Transcripts For CSPAN Senate Finance Cmte. On 2019 Health Human Services Budget 20180216

Health and Human Services secretary took questions on the president s proposed budget for 2019. He was asked about funding for medicare and medicaid, combating the Opioid Epidemic and the cost of Prescription Drugs. He testified before the Senate Finance committee. The committee will come to order. I want to express the sadness we all feel in light of yesterdays events in florida. I was personally horrified as i watched the news unfold yesterday though i was also moved to hear some of the stories of the heroism displayed by some of the students and teachers at the school. Am praying for those who were affected. May they all find peace, healing, and a speedy recovery. I welcome everybody here to todays hearing which will be hearing on final the president s budget for fiscal year 2019. We have already had the treasury secretary and hearing acting i. R. S. Commissioner appear before us. Today well be talking with secretary aczar from the department of health and Human Services. I want to thank you for being here and cooperating with us and welcome back. It has been just a little over a month since you last appeared before us. This could cause some nervous reactions. You never know. Of course you are still very new to your position but we are glad to have you back because we have a lot to discuss. Since you were last year this committee has amassed a number of legislative victories. I want to take a few minutes to highlight these accomplishments as many are within h. H. S. s jurisdiction. Last month as a result of countless hours of work by this Committee Congress passed and the president signed a sixyear chip extension. A few weeks later we added another four years to that extension. That is ten more years of chip funding which is quite frankly really an historic accomplishment. Senator ted kennedy and i created the chip program more than two decades ago and despite always enjoying bipartisan support at no point in the programs history have we been able to deliver this much certainty and security for the families and children who depend on chip. I want to once again commend my colleagues on both sides who joined in this effort who share in this success, especially my colleague from oregon. It was no small feat. In addition to the chip extension the chronic care act, another bipartisan legislative product out of this committee, was also signed into law recently. This new law will improve care for Medicare Beneficiaries living with chronic conditions stream line care coordination and improve quality outcomes without worsening medicares shaky fiscal status. Again, i want to thank everyone on this committee who worked on this bill most notably our Ranking Member senator widen as well as senators ikesenson and warner who were key leaders in the drafting and passage of this important bill. It doesnt end there. The budget bill also included the bipartisan Family First Prevention Services act which will help keep more children safely with their families specifically by funding Substance Abuse and Mental Health services that have been shown to prevent children from entering foster care. All of this success is testament to bipartisanship it is roves that possible for parties to find Common Ground and Work Together. As always there is more work to be done and i am optimistic that we can be just as effective in the coming months. These wont mean much if they are not complemented properly. I look forward to working with you as this process moves forward. Would like to take a moment o talk about some of the specifics in the president s budget for the need to eliminate wasteful spending, rein, in our National Debt and focus on protecting americans at home. I appreciate the president s budget takes steps toward a course correction that will lead to a more economically sound future all while still ensuring high quality and Accessible Health care. One of the key and critical assumptions in the president s budget is the repeal of obamacare. The budget bakes in this repeal and replaces it with a state based grant system. All told the administration estimates this will save more than 675 billion. That is with a b. I think all of us on the republican side share this desire to repeal obamacare and we have actually done some great work on rolling back major elements of the socalled Affordable Care act this congress. For starters, our tax reform bill zeroed out the individual tax. Te recent budget bill also included the sow call medicare extenders and repealed the independent payment advisory board, and in that same bill we xtended previous delays on other obamacare other obamacare taxes, including the medical device tax, the Health Insurance, and the socalled cadillac tax. But as the budget points out, we are not quite there yet. I hope we can take additional steps in the future and i look forward to continuing our discussions on how we can stop the recent budget bill also included the sow call medicare extenders and cost of health care in a meaning skyrocketing governed way. Beyond the critical repeal and replace efforts with obamacare we also need to start getting serious about medicare and medicaid reforms. Both of these programs need to be put on a more sustainable path so that we can fulfill the programs for se future generations. I know that any time a republican mentions the fiscal predicament of medicare and medicaid we are essentially asking to be accused of robbing the elderly and loik families of their health care. But none of these scare tactics will improve the outlook of our federal health care programs. That is going to take some hard work and hopefully we can find a path forward there as well. During your confirmation hearing you emphasized that addressing rising drug prices would future generations. I know that any time a republican mentions the be one priorities. As you know top priorities. I have spent quite a bit of time on this issue working to ensure that patients have access to innovative and high quality makeses. It can be tricky to encourage he need of new and effective drugs and treatments while also working to make sure that those who need can obtain access to those potentially drugs and treatments lifesavin and lifeimproving products. Some have made a crusade out of scapegoating the companies that develop drugs and treatments. When this almost singular focus is policy e result that tends to be less than perfect to put it charitibly. We saw this last week that increased the discount manufacturers were required to provide under the socalled donut hole in Medicare Part d. I have voiced my opposition to the inclusion of this provision in the budget. In the budget agreement on the senate floor last week. I am working with my colleagues who share my concern on the discount provision to mitigate ts impact. I implore the administration to take care to strike a balance between access and innovation. It is a balance that i hope we should all strive to achieve. Now you also emphasized that addressing americas Opioid Crisis is another one of your top priorities. I am happy to see that the president s budget stresses the importance of working together to fight this epidemic. The c. D. C. Estimates that each day our country experiences more than 100 opioidrelated deaths. My home state of utah has been especially hard hit and while the Drug Overdose rate has risen over the the past decade we are starting to see a shifting tide thanks to the leadership of many officials in my state. With that said, they need federal help. And i know that many in congress, including several members of this committee, have been outspoken leaders in this effort. I can commend them for their work. We are committed to continuing our Bipartisan Committee process to address the Opioid Epidemic especially through mandatory Program Proposals that can bring about meaningful and enduring change to a system plagued with issues. I look forward to working with you in the coming months as we look for solutions to address this crisis and i hope that we as a committee can continue our ipartisan efforts to curtail this growing string of tragedies. To close let me just say that as we all know it is Congress Responsibility to pass a budget. The president s proposed budget merely sets the tone and provides us with a baseline for debate. I hope that we can Work Together to implement many of the commonsense reforms we have been debating for so long. I hope that we can continue to work to set aside our differences in order to find beneficial solutions. I look forward to having an open and frank discussion with the secretary about these and other matters. Before i close i do want to note that because we were unable to get a quorium yesterday, if at any point during the hearing a suitable quorm is present i intend to pause the hearing and move to vote on the nominations of mr. Dennis shea and mr. Cj mahoney. Thereafter we will resume our hearing. Turn to my t me friend the Ranking Member for his opening remarks. Thank you very much, mr. Chairman. Mr. Chairman and colleagues, 18 School Shootings this year. And i am just going to begin by aying when is enough enough . We watch these young people from the high schools and i heard one in effect say, you know, were kids. We cant fix this. You adults get over my friend the Ranking Member for his opening remarks. Thank you very much it and d with it. That to me is central to what we are talking about this morning, because we are going to talk about health care. And what we have been hearing on the news is that it sure sounds like there are a lot of young people that are can tened about what happen at their school. So we deal with lots of bills and can lots of amendments. But like those students said, its time to get over it. Its time to act. Weve learned in the last 24 ours enough is enough. Mr. Chairman, i want to pick up first on the point you made, because in the last couple of weeks on the health care front as you have noted weve had some very positive developments here in the last few weeks. If you had told me in the winter of 2017 that we would have a 10year chip authorization, everybody would have said what planet is this person residing on . The chronic care bill and i see senator ikesson who was with me on day one, senator warner is not here. Senator isaacson in this room we launched chairman hatch to his credit pulled together a Bipartisan Group of us. Colleagues, lets make sure we understand what this chronic care bill is all about. The chronic care bill is about updating the medicare guarantee and modernizing the program to deal with where most of the money is going to be spent cancer, diabetes, heart disease, and strokes. When i was director of the gray panthers there was a real difference Medicare Program part a for hospitals and part b for doctors, and that was that. Because colleagues like senator isaacson, senator warner and our Bipartisan Group said when you have 10,000 people turning 65 every day and it is going to happen for years and years to come, you have got to dig in. Chairman hatch made that possible. I want to thank the chairman. And then of course a lot of people who work in the Child Welfare field are saying that the Families First bill was what they had been dreaming about for three full decades. That came together here in the last couple of weeks and i want to thank you for that, mr. Chairman. Now, on a not so positive note, the budget season is at hand again. So the trump agenda of Health Care Discrimination is back. I am going to go through the examples. Start with discrimination against americans with preexisting conditions. People who have preexisting conditions count on having a private Insurance Market with strong consumer protections. What the trump budget offers is chaos in the private Insurance Market and the elimination of key consumer protections. The budget embraces the old graemecassidy proposal, outlived a mercifully short life last fall. Because in this room we blew he whistle on the fact that it didnt lock in protection for those who have preexisting conditions. On top of that, the administration is giving green light didnt lock in protection for to junk insurance policy that is revive the worst insurance abuses in the past such as skimpy coverage. So with millions of people, the Trump Administration seems dead set on making the care they need unaffordable and inaccessible. Next on the agenda of Health Care Discrimination is discrimination against women. When you to junk get rid of the Affordable Care act you return to an era when 75 pshts of the insurance plans dont cover Maternity Care or birth control. Under the trump budget which arbitrarily attacks key providers, planned parenthood, and others, millions of women could lose the right to see the doctor they trust, the doctor of their choosing. Then the trump agenda of Health Care Discrimination go after americans who walk an economic tight rope. Trillion cut from medicaid, millions of americans locked out of the program, a scheme to knock out nationwide programs especially ending trillion cut millions of the guarantee of care for those who qualify for medicaid. Now the Administration Reportedly is discussing lifetime limits. Both sides used to agree that lift limits in health care were absolutely wrong. No exception. A ban on lifetime limits in the Affordable Care act was one of the core protections. And republicans republicans said they ought to stay, introducing lifetime limits in medicaid raises the frightening question of what happens if somebody maxes out after Cancer Treatment at age 45 . Are they going to be on the street in old age capped out of nursing home benefits . We are going to be discussing this. Of ly, the trump Agenda Health care discriminates against older americans. Medicare helped to pay for two out of three seniors of Nursing Homes and is essential for seniors who count on homebased care. Even for older people theres bad news. The trump budget hits them with an age tax allowing Insurance Companies to charge them far higher rates than they charge thers. The agenda of Health Care Discrimination is out in force in this trump budget and in my view it is a comprehensive plan to drag the country back to the days when the Health Care System the agen Health Care Discrimination is out in force in this trump budget and was basically working for people who are healthy and wealthy and everybody else was on their own. Drugs Companies Set price that is are way too high. If pharmaceutical companies can come out of the gate with unaffordable prices patients will suffer and i dont see where you fix that with some efforts to play catch up on. The trump Prescription Drug plan lets pharmaceutical Companies Keep on to borrow a phrase getting away with murder. Finally, a lot of what the administration put forward looks fam la on the pharmaceutical side. From f it is borrowed legislation i from legislation i proposed recommendation that is came from outsiders. There is value in these ideas. There is an opportunity to move on a bipartisan basis. But that is not what the American People were promised. The American People were promised a muscular approach, a position where the American People would know that their government was on their side and helping them deal with this question of their getting clobbered at the pharmaceutical window when they go in to get their medicine. Ill wrap up by talking about part of the secretarys agenda vital to kids. Chairman hatch and i both mentioned family part of first proud of that effort because for too long the Child Welfare system has basically been about families apart. That is what family first seeks to reform because instead of just two lack luster options leaving young people in a family setting where they were still families apart. That is what family first going sending them off to a future of uncertainty in foster care, we said we would allow states to find safe ways to the keep Families Together and families healthier. Foster dollars to for services with the goal prolonged slide oster into the crises that end with families breaking apart. I share chairman hatchs view the the Opioid Epidemic. It is good that additional funds were made available in the recent budget agreement. And now that we have to do is make sure prolonged slide that moves quickly so the states can get away from business as usual and deal with the epidemic. We look forward to hearing from you. The aid publicly cretary indicated in our prenomination hearing that he was going to take the initiative and be in touch on a regular basis to discuss the issues, and he has already shown he is serious about that with a call here recently. I appreciate it, look forward to our Work Together, and lets try to make more of prenomination hearing that he was going to take the initiative and be in touch it l like whats happened out of this committee in the last couple of weeks and lets make less of it look like the agenda of Health Care Discrimination that i believe is what the budget is all about. Thank you. Thank you senator. Today we have the pleasure of being joined by mr. Alex azar, the secretary for health and Human Services. I thank you for taking time out i know is a tremendous schedule and for your appearing here today. Because we heard two very eloquent introductions for you just over a month ago i will keep my introduction short and to the point. After graduating with his law degree from i know is a tremend schedule and for your yale univ mr. Azar also clerked for justice scleia on the supreme urt and later became a partner at wiley rine and fielding before being confirmed as general counsel at h. H. S. Back in partner at 2001. Then in 2005, he was asked to serve as deputy secretary at h. H. S. Where he served as the chief Operations Officer for the largest civilian Cabinet Department in the United States of america in our government with over 66,000 employees and a budget of nearly 700 billion. Following his service at azar rejoined ry the private sector as Senior Vice President for Corporate Affairs and communications at eli lily and company. He went on to become president of the largest affiliate. Rejoi the private sector as Senior Vice President for Corporate Affairs and then just last month secretary aczar was confirmed to his current role as secretary of h. H. S. So we are grateful to have you here, grateful for your time, grateful for your expertise, grateful for the service you have given and are about to continue to give. Please proceed with your statement. Chairman hatch and Ranking Member widen, and members of the committee, thank you for inviting me here today to discuss the president s budget for the department of health and Human Services for fiscal year 2019. I would like to begin though by joining chairman hatch and Ranking Member widen in expressing our deepest sympathies and prayers for the victims and their families in florida. It is an honor to be here today and it is an honor to be able to serve as secretary of h. H. S. Thanks to the support of the members of this committee. Our mission at h. H. S. Is to enhance and protect the health and well being of all americans. It is a Vital Mission and the president s budgeted clearly recognizes that. The budget makes significant Strategic Investments in h. H. S. s work boosting Discretionary Spending at the 2019 to t by 11 in fy 95. 4 billion. Among other targeted investments, that is an increase of 747 million for the National Institutes of health, a 473 million 2019 to for the food and drug administration, and a 157 million increase over 2018 funding for Emergency Preparedness across the department. The president s budget especially supports four priorities issues that the men and women of h. H. S. Are hard at work on already. Fighting the Opioid Crisis, increasing the affordability and accessibility of Health Insurance, tackling the high price of Prescription Drugs, and using narke to move our Health Care System medicare to use our Health Care System in a valuebased direction. The president s budget brings a commitment to fighting opioid addiction and overdose stealing 100 american lives every single day. Commitment to under President Trump h. H. S. Has already disbursed unprecedented resources to address access to treatment. The budgeted would take total investment to 10 billion in a joint allocation to address the Opioid Epidemic and related Mental Health challenges. Second, we are committed to bringing down the skyrocketing cost of Health Insurance, especially in the individual and Small Group Market soss more americans can access quality Affordable Health care. This budget recognizes that this will not be accomplished by one size fits all solutions from washington. It will require giving states room to experiment with models that work for them and allowing customers to purchase individual liesed plans to meet their needs. That is why the budget proposes authority from the federal Government Back to the states empowering those who are closest to the people and can best determine their needs. The budget would also restore balance Medicaid Program fixing a structure that addresses a run away costs. Third Prescription Drugs costs in our country are too high. President trump recognizes this, i recognize this, and we are doing something about it. This budget had a raft of proposals to bring down drug prices especially for americas seniors. We propose a fivepart reform plan to further improve the already successful Medicare Part d Prescription Drug program. These major changes will straighten out incentives that too often Serve Program middlemen more than they do our seniors over the next 10 years, adding to savings that we are already generating with reforms to Medicare Part b payments under the 340 b drug discount programs. The budget proposes further reforms in medicaid and Medicare Part b to save patients money on drugs and provides strong support for f. D. A. s embts to spur innovation and competition in generic drug markets. We want programs like medicare and medicaid to work for the people they serve. That means empowering patients and providers with the right incentives to pay for health and outcomes rather than procedures and sickness. Our fourth departmental priority is to use the tremendous power we have through medicare as the largest purchaser of medical services in the United States to move our whole Health Care System in this direction. This budget takes steps toward that by for instance eliminating price variation based on where post acute care is driven, supporting investments in telehealth and advancing the work of Accountable Care organizations. The future of medicare must be driven by value, quality, and outcomes not the current thicket of open pake unproductive incentives. The president s budget will help accomplish three important goals at h. H. S. First, making the programs we run really work for the people to serve eant including by making insurance affordable for all americans. Second, making sure that our programs are in a sound fiscal footing that will allow them to serve future generations, too. And third, making the necessary investments to keep americans safe from Natural Disasters and infectious threats. Making our programs work for todays americans sustaining them for future generations and keeping our country safe is a sound vision for the department of health and Human Services and i am proud to support it. Thank you, mr. Chairman. As you may know, the finance committee is undertaking a bipartisan process to identify opioid ddress the crisis. Or epidemic. In medicare and medicaid. So that the right opioid incent exist for addressing pain and addiction. When you testified before this committee earlier, this year, you mentioned that 50d dressing the Opioid Epidemic would be one of your top priorities. Im personally pleased to see a number of proposals included in the president s budget on this particular topic. I am sure you have helped do that. Will you commit to working with this committee to find Bipartisan Solutions to address this epidemic within medicare and medicaid . Absolutely. I appreciate that. I am not going to ask any further questions at this time. So well turn to the Ranking Member. Thank you very much, mr. Chairman. And i am going to start as we have talked about this matter of junk insurance and particularly what seems to be an Administration Plan to greenlight it. And i recognize that this didnt essentially demens on your watch commence on your watch but you are there now so i have to make sure we are going to have a sensible policy. What junk insurance is all about is making sure that Insurance Companies can charge more for people with preexisting conditions and include arbitrary caps on the amount of care. In a lot of ways, junk nsurance just turns back the clock. When i heard about this, the first thing i thought about is when i was director of the gray panthers it was common for an older person to have clock. When i heard about this, the first thing 15, 20, 25 policies that were sold to supplement their medicare. They were called medi gap. Finally we wrote a bipartisan law. Senator dole was helpful in it. Which drained the swamp. An appropriate phrase for the time. And now i look at what seems to be bubbling up again, different population groups not seniors but the same sort of thing. We are going to greenlight policies that are appropriately called junk because they werent worth the the paper they were written on. Idaho seems to have the most active effort once again people spending hardearned money on a plan they need only to find that they are being ripped off by an insurer. Idaho far blue cross of is the only insurer who has applied to sell the junk plan. I have got the application here. Idaho is the it looks all about finding out if people have preexisting conditions so they can discriminate against them, charge them more, all the questions in section 5 a deal with that issue. Have you been pregnant . Have you been tested for aleries . Has anybody had a claim over 5,000 . If an insurer is following the law banning discrimination against those with preexisting conditions, what are all those questions about . Senator widen, i have seen the media reports about the blue plan request and the actions in idaho. I have not yet seen the plan or have received any type of waiver request. I can assure you if that does progress forward we will be looking at that very carefully and measuring it up against the standards of the law as is our duty. I appreciate that. Nd i know this is new for you. This as i understand it is not a waiver. In effect idahos saying we are going to do this. We are going to do it because we are a state that wants to do it. But theres a federal law, something i fought very hard for. It was right in the heart of a bipartisan proposal healthy americans act. The centerpiece. Seven democrats, seven republicans, air tight protection, loophole free. Air tight protection for those who had a preexisting condition. And now what this is going to be all about and as when we talked in the office i said you are not going to be sitting around reading paperbacks in your job. This is going to be a question of whether the department is going to say federal law which protects people from discrimination against preexisting conditions controls or idaho can start something that just moves america back towards yesteryear where we can have insurers beat the stuffing out of people with a preexisting condition. Mr. Chairman scuke to enter the blue cross Application Form into the record. My second request is to enter in a letter to the secretary from 15 organizations that patients illions of expressing serious concerns with essentially the points i am talking about that idaho is breaking a federal law. In other words, the first time i heard about it i thought maybe it is just a waiver. I have been very interested in waivers. This isnt a waiver. This is just saying we are going to do it. So i want to enter into the record the letter from the 15 organizations that represent millions of patients expressing the concerns i have with idaho breaking the law, the harm it will have on patients, the implications as the precedent, and then is it acceptable to you that you will get back in some way to outline how the department intends to pursue this within 10 days . I am very happy to get back. I dont want to commit on the ten days because this has to run through a process of first i guess they are applying to idaho. Idaho will have to decide its own thing under its laws that it has. And then anything would presumably come to us. Be happy to work with you and be very transparent about that process. I just dont want to prematurely be involved before there is even a matter in controversy at the state level. So all we have seen is a press report that the blues have submitted an application. Would know whether it even be approved by idaho or certified as compliant under the aca. So it is really just a question of timing. I can assure you we will be looking at the right time looking very searching against the legal requirements rfmenter i am over my time. Here is what concerns me. They are not planning to come to you and ask permission. They have made the argument that they can just do it on their own. So this idea that we are going to just sit in our offices back here and wait for somebody to tell us oh we are going to discriminate against people with preexisting conditions, that the will not cut it with me. It doesnt cut it. Thats not what i propozzed. How about if we say i will be told how the department is going to pursue this within 30 days . I believe that would be acceptable. I need a case in controversy. I need to know there is actually action happening. I think we have made the point. I dont think we have any need about the need for the department i dont think we have any differences about the need for the department to be involved. Thank you for being here. I am from idaho and i am very familiar with what idaho is doing. And once again this is like ground hog day. Every time a new idea for how Health Care System comes ut it is accused of eliminating preexisting conditions as well as every hea comes ut other possible attack that can be dreamed up against it. I think it is appropriate for you to wait to see exactly what is developing and evaluate it carefully. And i would encourage all of my colleagues to review what is actually being done rather than just jumping right back in and my good friend from oregon and i work very closely together on many, many issues. I look forward to working with you on this issue. This plan as i understood it does not eliminate the preexisting conditions. When the graemecassidy proposal the attack was that as we give greater responsibilities to states to be that incubater of new ideas and new approaches to health care, that it was going to get rid of preexisting conditions, that it was going to drive people out of the marketplace, that it was going to cause people to lose their insurance. The efforts being undertaken by the the people in idaho is one to protect and expand the opportunities and access that people have to insurance of their choice. Insurance that will work for them. And yes it does move away from the notion that the only insurance policy anyone in america should be able to buy is one that this committee or this congress or this federal government decides they can buy. Fortunately, in the tax legislation that we just passed we eliminated the tax penalty for people who do not want to buy the product the federal government wants to force on them. Now the states are seeking to have some flexibility. In your testimony, you talked about the fact that we want to encourage the states to experiment and that Additional Resources are going to be provided to the states to allow them to experiment. I understand what the law is. As i evaluate this, i dont see a violation at all. Idaho is still providing obama carecompliant plans for anyone whopts to purchase them. Thu they are allowing others to have options. And if the idea that people in america can have options, comply with all the obamacare mandates for anyone whopts it t allow others who want to buy a different kind of insurance policy to have an option, the idea that that is a direction that we should choke off right at the beginning is one that i resist. I would just like i know you cant comment on the idaho situation specifically, but i would just like your observation on the notion that we need to facilitate, incentivize, and provide Additional Resources to the states so they can do exactly what many states are trying to do right now, which is to find a way to give their citizens greater choice and greater access. Thank you, senator. And as you said, i think any conversation of a state proposal or any matter like this requires great deliblation and caution and care in assessing it. So i just simply cant state a view based on media reports around a states program. But i think what we are seeing here is a cry for help. It is saying that where we are right now with our individual narkt, because of the structure we have, is not serving enough of our citizens and there are too many citizens who simply cannot afford the insurance packages that we have in our program because of the way the statute is designed and the way it has been implemented. So that is why it is so important that we work to give states flexibility so that we try to offer for those 28 million americans who cannot afford access to the individual market Affordable Care act plans that they can have other options to choose from that may meet their needs, and that also try to fix whats in the program also to help make that as affordable as possible working together with the congress. Well, thank you. Inconclude with an observation. In addition to the program that my colleague from oregon referenced, i ookspect that idaho like many other states is probably going to apply for a waiver or two from h. H. S. With regard to some aspect of federal law as states are starting i think increasingly to seek the flexibility that they can get from the federal overnment to do this kind of Creative Work on our Health Care System to help us find the right path to provide the best and the most effective and efficient and inexpensive insurance that we can find. I would just encourage you not just with regard to any applications that idaho provides but with regard to all 50 of the states as they seek to ask you under the authorities you have to grant to do to allow them this kind of thing and to work to improve our health care markets, that you give those applications very careful conversation. To do thank you. Senator carper. Thanks, mr. Chairman. Several of my colleagues have expressed their remorse and sorrow over the latest mass shooting down in florida. I share that. I grew up in West Virginia, grew up in virginia, a family of hunters. My dad thank you. Senator introduced me to hun at a very young age, got my first bb gun when i was about 10 and my grandfather died and illed his shot gub to me and i used it for many years. My dad was a gun collecter and sold guns until near the end of his life down in florida. I believe my family believes in the Second Amendment to the constitution, the right to bear arms. I want to say, though, i am tired, sick and tired, of opening a hearing like this and we express our remorse in yet another mass shooting. This has to end. My dad used to say we ought to use some common sense. In this case we ought to use common sense with respect to guns and gun legislation. Senator feinstein has legislation no fly no buy bill. You cant if you are on a terrorist watch list shouldnt be able to buy weapons. And we cant even get that passed. It is a sad commentary. Colleagues, we have to use some common sense and use our hearts here. Enough of these expressions of remorse. I know they are heartfelt but enough. I just want to say mr. Secretary congratulations to you. Thank you for the dialogue and the conversations that we had during the nomination process. Thank you for the conversation we had earlier this week and i look forward to that as well. Sometimes we vote our hopes over our fierce here and i voted for you and your confirmation out of my hopes. We have this moral obligation. I have talked to you about to my colleagues about until they are sick of hearing it. We have a moral obligation to the least of these. That is make sure everybody has access to health care. We have a fiscal imperative to make sure we do it in a responsible way. One of the ways is the chip program. Congratulations on this latest extension of your latest creation with ted kennedy. We know a little bit about what states can do when they are given some flexibility. By the same token people can buy cheap insurance and it is not worth the paper it is written on so we have to be careful and mindful of that. I want to talk a little bit about our efforts to move away from fee for Service Payments to valuebased. Before i do that i want to mention despite the efforts of he administration to undermine, even sabotage our Insurance Marketplaces, almost 9 million americans, 95 of the enrollment population in 2007, signed up for insurance plans for 2018. Americans support. They want to keep the Affordable Care act. N contrast the president s repeal it ses to Health Insurance cuts medicaid. I know you were not in the administration when this committee reviewed this proposal last year. I want you to know every group, roup, hospital Health Insurance group, Health Insurance group strongly opposed the president s proposal. More than two thirds of governors under congress not to pass that proposal. The Brookings Institute found that more than 20 million americans could lose insurance if we go that path. And individuals with preexisting conditions would lose the guarantee of Affordable Health insurance. With that, do you think it might be worthwhile to first reexamine this proposal and Work Together with our patients, doctors, Health Care Providers to make some substantive changes before offering this idea up again . On this proposal, our concept is of course to change it to a 1. 2 trillion Grant Program to the states that still retains protections for preexisting condition, maternal care, newborn care, reconstructive surgery. So certain coverage for those under the age of 26 on family plans. I am very happy to work with on details to see if we can make this program work and have it make sense. Where we are isnt working for so many people. I will work with whatever the congress is giving me to make affordable as possible, as much choice as possible. We would like to pursue legislative change to see if this can be affordable as the a because insurance is so complex i dont think from the federal level we can do it all. Your colleague senator caffereden has a state that has taken a different approach. Other states will take different approaches. I love the laboratory of states trying in this very complex area. The administration and our secretary has offered a couple ways to stabilize the exchanges. This administration has been hell bent on undermining the exchanges. I want to thank you for some encouraging developments there. I think there are some things including together reinsurance. But well talk about that. Thank you. The senator from georgia. Thank you, mr. Chairman. I can testify that you hit the ground running because the first weekend you were on the phone with me talking about the c. D. C. I also know you probably had no hand in crafting of this budget because you werent on board, or at least you saw it after it was done. But with regard to the center for Disease Control i am deeply concerned this has a 1 billion reduction in funding for c. D. C. At a critical time for our ntainment laboratories and research and Development Done there as well as our preparedness at c. D. C. C. D. C. Was on the job ready to go when research and development ebola additional appropriations they hit the ground running, appropriations came later. We stopped an epidemic which could have been a disaster around the world. C. D. C. Was the first people on the ground here when the in rax broke out after 9 11 washington against members of the senate and the house. They are our safety blanket. It is the finest facility that there is. And to cut almost 10 , 1 billion in one fell swoop to me is unconscionable. Have you had time to washington against members of the senate and the house. They are our safety blanket. It is the look at this . Will you work to get it to an appropriate level . Senator, you know the care that i give the c. D. C. And the value i place on it both domestically and internationally. As i look at the budget for c. D. C. , the biggest part of change there really is are two transfers part of the reorganization that was begun at h. H. S. One is to move the leadership of the Strategic National stockpile and the budgeting under the assistant secretary for preparedness and response. That moves where it reports to doesnt change the atlanta aspect but moves where it reports to. That is one major chunk. The other is the National Institute for Occupational Safety and health. Not moving it but changes its leadership to be reporting into the National Institutes of health. So netnet it is actually only about a 100 million reduction. What i am really proud of is that we were able to get the c. D. C. Regularized here in our proposal. We have been operating out of the prevention fund. We have moved that over so that the core operations of c. D. C. Are now regularized in the budget and dont just sit there as a payfor as we look at other legislation. I think that is really critical to the longterm stability of c. D. C. That we show that that is not variably each year. Its built into the base of operations. I share the commitment and look forward to working with you. As we transition to a new director, we dont need to lose focus on the importance of that agency and see to it that we are funding them to the level they need to be. He containment laboratories, it is time we did some replacing and thats where all the bad pathogens are out there and a lot of young people risk their lives every day working with Dangerous Things trying to keep us safe. So we want to ensure those are as safe as possible. Yes, sir. We also had another bill last night when the train went through left the station, a lot of cabooses on that train. One of them was reimbursement for Home Infusion, legislation i worked on for a long time and has a deadline of january 1 of next year for you to develop reimbursement under part b to see those are Home Infusion therapy take place. It is a real reduction in the cost to us because Home Infusion is a lot better than hospital infusion in terms of what it costs, as well as a better place for the patient to receive care. Will you work with me to ensure those are done . Certainly. Im not familiar but i will work with you to make sure we get the job done on time. I dont ookspect you to be familiar with it but i would never leave here without make youg familiar with it. Yes. The graduate medical Education Programs were onsolidated in the budget. With a net decrease in appropriation. Those programs are fantastic for creating good physicians and new physicians in health care for children and the elderly. Will you work with me to see we t the maximum appropriations appropriate to meet the needs of the people . Absolutely. What were doing with the proposal on graduate medical ducation is to try to pull the three different streams together and actually give flexibility to make sure that we are able to invest in specialties and underserved geographic areas that need it the most. Right now we are very osfid from 1996 Program Levels and sort of stuck there. This would grant flexibility to ensure that scarce money is going where needed most. I would be happy to work with you on that. I look forward to working with you. Thank you. Thank you. It is a pleasure to see you here. I want to talk about a few issues in the president s budget following up on some of our conversations from your confirmation hearings and discussions that weve had. You and i talked about our commitment in regards to Minority Health and health disparities. I was disappointed to see there was a reduction of the resources and a reduction of resources at the office of Minority Health within h. H. S. Can you just share with me the rationale of those budget cuts and reassure us of your commitment to the mission of Minority Health and health digsparets . Yes. Thank you for raising that. The nih issue if i could i would like to get back to you on that because i wasnt familiar 14 days on the job at that granular level. Were delighted we were able to at lly keep nih funding that we are is proposing. So i dont know about some of the ups and downs. I would like to get back to you on that. On the office of Minority Health, one thing in the tha proposing. So i dont know about some of the ups and downs. I would like to get back to one was we tried to do prioritize scholarship in underserved areas promotional activities around health professions. So as we looked across the budget the approach is this delivering direct care or is this supporting the development of Health Professionals who will serve in underserved areas hrough scholarship and reimbursement programs . So that was the thesis that we tried to operate from. And more general programic activities sometimes would have been deemphasized against those in just the budget tradeoff that get made there. It is the certainly not a minimization around Minority Health programs. It is really the tradeoff and focus on Service Delivery. Thats helpful. If you could work with our office so that we are aware of your strategies . We want to make sure you have the resource that is you need here and are able to deal with the mission that we believe in reducing disparities. I want to caution on another area in regards to the budget imposing some additional costs on Emergency Care which turns out to be nonemergency conditions. My concern here is that we are seeing an attack on the pursueden layperson standard in the private Insurance Market place. Congress has passed legislation n this to make it clear that if it is prudent for you to seek Emergency Care it is going to be reimbursed and we are very happy if you end up in the emergency room and the condition is not life threatening that is good news. But then you might get a shock when you get the bill and recognize it is not being paid by your Insurance Company. So the policies in the Government Programs become particularly important because they are used as goal post business the private company. It looks like you are now imposing additional copayment and costs on Emergency Care where the individual may have gone into the emergency room for proper reasons but now find there is a cost issue which could be used to deter people from seeking care who need it. I believe you are referring to a suggest prod postal that is in the budget that would allow for medicaid copays for emergency room visits determined to be mission use. I agree with you i didnt know it was misuse. The standard we would need wemmed want to work with you to make sure that any legislation there is done in a common sense way. There is zero desire that it should deter anyone from going to the Emergency Rooms for care that they ought to be going in to and we need to make sure there is enough of a cushion there that is common sense and that doesnt as you said create a situation where it deters people from going in when they ought to go in. We worked a long time on the prudent lay pench standards. They had horrible practices reauthorizations and things like that that were jeopardizing peoples health. One last point. I disagree with the budget on the medicaid cuts and the basis behind the medicaid cuts. But i want to raise one issue that i would urge you to be very careful about. We dont really have a longterm care policy in america. The states have the lions share of the burden. To the extent we put more pressure on the states on Medicaid Programs, we jeopardize longterm care which is a critically important to our seniors in america. I just think it is important that whatever policies we adopt here at the federal level were mindful of the negative impact it could have on care for seniors. We would like seniors to be able to pay for their longterm care. We would love them to have third party coverage. Therefore fall under the Medicaid Program. If we put too much of a strap on the Medicaid Program, were going to jeopardize longterm care for our seniors. Thank you, senator. Senator portman. Thank you, mr. Chairman. And secretary, thank you for coming before therefore fall under the Medicaid Program. If we put us. I think you are now fully in place and it is great to see the good work that you are already starting to do. I know you are very interested in this issue of Substance Abuse and particularly the Opioid Crisis. We have talked about it at some length. I would ask you a couple questions about that. First with regard to the funding i noticed in your budget you have additional funding for h. H. S. This body during this fiscal year actually increased the funding for the comprehensive addiction and recovery act programs over the authorization this body during this fiscal year level. Have 267 million for fy 17 which is over the roufrl 181 authorized, because we think these evidencebased programs are where we ought to be directing some of this funding rather than throwing money after the problem, to find out what works. These are the right kind of programs, helping our first responders, my question to you with the president s budget indicating that h. H. S. Would have additional funding with our recent budget indicating that there be 6 billion directed toward this effort over the next two years, would you support additional funding for these evidencebased programs . So i dont know where our additional additional 3 billion in 18 and 3 billion in 19. If i could get back to you. I just want to see if we have put the allocation the funding toward those particular programs. But i am just delighted by the the support of congress and of the president here and the amount of funding. Were going to be able to support our addiction and treatment programs at historic levels. We already put more money out last year than ever before in history to help with the Opioid Crisis. D then with these and the 10 billion total im excited to of you. All again, i would say that the 267 million that was unprecedent that had we appropriated for this of you. Fiscal year is a relatively small amount compared to the 10 billion as you say that h. H. S. Was budgetted without specificity. And we want to work with you to be sure that funding is used for evidencebased programs that work. We have an example of one that works and i am concerned that your budget is going to make less effective and thats the drugfree communities act. I was the author of this many years ago in the house so maybe i have a little bias but i also spent nine years as chair of our local coalition funded with eed money from this program. This essentially provides matching fund for short period of time. E require that these coalitions have Performance Measures so we know whether they are working or not. We think this is very effective at the time of an Opioid Crisis it seems to be the coalitions have Performance Measures so we know whether they are working or not. We think this is very effective at the time of an Opioid Crisis it seems to be the wrong thing to do to take something that is working and risk its ability to be effective in the future by moving it from in the case of your budget to h. H. S. To combine with other prevention coalitions have Performance Measures so we know whether they are programs that are different in kind. So i would ask you to take a look at that. Why you explain be moved i t to would be interested to hear. But i hope you not promote this idea. I am going to fight against it. Again, if its not broken lets not try to fix it particularly at a time when we need desperately to have more education out there. I hope that i am remembering the correct program but i believe the change that you may be referring to is the movement of the program from funding. We already administrator that program and i think this is just regularizing where the funding is since they are not a grantmaking organization, doesnt have those capabilities and staffing around that we do that already and it is just putting the money where the function is. I dont believe it is i know it is in no way a deemphasis of the program. It was much more regularizing the function where the work was already getting done. I believe thats the case. I will be happy to confirm that. Again, it has gone back and forth over the years. It was with d. O. J. And h. H. S. In terms of administratoring the grants as we talked about. But the direction comes from omdcp which has the ability to take an interagency approach and does involve a number of agencies. So i would hope you take a look because it is working out there at a time when we need more help than ever. So i thank you again for your service. My time has expired. I have a couple questions i will submit for the record and appreciate the fact that you have stepped up and look forward to working with ow on the Opioid Crisis and other matters. Senator toomy. Thank you mr. Chairman. Thank you for joining us. Good to see you again. The administrations budget in ur area i think strikes some constructive balances. You have emphasis in some important Priority Areas like senator portman has alluded to opioid abuse, research and treatment. I do hope we will be doing more to understand root causes of addiction as well as treatment of addiction. I think we have a long way to go there. Also, ideas about lowering the cost of Prescription Drugs and continued investment in medical research generally all good. But i also want to commend you for addressing a huge, huge fiscal challenge that we have which i think your budget does address and i am going to ask you to comment on in a moment and that is dealing with the unsustainable spending of our entitlement programs. I just think we cant underscore enough, you cannot tax your way out of a problem. There is no revenue solution to Government Spending programs that are growing faster than our economy. Ultimately tax revenue can never, for long, grow at a gove programs that are growing faster than our rate faster than our economy. T strikes me, as long that one of the sensible places to address this is with medicaid n part because it is the biggest Net Expenditure Program in the federal government. There is no dedicated revenue stream as with Social Security medicaid. So they have this huge outlays. The growth has been staggering. In 1980 is the biggest spending was 2. 4 of our budget. Today it is 10 of our budget and 2 Percentage Points of g. D. P. Yesterday, the cms act wary report on National Health expenditures project that is will continue to grow at 6 per year. 6 . Nobody believes that our economy is going to grow at 6 . So what that means is this program is going to continue to consume ever greater share of federal spending and the economy. If we dont do something about it. One of the things we might consider doing about it is restructuring this program so that there are federal government caps on spending on a per capita basis. Of course is a completely bipartisan idea. First floated seriously by president bill clinton, supported by donna slal lay and howard dean and the american pediatrics and at one point every democrat in the United States senate supported establishing these per capita caps in a restructure of medicaid. Your budget, as i understand it, further would allow this per capita cap to grow every year and you would tie it to a measure of inflation that we might actually be able to keep up with. So the net effect of all that is that medicaid spending every year would grow. Medicaid spending per beneficiary would grow. But it might just grow at a rate that we could afford that we could keep up with. Now, i think it is also critical that you tie this to giving states more flexibility to discover ever more efficient and effective ways to deliver services. My colleague from rhode island and i discussed yesterday how important and how many opportunities there are to encourage the development of more efficient ways to deliver Health Care System. So i am just wondering if you would elaborate on how you envision this reform idea, how it would still work for the people who need this program. Because that is a necessary criteria of anything that could possibly be considered successful. And if you would care to elaborate on how appropriate setting. I know you touched on that. How that might fit in. Thank you. Actually the president s budget goes exactly along the lines of the concerns and the solutions that you just expressed. It adds in to it also helping to fix the concerns that we have around the individual marketplace. So changes medicaid to allow for these per capita grants to the states that then they would have tremendous flexibility in how to run their Medicaid Program. But they would have the skin in that game to run that program but within a budget. And it would combine money in a 1. 2 trillion program out to the states that would allow for coverage of what we currently call the Medicaid Expansion folks as well as the individual markets. So money that could be used as states determine to create really effective mechanisms to provide insurance for individuals in their state that would still have protections for preexisting condition, maternal care, newborn care et cetera. So that is what actually i think is one of the really constructive aspects of this budget, is putting all those people together. It gives the state a real tool to create effective risk pools that can create sustainable affordable insurance in the future and even core medicaid would grow from 400 billion to 453 billion over ten years. So even the core tradition of medicaid as you said would grow because of inflation adjustment. So im excited to work with congress on this as a possible idea. Thank you very much. I look forward to working with you. Thank you, chairman. When we met in my office i showed you i think one of my favorite charts, which is this one, which shows the cbo estimates for total federal medical expenditure. And the red line along the top was the predicted total federal edical expenditure as of 2010. Then the Affordable Care act went into effect and time went on, and it turned out that instead of that red line what actually happened was that green line. And then here in 2017, cbo did another forecast. So from this dot forward, the green line here is the newer forecast. As you know from our budget process, we think in 10year increments in the budget process. So this green area is the 10year budget window from 2018 through 2027. D in that period, we reduced anticipated federal Health Care Costs by 3. 3 trillion according to those estimates. Now, i dont know how that happened. Ive got a terrific staff but they are not like your staff. I think it should be a matter of urgency to try to really think hard about why that happened. I hope that you will take a look. Because if we can find 3. 3 trillion in federal Health Care Savings without inflicting pain on seniors and other beneficiaries, that is a goal worth fighting for. Now, my sense of it to go from the global scale down to local is it has a lot to do with Delivery System reform and payment reform. I want to focus on the group that i mentioned to you i think also in our meeting, the coastal medical Provider Group, a primary care Provider Group in rhode island which was one of the early pioneer ac omps. In the five years that they have been an aco they have reduced their cost per patient per year by 700. They werent high fliers to begin with. In 2016, which the year we got the last complete data for, they were down 700 from their previous measure but down 1,000 from the average. So it is not like they were one of the most expensive people saving, they were actually doing better than average when they began and they still saved 700 per patient per year and the patients couldnt be happier because those savings came through Better Service and better care. So it seems to me if you spread that across the federal Health Care System you start to look at numbers like 3. 3 trillion. That theres a connection perhaps between the payment reforms that empowered coastal medical to change their means of practice to save that money and better serve their patients and that big projection savings that we are seeing. So i just want to flage that for you. Saved them 28 million with what the coastal medical people did. 28 million is not big bucks to you. You would probably have to put a b instead of an m. But in small rhode island from one Provider Group to save 28 million is pretty significant. And you start adding in the multipliers nationally and i think there is a big gain here. So i really want to work with this. I would urge that the more that we talk about repealing obamacare and having those fights, fine if thats what you want to do. I dont think this. I would urge that the more that we thats good policy. I dont think thats good for the recipients. But what i dont want is for you to get so involved in that you wont work on the delivery you wont work on the Delivery System reform piece which i think is strongly bipartisan, it is completely beside the obamacare wars. I dont think the people who want to repeal and replace obamacare the most want to go back and repeal and replace the acos. They have an explosion from their home state doctors and providers if the they tried. So i think this is a safe bipartisan place where Real Progress can be made. And i just want to take my time with you today to urge that. We are coupting on a visit from you at some point to meet the coastal medical team in rhode island. We have other primary care physician whose are producing similar results and there is a lot of excitement and satisfaction around that. If i could say i totally agree about the need for the valuebased transformation. I think it is a bipartisan issue. We can improve quality, decrease cogses and make our programs sustainable. Im going to be harassing your folks at the staff level for more information out of the macro program, the center for medical innovation, all those things. I hope i will get good answers to my questions. Thank you. Senator cant well. Thank you. Welcome, secretary. You mentioned gme in the discussion with our colleague. How would the proposal encourage medical training in Community Clinics where most physicians actually care for patients . And how would it help the Community Clinics that are not under the current cap . In terms of the is this the Community Health Center Program on gme that youre referring to . Your proposal to change the structure. Im just trying to understand how it would address a couple of things that are in the need area. Which is Community Based clinic training and Teaching Hospitals that arent under the current cap program. Right. So the we are not proposing a change to the Community Health center based Training Programs that we have. Those are separate. These are the medicare, medicaid, and then the Childrens Hospital programs on gme. And it puts those together so that we dont operate under these artificial 1996based caps and instead can really focus on the providers that can help train our physicians and get them to both make sure we funding in the underserved specialties and areas where we need physicians the most. Including primary care. Absolutely. As well as underserved areas. How can we make sure that were dedicating the money to get training of physicians that are or will serve in areas that are lacking in appropriate physician care. So if you are saying you are willing to take on the big east coast teaching institutions having most of the capacity, i am all with you. Because i think the dwirgeance of medicine and where we are need to train physicians in all sorts of ways. So i am all for that. I dont like the fact that you have actually then cut the program, because from my estimation of what need to trai physicians in all sorts of ways. I see in the Pacific Northwest and our shortage and the whole notion of everybody having a medical home and were very excited about p4 medicine, preventive, prescription, personalized, so that physicians are being trained on what you would i hope describe as a way to drive value into the system and get off of fee for service. So what about that i see in the . Why cut the program when i am pretty sure we need probably like four or five times that amount . Well, the overall one of the philosophies that we had was to try to move some of our programs where right now we are having medicare carry the burden across the whole health care profession. As we look how can we make medicare more sustainable, our proposals actually stretch out the life of the program for another eight years as a result. And it is tough choices, i will admit that. But right now we are having medicare and Medicaid Fund graduate medical education that private insurers, commercial people, get the benefit of. And so theres a bit of recalibrating in there from the federal taxpayer perspective and medicare, medicaid, that transition to cut that back a bit as a result i think it is 48 billion off of where we stand right now. Over ten. But if we examine the shortage and the need you wouldnt cry if congress basically boosted that number . I would have to do so within our budget targets so if that goes up Something Else has to go down. Thats the ageold challenge of these budgets. Please mark me down as very counter to what senator toomy just said. I believe that we have a growth in our Medicare Medicaid population because we have a burgeoning baby boomer population reaching retirement. So the notion that somehow people think that you should cut medicaid and medicare or block grant medicaid as a way to save dollars just because the population is growing because of the demographics in our population, i just think is wrongheaded. Do i think there is sufficiencies . You and i have had a chance to talk about rebalancing. Thats a huge saving. But the notion that somebody after giving big tax breaks to big corporations say that we ave to block grant medicaid as the only solution is just i just dont agree with it. As my providers have told the only solution me, hospitals, they view the block granting proposal as nothing but a budget mechanism to cut medicaid. So what they do support is the efficiencies that were driving in the northwest and implementing those in the system, which are driving who doesnt want to stay at home and get longterm care . Who doesnt want to do that . Cost. One third the you could comment on rebalancing from nursing home care to communitybased care as a big savings. For some individuals institutional nursing home care meets their you could comment o rebalancing from nursing home care to needs and is what theyre need. But as i said, i am a firm supporter of the notion of homebased care and these alternative ways i believe can save us money. I believe that for many it can be the best solution. It can be the way to age with dignity. So i am very supportive and very much want to work with you on ways we can generalize that more across the United States. I appreciate that. I just very concerned about some of my colleagues. We have been very suspecting that this is what might happen is that people are going to try to go back to block grant medicaid. Mark me down as very opposed, and we are already doing the job. We are already doing the job of reducing the costs so the notion that somebody wants to create a budget mechanism to cut people off medicaid my providers, the community services, the Childrens Hospital, theyre not going to support it. Thank you. Senator nelson. Mr. Chairman, thank you for the kind comments of several of you with regard to the slaughter of 17 students and teachers. Senator rubio and i will be addressing this issue on the floor of the senate at noon today. Secretary, i want you to very at you are a prepared individual. You are a fine person. When you were here on your confirmation hearing, i asked you several questions about medicaid and medicare, and you side stepped the questions. Ver prepared individual. You are about cuts. Now, coming forth just a few weeks late we are the budget, about 1. 4 you have trillion over ten years in cuts to medicaid. That is going to shift about co the states, and the states will plug the holes by raising taxes or cutting other parts of the budget that they are responsible for, like education. A state alternatively could how would you expect a state like florida that has a big population to afford to cover the high cost . We are proposing to congress it make some changes their and how we do various payments to providers. We are actually not suggesting payments that would benefit the beneficiaries. What we do is the net changes to is 250 that we propose billion over 10 years which is about a 2. 8 reduction. , which is medicare growing at 1. 9 annual rate of growth over that tenure. 10 year period. My question was medicaid. For example, veterans rely on medicaid. Seniors in Nursing Homes rely on medicaid in florida. Couldg medicaid benefits lead to states cutting these Veterans Benefits and the seniors. What do you say to that. Sec. Azar we believe states are in the best positions to allocate among various populations. The core medicaid actually grows from 400 billion to 450 billion over the 10 year. Period. On the expansion population, the states then do not have that 10 copayment federal matching that they would have to come up with to do that. It actually gives them flexibility and it sort of found money for them in that sense sen. Nelson . Sen. Nelson that is what is typically the place case with a block grant or turning it over to the states. My state is subject to hurricanes. Puerto rico is subject to hurricanes. So what has happened with medicaid. It has to respond to a Public Health emergency in a Natural Disaster and if your response is the further Medicaid Funding would be provided after a hurricane, the fact is that congress waited nearly five months for passing disaster aid to hurricane victims in florida. After foot, michigans lead poisoning flint, michigans lead poisoning, i know what your answer is and you have provided it and we have a significant difference. A 1. 3 billion in higher medicaid drug costs with the introduction of the then new 2014 bys c drug in cutting medicaid, are you suggesting that states should not cover these kind of breakthrough treatments that ensure conditions and come with high cost . Sec. Azar absolutely not. That case is actually a really good example of how all of our Payment Systems are really not equipped to deal with what we call curative therapies. Our Payment Systems just cannot handle the notion of a highcost drugs that we would pay for, but get the benefit over the course of somebodys entire lifetime. We need to be creative and think about ways all of our programs can handle in the future products like that. In closing, i just want to point out that in a gross state like your state, especially my state that is growing at 1000 people a day, where we educate the doctors and then we dont have the residency programs, they end up going and doing the residency outside of the state of florida and they usually stay in practice there, and yet we have borne the cost of educating them. When we start cutting 48 billion in cuts over 10 years to the graduate medical education payments, it is going to severely hurt a state like ours that is a gross state that desperately needs those residency programs to keep our doctors. Casey we are grateful you are here and you and i have had discussions before about medicaid. Approaches to it differ so im going to raise it with you in the context of not just the program, but also i believe the administration has been trying to do. With regard to medicaid pennsylvaniae aboutic when i think the expansion, i try to think about it in terms of the people who are impacted. In can also think about it 40 of thenumbers, children of pennsylvania, 50 of individuals with disabilities in of state, and a 60 individuals who are in Nursing Homes. As you can kill tell, three big numbers. , we have 38 world counties out of 62. The horror which you know well, the horror of the opioid and epidemic and overdoses that come with that as well as related just in pennsylvania, we look at between 15 and 16, the death rate is up some 37 . It is higher actually in the low 40s for rural areas. One county where the overdose death rate has gone way up. 94 deaths just in that county in 2016. I raise that because medicaid is critically important to our state. This especially important, the Medicaid Expansion part of that story is especially important to deal with the opioid prices because it is the number one payer for those who need treatment and services. My real concern is twofold. Administration has been sabotaging the Affordable Care act, taking a ministry to the actions and doing everything it can to undermine the Affordable Care act in the absence of getting full repeal i way of legislation. I would hope that you would put an end to that. Secondly, what appears to be an to use thehe budget budget process over time, not only to cut medicaid dramatically, but to end the Medicaid Expansion. One is will you commit to ending the sabotage through the efforts of an agency like yours, and secondly, tell us about the impact of the budget on Medicaid Expansion in particular. Sec. Azar on the first point, as we have talked about before, you have my commitment that i and my department will work to make Health Insurance as affordable as possible and have as much choice for people and meet their needs as much as we can and to do so faithfully within the law. I am about making our programs work as best as they can. The team around me has the same commitment. You and i will often disagree theologically about what might wontwhat what work work. Our desire is the same. I want as many people as haveble as do you to access. We certainly share those goals. On the second point, i hope your goal would also be the no one would lose coverage. Our goal is to make sure that people have access to affordable insurance and that they have a choice of those packages. On medicaid, you mentioned some populations that i do care a lot about. Children, the disabled, the elderly and Nursing Homes, one of the really odd incentives of the way the expansion was done was it created a perverse incentive because of the differential matching from the federal government. It actually prioritized the expansion of ablebodied new populations over the traditional medicaid populations. I hope that through our proposals and Work Together we can reorient medicaid to fix a lot of those counter incentives that are in the traditional medicaid populations. I just hope that we are not to the point where we are just talking about access. The people who are on medicaid and dont lose it. Chairman with your indulgence one more minute, you probably have not seen this yet, i have a letter that i sent you applyingt states are for the waivers. I will just read one sentence. At the end of the first paragraph, i say i urge you to reject medicaid waiver applications from the states that would further three things, limit, restrict, or block americans guaranteed access to affordable coverage. I hope you take a close look at that and provide a response. Sec. Azar i will thank you. Chairman cassidy we have been speaking to, Graham Cassidy addressed. One of my colleagues expressed to the there has been a problem after match Natural Disasters that there were not dollars made immediately available for medicaid for those who were impoverished because of the disaster. Under Graham Cassidy, we have every three or six months registration in which a state would say these people are now eligible so therefore we get money for them. They would get money on a riskadjusted per person and enrollee. It in acknowledges something indulgings are now who are under the Obama Administration, which is that the status quo is not working. A group of people a constellation of democrats who were in the Obama Administration saying the status quo is not working. It is interesting that people are defending a status quo that which is not working. State in the individual markets if they are not getting the subsidy, can no longer afford insurance. Folks in louisiana are paying as much as 40,000 a year for premiums. Some people are a technology that in some folks up here are not. This is not sustainable. Oregon is having to pass new taxes in order to pay for the state share of Medicaid Expansion. I have 1 i heard one person say that we are excluding unions but we are taxing individuals and Small Businesses. They are the only ones without lobbyists. Those without lobbyists will pay the tax for everyone else, oregon having to pass new taxes to afford the Medicaid Expansion. What Graham Cassidy did was it told states that if they cant not afford the match, they dont have to put it up. Under Graham Cassidy, florida would have gotten 15 billion more than under current law to care for those who are poor or poorly insured in their state. Oppose as a would doctor who took care of the uninsured for 25 years, why somebody would oppose 15 billion more over 10 years to care for these poorly insured in their state, i have no clue. I have no clue whatsoever except a dogged determination to support the status quo. That said, i would get to my question. I had an intriguing conversation yesterday. Like your thoughts, that medicaid best price actually drives up the cost of medicines for everybody else. When medicaid best price is put into place, only one out of 11 americans were covered by medicaid, but now one out of four americans are. This is not because of democrats ands, it is because of an expansion of medicaid under obama. This one quarter of the population getting the best price has an hydraulic affect and raises the cost for everybody else. What are your thoughts . Sec. Azar i think that is a very perceptive oxidation and i think it is something we have to abouteful of when we talk our Hospital Physician services with medicare and medicaid. If we end up under paying what the Market Forces would lead to, we will see high rates in the commercial space and we end up having a cross subsidization prod problem. Chairman cassidy this medicaid pricing increase the cost . If we underpay and medicaid, it will increase cost elsewhere. Chairman cassidy related to that, i was also told that some thees have carved out pharmacy benefit from their managed care contracts and carving out that allows them to get the rebates. They are preferentially going to namebrand drugs, the higherpriced drugs because it increases the rebate as long as the federal taxpayers are paying 90 in the Medicaid Expansion, it is a good deal for them. More an rebate, have you observed that . Sec. Azar i have seen that and theres a bit of a perverse in the system to carry branded drugs because of the rebates. Perspective, it can actually be beneficial to the state Medicaid Program to receive the branded rebate as opposed to paying the reimbursement to the pharmacy which is requiring a generic drug a quite a low price. Chairman cassidy so we have misaligned incentives dont we . Sec. Azar yes, we will work on that. Chairman cassidy ultimately driving up costs for everybody else, thank you and i may have a second round. I dont know where to start. I greatly respect my colleague but we have such a different view of the world in terms of health care. It is not a commodity, i think it ought to be a basic human right. We all get sick. I would love everybody to buy a new car from michigan, but if you dont, it is not going to affect everybody elses rates. Oing up health care is very different because we are all human and we all get sick. Stay say status quo, this is the new status quo under the Trump Administration where there are no requirements that people share in their own health care in terms of responsibility. We are back to junk plants and people buying insurance that may not cover basic so they dont know until they get sick. Folks walking into Emergency Rooms without insurance and people are going to pay for it. That is a lee coel uncompensated call what we uncompensated care. Michigan actually save hundreds of millions of dollars last year. Were market rates flattened for a lot of Small Businesses in michigan. There are a different view of the world and i look forward to debating that as we go on. I do want to start with positive that i have seen in the budget. A lot of things i disagree with, certainly when it comes to the few unmedicated and what that means for seniors and children in michigan when we see these kinds of cuts. Part of the recent budget agreement included a muchneeded 6 billion investment over two years in combating the Opioid Crisis and Mental Illness which is a major focus for me and has been. I want to acknowledge the fact , the hh se budget budget actually expands on what we have been working on for certifiable behavioral clinics and being able to do with Behavioral Health what we have done for health centers. Have beenstrations the fact that we literally pay for service and pay providers that provide physical health care, but for Mental Health or addiction services, we do something we would never do which is we provide service until the grant runs out. I cannot imagine that if somebody needs heart surgery, the doctor would say i would love to provide your surgery, but the grant ran out. We do that every day for Mental Illness and opioid addiction. Of whatthis is part needs to happen around violence and what we saw yesterday. Say that iirst appreciate that that is in the begun at we have eight states happen fully funded and have demonstrations across the country. That. Working to expand i would like very much to work with you as we move forward to expand comprehensive services in the community including 24 hour Psychiatric Services and facilities so people are not going either to the emergency room or to jail, which is exactly what is happening right now. I am concerned that if we go on to talk about opioids and Mental Health, that when we look at the change, the cuts in medicaid, this time about 1. 4 chilean 1. 4 four alien 1. 4 trillion, i am worried that the opioid cuts would reduce in michigan and what we need to do with Mental Health. Expanding healthy michigan, if we were to end that, the Addiction Treatment gap would decrease by 50 . Mental Health Funding would become over 5 billion over the country. Sec. Azar the points you raise are important concerns that we would want to work with in any legislative practice. Ensuring that what we are doing provides resources around Substance Abuse treatment. Do you believe that these treatments should be included in all health care . S rocco sec. Azar i believe our requirements would provide that. I believe that is part of that. Sen. Stabenow wesec. Azar do l Health Parity but i authored a language in the aca to make sure that this was included in everything because it has not been happening up until then. It is part of the essential benefits package that would be eliminated under the kind of approach that the large block grant approach that is being talked about. I am very concerned about that. Ifould you suggest people lose coverage under the budget, if these medicaid cuts go through, what would you recommend to the state of michigan and those right now that desperately need services . Sec. Azar the challenge we have now is that for 28 million americans what we have a sibling not affordable. The status quo is leaving tens of millions out to run affordable options. We want to Work Together to see what we can do to build a stable, good, affordable, tailored options for individuals out there because that status quo is not working for us money people as it ought to. Sen. Stabenow i would disclose by saying that it has been a year and a half under the new administration with a very , i will saypproach a war on health care and multiple changes that are raising costs. The status quo today is a new status quo based on actions that have been done and it ramifications that will continue to be felt as new insurance rates come out based on what has been done as part of the tax bill and other decisions to rollback efforts to Keep Health Care affordable. I do want to say also that some points we can debate how medicaid pricing is the reason Drug Companies are dramatically raising their prices. In terms of the pricing, i would have Major Concerns about that. Sec. Azar i certainly did not mean to be saying that that is the reason. It is an economic incentive. How do we flip those incentives around . Mr. Secretary, welcome. In new jersey, one and 41 children are diagnosed as having autism spectrum disorder, much higher than the average of one in 68. I am 14 days into this and i know that we have as part ofgrams that just prioritizing direct care delivery, direct Service Delivery and under care Service Delivery, there are programs that simply we have to not recommend funding because in the tradeoffs sen. Menendez i have been here a little longer and it is zero in the budget. In fy 18, the congressional justification was that the department believed that the same services to be provided to the states and the maternal and child block grant. That is the same reasoning. The challenges that we have is that we are prioritizing direct care Service Delivery. Is it your view that the congressional justification of can bef the Services Provided is the reason why you have zero in this budget . Sec. Azar i do not know if that washe reason this budget prepared with that program zero doubt. It is more likely, if it is not a direct Delivery Service program or was viewed as being otherffective as expenditures, tough choices have to be made. The autismez community does not need those tough choices, they have a tough life as it is. I have a feeling that that is the justification, the problem with that is that you also cut funding for maternal and Child Health Block grants as well. Explain to me how you think that states are best positioned to replace the Education Training research authorized by the autism cares act with reduced funding for the programs that supposedly you can claim that you replicate the progress . Sec. Azar what i told you was that are programs that we prioritized our direct care delivery programs. We had to do prioritized against others. Not menendez they are backdoor to these committees, they are front door. Providing direct care is what we had to prioritize in the budget. Sen. Menendez how is it that inn i wrote cute of ours your confirmation, i specifically asked you about working with me on reauthorizing the autism carers act and you a big answer and said you are fully committed to in promoting the laws passed passed by congress, that was your answer. How does it zero out funding to implement a law passed by congress and signed into law by the president allow you to do that . Member of you are a the senate and part of setting the targets that we have to operate within the operate within that and have to propose a budget. Sen. Menendez the law is clear. Is notar there limitless money senator, im sorry. Sen. Menendez that is why we should not have spent money on tax cuts for the wealthiest people in this country and maybe we would not be having this debate. Inexcusable to take a community that is so challenged, that the law specifically directs the and thent to engage in, new zero it out. Have you think eliminating the medicaids proportionate share payments at the same time you strip the Medicaid Funding to states are going to be able to deal with that . Sec. Azar that is a continuation of the medicare disproportionate reductions that are a part of the Affordable Care act. Andave many other programs will be putting out 1. 2 trillion in the budget of the Americas Health Grant Program so that we have alternative insurance vehicles that should be the alternative to deal with the afford will care act. Sen. Menendez it is not a scaling down, it is an illumination. Zero. That is not a scaling down. I expect you to enforce the law. Clear. On autism is very i will challenge this administration to respect the law and enforce it. Welcome. N clear secretary, i concur with senator menendez and what he is saying about the taxcut and how you are just taking away so much from so many people who are a whole lot less privilege than ceos and cabinet secretaries and members of the senate. Starting about january 20, going , the the Health Care Law republican approach has been to decrease the deficit by billions of dollars. Tax will to the richest individuals and the new cut programs that millions of working families rely on to pay for those tax cuts. It is just morally reprehensible. A few months ago, the first lady and Kellyanne Conway visited a facility in West Virginia that provides treatment for babies born with the syndrome. We have a similar facility in ohio that is focused on keeping Families Together and helping both moms and babies overcome addiction and withdraw. I introduced a bill last year with a number of members of this with legislation that would provide state Medicaid Programs with flexibility. I understand yesterday that you all announced they approve reimbursement for this type of Residential Treatment Services in West Virginia, we should not have to do this statebystate. I would like to ask for your commitment that you would assure that babies in ohio have the same opportunities as those in West Virginia whether it be through administrative action or helping to pass the credit act crib act. Sec. Azar i am happy to work with you and the senator if it complies with our waiver requirements. It seems a very noble purpose to me. I appreciate the efforts you put into proposing some initiatives that would lower the cost of Prescription Drugs. This, can you point to a single proposal in this budget that would force the lowerceutical company to the list price of a drug in a way where all americans rely on that drug will benefit . Sec. Azar that is one of the things we are trying to do in the Budget Proposal is create the incentives in a downward pressure on list price of drugs. In the catastrophic coverage of part d is changing the incentive structure. Is on the hook for most of the cost once a Senior Citizen is on the hook for most of the cost gets 2 now, they have a lot of incentive to drive to the catastrophic coverage and offload that expense on to us. This is just one step and working on the issue of drug pricing and this is the one that is in the context of budget and medicare and medicaid. Anymore think that we are working on and if any ideas you have around list prices of ways you can reverse those incentives, i would love to hear that. It sounds to me like relying on a middleman here. None of these policies actually go after the pharmaceutical industry, your former employees employers. And as tenney worked with Insurance Companies to push, but none of these prices it guarantee individuals who rely on insulin, nothing will help that we can see will help individuals who pay for drugs out of pocket. It seems the administration that promised it would make the Drug Companies pay until the present met with the drug Company Executives and was singing a very different song when he met with his ceo friends. It seems he left out anything and the Budget Proposal that would hold these countries responsible. We need to do better. Know Ranking Member wide and is willing to do that and go after pharmaceutical companies that will reduce patient choice. Have aar i hope i will chance to brief you on our Budget Proposals, because there that will proposal dramatically reduce Senior Citizen cost. We are proposing an inflation cap on list prices, if you increase the price above inflation, just like in medicaid, the Pharma Company will do a lower reimbursement paid out. We have a whole suite that we believe will dramatically reduce Senior Citizens out of pockets when they walk into the pharmacy for medicines and getting their part b drugs. Would love to sit with you and brief you on that. That is good news, but that is medicare, what about everybody else . We have lots to do. Sen. Thune thank you for being here today. I appreciate the priorities you particularly what you laid out for reducing regulatory burdens. While it is not the jurisdiction ,f this community, committee it was great to see the proposed rease in funding for ihs cms. Money alone cannot solve those problems. One thing i had hoped to see in the budget was a puzzle signaling the ministry should commitment to restructuring the ihs. Is, is that legislative solution something the administration a recession will continue to work with us on . Sec. Azar ive not been able to get into it, but will be happy to work with you on that senator. Regarding the application of Competitive Bidding rates and bidding areas,ly i relies you have only been sorted for a couple of weeks, i get that, but i wanted to ask you to please provide a status update on when that role will be finalized whether the president s Budget Proposal on Competitive Bidding, which projects more than 16 in savings takes that role into 6 billion in savings takes that rule into account. Sec. Azar the proposal we have would have the dme bidding be targeted toward the areas in which it is dead. If you happen to win and be entered into the process, i am concerned about access and areas. Bility in rural im hoping that we can solve that problem. Sen. Thune i am encouraged by seeing i doto think there will be a positive impact on Health Care Providers and i have been working with others here on the finance committee to address the challenges for many years. One of the provisions to eliminate the requirements for meaningful use standards to become more stringent overtime was signed into law as part of the budget deal. Is this change incorporated into a Budget Proposal and what other forms do you expect to make in the space . I got no is the most recent change has made it into the budget. I do know that was fully integrated yet. Aspect that you mentioned, im very proud of which is for positions physicians who are being paid under macro. We are taking a whole host of where we would be able to independently look at data ourselves to decide their compliance with the quality programs rather than their having to report anything. Think its one of many significantly significant regulatory burdens that cmr is taking care of. Sen. Thune could you approach commitment . Othing sec. Azar i want to delve more into the status of the meaningful use. Becomingt is about and it willlity, not do us any good if everybody is electrified if they dont actually communicate with each other. My energies and focus is how do we now get those connected to each other. I want us to make sure that we answer that accurately for you. Sen. Scott and other you have had a number of questions on opioids and abuse and the challenges we face as a nation. The last time you and i had an opportunity to discuss opioids was at your first hearing. Congratulations and condolences. The importance of addressing the growing opioid abuse epidemic from the bottom up, from the local level. We have aarolina, county where a lot of folks come , the myrtle beach area. More than 100 folks have lost their lives in that county as. Ell because of opioids in your response to my questions on the crisis, you mentioned that there is not a one size fits all approach to opioid treatment and prevention programs. How does your department when to use the 6 million to customize and create more flexibility for local jurisdictions to play a more Important Role in addressing the challenges that we see . The 3 billion initially that we have allocated into the 2019 funding that we have 1osing, we would billion in grants under the program. That is a doubling of the of 500 million a year. That is very flexible. Very customized approaches. Another the program we are is we areerested in going to be investing 150 million in rural Substance Abuse programs to try to develop novel methods of care and treatment for addictions in more world communities because of access issues and distribution of resource issues. Another 400 Million Dollars goes to quality incentive work with our Committee Health centers. Im not sure if you im not surescott if you have answered a question on wellness yet. One of the things we have talked about his the access to Health Insurance. We have talked about who is insured and not an underinsured, we have talked about issues around the exploding cost. The underlying driver is obviously the exploiting exploding cost of health care. A monthly spend more time talking about the costs, we will not be able to address the actual challenges. Week facee issues around the cost perspective as thentinue to rise azar explosive drivers of our Health Care Costs. When it comes to making Healthy Habits so that we can prevent some of the challenges that we requires a local bottomup approach to creating more flexibility in the alternatives. I know in south carolina, we have a unique population. Some of the programs we see are very effective in the state are programs that work with nonprofits whether it is churches or synagogues. We have found that these programs have been quite successful in south carolina. What do you plan to do the share to empower and encourage states in this space of Wellness Programs so we can get a control of future cost perhaps . You put yourthink finger on one of the more important drivers on Health Care Cost in our Healthcare System which are the social and behavioral determinants of health. With hope to provide alternatives to minimize medical spending their if we can do so in alternative ways, but also on the behavioral side, can we create adequate incentives are flexibility for adequate incentives on a behavioral side . The 2000, wehhs in were involved in helping to create greater looks ability. Hrough hepa hippa if you have other ideas to address barriers, i would love to learn more about that because i think it could be very constructive. Look forward to having that conversation with you perhaps another time. Look forward to having a conversation. Chairman cassidy not related to you, someone earlier criticized the tax cuts and job ask provision which does not allow the deductions of state and local taxes, they were creating criticizing it for the benefit of the upper income. The same senators who say the also complain about the salt tax provision. They complain about that. Havee one hand, you cannot the wealthy getting taxed more, on the other hand having a tax that benefits the wealthy. We encourage provisions such as auto enrollment which could increase enrollment relative to now. We allow pulling of the individual markets in the medicaid pools which im told the lower premiums by 20 , therefore making insurance more affordable. Notfolks on the left do seem to care about those middleclass families paying 40,000 a year. The statussms and quo, the status quo still includes individual mandates. I suppose all of this is the reason why some folks are saying that we need to do something different. You spoke question, earlier of the part d provisions. Increasingat despite the mandates pharmaceutical Companies Must pay. The concern is that these cap at anat the pay outofpocket costs. This means the taxpayers are paying even more. The other thing i have observed is that when Drug Companies have to increase the rebate, they just increase the cost of the drug. If we are going back to our earlier discussion, if we are forcing them to increase the cost of the drug if you are , and youre not on medicaid, you are going to pay a lot more. If we are counting these rebates cost,e two outofpocket were pushing people up into that provision and the taxpayer is paying more. Im not saying that this is a great benefit for the society at large. The proposals we have around the drug pricing, think we need to look at them as a holistic whole. We would have a genuine outofpocket maximum in part d for the first time. Even in catastrophic coverage, the Senior Citizens have to pay 5 which can be a lot of money. That would now be zero. We would then in fit fix this incentive where the federal government is picking up a catastrophic care to the tune of 80 and a reverse that so that the Insurance Company pays 80 and we pay 20 in the future. Have that two questioncket costs for our low Income Subsidy seniors, bridge errors. Lets go backdy to what we discussed earlier. Medicaid and medicare are both getting large rebates and taxes are pulling the cost of the drug. This causes the Drug Companies to raise prices. Is that going to increase the price of a person is either paying cash for a Small Business , group plan, or through the individual market sec. Azar . Sec. Azar i dont believe the hanisms we are proposing we want to get outofpocket up from the patient down. The nets could even remain the same to the program level. I do hope that we will keep good incentives to keep driving our net prices down as we did quite effectively. It is that list price that we reverse as you said, every incentive for that list price we have to try and flip those incentives backward on that. This is a starting point on that, and i am going to keep working with you all to come up with other ideas that we can either contain or pullback this list prices and create financial incentives and Market Forces that will actually get this was prices down. Chairman cassidy i was following you with everything up in the last 45 seconds. I want to come back to what senator brown said and do it very quickly. You are going to have to spend a lot of time to really dig into these issues. People in organizations like the work i have done with the gray panthers over the year, they talk about how they are getting clobbered and they go. To the pharmaceutical window senator brown asked you about that because i was with him in ohio and i heard seniors talking about it. You said what we are going to do is change the incentives for the middlemen. I have legislation. That is a key part of the puzzle. What senator brown was saying and what i am saying, we will talk more about this in the future, you cannot solve this problem if you let the man many fractures off the hook manufacturers off the hook. That is at the budget does and that will be a topic for another day. My question for you deals with question of atis cars. Has been blocked or put on hold or something of this nature. This gives us Critical Data like how many foster kids get terrorized in the sex trafficking system. We really want to get this out. Are you supportive of this, we work with us, this is what congressman davis was talking about. Sec. Azar i did not get a chance to follow up on his comments. This is the first ive heard of on this issue. I would love to learn more about this at that is the impact, we want to be doing everything in our impact power to stop this question. You know, a lot of us are supportive of the idea of states having a bigger role in these kinds of areas, but we have to know what is going on at the state level and have this kind of information and partnership. Because my friend is here, i am going to put into the record, because we talked a fair amount about Graham Cassidy, and sometimes people dont know this, but the two of us talk often about health policy. Left on thee it was preexisting condition issue. Im going to put it in the record because i suspect will come back to it. When we had the hearing, i have received voluminous amounts of information from doctors and hospitals who were concerned that Graham Cassidy did not protect people with preexisting conditions. My colleague said that is not right. People mean well but they are not right. Sitting on the far end of the table was a representative from the cancer society. Me representative looked at and look at my colleague and said we know something about thisxisting conditions, does not protect people with preexisting conditions. The reason im going to put in the record is i want my colleague and others to have a chance to comment and be part of the debate. Graham cassidy has come up several times and i am particularly concerned with the trend that has been apparently started by idaho to go back to junk insurance and no protection for people with existing conditions. I want all sides to have a fair. Hance to comment on this we will put into the record why have just given, a shorthand description. Im sure my colleague sees this differently but at least we are going to be picking up where it was left when we actually had a hearing. Chairman cassidy since it appears we will not attain a , i want to thank secretary is therefore attending and think all of my colleagues for precipitation parsippany participation. Was of that, this hearing is that, this with hearing is adjourned. Is a look at our live coverage for friday. Former president ial candidate mitt romney has announced he is running for senate in utah. That is at 9 00 p. M. On cspan. Cspan2, congressman adam schiff will be at the council on Foreign Relations talking about some of the global challenges facing the u. S. On cspan3, a conversation about vietnams changing relationship with the u. S. And china. T 9 30 a. M. Eastern cspan, where history unfold daily. In 1979, cspan was created as a Public Service by americas television companies. Today, we continue to bring you unfiltered coverage of congress, the white house, the supreme court, and Public Policy events in washington dc and around the country. On this mornings washington journal, former fbi agent Jeffrey Ringle discusses procedures is running security clearances for white house aides. And was a