and prices didnt drop. How will you do that as secretary . We can talk about it later. There is this fox guarding the hen house, from what i hear. I know others will ask about that. I want to ask a question about women as ehealth because so far under President Trumps leadership and former secretary price, a number of detrimental steps were taken that undermine Womens Health care, including appointing multiple antichoice ideologues, undermining title x, teen pregnancy prevention programs and critically rolling back protections for women to have full coverage for Birth Control from their Insurance Plan. Ifi wanted to ask you, confirmed, will you commit to putting science and access to Health Care First rather than ideology and extremism . Mr. Azar so senator murray, as we discussed in your office, if im secretary, im secretary for all americans. Im there to protect all americans, men and women. We have programs that this congress has created and that hhs is there to implement. I would faithfully implement those programs. We may differ in different elements of how those get implemented, but i firmly believe in following evidence and science where it will take us in running these programs. Sen. Murray do you believe that all women should have access to health care that their doctor recommends for them . Issue is thethe conscience exception, i believe we have to balance a womans choice of insurance that she would want with the conscious of employers and others in a balance thats sort of an american values, trying to balance those and its a very small group. Sen. Murray the womens doctor recommended but you believe the employer has precedent over that . Mr. Azar not in terms of access, but in terms of insurance, to force those very few i believe its less than 200 have come forward. Very few employers that would be impacted by that conscious exception to respect their rights as well as respecting womens access through the insurance. I disagree. Sen. Murray i think womens access to health care, their doctors require for them should take precedence. We disagree on that. I want to ask you about a question for senator and i have both raised. If confirmed, will you commit to implementing it as intended andworking with us to improve affordable coverage for patients. . Mr. Azar absolutely. Sen. Murray i know that some people today are claiming that bill that we designed will fix other problems being proposed. Do you think the cost sharing reduction payments will be sufficient to make up for chaos if other tax cut proposals are passed. . Mr. Azar i think the work of this committee on a bipartisan basis is awonderful model for addressing it. It recognizes problems with before the formal care act. There are problems with the implantation. There are going to be some new authorities in the package that youre talking about. Those will be useful. I do want to caution, i dont believe its a longterm solution to problems that are just inherent to the Affordable Care act that we need to work to address in terms of getting to affordable insurance. Choice of insurance, that insurance delivering real access to health care for people. So not just a card but access to physicians and the insurance that lets the people get the insurance that they want not what we are telling them from the center. But it is an important stopgap to help along the way. Sen. Murray i have other questions but i am way over time. Ill let the members ask at this point. Senator paul. Sen. Paul i think most americans dont disparage or dislike people who accumulate wealth. Were fine if people accumulate wealth. If you ask americans, sam walton developed this great store and became wealthy. Most americans dont think hes a terrible person or abused the system. I dont think americans have the same warm fuzzy feel inging for big pharma. I think most of us feel that they use their economic might to manipulate the system to maximize profits. Its not like they are selling a cheaper product to more people. They are using government to maximize their profits. Do you acknowledge that the Current System big far ma uses big pharma uses clout to manipulate the patent system to increase drug prices . Mr. Azar there are clearly abuses in the system. Thats why one of the steps that i mentioned to senator murray that we have to go after is the gaming of that. I have always believed we have a waxman regime. It gives innovators a time period to sell the product. But there should be a moment with her should be full in the system and to the patients when they walk into the pharmacy. Sen. Paul i will say this is a huge problem thats been going on for decades. We have had insulin since the 20s. Everybody says they are going to fix it, but i tend to be a doubter because these problems go on and on and on. When you look at the drug problem, one of the things that people proposed was to allow us to buy drugs from europe, buy drugs from canada, from mexico or australia. In fact, this was the president s position when you when he said allowing consumers access to safe and dependable drugs from overseas will bring more options to consumers. We have had legislation on this, i stated the position several times and it never happened. How do you feel about the president s position . Mr. Azar i stated a position against unsafe importation of drugs into the United States. The president has said the same. Reliable and safe. Sen. Paul the drugs they use in the European Union are unsafe . We have had a succession of democratic and republican commissioners who have been unable to certify under the law sen. Paul they have been wrong and beholden to the Drug Companies frankly. Youd have to sit there and say that the European Union has unsafe drugs and it would be unsafe for americans to buy drugs from the European Union or canada or australia. It is frankly not true. Its been going on year after year after year. We have this enormous problem and people say were going to fix the drug problem and it never happens. What i think is important for america to know this isnt capitalism. Walmart is capitalism. Bill gates was capitalism. Big pharma it is not even their fault, they are try to maximize profit by using government but we are letting them do it. We have a terrible system. You get an epipen, you have it for 20 years, manipulate one little thing in the spring and they get another five years and another five years. So one of the things we could do that would dramatically change this is if you have a patent on the epipen for 20 years, you get it. If you change it and make it better, you get a patent on the new epipen. Currently you cant have that. Why dont we have generic insulin . It is going to take someone who really believes it. You have some convincing to make me believe that youre going to represent the American People and not big pharma. That is insulting and i dont mean it to be, im sure you are an upright person. We also have our doubts. It is not capitalism. Its big government. We have to fix it. We cant tepidly go at it. We have to really fix it. You need to convince those of us who are skeptical that youll be part of fixing it and wont be beholden to bigfharma. Big pharma. Mr. Azar as i said in your office yesterday, that issue of iplying the patents completely agree with you. I think that is one of the important avenues we ought to be pursuing. Again, there should be a time certain when competition begins with generics and you shouldnt be able to simply make a change there and evergreen your patent. Sen. Paul one thing in my last few seconds on the drug reimportation, were going to give you a question that you can think about and write. So everybody says its not safe. I hope you will come back with an answer that says this is how i would make reimportation safe. Thank you. Thank you, senator paul. Senator bennett. Sen. Bennet thank you, mr. Chairman. I tell you just following on my colleagues comments. Another option is to figure out how to make prices the same. So people in america didnt have to go through the ridiculous contortion of having to import drugs from overseas but could afford drugs here. I want to congratulate you and your appointment and your willingness to serve during the difficult times. When president clinton left the white house, he left behind a projected 5. 6 trillion surplus. And thats what he gave to president bush. Then we fought two wars and didnt pay for those wars. We and acted Medicare Part d. Which was not paid for. Then we had the worst recession since the great depression. Becameesident obama president we had a 1. 5 trillion deficit. President trump ran for office. This is the one thing he was consistent on in his primary. The Republican Party nominated him and the American People elected him. His promises were these. He would illuminate our debt over a period of eight years. He would deliver a massive tax cut. He would pass of the largest one increases in American History while saying, quote, im not going to touch Social Security and im not going to touch medicare and medicaid. Those are the president s solemn promises to the United States. In the nine years i have been here, this congress has disgraced itself by not being able to pass a budget, having 30 continuing resolutions, by not being able to establish a set of priorities for the American People and we sit here today collecting 18 of our gdp and revenue and spending 21 of our gdp in expenditures. And on the floor this week, disgracefully, is a taxbill that would reduce that 18 to a lower number, at least a 1. 5 trillion additional deficit in our balance sheet. As much as 2. 5 trillion. And the concern that a lot of people have in my state is that after this incredibley unpopular tax cut is jammed through with no hearing, that the administration is then going to break the president s promise to not touch medicare and medicaid and instead exploit the deficits that the republican majority has created in the time that george bush was president and now in the time that donald trump was president to go after medicare and medicaid. Im wondering if you can assure this committee that the president through you is the head of hhs will honor the promises that he made on the campaign trail to make sure that hes not going to cut medicare and medicaid, which is what he said. I apologize for the long windup, but the history has been forgotten by my colleagues and i think its important. Thank you, senator. It is a pleasure to see you and it was a great pleasure to meet with you yesterday. I hope well have the chance to Work Together. As i mentioned, one of the areas i want to focus on is about strengthening our Medicare Program. Because theres so much mistake, fraud, waste, abuse in the program, and inefficiency in how we pay for Health Care Procedures and sickness. If we can tackle that and if we can move to a valuedriven system of health care, we can do two things that are important. Well actually stretch out the resources and the Medicare Program to keep its solvency longer and along it to serve its beneficiary, especially as we reach the baby boom generation. It will serve as acatalyst for change throughout the Health Care System because so much of the Health Care System free rides off of whatever medicare is doing on payments. So i think its a really unique opportunity. The president is committed to both the strengthening, making medicare and medicaid as efficient as possible. Sen. Bennet i hope we can do that in a way that isnt infected by the idiotic politics on health care we have had in this place. I completely agree that the incentives and disincentives are misaligned. We need to align them. Its also true that the reason why we are paying 1 in for every 3 were consume inging in we are consuming and medicare is largely because of Medicare Part d, which was not paid for when it was enact eded by this and acted by this congress and under president bush. And because of the drug crisis. Which is a double whammy that has caused us to blow this whole. So my concern, i have a fiscal concern, which i dont think is for some reason shared today by my colleagues on the otherside other side of the aisle, but i have a concern that benefit. Beneficiaries in my state are going to pay a price for the fecklessness of washington, d. C. I dont think thats fair. I hope we can proceed on a shared understanding of the facts. Mr. Chairman, thank you. Thank you senator bennett. Senator collins. Sen. Collins thank you, mr. Chairman. Enjoyed, i very much our discussion in my office on drug pricing. I want to follow up on a couple issues. There was a recent investigation that found a wide variety of Prescription Drugs, uncertain drugs on certain Insurance Plans were actually less expensive when the consumer paid outofpocket than if the consumer used his or her Insurance Plan. An example was a customer who had a copay of 43 for a common cholesterol drop where if she had not used or insurance, she would have paid less than half of that, 19. I met with a group of pharmacists in the state of maine. I was outraged to learn that they are under gag orders that prohibit them from informing their customers that there is this differential in price. That they would be better off and payingnsurance outofpocket. Do you support prohibiting those prevent agreements that a pharmacist from giving true transparency on the drug pricing to their customer . Mr. Azar senator, thank you for the meeting. I enjoyed our discussion. How can you not hear about that and have your job jaw drop . How can you not find that frightening that that could go on . So i think those are the types of issues across the entire channel in Drug Distribution and payment that i want to bring the expertise i have to the table to work with you and others at hhs to try to resolve. That shouldnt be happening. There are many other things that shouldnt be happening in the channel. And how that system works. I think we can Work Together to come up with solutions here that are going to help haitians to pay as little as possible. That absolutely should be our goal. Sen. Collins thank you. And i cant tell you how frustrated these pharmacists were that they were una able to were unable to give that information to their customers who knew they were struggling to pay a high copay. A second issue that i wantto explore with you today has to do with the investigation that the Senate Ageing Committee undertook into sudden price spikes in off patent drugs. We found that the risk evaluation and mitigation r. E. M. Ies, or the system, which were intended to manage drugs with increased risk factors were being used by certain Drug Companies to block potential competitors from accessing a sufficient amount of the drug, once the patent has expired to do the bioequivalence equivalent o bioequivalency exams that the fda requires. And i have had extensive discussions with fda officials about this. Dr. Janet testified that the fda has referred 150 cases of potential anticompetitive behavior to the ftc. The ftc claims it doesnt really have enough authority. The new fda commissioner has suggested that there could be opportunities where the fda could partner strategically with medicare to prevent the deliberate blocking of generic competitors. From your perspective, how can we address this issue . Mr. Azar i am aware of that also as one of the abuses that occur, genericbrand competition in the market. I would look forward to working with you to get to real solution the r. E. M. Program could be used to block entry. And once we get to the end of life, do the rems programs continue to make sense. Are they legacies . Are they still required for safety . Be statutory changes, i dont know, but we need to solve that. Thats one of the things that has to be solved. Sen. Collins thank you very much. You referred to the end of life. Mr. Azar the end of patent life [laughter] thank you for clarifying that for me. Senator warren. Sen. Warren thank you, mr. Chairman. Ill get right to the point. Your resume reads like a howto manual for profiting from Government Service. About a decade ago, you worked in government helping regulate the nations most profitable Drug Companies. And when you left, you went through the revolving door and became an executive at eli lilly. Last year they paid you 3. 5 million for doing that. Not bad. And now you want to go back through the revolving door and regulate the same Drug Companies, at least do it until you decide to go through the revolving door again. I dont think private sector experience should disqualify serving, but the American People have is a right to know that the person running hhs is looking out for them and not for their own bank account or for the profitability of their former and maybe future employers. So i have some questions along that line. The first is, do you agree when a drug company lies about its products or defrauds taxpayers, it should be held accountable by the federal government . Mr. Azar of course. Sen. Warren good. Because right before you went to work for eli lilly, you worked at hhs while they help the Justice Department with an investigation of the drug zyprexa. It was approved to treat schizophrenia and bipolar disorder. But eli lilly decided to boost profits by pushing the drug ob on Nursing Homes for uses like dementia and alzheimers. With no proof that it would work. The word for that is fraud. And it cost the government and taxpayers billions of dollars. Eli lilly was still under investigation when you left Government Service and went straight to work for eli lilly. As the companys top spokesman, you helped manage the fallout in when the company was forced to 2009 pay the largest criminal fine ever imposed in a prosecution like this. 500 million. At that time, eli lillys ceo isd doing the right thing nonnegotiable at eli lilly. Do you think that settlement represented adequate accountability for eli lillys criminal behavior . Mr. Azar so senator, i want to be really clear the conduct in that case occurred and ended long before i ever even left the government or thought about going to lilly. I was not involved in that case when i was in the government. I think i actually learned about even the investigation for the first time, although it had been in the media, i think i learned about it when i was interviewing and learned about it and wanted to do my own inquiring. Sen. Warren then you became the spokesman for lilly. Mr. Azar i became the global head of corporate affairs. I will tell you, the conduct that occurred there was unacceptable. And theres not a leader at lilly that would say differently. It was a massive learning and transformational experience for the company. Sen. Warren was the settlement adequate accountability for eli lillys unacceptable behavior . Mr. Azar it was the largest at the time for about a week and then another company had one. Sen. Warren do you think it was adequate . That was my question. Mr. Azar it was the largest ever. Sen. Warren but was it adequate . What was senator, important about that is that it changed behaviors. Sen. Warren im sorry. What is important is the and that is asking whether or not there was adequate accountability. Mr. Azar i do believe so. I dont have any reason to believe not. Sen. Warren lilly made billions of dollars off this scheme. And they paid a half a billion dollar fine. And they said thats a huge fine. The truth is it is a huge fine. But they made far more money than they actually paid out. And for me, thats just not adequate accountability. Your ceo got to keep sleeping in his own bed at night. At the end of that year he was paid 1. 5 million for his troubles and another 3. 6 billion in socalled performance bonuses. I think the message was clear to other Drug Companies. Within eight months, pfizer was caught doing the same kind of marketing. And slapped with a criminal fine. Since then there have been four more drug company settlements in excess of these settlements have 1 billion. Become a cost for doing business for the Drug Companies. And as we speak, eli lilly is the subject of multiple lawsuits and investigations accusing the company of conspiring to illegally raise its prices of its insulin products. But were supposed to believe that this time around, youre going to be willing to hold them accountable in a way thats going to make a difference. Shouldou think the ceos be held personally accountable when Drug Companies like eli lilly break the law . Mr. Azar so senator, there was a period of time where across the pharmaceutical industry, there were various practices that got resolved through litigation. What im quite proud of is the fact that i was not there as general counsel. I did not negotiate the settlement of that case. But the attitude that i saw top to bottom globally of the company around that was one of , how do we make sure this doesnt happen again . How do we ensure that the processes, the culture, the ethics, the oversight sen. Warren im out of time. I understand that im out of time. I just want to make it clear for the record i asked the question , about whether or not you think ceos ought to be held accountable when the companies they are running break the law . Im just try to get a little accountability question answered. If you have a yes or no answer, ill take it. Mr. Azar im satisfied with our discussion. Sen. Warren i will take that as a no, you would not hold them accountable. Thank you. Senator cassidy . Senator young . Sen. Young thank you, chairman. You have been caricatured by predatory, avaritionary advisor. I want to say a few words here opposed to my giving an extended speech. Can you talk about what you did in your previous tenure at the agency around the drugpricing issues . Mr. Azar senator, thank you for asking about that. Back in the Bush Administration when i was general counsel, there was a clear abuse occurring where pharmaceutical companies were taking advantage of a loophole in the drug laws to allow them to have longer, longer, longer patent periods. They would get to the end, they would file a new patent and get another extension. And what i said to our legal team was this is unacceptable. Nobody has ever thought of a way to deal with this without legislation. Let us see, can we interpret the statute in a way that prevents that . Drove that, drove that. We got to the point that we put out a rule that allowed only a single 30month stay in litigations. You got one shot at the apple, instead of these things that could cause a drug to last for years and years longer. The Economic Impact of that rule was estimated to save consumers 34 billion over 10 years. That rule was later entliened through the leadership of senator mccain into statute. In the medicare modernization act. Young i would like you to repeat that for those who may not have been paying attention and may want to fuel a false narrative that you are not sensitive to drug pricing. You created a process by recognizing an anomaly in the law that led to a regulatory change that saved how many billions for consumers in Prescription Drug prices . Mr. Azar 34 billion over 10 years. Sen. Young my constituents will be happy to know that. Mr. Azar, you participated in a symposium at the Manhattan Institute last year. Do you recall that . Mr. Azar i do. Sen. Young at that symposium you stated were on the cusp of a golden age of pharmaceutical breakthroughs, but the problem is our outdated process is threatening to squelch Patient Access to this recent and revolutionary burst of information by shifting a crushing burden directly onto individuals. A lot of americans paid for their drugs through Health Savings accounts. Is there something we can do with hsas or other vehicles to help with drug costs . Mr. Azar i do think that there is. So one of the things when you have a high deductible plan, thats one that has 6,000 that you have to pay out of pocket before the insurance starts paying. The law says that you that the plan cant cover during that period of deductible unless it but the government hasnt put out really good guidelines on what can be covered as Preventive Services so patients can have first dollar coverage, so their Health Savings account could cover those Preventive Services. Also, changes that would allow more money to be put away, more flexibility, anything that lets the patient have access to more money or lower copays when they walk into the pharmacy has to be part of what we drive towards. Sen. Young ive asked that your past professional history. You were able to lower drug costs. I asked about any ideas you might have revolving around Health Savings accounts. You put forward an idea that could help reduce the cost burden on consumers. Im encouraged by that. I hope others are as well. I have roughly 40 seconds left. President trump has indicated welfare reform will be a priority moving forward. It is a priority of mine. Much of the policies that fall under the category of welfare are under the jurisdiction of hhs. I will submit a question for the record. I want to see what sort of changes you anticipate hhs making through executive order to improve our welfare systems, and serve us. With that, thank you. Thank you, senator young. Senator hassan. Hassan thank you. Good morning, mr. Azar. Congratulations on your nomination and congratulations to your family. As you know, New Hampshire has been ravaged by the heroine and Opioid Crisis. We are in need of resources to help those on the front lines. Flawed funding formula to allocate resources from the 21st century cures act, so the hardest hit states didnt get adequate resources. Even though weve asked them to change the formula am a hhs has declined to do that. That theig problem is Trump Administration has refused to request additional funding to fight the crisis, which has prompted many to question whether the president is serious about addressing it. We need this administration to send a request to congress for Additional Resources to combat the Opioid Epidemic. Yes or no, if you are confirmed, will you commit to me that you will encourage the Trump Administration to ask congress for at least 45 billion to fight this crisis, a number that has bipartisan support . Mr. Azar thank you. Im glad we are able to have the discussion. I dont know the number, but what i will commit to you is, if im confirmed, im going to work to assess if we have the resources we need. If i do not believe we have the resources we need, work with congress to do that. Sen. Hassan i dont know a governor of either Political Party who believes we have the resources we need. Will you also commit to examining all substances use Funding Sources and formulas and directing more funds to the states hardest hit by the crisis . Sen. Hassan i dont know mr. Azar i dont know the precise issues, how much is statute and discretionary, but absolutely. I know your concern about the money going to New Hampshire. I certainly will work with you to look at that and see what flexibilities there are. Sen. Hassan the money has been distributed basically on population as opposed to the overdose death rate per capita in particular states. Lets move onto another issue. Hasdrug Company Allergan engaged in unacceptable behavior to shield patents of its drug from review, in order to prevent generic products from entering the market, and denying consumers alternatives. Allergan announced it paid a native american tribe to take ownership of the patents, and licensed the patents back from the tribe, continuing to sell the drug as usual, exploiting tribal sovereign immunity. Allergan is renting the tribes sovereign immunity to protect profits. The move ultimately is meant to stop generic versions from coming to the market. This outrageous deal was called a ploy by a Federal District court judge. I would like to know what you think about this deal. Should Drug Companies like allergan be allowed to rent out tribal sovereign immunity to shield their patents . Mr. Azar i do not know if i would have any actual enforcement. But i would say i would share your concern about any type of abuse around extensions of patent or protecting from whatever legitimate processes there are. Sen. Hassan i appreciate that. If you are confirmed, i hope you will work with me and others on this issue, understanding there are multiple agencies that have some jurisdiction here. I want to touch on another issue. The country recently learned of the case of jane doe, a 17yearold woman forced to continue her pregnancy against her will in the custody of a shelter that contracts with hhs. Jane doe was eventually able to receive the abortion that she decided was necessary for her and the court confirmed was necessary for her. That theme to light director of the hhs office used very disturbing tactics to block abortion access. Seekingnted miners abortion care from meeting with attorneys. He suggested placing pregnant minors with sponsors who would override their choice about pregnancy. He personally visited pregnant minors to pressure them to continue their pregnancies. Political appointees in washington at hhs should not be imposing their own ideology on these young women, nor should they be coercing or shaming them. If confirmed as secretary, do you agree you have an obligation to follow the constitution and the laws of the United States, even those you do not personally agree with . Mr. Azar i take the obligation as a solemn obligation, absolutely. Sen. Hassan im glad to hear that. I will follow up in discussion with you. Thank you. Senator cassidy. enjoyed our conversation yesterday. Thank you. Im a physician. Ive worked in louisiana, taking care of the uninsured and the poorly insured, which is to say medicaid patients. Theres a lot of data that patients covered through medicaid oftentimes have worse outcomes than those who are covered through other forms of insurance, even when correcting for Disease Burden and social economic factors. Clearly we should have a bipartisan interest in having Outcomes Data that shows who is doing a good job and who is not. If someone is doing a good job, reward it. If not, find out why. Fair statement . Mr. Azar i couldnt agree more. Sen. Cassidy im told that for medicaid and chip, right now there is in theory a structure for this Outcomes Data to be accumulated and prepared. Thoughts on that . Mr. Azar i do not know the data sets, but if confirmed, i will gladly look into that. Evaluating always be programs to see what works, what doesnt work. Our goal is that people have Affordable Care, access to care. We ought to be using any data we have to find that. Sen. Cassidy yesterday, you were meeting with senators from both sides to go over certain issues. Our Ranking Member and chair have been very good about that. What can we do to have better data sets so that Patient Outcomes can be monitored . If you dont measure it, it doesnt improve. We need to measure that. Mr. Azar i appreciate your invitation in the event that im of processo any kind to work through these issues. If i am confirmed, i hope you will find that my style is, i dont believe ive got the answer to every problem. I want to have an open dialogue. Im a problem solver. My brand is that if theres a program that is not working, i want to work on solving that problem and get the best input and best ideas. Theres something you can do administratively, we dont have to mess with it. If theres something you need legislatively, that is the purpose of this. Mr. Azar if there are ideas about what can be done, i would want those ideas also. Sen. Cassidy Public Health, i as working with others regards how to have a Public Health fund. Weve got another zika, it doesnt take a special appropriation, just to give you my thoughts on that. Under katrina, congress had to appropriate money to respond to katrina. Out, lets putd the money up front. From my perspective, we should be doing that for Public Health as well. What thoughts do you have as regards how we can help you better respond to Public Health emergencies . Mr. Azar i was one of the architects around project bio shield. I really see the benefit of having predictable funding and the ability for the government to be a reliable partner in the development process. I would be happy to work with you. Sen. Cassidy how do you safeguard from the money being frittered away on things which are not Public Health emergencies . Mr. Azar one would have to draw the line. I would share that concern. You would need to make sure it is built into a program for Public Health emergencies like zika, ebola, or the Countermeasures Development programs. Sen. Cassidy this may be something to encourage that you monitor. I, if i say white house, they think pennsylvania avenue, sheldon and i put forward something for health i. T. My physician colleagues are retiring at age 55 because they are sick of Electronic Medical records and the dampening on their ability to interact as well as their productivity. Includedh i. T. Act was , supposedly it is progressing well, any thoughts about that and how we can ensure that health i. T. Becomes an enabler of patient physician relationships . Mr. Azar i need to be careful here because my father may jump to the table and start telling you about all the problems you are talking about. I think when secretary leavitt was secretary and we went down the journey on health i. T. , he was adamant. Electrification of Health Records without interoperability is not useful. That is just moving files to a different place. Im afraid weve done a bit of that. Weve electrified, but we havent gotten interoperability. We have made it to complex. I would love to work with this committee. I will work within hhs to drive towards interoperability. It should be an enabler. The doctors eyes should be on the patient, not on the computer screen. Sen. Cassidy fantastic. I yield back. During our 21st century cures, we veered off to the side and held hearings on Electronic Medical records. All of us are interested in it. We made some progress with the last administration. Tomay set up a roundtable try to continue that focus over the next couple of years. Senator baldwin. Sen. Baldwin thank you. Thank you, mr. Azar. Theres been a lot of discussion about experience, insight, as well as potential for conflicts. Obviously experience and insights can be extraordinarily helpful. President d from the that he wanted to drain the swamp. Weve heard phrases like, foxes guarding the henhouse. And the revolving door. That, the perspectives you would bring, having served in large pharmaceutical corporations in a leadership post, brings a very specific perspective, especially as we tackle one of the critical problems of our day, the high cost of Prescription Drugs. Hearing recently in this committee on drug prices. I felt there was a lot of fingerpointing from the folks dais, talkingr about whether they were from the perspective of big pharma, or pharmaceutical benefit managers, or all the other players in this system, citing complexity, citing their fault, not ours. But because of your background in the pharmaceutical industry, i would like to not hear fingerpointing, but what can be done. Whove many constituents share personal stories about their challenges with the increasing and skyrocketing cost of lifesaving medications. Wisconsinstoddard, sons with type 1 diabetes. Extending over 1000 a month just to maintain insulin and test strips. President at eli lilly, you were there during a time that there were radical increases in insulin prices. 1000 reased more than since 1996 and over 200 during your tenure. , moreu tell us specifically greg and his sons, why eli lilly and other companies are systematically increasing the list prices of drugs that are already on the market . Mr. Azar thank you for that question and thank you, i really enjoyed our discussion the other day on this and other issues. Fingerpointing, ive been really clear, even when i was at lilly, fingerpointing is not a constructive enterprise. Everybody owns a piece of this. The government owns a piece of this. That is why i want to serve. The experience i bring can help me with changes that one company cant impact. Sen. Baldwin my question specifically is, what would you tell greg and other constituents about eli lillys role . Mr. Azar the insulin prices increases have been significant. The problem is that system. Greg and his kids o i should tellho them it is the system . What about the drug manufacturers are the starting point . What should i tell greg about increase during the time you were there in the price of insulin . Mr. Azar what we need to do is work to fix so that greg and his kids have insurance that covers that insulin, so they have low outofpocket, so we have to get the list prices down. Sen. Baldwin that starts with the drug manufacturers. This is reminiscent of the hearing we just had. It is a complicated system, this and that. It starts with manufacturers setting the list price. I see im already hitting my time and i had lots of questions. You talked about generic and branded competition. You talked about the gaming of the patent system. Theres a bit of q a about reimportation. The things i want to talk about, the role of transparency and getting the pharmaceutical companies to justify their increases in price. I have a bill along with senator mccain to require that for Companies Planning on increasing their prices. And secondly, the role of negotiation. Thank you, senator. Senator isakson. Sen. Isakson thank you. Im glad we didnt have our meeting before this. Im going to ask a question i might have been talked out of asking you. Having heard ms. Warren, having been part of the debate, being a senior that buys a lot of pharmaceuticals myself, the cost of pharmaceuticals, the gaming of the system, is a huge issue. At the risk of being presumptuous, i would give you a homework assignment that i hope the chairman and senator will back me up on. Will you come back to us with your recommendations on what to do to help end the gaming of the system . Mr. Azar absolutely. Sen. Isakson you are uniquely qualified, having been a ceo, knowing what you know, taking on the responsibility you are about to take on, to say these are the things that are being abused by the pharmaceutical companies or whoever it is. Im not interested in blame. Im interested in solutions. Oftentimes these debates and responses end at obfuscating solutions that otherwise might be talked about. Mr. Azar i would look forward to the opportunity. Sen. Isakson secondly, i live in atlanta, georgia. Ive been a representative for 20 years. Cdc, the home of Worlds Health center, which got very little notoriety, but solved the ebola problem when it contained an outbreak. Same thing with ceca. Zika. We were able to get people under care, isolate them, treat them, and all for who went to emory survived ebola infection. Commitment that you will continue to advocate for cdc and its funding and its ability to meet the challenges of the 21st century. We dont yet know what they are. The cdc and its leadership and career staff are the envy of the world. I share that view. Sen. Isakson theyve saved a lot of lives and prevented so many tragedies from happening. This may seem to be a silly question. I was a salesman all my life. The medical loss ratio in the Affordable Care act includes the cost of a Sales Commission as part of the medical loss ratio formula, which put most people who sold Health Insurance to individuals out of business. The commission they would be paid, though very modest, would throw it over the cost ratio. Today would try to find a way to get insurance. Theres no financial insurance, security, for anybody to offer them, because they are priced out. Senator kunz and i have introduced legislation to end that by taking it out of the calculation. I think that will expand access and exposure. Would you help us with that . Mr. Azar i would be happy to work with you looking at that. It is an issue i havent focused on. I had not known of that concern before. Sen. Isakson thank you very much. Thank you, senator. Senator franken. Sen. Franken thank you, mr. Chairman. Congratulations on your nomination. I would like to ask a few short questions, yes or no. Are you aware that the aca required health plans to cover evidencebased Preventive Health Services Free of charge . Mr. Azar theres a provision those are part of the essential Health Benefits, if i understand the framework correctly. Sen. Franken are you aware that hhs commissioned the institute of medicine and the independent Nonpartisan Organization of experts on health and medicine to review what Preventive Services are necessary for Womens Health and wellbeing . The institute of medicine recommended coverage for all fda approved Birth Control methods free of charge. Mr. Azar i believe that is the case. Sen. Franken do you agree with the conclusion that access to free Birth Control is vital to Womens Health and wellbeing . Mr. Azar separate from the issue of any Birth Control or which ones should be covered, one of the principles we have around thinking about access to insurance, is it ought to be assurance the individual wants to acquire. If i have concerns, my concerns are at a much more precedent level, not about this drug, that product, but rather, should there be flexible for the individual to choose the insurance package they want . Animus toward any preventive service. Our system off to enable flexibility that does not exist with the current framework. But you agree thatou the institute of medicines conclusion that free Birth Control is vital to Womens Health and wellbeing . Mr. Azar i havent studied the report. Programs has important to provide Family Planning assistance and services. Sen. Franken do you agree with the institute of medicines conclusion that access to contraception free of charge reduces unintended pregnancy, which reduces frequency of abortions . Mr. Azar i havent studied it. It seems to make some sense as you state it. Sen. Franken do you agree with the institute of medicines conclusion that reducing unintended pregnancy also reduces the Health Risks Associated with such pregnancies, and that contraception helps women to increase the length of time between birth, which reduces Maternal Mortality and pregnancy related convocations . Mr. Azar i think we all share the goal that unintended pregnancies, especially by teens, is something we want to work to prevent, and educate, and use our programs to support that. Sen. Franken do you agree with the Trump Administrations actions to undermine the access to Birth Control . Mr. Azar on that issue, that is a balance between the essential Health Benefit and the conscience of the organizations involved. I think it was close to only 200 organizations, whereas the actual Affordable Care act implementation around the contraception mandate actually excluded tens of millions of people who were in grandfathered plans. This conscience exemption has a much smaller impact, i believe. Sen. Franken the law requires that Preventive Services be evidencebased. This is evidencebased. Hhs you take steps as secretary to make sure that women have free access to contraception . Mr. Azar i will follow the law. If the law requires the coverage and the evidence and science and facts support that, i will follow the law there. I will also, as the president has done, try to balance the conscience objections of organizations and individuals. Sen. Franken a number of my colleagues have expressed concerns regarding your track record and eli lillys track record on drug pricing, and i share their concerns, especially in regard to eli lillys actions to spike insulin prices. Im running out of time, so im not going to be able to, but i wanted to get into medicare drug price negotiation. The president has said he is for medicare being able to negotiate in part d with the pharmaceutical companies on the price of drugs. Do you agree with the president that medicare should negotiate for lower drug prices . Sen. Franken the president mr. Azar the president has spoken to the fact that medicare is negotiating and getting the best prices. Part d has negotiation through the biggest pharmacy benefit managers that secure the best net prices of any players in the commercialsystem. The commercial system. I sat on the other side of that. What id like to do is think about how can we take the learnings from part d maybe into part b . Part b is the program when a physician administers a drug, the government simply pays the sales price plus 6 . How could we think about ways to take the learnings from part d and actually bring lower costs to the system but also lower costs to the patient, because they pay a share of whatever medicare reimburses in part b. Thats a double win. It could lower for the system and lower for the patient on their outofpocket. Thats the kind of thing i would have energy to see where we could actually really save money and improve things for our patients. Im out of time but i would just note that the v. A. Is able to negotiate for prices for their drugs and i think in Medicare Part d we should be able to do the same thing they do in the v. A. Thank you, senator franken. Senator roberts. Thank you, mr. Chairman. Mr. Azar, alex, thank you for coming. Congratulations on your nomination and thank you for being here today. Its already been stressed about your prior work at the department of health and Human Services, as well as the confidence in you shown by the senate. Sometimes we have to do a multitask here. I apologize for that. But at any rate, the confidence shown by the senate to unanimously confirm you to positions at that agency twice already and highlight the strength of your qualifications. I appreciate the chance we had to chat. I think it was monday. Some particular areas of interest for me, improving our care system. You are a hoosier but you did find a kansas girl to marry. As the folks in kansas know, theres Nothing Better than a south raider. I wanted to make sure that you understood that. Thank you for bringing your family. As both a member of the Health Committee and chairman of the agriculture committee, particularly interested in hhs and more importantly the fdas work on food and nutrition policy. We talked about that. A common message i hear is the need for regulatory certainty. Just a moment. I beg your pardon. Will you turn that off . Thank you. More importantly, fdas work on food and nutrition policy. A common message i hear is the need for regulatory certainty, in particular on the biotech front which is a critical tool for agriculture today. Back in january, both fda and the usda proposed rules and guidance on biotechnology. Recently, as a recent stake holder comments, the usdas animal plant and Health Inspection service has decided to withdraw the proposed rule, reengage stake holders and solicit comments to create a new rule. If confirmed, what steps would you take to engage and coordinate with other agencies involved with the regulatory review of Biotech Products to harmonize future rule making efforts . Im not familiar on that particular rule making with the pullback, but i can assure you that i would share both goals that i think you have articulated. The first is it is the job of the government when regulating to give clarity. They want to comply, they want to know the rules of the road. The second is especially in the area of food safety the level of coordination between hhs and the Agriculture Department is absolutely essential. I appreciate that very much. Absolutely essential. I appreciate that very much. I just want to make one other observation, mr. Chairman. Ive been watching your children and these youngsters are here and ive been watching your dad. Your dad is very proud of you and your wife is obviously very proud of you. I want to tell you young folks welcome to politics 101. Polly site on a one. Were asking questions that many members have on their mind and theyre very important questions. I want you to be proud of you dad. Hes done a good job in the past. He will do a good job in the future. He will be confirmed in my view and not only by this committee and not only by the finance committee but also on the floor of the United States senate and then also by the president. Thats a long process. Sometimes it gets a little tough. We ought to be handing out selective earmuffs for young people. Be proud of your father. Hes a good man. Thank you. Senator roberts. Senator whitehouse . Welcome, cesar mr. As are. I dont think there is much that you and i are going to accomplish today on the question of drug pricing, but i hopevery hope very much in office you will take the side of the American People and not just the pharmaceutical industry or worse yet the investors who have raided the pharmaceutical industry with the solo mission to jack up prices on necessary pharmaceuticals and extract money with monopoly authority. We know how to deal with that ordinarily. I want to talk about a different situation, which i think is an opportunity for considerable bipartisan progress. I want to start with tworhode two rhode island stories. You know what a medicare aco is. I do. I do. We have two in rhode island. One is a very early one, coastal medical, which over four years has saved medicare 28 million relative to its benchmark while maintaining a 99 quality score. That makes it one of the best in the country. Its average per member per year expenditure is going down, while the satisfaction and health of its members are going up. Similarly, Integra Community Care network has saved medicare 12 million while achieving a 95 quality score. I say this not just to bragon brag on rhode island providers but because i think , it is the answer to a much larger question that we face which is heres the graph of Health Expenditures more or less in my lifetime for the country. 27 billion to 3. 2 trillion. Its a curve that is breaking the bank. We have got to figure out how to fix it. One of the ways that we can look at fixing it is to look at this oecd chart which shows a lot of our competitor nations right here. Theres the usa as a big outlier. This maps Life Expectancy puts us at the highest cost per capita for health care in the world and gives us Life Expectancy comparable to the Czech Republic and chile. Were actually beginning to see a little progress here. Let me explain what this is. This top line, the red line, is what cbo predicted for federal Health Care Expenditure back here when it made the prediction in 2010. Then events moved forward post the Affordable Care act. Sure enough, we were coming in below. Here in 2017, the baseline was rewritten by cbo. The difference in this tenyear budget period between what cbo predicted in 2010 and 2017 amounts to 3. 3 trillion in savings. So the case that i would make to you is that if we want to take on the Health Care Cost problem, weve got to take it on through entities like these acos, because there is a sweet spot that we can bring that cost back from our outlier position in the United States while improving the quality of care. Ive seen it happen in rhode island. The reason the cost is going down for coastal medicals patients is because they get home visits when theyre sick because theres telemedicine that gets their testing results in because a nurse will call them when they dont hear with them. Over and over again, it is better humane engagement that reaches the patient where they are that has this wonderful benefit of improving health and Patient Experience while also bringing costs down. Were not seeing less increase in the costcurve from integra and coastal medical. We are seeing cost per medical going down. Promise me you will not get idealogical when it comes to solving this problem and you will work to solve it in a sensible, bipartisan, thoughtful way. I would just say amen. Just hearing those stories is exciting to me. It is i think one of the great legacies of secretary burrwells tenure was launching so many of the alternative payment models that we have out there. That was that third leg of my priorities if i am confirmed as secretary. I think for those of us who care so deeply about improving quality, reducing cost in our Health Care System, improving coordination. Theres just so much opportunity for bipartisanship here because we share so much of the same goals on this. Medicare can play such a role. Its the only payer that sits there with enough concentration of lives to change the system. Correct. I think United Health care i dont think theres a market that has more than a couple percent of patients and has to follow what medicare does. Im going to invite you to come to rhode island and see these guys. I would love to. I look forward to that visit. Thank you, chairman. Senator casey . Excuse me, i made a mistake. Senator murkowski is here. Thank you, mr. Chairman. I know im at the end of the dais and came in later but there is added benefit to being one of the later ones and having the full opportunity to not only hear most of your opening comments, sir, but to hear the questions and inquiries in your responses back. Again, congratulations on your nomination. I will also be curious to hear your response to senator pauls inquiry regarding importation of drugs. Certainly for those of us in alaska where our neighboring country is canada. Many in my state wonder why we are not able to do more when it comes to safely importing. I too am curious to know what you might propose in that area. Senator baldwin mentioned the hearing we had some weeks ago about drug pricing. And i think a general level of just confusion and bemusement that many of us had, were engaged in a fair amount of finger pointing. When you try to drill down to how we can do more from a transparency perspective, i think this is something that we all recognize that we can do a better job with. Again, i look forward to more detailed response from you. Were going to have an opportunity to meet tomorrow. So i will probably hold more of my alaska specific questions for that time. One of the other discussions that we have had in this committee recently as we have been discussing the aca and some of the requirements within it. We had recommendations from some who have suggested that the Navigator Program currently in place no longer needs to be funded. The president really axed it not too many months ago and it was pointed out that not all parts of america are equally situated. We dont have a drug store on every corner in alaska. In most of my communities we dont even have a drugstore. So the role that the navigators have played in helping walk many alaskans through the intricacies of insurance and what is available has been important to us. Nobodys really asked that question here today so i would ask for your views, your plans. What do you see the role of navigators moving forward . How can you provide assurances in areas where we simply dont have the professionals that could assist individuals, that they know what their options are . Thank you. Its good to see you again. I look forward to discussing alaska issues with you when we meet. I doubt there will be a secretarial nominee who has spent as much time in alaska as i have. I think you recognize there are some unique aspects and your focus on Behavioral Health with native peoples. Absolutely. In terms of the Navigator Program and outreach, myfew, as outreach, my view, as it is with so much of the programs, is do what works. I am not at the department, so i dont have the data. I havent seen everything. My understanding about the changes in the Navigator Program were focused on Navigator Program elements that werent working in renewing and funding navigators that were age to demonstrate results in doing the work. I dont know the specifics about the alaska situation. I can only tell you i do genuinely get it in understanding the uniqueness of the very frontier nature of so much of alaska. Id be happy to work with you so see what are the ways we deal with that. Its really just what works. I think i said pharmacies. Its not only pharmacies. Its also those who help us navigate through the insurance side. Very quickly, theres been a lot of focus also on Womens Health care, preventive care, eliminating the risk of unwanted pregnancies. I happen to believe the more we can make contraception available and affordable to women, the better off we are. I have long wondered why we are still these many, many, many decades after prescription Birth Control was made readily available, why we have been so reluctant to move to over the counter products for Birth Control. You also have the requirement for a medical appointment in in order to get that prescription. Do you see a way or an opportunity for us to reduce the barriers for more affordable Birth Control, pills, contraception and in a way that can really help women in gaining greater access to contraception . So the over the counter regulatory regime, as you know, is this otc monograph procedure that commissioner gottlieb, i am very glad, has was out of date in the 1970s and need a lot of updating and work to really speed to approval of products over the counter for the course availability, cost to the system. Of course there are scientific and legal standards that have to be met by the sponsors of a product in terms of theability in terms of the ability to selfdiagnosis, selftreat. And there are user studies that basically need to be conducted. It would be driven by that, would be my view on any product that the fda would have to decide on. I think the regulatory system really needs a close look at on how we just generally think about over the counter and improving availability of otc products for people. I would encourage you. Mr. Azar, good to be with you. We had some opportunity to talk in my office yesterday. Im grateful for that. Grateful for your willingness to put yourself forward again for this work. I want to thank you family and extended family for their commitment. As much as Public Officials work hard, their families often sacrifice more. You and i have a home state in common in terms of where we were born, not where we were raised. I know youre a johnstown native. Im a scranton native. But i wanted to start with something fundamental. I wish we didnt have to start here but because of the interaction between dr. Price and this committee i have to ask this question. When dr. Price came before this Committee Prior to his confirmations, members of this committee submitted a number of questions to him to answer on the record in writing. He didnt provide a lot of responses. Im going to be very precise in these questions. Do you commit to finding answers to all the questions you received following appearances before this committee . Ill certainly be happy to comply with the senates nomination procedures and the nomination setting. And then of course, ongoing appearances before the committee with the protocols of the committees in the senate. Do you agree that answers questions for the record posed by Committee Members during the nomination process is part of that compliance . What i do not know is just what the protocols are between the Health Committee and the finance committees. I am not familiar with the customs. Id be happy the get back to you on that ill take that as a happy to get back to you on that. Ill take that as a tentative yes for now. I hope you familiarize yourself with those rules and respond accordingly. We should not have to engage in a back and forth on basic questions for the record. I wanted to ask you in light of the debate on health care, the substantial debate that undertaken over the last couple of months on the Affordable Care act and especially medicaid. In addition to that debate, some of the statements youve made that have been critical in one way or the other of the Affordable Care act and commenting on the process. Now butre seeing appointment, a confirmation vote on hhs secretary. That, of course would confer on you responsibilities you dont currently have. In light of that and in light of that and in light of the debate, just to be very clear, do you commit to faithfully implementing the Affordable Care act . If i am confirmed as secretary, my job is to faithfully implement whatever the congress has decided. My hope would be to implement it in ways if it remains, i obviously belief, the administration believes that statutory changes would be good. If it remains the law my goal is to have a way that leads to affordable insurance, choice of insurance, real access, not a meaning a meaningful insurance card. And insurance that has the benefits that people want. Let me ask you about an issue that frankly doesnt get enough attention. Its the efforts that have been made by the administration to undermine the Affordable Care act. That is my view of it. I used the word sabotage. I think thats an appropriate description. Let me define more specifically what i mean. When i say sabotage of the forgot, i mean the following. Drastically cutting funding for advertising and out reach activities. Number three, spending funds meant to promote enrollment on a pr campaign to instead undermine the law and support repeal of the aca. Number four, spreading false health about the health of the marketplaces. Number five, working to roll back Health Insurance protections in undermined coverage. Thats the predicate for the question. Would you oppose those efforts knowing you have a responsibility to faithfully implement the wall . Implement the law . I would disagree that theres any effort to sabotage the program. People want to make the program work. The csrs was a legal decision that congress had not appropriated the money. Other elements i can speak for myself how about cutting funding on out reach and advertising, appropriate or inappropriate . At some point these Insurance Companies have to do their own job. Are you asserting the advertising dollars are not cut. They are cut. To the level of this program to the level of Medicare Part d. Are you asserting that the senator kaine . Good visiting with you yesterday. I have one question about each of your four goals, but before i do ill tell you what i said to you yes. What im looking for from you is a commitment to the health care safety. I voted against your predecessor because he had commented negatively about planned parenthood, chip, medicare, medical care and the Affordable Care act. I dont think we can have an hhs secretary who doesnt support the safety net. Thats what im looking for you. You say drug prices are too high. As a member of the aging committee, i kind of became convinced that theres a new model out there thats patients as hostages, patient who is need patients who need drugs who cant afford to go without them without risk to their life or health are treated ashostages. As hostages by pharmaceutical companies. Theres a story in the Washington Post why treating diabetes keeps getting more expensive. Over the past two decades eli lily and nova raised prices on their insulins 450 above inflation. Convince me that eli lillys not a partivity is of this patience as hostages business model. I said in my remarks earlier today, the insulin prices are high and theyre too high. The system that weve got, it may fit for the stake holders behind the scenes, but for the patient that youre talking about weve got to recognize its not working. Do individual actors in the system have no culpability . Theyre making the decisions, the choices are happening. I think everyone shares blame here. What weve got to do is i want to be a productive engine if i can be secretary to work with you on solutions to fix that for the patient. Let me ask you about your second one. We must make health care for affordable and more tailored to what individuals want in need of their care. Amen. Then youve got a system thats youve got a sentence that is interesting. We must address those challenges for those who have been pushed out of the Affordable Care act. Its interesting that you talk about people pushed out of the market by the aca. Of course you know that the uninsurance rate has dramatically reduced in the country. Im not arguing that its perfect. But if you just read your statement it suggests there are fewer people insured because of the aca. We had dr. Adams in here recently from indiana. He said the uninsured rate in indiana has gone dramatically down because of the Affordable Care act, and the availability of premiums to help folks afford. In looking at this question, are you going to be part of the wrecking crew, i dont think thats an accurate or fair summary. Im happy to explain. I believe we can do better. I do too. I believe both for the folks that are in the mid markets right now that too many of them are paying too much for insurance. Was that your opinion before the Affordable Care act passed . I thought that was how it would happen, unfortunately. But the numbers of people uninsured in this country were dramatically higher than they are now. Our goals are the same in the sense that we want to improve access to affordable insurances better. The president wants this. I want this. I think we may only differ about tactics and approaches. I worry about the forgotten who arent in that individual market because it isnt affordable for them. Third, we must harness the power of medical care. Why didnt you mention medicaid . Medicaid is a very important part of your portfolio. I found it interesting in read in reading that sentence, you didnt say a word about medicaid. The only reason i dont mention medicaid in that context, its really that medicaid does not have the same kind of payment rules at the national level. That was my focus. Say im a governor and i ran a program. Its interesting. Wouldnt you also agree that we can focus to paying for procedures and sickness, shift that focus to paying for health and outcomes. The Medicaid Program can be part of that as well. It certainly could. If governors are willing partners to try to drive that, medically the secretary has more levers in his or her control to do would you try to do the same thing in medicaid . Public school. If we can make medicaid better, it will let us solve that. I enjoyed our conversation. I was very open to your namtion. Open to your nomination. Im very concerned about your answer to senator caseys series of questions. I just want to state it to you one more time and give a Second Chance here. This administration has shortened the open Enrollment Period by half. It has cut outreach funding by9d by 90 . It has cut funding for navigators by 40 . It is pulled out of state enrollment partnerships. Is your testimony today that this is all in service of an effort to make the aca better . Do you really believe the goal of this administration is to help people sign up for the Affordable Care act . So obviously im not in the government. I dont have access to all the data. My understanding and i cant validate this from the outside was that choices were made about whats working and whats not working. There also a policy decision around advertising that its time for it to be regularized in its amount of funding and advertising. So you think President Trump is taking these actions in the goal of making the Affordable Care act work better. I dont know that President Trump was involved. Those are probably decisions made at the hhs level or made as a matter of budgeting. I think the goal with the program youve got is do as best you can. This one has a lot of problems. If the Alexander Murray bipartisan package here helps what does cutting the Enrollment Period in half do to help . I wasnt involved, nor did i study the comments on the role on the Enrollment Period change. The Enrollment Period went from days. S to 45 let the plans know kwhos in their plans so they can plan predictably for the following year. If you run right up until the end, its harder for the plans to set their actuarial basis for the open Enrollment Period in the pricing. If you run that open enrollment the closer the end, you run up to january 1, it is very hard to implement effectually in the coming here. This is not insurers making for the open Enrollment Period. You put it next to an evisceration of all the programs that would help people understand the fact that the Enrollment Period has been cut in half. I think it strange. Im happy to look at that. I was not involved in that. So you said that there are things that the hhs secretary could be doing to make the open Enrollment Period work petter or to what do you think that you could do in the face of these changes to make open enrollment work better to make sure that people have the ability to choose wisely within the exchange . If you say these are changes that are made in the service of making the open Enrollment Period better, what else do you think can be done . Just to clarify, i dont believe i said these are changes to make it better but rather to eliminate what i think again, im on the outside. Im not looking at data or running the programs. So i dont know the status of thinking on each individual element there. My point is if something is not working, why arent we for why are we funding it . We ought to look at it. If certain of these vendors are not delivering, why keep funding that. That would be my perspective in looking at it. And then using your resources to put it on whatever the most effect live outreach programs. I havent been involved. I havent been at hhs for the Affordable Care act initiation or implementation. Let me follow up on some questions that senator warren was asking. I agree with her. Experience in the private sector shouldnt be disqualifying. We want to make sure you are not bringing the advocacy of who you used to work for into the government. Legalization of director consumer advertising. I know youve been critical of specific practices of individual Drug Companies. Is there any major issue on on pharmas legislative advocacy list that you disagree with. Senator, if i get this job, my enchance is to advance and protect the wellbeing of americans. I dont have pharmas policy agenda. Ive been gone for a year thats not my area of focus. My area of focus is the president s agenda and how can i work with this congress to make the programs of hhs better in the interests of all americans, not interest of any trade group for any company. This is the most important job i will ever have in my lifetime, and my commitment is to the American People, not to anywhere that i have worked in the past or any industry ive. I thank you for that answer. I think we have some senators who want to ask additional questions, so well have a second round. Mr. Azar, let me begin. Senator cassidy asked, senator white house would have. We can do something about this in the congress. Most of what needs to be done, youll have to do. Its a matter of administration. I had urged the Previous Administration to delay meeting because it was implementing it at a time when it was changing the way doctors and providers are paid. I think it would be wise to slow that down and get it right and build confidence among the physicians and other providers want what we are trying to do. I said that based on visits with hospitals like Vanderbilt University where they said meaning full use was helpful. Number two was ok and number three was terrifying. And i think so we ended up with six different hearings and a love of bipartisan interest in this. One thing that seemed to me to make some difference would be pretty simple. There was an ama study that showed that doctors believe theyre spending 50 or 60 of their time on documentation. It seemed to me that a good approach for this would be if thats true or not, at least thats the perception. Might be for the secretary to work for the doctors in medicare. And there are a half million of them say, ok, if you think you are spending that much time on documentation, either youre not doing your job right or were not doing our job right. Why dont we Work Together and set a goal to bring that from 5060 down to some other goal over the next three or four years and change the reality and the perception over time. I would seem to me that some is essential because the inoperability is one problem, excessive documentation is another. Its a big mess still. Even at a sophisticated hospital, and you want to take your own medical records to some other place, the best thing you can do is xerox them yourself, put them in your briefcase, carry them over and hand them to the next doctor. Even in a sophisticated place, after we spent 30 billion or 35 billion. Can you make it a priority, and you use some of this skillful managerial and executive experience background you have, to help us improve, a, interoperability, and b, reduce excessive physician documentation, both in reality and in perception. What are your thoughts on that . I think in both of those areas, thats a very sensible approach, mr. Chairman. Interoperability, again, it is ridiculous if we have a system now where you have to collect your paper records to go to a different facility. That is a betrayal of Division Secretary levittt laid out originally when we started down that journey and working towards, he would talk about the Railway System and if you dont get a single gauge, it doesnt work. And how in australia, they never decided on a gauge. You have three Different Railway gauges to get around australia now. My brotherinlaw can tell you about that. Thats where hes from. We need to work on that and get that fixed. On the Regulatory Burden or just the burden on the electronic Health Records with physicians, that would be my style of how to work, the affected individuals, they know whats wrong, whats happening, and get the input from them to see if there are appropriate changes that can be made. Might get your father to help you with that. Hes probably got some ideas. Secretary burr will actually change something in her administration with she believed the reality was different than the perception. It was the Patient Satisfaction survey that many of us were convinced was causing doctors and hospitals to prescribe more opioids in order to get a higher score on Patient Satisfaction. She was convinced that wasnt true. But it was true that people believed that. So she persuaded president obama to change the policy. I dont know exactly the amount of time that physicians are spending on documentation, but theyre really fed up with it. And for a whole variety of reasons which you understand well, we need to change that. So i would think some simple initiative, working with physicians especially, and hospitals, to say lets, if its 60 and the perception is 60 , lets agree on a goal. Lets take it a step at a time, lets take it to 50 . If its 40 , lets take it to 30 , and lets see whats being done about that. We cant do that well here. We can monitor it, encourage you, make some changes in the law, but basically, itsan its an administrative challenge, one you will hopefully take up and well let the senators here who are interested in that work withyou that work with you in a way that would encourage that. Senator murray, do you have additional questions . I do. Thank you again. I am very concerned about some of the responses, particularly to senator casey and senator murphy, who talked to you about what many perceive as this president directly and his direction to the administration, hhs, has been to make sure that aca does not work. The reason that we very adamantly support that is because many people are now getting access to care through insurance that did not get it before. Those are the harder to reach people, lower income, tougher populations. And they end up, we all pay for them at the end of the day if theyre not covered by insurance. The goal is to have as many people as possible insured, have access, get their preventive care, and dont show up in emergency rooms, costing everybody else, taxpayers and other folks who own insurance. Part of making sure, a critical part of making sure that they get access is through the outreach and through the longer enrollment. You answered a question about the open enrollment to make it in half, had to do with actuarials. The exact opposite is true. Insurance Companies Put their prices out. They have already figured that out. The open enrollment doesnt change their prices or their actuarial costs. What it does is make sure we have time for the harder to reach people to get enrolled and that they know what theyre doing, they often havent bought insurance before or have different kinds of access problems that take time to reach them into a sure and to make sure they understand what theyre buying. That is the intent ofthe longer enrollment, which this administration has cut in half and made it more difficult. The second thing is the outreach. And i was surprised to hear you answer senator casey by saying that Insurance Companies should pay for that outreach. They have a very different goal here. Theyre not looking for the tougher, sicker, harder to reach, more rural folks to sign up. They have a very different goal. As a country, as other people who pay for insurance see our premiums go up, we have that goal, and thats why its so imperative, and in fact, in the Murray Alexander bill, which you have been asked about, we reinstate that outreach money for that exact purpose. You will be hhs secretary if youre confirmed. You will be responsible for making sure that outreach money is used, used effectively, and the Enrollment Period works so that we reachthat. That we reach that. Do i hear you that thats not what youre going to do . Senator, i share your commitment. Any program hhs has, i want it to run as efficiently and effectively as possible and serve the beneficiaries of the program. Thats my style, my commitment to you and how i would work. Any particulars here, im not there, i have not studied the particulars of why the changes were made. I offered a hypothesis of what might have been the reason ofthe reason of the cutting in half of that to the 45 days, pricing before, and then implementation afterwards. I did see that with part d, when you bump up against january 1, just the Insurance Companies have time to get them insured, getting them cards and up and running. I have not seen that problem. I dont know, but senator, i want to be really clear. I want the programs to work for our people. I want to work with you if there are ideas to make them work, i want to make that happen. Do you share the goal of making sure as many people as possible who may be sick or harder to reach in rural or communities that havent been reached before should be part of what were working for . Of course i do. I want to make sure as many people have affordable insurance as possible. Absolutely. Who do you think is best equipped to do that . Reach them . The question you had asked there around advertising, advertising budgets, that money, my understand is that thelevel that the level of part d in medicare advantage, thats my understanding, is television. I dont think thats your Rural Outreach or hard toreach. Or hardtoreach. That was just your television, is my understanding. I may be wrong. That was my understanding there. So not about trying to reach potential beneficiaries get people enrolled into the program. It may just be talking past each other on that issue or my misunderstanding the nature of that part of the program. Ok. Well, im confused by your answer. I will say that. I want to ask one more quick question. I know my colleagues do as well. And that is, will you advocate for women to be able to make their own Health Care Decisions by supporting a broad safety net and insuring all women are able to see the willing, able, and qualified provider of their choice . So senator, the administration has, i believe you are asking a question about a particular provider that would be at issue. The administration has a perspective about whether that should be funded or not. That is a legislative choice. If i am secretary, i will implement what congress has passed and whatever congress has passed and the laws that we have there faithfully. Im out of time, but that does concern me. I will turn it over to my colleagues. Thank you, senator murray. Senator franken. Thank you. Mr. Azar, on monday, the l. A. The l. A. Times published an analysis of the Senate Republican tax plan. Which repeals the individual mandate or the federal requirement that americans have health Insurance Coverage. The Analysis Shows thatrepealing the Analysis Shows that repealing this provision threatens to derail Insurance Markets and conservative rural and couldthe country leave consumers in these regions sorry, mostvil missouriaska, iowa, nebraska, nevada,and wyoming, as well as parts of many other states, with either no options for coverage or health plans that are prohibitively expensive. Mr. Azar, in your Opening Statement, you said that you want to make health care more affordable and available to individuals. Given this new data, do you support repealing the individual mandate as part of the republican tax plan . Knowing that it puts rural americans coverage in jeopardy . So senator franken, what i do not support is forcing 6. 7 million americans to pay 3 billion of penalties to not buy something they dont want to buy through a mandate upon them. And 90 of whom make 75,000 a year or less. That i do not support. Well, i think you understand the structure of the aca, which is that you guarantee that you arent discriminated against for having preexisting conditions. And then if youre not discriminated against because you have preexisting conditions, then the motive for someone to get care, to get insurance, buy insurance, we have to mandate it. This is my understanding of the logic behind this. That to mandate it, people dont wait until they get sick to get insurance. And that just is the way and then you give subsidies to people who dont have the means to buy it. Thats sort of the threelegged stool of this. If the individual mandate is repealed, the Congressional Budget Office estimates that 13 million more people will be uninsured, and that premiums will go up by 10 . The Alexander Murray deal, which i worked on those negotiations and thank the chairman and the rankingmember for that, those are helpful. Its helpful, but its a temporary measure that cannot offset these estimated price increases or coverage losses. And given this and given that People Living in rural areas tend to be older and have Greater Health care needs than the average populations, what specifically will you do to make sure that People Living in rural areas are not hurt by all these current efforts by the Trump Administration to undermine the Affordable Care act . So as you articulated, i think you articulated well the theory of the mandate was a mechanism to pool Insurance Risk to create an insurable risk pool for the Insurance Companies to do their actuarial business. That was the theory. The challenge was Human Behavior decided otherwise. 28 Million People are not inthat are not in that pool, and it eroded the risk pool there. What i would love to work with you and congress on is coming up with systems that create effective the fact of the matter is so your rural citizens can actually have Affordable Care that gives them access, gives them choice, real choice. Half of our counties have one plan available to them. Right, and the fact i worry about that. Fact of the matter is under the aca, over 20 Million People who werent insured have insurance. And it feels to me that everything that this administration has been doing is basically aimed at undermining the markets and undermining the way the aca and undermining so that we can throw away these gains, but everything that is getting rid of the individual mandate, putting out plans, temporary plans, shortterm plans that will not cover the basic, you know, the ten basic health guarantees. It just seems that this is a conscious effort to undermine the health of americans. And it just i think that aswe that as we go forward, we have to find ways to make sure that people arent discriminated against because they have preexisting conditions and that we have the largest pools possible and we spread the risk, and we make sure that people have, as many people have health care, and if you repeal this, 13 million more people will be uninsured, and premiums will rise. Senator, i think we share so many of the same goals and just disagree about the approaches and tactics to get there. My heart and my goal is to share so much of what youre talking about in terms of Affordable Care for people. Thank you. Thank you. Thank you. Thank you, senator franken. Well continue with our second round of questioning. Well conclude the hearing after the second round. I think there may be at least one other senator who wants to come back, so well go next to senator warren. Thank you, mr. Chairman. I share the concerns that have been raised by a number of my colleagues that this administration has spent the first 11 months of this year trying every trick in the book to destroy Health Insurance system in this country. And mr. Azar, youre being considered now for the top job to oversee key parts of the Affordable Care act and medicaid. So i want to start by asking about a basic principle. Mr. Azar, would you agree that its important that we have a system that allows for every single american to have access to the kind of coverage they need . I think we all share the goal that we want all americans to have access to affordable insurance that they desire. So is that a yes . As i framed it, yes. Ok. Good. Heres the problem. Those are the exact words that dr. Price used during his confirmation hearing before this committee. He sat exactly where youre sitting right now and said exactly that. He pretended that he cared about people being able to get their health Care Coverage. And then he got confirmed, and spent eight months doing everything he could to take away Peoples Health Care Coverage and crash the Health Care System. So i think thats the reason were trying to be very specific about what it is you will and wont do. So i want to follow up on senator murphy and senator murrays questions. They asked about shortening the time period for the enrollment, and you said you wanted to be very data driven about that. And you thought maybe there was a data reason for doing that. That is that it was ineffective and somehow it hadnt worked. So let me ask the question this way. Mr. Azar, if youre confirmed as hhs secretary, and there are no data showing that cutting the Enrollment Period improves enrollment, will you commit to going back to a threemonthlong period for Health Insurance enrollment . My view would be that if the Enrollment Period does not make sense and work for the efficacy of the program, for the insurers who have to work in it and for beneficiaries, i would be open to changing it back if confirmed as secretary. Im not in the government. I cant commit to Government Action not having seen anything there. Thats the question im asking. You have used data as an excuse. You said i care about the facts, i want to be data driven. You had a Good Exchange with senator alexander about the importance of data. I agree with that, so im just asking. If there are no data to support your hypothesis that cutting the time period somehow might improve enrollment, will you commit to going back to the threemonth Enrollment Period . I would need to look at the data. If the data drives in that direction, then im going to push to insure that the program is effective and if a longer period is needed i dont know what balancing factors there might be. Im not in the inside to know. So its not all about data for you. Theres data, but i dont know the other elements. Ill take that as a no. Let me ask another question. When secretary price was in office, he supported republican bills to repeal major portions of the Affordable Care act. If confirmed as secretary, will you oppose such bills . Senator, i and this Administration Support legislation, various forms of legislation that would have a system that leads to more affordable insurance, more choice, and more access. Theres not support of getting rid of i asked a very specific question. Because im trying to get this. This is what price said when he was in here. So im trying to get avery specific question. Would you publicly oppose republican bills to repeal the aca like the ones we have seen so far this year . Are you saying we should just wait and see what youll do . I would work with this congress and within the administration to build a system that helps people get affordable insurance. You and i will differ fundamentally, senator, i guarantee you, on what the contours of the system to do that will lead to. You will not oppose the bills we have heard so far . All right, let me ask another one. What about turning medicaid into a block grant . Secretary price pushed that idea while he was in office. Would you do the same . I have actually said before that i think looking at block granting and empowering states to be fiscal stewards there can be effective, can be an effective approach. The contours of that, the amount of funding, the size, what the baseline you support block granting . I support it as a concept to look at. One needs to look at block granting as an abstract. The question is instead, what is the precise program, but the notion of a state being empowered to run a program and having all of the sentives to run an effective program. You could own up to the fact that you want to cut medicaid and gut the Affordable Care act, like every other member of the Trump Administration, but you want to smile and pretend otherwise until you get the job, and yet you say exactly thesame just the same things the same things that would let you pick up right where tom price left off in trying to gut the Affordable Care act. Tom price lied through his confirmation hearing. And now you come in here and say the same things he said. No one should be fooled. Thank you, senator warren. Senator hassan. Thank you, mr. Chair. I wanted to pick up where we left off on the question about the case of jane doe, the young woman i asked you about. At the end of that question, you said that, yes, you agree that you have an obligation to follow the constitution and all of the laws of the United States, even if you dont personally agree with that. Is that correct . That is correct, yes. Is that correct . That is correct, yes. And im glad to hear that. As you know, under the supreme in roe v. Wade, women have a constitutional right to make their own reproductive Health Care Decisions. So yes or no, will you commit to upholding those Constitutional Rights as well . For a second. You had said that you would make the opioid addiction crisis a priority of if you are confirmed and i appreciate that, but we need a lot more than lip service to make a dent in this epidemic. One of the key tools to combat this crisis is 10 essential Health Benefits requiring that insurance cover Substance Use disorders. In october cms proposed 2019 benefit payment parameters which have finalized if finalized could let states erode the Health Benefits including the Substance Use Disorder Services benefit. Developevelopment their own benchmark the rule would set the ceiling on the generosity of benefits that states could in include in their plan. More than one third of plans before the aca on the individual market did not divide coverage from substance four Substance Use services. Wouldthe role, states decide to limit this benefit. Given your stated commitment to address the Opioid Epidemic, would you commit to rejecting the harmful changes in the proposed rules . A believe states are most effective in determined determining the benefit packages for their citizens in the circumstances you described. When they dom is that, the Insurance Companies come in and charge more for the benefit and that is one of the advantages. Nobody in my state plans to get an illness that their insurance does not cover. Nobody plans to become addicted to Prescription Drugs after surgery, lets say. Says, too bad i did not buy Insurance Coverage for that. The advantage is that millions not only got coverage from the aca but coverage that addressed their needs. As governor and before when i was in the state senate, it was often the case that Insurance Companies kept dropping coverage for things they could not make money on. Eventually the public picks up that cost. I ask you to look at that issue closely because the essential Health Benefits under the aca have been critical to fighting the epidemic in our state. Last topic i wanted to touch on with you, and you have heard a lot about it. It is about drug pricing. Some of it is about your past appointment as president of the part of eli lilly. I want to read a quote of yours because there is a reason that people are skeptical about your commitment to lowering drug prices. This is what you are quoted as saying in the new york times, all players, wholesales, pharmacies like cbs and walgreens, benefit managers make more money when list prices increase. The victims of these trends are patients. In that quote, you are admitting that high list prices are hurting consumers and creating profits for Drug Companies but you continue and you did this just last spring to push the blame, here you said it was everybody, everybody has to a part to play but last may at a conference, you pushed the blame on everyone but pharmaceutical companies for higher list prices. Is somethingprices that manufacturers directly control. You have also blamed Insurance Plan designs for high drug prices but it is the list price set by manufacturers that is driving the increases in what consumers are paying because requiring lower cost sharing for drugs will lead to increased premiums. All of the expenses for consumers. I want to ask if you will be taken off the Pharmaceutical Company had and will be responsible for advocating for consumers. Do think it is time the Government Take Action to limit the Profit Companies can make off of high list prices . In my earlier remarks, i certainly did not mean to be suggesting that list price was irrelevant or that pharma does not have a piece of this also. The challenge is, as we think about the burden on the patient when they walk into that pharmacy, if the list prices 500, and they have to bear that is0, or if the list price 250 and they have to bear the 250 dollars under the high deductible plan both of those can be unaffordable. Where i want to work both can be helpful. Were running out of time. Without some action by us, it will be passed on and the Insurance Premium will be also unaffordable. Thank you. Thank you. Sen. Baldwin at sen. Baldwin thank you. To continue on the same lines that senator hassan was asking you about and what we were talking about in round one of questioning. You mentioned your example at 500 a month. I told you a story earlier about greg from stoddard, wisconsin but mentioned i and who lives in western diane who lives in western wisconsin and has taken a medication for over 23 years to slow the progression of her ms. When she became medicare eligible and therefore the way in which the family was insured shepaying for medication, and her husband had a heartbreaking discussion at the beginning of this year whereby she and he decided that she would stop taking the medication and had reached 90,000 90,000 a year. Andhange as far as i know the ingredients, the manufacturing process, or anything else. Up over all ofpt that time. Want to return to the issue of transparency. We talked about this when we met yesterday. I have offered along with my colleague senator john mccain the drug pricing act which would require basic transparency from drugs from corporations. It is a complex system, but the list price setting starts with the drug corporations. Towould require disclosure the department of hhs on elements like executive pay, investment in research and development, investment in marketing, stock buybacks, etc. Policymakers,form so that we can take better and stronger approaches to this crisis in many respects. What are your views on requiring basicompanies to make information public when they are intending to increase the list price of existing drugs . Even as i referred to in my opening remarks, i generally am in favor of increased transparency within our Health Care System. It generally is a good thing. We always need to look to see if there might be any counterproductive and expect aspects to transparency. Transparency can be good and useful. I would be happy to study that more and work with you as part of all the options that need to be on the table to think about this, to see doesnt help with reducing what a patient pays outofpocket, does it work with reducing list prices, with reducing with the system ends up paying . I am very open to looking at all of these options with you. To make,te i want oftentimes, the difference productpharmaceutical prices in the u. S. And overseas has pointed back to the investment in research and development. Investment,ars, the if you can call it that in stock buybacks and dividend payouts. As surpassed that of r d is that a troubling trend in your opinion . I do not know, i do not study the financials of the companies on buybacks. I certainly believe that one of the r dbasedf pharmaceutical industries that kind of heavy investment. Where i was employed it was upwards of 20 or twice 5 was invested of revenue which was in the u. S. As we talked a bit earlier, at the hearing in reference to some of those entities to buy a product and increase the price, i am very supportive of that type of intensive r d work. If i am in this role i will have nih which lays a key role in the foundational science as a partner in all of that work. The particulars of that issue, i have not connected those two things but i am supportive. It is striking in the academic report earlier this said an aggregate over half 1 trillion invested in stock buybacks and less than that in r d. Tois certainly not specific the pharmaceutical industry but very pronounced in the pharmaceutical industry. Is last point i would make just to note for the record that i agreed when President Trump, regarding his emphasis on authorizing the secretary of hhs to negotiate directly with pharmaceutical companies for a lower drug lower drug prices and medicare, hope that that is something that you will embrace if confirmed. Thank you. Thank you, senator baldwin. Senator whitehouse. Senator whitehouse we talked about in our last conversation about how the Care Organizations and the ways we can deliver better care at less expense. There is another much more particular area where i think theres another bipartisan opportunity. To improve care. In this case it would lower expense, but that would not be the point. That area is endoflife care. Advanced care. There is a good group you may be familiar with called the coalition of transform events care that has very broad corporate Institutional Support that is focusing in these areas. Rhode island has been active in this space. We have enormous support from, where the most catholic state in the country, the Catholic Diocese has been helpful in the council of churches have been helpful, the Major Hospital groups and medical society have been extremely helpful. What we see is that from time to time, we bump up against problems within the medicare, medicaid ailing systems. Which in a general arbitrary world might make some sense, but once a state or community have decided it will undertake a path withal more humanely people near the end of their lives, suddenly, those prescriptions become obstacles. I think do more harm than good to the patient and probably to the public as well. Heres some examples we are trying to fix. Medicare and medicaid patients are not supposed to receive hospice care and Curative Care at the same time. Seriously focusing on the care of an end of life patient that is a stupid distinction to force into that situation. Nurse practitioners have way too small a role and their role could be increased. , three dayonight inpatient stay role before somebody can be moved into a nursing home is nonsensical in the context of somebody who is operating under a good and of life care based or hospice plan. Home Health Services are to be provided without having to meet the full regulatory definition of being homebound. Can often, a dying patient still move around and is not fully homebound but it would be cheaper for the system, better for the family, easier for loved ones providing care to get home Health Services so that rule again backfires. Finally, caregivers often need care is ad respite very valuable thing because without that, you wear out the caregiver and the system has to come in and advanced expense pickup potentially inpatient treatment. Home based respite care where you do not have to put your Family Member into an inpatient place while you yet your couple of days of rest would seem to make a ton of sense. None of those things are being done. The result is that this precious time of life towards the end, states do not want to make it better. To make sure the wishes of the are honored and it is clear with the wishes are. So there are not horrible fights at the end of life. Those things could be made so much better and heres the government with all of these roles that they make sense again in isolation. Once you start to deal with endoflife care in any comprehensive, humane fashion they begin backfiring. Will you work with us particularly with rhode island to try to support models, we do not need to get rid of them entirely that what we want to do is support waivers so when a state or Community Steps forward with a good humane, i am saying this saying next to senator baldwin, the state is legendary for and of life care planning. Someuld give wisconsin props here as well. Would you help us with that . I want to thank you for those very thoughtful comments and reflections. As i mentioned in my opening wilmoth my stepmother died in july. It was a blessing that she was able to be in her house in her bed the whole time. I want to make sure people have that chance. And so happy to work with you. I think what we will find is it helps the public fisk. I do not carefully have to spend more money so the people at that tender time of their life and the family who were surrounding them at that tender an important time of life are not treated disrespectfully and are not pushed to make dumb decisions based on bureaucratic rules that do not make sense at that time. God bless you and thank you. , senatoryou whitehouse. Senator murray, do you have Closing Remarks or questions . Senator murray thank you. I have additional questions and i would ask that we do get timely and sufficient answers to our questions. We have had that problem before under secretary price and i vote i ask that we get timely answers so that we can do our jobs as well. I did want to put one issue on the table that we did not have time to address and that is hhs plans for implementing the preschool Development Grants program. Ouruthorized that in succeeds act, it is something i am concerned about and i will be watching closely to make sure that final program is in fomented the way that congress intended so that it helps us expand access to hike quality Early Learning and care for our most vulnerable children, and i will follow up with you but know that i will be following that closely. Thank you for being here. I know you have another hearing to go through and numerous questions, we will be looking at those but if you are confirmed, i want you to know that we will talk to you, work with you, and hope that you will be as responsive as we need you to be. Thank you, senator murray. For for being here, for your willingness to serve, france or your questions. I do hope you will respond to the senators questions and dashes senators questions. We do not have a limit but i hope there will be of reasonable number of questions. 30 members are members of the finance committee which is the committee that will vote on your confirmation and reported to the floor of the senate. You have seen today the diverse points of view on this committee and some people wonder how we could get everything done but the fact is we get quite a bit done. Fixedle of years ago, we no child left behind in a way that president obama called a christmas miracle. Last year was the 21st century thes legislation that majority leader said was the most important legislation of the year. You will have a chance to implement that legislation as well as the Mental Health reorganization that was part of it. To seear, we have worked if we could find some area of agreement even though it is for a short time on the Affordable Care act, which still, which we were able to do. It is not law yet that we were able to take the step. There are a number of areas and you have heard many of them today, senator whitehouse suggested two major areas of bipartisan cooperation, we talked about Electronic Health care records, a lot we can do working with you and you will find that most of us would like to create an environment in which you are able to succeed. We are not shy about giving you our points of view as youre able to tell today. I hope also that we can talk work with you on more than individual insurance issues. , seems like forever, we have focused on Health Insurance and only 6 of the americans who buy Health Insurance on the individual market, they are every single one important, but year after year, we give ourselves, it is like going to college and going to one course and earning a c or d or an f every semester. We do not seem to be making much progress. And the important thing about it is there is so much other important that we should be working on when we talk about health and health care and the agencies you worked on. Drug pricing is one that this committee has a great interest in. You excited about the fact know something about this. Health insurance is complex. Drug pricing is byzantine. Secretary we had a who was new to the subject, that twor she would leave after wouldr or eight years, it take that long to understand what is going on. You arrived knowing the subject. And helping us answer the the moneywhere does go . Do we need rebates . Can there be more negotiations . On drug pricing. Should we really think seriously about finding a way to let americans buy drugs in the u. S. By thee not approved fda . We have never done that before. Several senators think we should. We will need to talk about that. We should be talking about wellness. We had two or three earning hearings on that that offers great progress promise of reducing Health Care Costs, we hear a lot about the president budget proposals and less about the fact that senator murray and senator lunt for two years, hopefully for three years have increased funding for the National Institutes of health that 2 billion a year, and we added another 4. 8 million in the . 20 20th century cure. We are putting big dollars in nihnih and authority into and the fda, all of which you will have a chance to take advantage of and make something of. It is a very exciting time with for someone with your experience and background and energy to come to this position. You could help families all over america, and i hope if you are confirmed, which i am confident you will be, you will look to committee, democrats as well as republicans, as a source to create an opportunity in which you can succeed. I introduced for letters of support into the record which it will be done. If senators with wish to ask additional questions, additional questions are due by december 1 this friday. The hearing record will remain record open for 10 days and members may submit Additional Information in that time. The next hearing is tomorrow. November 30 at 10 00 a. M. To hear from experts on the Opioid Crisis. Thank you for being here. The committee will stand adjourned. [captions Copyright National cable satellite corp. 2014] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] cspans washington journal everyday. Kenng up, and thomas and thomas and mike discuss the week in washington. S reporterake tribune will speak. Be sure to watch Washington Life watch washington journal live. Tonight, on the communicators, a ceo of cloud flair, who boosted a neonazi group off of the internet discusses the action, hate speech, and the first amendment. 20 start down the path of saying an Infrastructure Company running the network gets to make decisions, i do not think you may like where you came out at the other end. It is akin to if become phone company if the phone company was listening to a conversation you had and they did not like the tone of voice, discussions, they would pull down the court and shut down the phone line. It would violate the contract with the phone company. A number of Companies Like cloth flair makese cloud the internetwork. The question is whether or not we are the right ones to be making the decision on what content should or should not be allowed online. Watch the communicators, tonight at 8 00 eastern on cspan2. Cspans student video documentary competition is underway. Students are underworked, sharing their experience with us through twitter. It is not too late to enter. Our deadline is january 18, 2018. We are asking students to choose a provision of the u. S. Constitution and create a video illustrating why it is important. Our competition is open to all middle school and high school students, grades six through 12. Cash prizes will be awarded. A grand prize of what 5,000 of 5,000 go to the best student or team with best overall entry. Go online. Cspan, where cspan watch history unfold daily. In 1979, cspan was created as a Public Service by americas Cable Television companies. It is brought to you by your cable or satellite provider. Announcer this week on q a, Hoover Institution senior fellow john cogan