Transcripts For CSPAN Health Human Services 2021 Budget Request 20240713

Coronas outbreak and the federal government coronavirus outbreak in the federal governments preparedness. And the federal governments preparedness. The appropriations subcommittee on labor, health, and Human Services, education and related agencies will come to order. Thank you, secretary azar, for being here. It has turned out to be a more eventful week than we anticipated, but we are grateful you have shown up as we asked to at the time we asked you to. The budget you suggested, the request, many of the same kinds of cuts that occurred in 2020, and i am sure we will have questions about that. It is not unexpected. I think you will recall when i called you with the final budget numbers from the 2020 budget. My first comment was, the good news is you didnt get what you asked for. Hopefully, that will be the case again this time. But you propose a 10 cut, similar cut you proposed in the past in programs that we would be very reluctant in the Health Care Workforces and preparedness programs and research programs, all that we have been about earlier today at the members reading on the current virus. Home energy, rural programs we would be reluctant to discuss. We will need more money this year in my view than the top line number is likely to give us. I do appreciate that in this budget, unlike some in the past, the administration has tried to focus on priorities where we would increase spending, ending the hiv epidemic, the effort to do that, the effort to improve maternal health, the effort to fight the Opioid Epidemic. Also to maintain some of the other investments we have made, but it also looks at highquality childcare, headstart, and Child Care Development block grants and really suggests that they appreciate what has been allowed in budget in the past to happen there. Many of the increases this budget requests are financed by unrealistic cuts, cuts that we dont want to make, in my opinion, and cuts at the end of the day that you probably wouldnt want us to make, like eliminating Childrens Hospital graduate medical education. That is not going to happen. Eliminating heap, highly unlikely to happen. It proposes a cut in Health Care Research that i think by now, in the last five years ive chaired this committee and senator murray and i have worked together on this topic on this committee, we are not likely to cut Health Care Research. And i hope we can continue our pattern of increasing Health Care Research at this incredible time. I think we have been making a difference. We have seen Life Expectancy numbers go up and quality of life for americans go up with the innovative opportunity in health care. Americans Life Expectancy rose for the First Time Since 2014. Last year, cancer death declined, the first decline in a long time with opioid Overdose Deaths are part of that. New treatments, screening tools, vaccines, all make a difference. This is such an incredible time to move forward in all of those areas based on what we know and what we think is in the future Pr Technology and other things. I know you had to make difficult decisions with the budget number you had and we will have to do the same thing. Hopefully we can Work Together to identify priorities and find Common Ground and hopefully our committee will be able to Work Together, as i think we have made a real effort to do for several years now. Two years ago, this subcommittee created an Infectious Disease fund to provide flexibility funding for the department for immediate response. You have used that money as intended, that first 105 million. I will let you respond to the coronavirus that let you respond to the coronavirus in ways that you wouldnt have otherwise. However, responding to this particular effort not only takes a Rapid Response, but if we are going to be partners in this, it takes a lot of sharing of information, and i encourage you to continue to do that. We gave you Broad Authority in the Infectious Disease fund, but Broad Authority also includes broad responsibility to be forthcoming with information. When we give you this authority to spend money, i think everyone on this committee would like a similar kind of treatment in your response to how that money is being spent. We have asked virtually every day for the department to give us specifics on spending money with the proposal that came out last night that you and i had a chance to talk about yesterday, i think we have a better sense of the path forward than we would have before. But whether it is your department or omb that makes it hard for you to share information, i just encourage you once again, this is going to work better if we have the kind of sharing that allows you to have the flexibility that you would like to have. Comes, in mythings sense of obligation and the other thing and the sharing of information to be part of that flexibility that we have given you. We are going to talk a lot today, i suspect, or at least i am, this morning about the virus and the supplemental and the time you think the supplemental fills the gap and what the backup plan would be if it is not adequate. I appreciate, secretary, your strong leadership at the cdc, hhs. Ih, and i look forward to your testimony today. We have both the chairman and the vice chairman of the committee with us. I know that senator murray and i are glad to have both of them. I think they will have some comments. Senator murray, lets go to you for your opening comments. Sen. Murray thank you very much for being here. Mr. Secretary, let me just say i am alarmed by the recent developments we have seen in the office of Refugee Resettlement and how it has handled children in its care following President Trumps inhumane separation policy. I have raised questions with you before and i hope we can continue that today as we review this administrations budget proposal. I hope we can get a straightforward answer on many of the other healthcare issues i am hearing about from my constituents in washington state. Because when it comes to helping families who are struggling to afford health care, this administration has continually said one thing and done the opposite. At the end of the day, none of the president s empty promises say as much about Health Care Priorities as his decision to champion a partisan lawsuit that could be catastrophic for families, because if republicans get their way in court, they will get protections for they will strike down protections for preexisting conditions, strip away health care for families who got it through exchanges and Medicaid Expansion, and give power back to the Insurance Companies to offer lowquality coverage and leave patients with Higher Health care costs. And much like that partisan lawsuit, President Trumps partisan budget exposes the truth behind that spin. Despite the promise to the contrary, this budget would slash 500 billion from medicare and medicaid. In fact, on seemingly every page of this, it takes huge steps backward on our nations most urgent challenges, proposing a small step forward with hiv pans but takesnsmissions, an enormously backwards with medicaid, which covers more than 2 5 of patients with hiv care, not to mention slashing investments in combating hiv overseas. These medicaid cuts would take us in the wrong direction when it comes to addressing mental and Behavioral Health challenges, like the ongoing Drug Overdose crisis or the increasing suicide rate by making it harder for people to get the care they need. In some states that have expanded medicaid, the Program Covers four out of five people receiving treatment for opioid addictions. To make matters worse for Behavioral Health, the budget eliminates funding for the new Suicide Prevention initiative at the centers for Disease Control and prevention, which congress included last year and our bipartisan spending bill. Then there is the Maternal Mortality rate, which is worse here in the United States than any developed country in the world. In any in than developed country in the world. Deaths are mostly preventable, and the impacted women are mostly black and native americans. Instead of treating this like the emergency it is, this budget offers a sleightofhand. It proposes expanding the Maternal Mortality initiative congress created in 2017 by 75 million, and i appreciate that. But unfortunately, that pales in comparison to proposed cuts over 100 times that amount from medicaid, which actually pays for nearly half of the births in this country. If that were not bad enough news for women and families, this budget continues the harmful trend of putting ideology over evidence and Patient Health by excluding planned parenthood from federal funding and eliminating the teen pregnancy program. Pregnancy Prevention Program. At a time when our nation is facing a Health Professional shortage, this budget proposes cutting nearly 800 million from programs that support tuition assistance, loan forgiveness, and training for several hundred thousand Health Professionals annually. And at a time when too many families are forced to choose between paying for health care or other basic needs, this budget seems to go out of its way to make things worse for People Living on the brink of poverty. It eliminates safety net programs and critical assistance to millions of people, like the low Income Assistance program low Income Home Energy assistance program, which we know helps families afford heating and cooling, and block grants that gives resources to challenge poverty. It eliminates the block grant and reduces programs that help families facing adversity from keeping their heads above water. And as it continues, the strong bipartisan investment in childcare and head start, this budget eliminates funding for preschool Development Grants which provide highquality preschool to tens of thousands of families. Finally, mr. Secretary, i have been in close contact with Health Experts dealing with the 2019 Novel Coronavirus outbreak which you declared an emergency last month. As we work to bring hundreds of americans from chinas Hubei Province and the infected cruise ship home and quarantine them for two weeks at a cost of roughly 6 million per flight, i have been pressing for more information about what resources are needed. I sent a letter to you and ms. Mick mulvaney expressing deep concerns about this. You finally sent a supplemental request last night, like i have been urging, and i am very concerned this request is not enough to ensure that we are putting all the necessary resources towards this emerging threat, including making sure our states and local Public Health departments have what they need to respond to this crisis and be reimbursed for those costs. And i am very concerned about how thin the details on that are, because despite with this despite what this budget proposes, not a single Public Health expert has told me the thing we really need to do right now is cut the cdcs program by 9 or cut critical programs by Critical Global Health programs by 80 million and cut the Rapid Reserve Response Fund by 35 million cut Health Preparedness programs. This will not help us deal with that. While i recognize the efforts happening across your department to contain this virus, i have to say this is unacceptable. It is important that we stay ahead of this crisis and we are ready when additional cases are detected in the u. S. , meaning we cannot plan on the cheap or at the last minute. Budget isays said the a reflection of our values, and that applies here. While President Trump may not tell the truth about his values, speaks volumes to all of us. It speaks volumes to all of us. It shows he is not serious about fighting for Family Health care or addressing National Crises like drug addiction, Maternal Mortality, or suicide. He is serious about cutting medicare and medicaid and critical programs and safety net programs and Health Care Workforce programs and more. Families across the country should know that we, as democrats, have no intention of letting those cuts happen and will continue to fight for patients. And we will continue to fight for patients against these attacks. Thank you, chairman. You bring a lot of experience at the right time in your job. I thank you for your service. I would like to focus on the Current Crisis that we have, and faces us in the world, how you are going to deal with it and so forth. To a lot of people, i think the American People are concerned and should be. I am concerned. This is a serious, serious disease that if it keeps spreading, nobody knows better than you what it could do. It could be an existential threat to a lot of people in this country. This is not politics, this is doing our job for the American People. I dont know i know the request you made the supplemental 1. 25 billion, but money should not be an object. We should be trying to contain and eradicate as much as we can this in the u. S. And make sure it doesnt spread in the u. S. , but help our friends all over they are, because disadvantaged. Some people believe this is a lowball number. I dont know. But i would like to hear from you on this, because this is not the time to try to shortchange the American People on anything or say omb has done this or that or whoever it is or whatever administration it is, democrat or republican. This is the time to step up, and i think you know this probably better than i do. There is a lot of concern in america today, and will be, is if this is going to spread. We brought some people into this country. Where is it going to go and how are we going to contain it . I look forward to your testimony. Thank you for your service, again. Thank you, chairman. Senator lahey do you want to wait for your question time . Or do you have an opening . Sen. Leahy i do have time i do have the proposal made most recently, which is vague and vast on the coronavirus. Ar, gladtary az youre here, and look forward to your opening statement. Maybe you can answer some of these questions even in that statement. Sec. Azar thank you very much. Thank you for having me and inviting me to discuss the president s budget for fiscal year 2021. I am honored to appear before the thirdttee for time, especially after the remarkable year results the hhs team has produced. With support from this committee, this past year we saw the number of drug Overdose Deaths decline for the first time in decades, another record year of generic approvals from fda, and historic drops in medicareadvantage, part d, and Affordable Care act exchange premiums. The budget aims to move toward a future where hhs programs work better for the people we serve, where Human Services programs put people at the center and where Americas Health care system is affordable, personalized, and puts patients in control, treats you like a human being and not a number. Hhs has the largest discriminant rate budget than any other nondefense department, which means Discretionary Spending must be on a sustainable path. This committee made important investments over the years in hhss large programs including at the National Institutes of health. We are grateful for that word. We want to protect it and make it better. I will mention two ways that we do that. The first way to facilitate patient in markets and the second to tackle key impact of health care challenges. The budgets Health Care Reforms gain to put the patient at the center. It would eliminate cost sharing for colonoscopies, lifesaving preventive service, reduce patient costs and promote competition by paying the same for Certain Services regardless of setting. And the budget endorses bipartisan, bicameral drug pricing legislation. These combined reforms will improve medicare and extend the life of the Hospital Insurance fund by at least 25 years. We propose investing 160 million in hhs initiative to reduce Maternal Mortality and morbidity. And we propose reforms to tackle americas rural health crisis, including telehealth expansion and new flexibility for rural hospitals. The budget increase is to combat the Opioid Epidemic and the opiod response program. We appreciate this committees work with us to give states flexibility to address stimulants like methamphetamines. It aims to end the hiv epidemic. By using effective evidencebased tools. Thanks to funding appropriated by this committee, we have begun implementing this initiative. The budget reflects how seriously we take the threat of other Infectious Diseases, such andhe china coronavirus maintaining investments in hospital preparedness. We now have 14 cases of the china coronavirus detected in the United States involving travel to china or close contacts with those travelers. Three cases among americans repatriated from wuhan and 40 cases among american passengers repatriated from the diamond princess. While the immediate risk to individual members of the American Public remains low, there is no community there is now Community Transmission in a number of countries, including outside of asia, which is deeply concerning. We are working fully with state and local closely with state and local agencies to prevent the spread in the United States, as we will likely see more cases here. Today, we will announce the launch of a Clinical Trial for investigational antiviral at the university of nebraska medical center. Omb requests to make 2. 5 billion in funding available for preparedness and response, including for therapeutics, vaccines, personal protective equipment, state and local support, and surveillance. I look forward to working closely with congress on that. Lastly when it comes to Human Services, the budget cuts back on programs without Proven Results and the benefits it brings for wellbeing. We continue the fy 2020 investments congress made in headstart and childcare which childcare programs which promote wellbeing and adults wellbeing. This aims to protect and advance americas wellbeing and deliver americans a more affordable system that works better rather than just spends more. I look forward to working with this committee to make that common sense goal a reality. Thank you, mr. Chairman. I will say for the members, that the votes scheduled at the vote is scheduled at 11 30, we will try to keep the hearing going through at least the first two of those votes. So there will be some effort made for members to leave and take the first vote and come back, and we will see if we cant make that work. Glad to have you and your time. I want to ask two questions. One is on the allocation process. The liver allocation policy. We sent you a letter on january 21 urging that you step in to prevent what we thought was a shortsighted and ill thought out policy, roughly 40 of the country will be harmed by the new process, which goes from a regional allocation to a nationwide allocation. We have already seen increased costs per transplant, increased waste in what was already a complex system, and organs that were discarded because people had to travel too far to get the organs to bring back to the recipient. Judge in theral litigation preferred to what would be a regional bias here. The Government Contractor on this effort provides no information to the committee on how the decision was made. They overruled experts in their own liver and intestine committee. Now they want to continue to have all the evidence and litigation under seal. So my question to you is, one, what made you determine after january letter couldnt do that you couldnt do anything, and two, are you going to work to get the evidence and what supposedly should have been available to this outside contractor to make that evidence public . Sec. Azar i share your concerns and frustrations. Requested them to reconsider their decision of their information they received. Hhs does not make decisions on organ allocation policy. The Procurement Network is responsible for organ allocation policy. We are charged with oversight of optn, but those decisions by statute are delegated to the op tn, and i do not have the ability to change those decisions. We continue to look for authorities that might do that and we certainly look forward to working with you if there were legislative proposals that might give me authority, but those have actually been walled off from the secretary. The number one thing we can do is increase the number of livers available, and that is why we are working to reform our organ procurement policies and our oversight policies and practices in organizations in the country so we can dramatically increase the number of organs available in this country. But im happy to keep working on this liver issue, but my degrees of freedom are limited, quite frankly, by congress. In my ability to influence the optn. Lets continue to see if we cant find ways to help you have more ability in the oversight process to have oversight. Lets go to the supplemental requests, the emergency supplemental. I understand it to be 2. 5 billion. About half of that would be counted as emergency spending and the other half would be paid for in various ways like the 105 million that you will soon have gone through. The fund i mentioned earlier, the Infectious Disease reaction ability that you did not have before, talk to us about putting that together and your thoughts for internal transfers. We are always concerned, as we should be, about big amounts of money being transferred under the secretarys authority in different ways than this committee and the president s signature decided that money should be spent. Hon. Azar first, let me be clear. We would like to focus on the top line of the 2. 5 billion dollars in terms of the key strategic needs. We have of course put forward a supplemental that would allow offsets and transfers to pay for about half of that, but that is congresss decision, and we look that is congress decision, and we look forward to working with you if that makes sense to you or if there are other approaches you would like to take. In terms of the top line, that 2. 5 billion, i focused my energies here in five key critical success factors. The first is we need to expand our Surveillance System for the china coronavirus to be comparable to our flu Surveillance System. This is the backbone of our effective Public Health response at the state, local, and federal level, to have that surveillance. Second, we need support for state and local governments. While we provide almost half of the funding for state and local Public Health department, and departments, and 675 million for emergency preparedness, we do believe we need more money to support contact tracing, communications with impacted individuals, and Laboratory Test work. And we have that in here. Third, we need to support the Research Development and procurement of vaccines and therapeutics. There is money in there to support both of those. And then finally, we need to support the acquisition of personal protective equipment, especially masks, into the Strategic National stockpile. Those key areas are where the funding is directed. Thank you, mr. Secretary. Based on the other challenges we are facing this morning, im going to keep my questions to five minutes and hope everybody will do their best to keep there is. To keep theirs. If there is time for a second round, people can stay for that, to be sure that everybody gives everybody else the ability to have a first round. Sen. Murray at the administrations briefing this morning on the coronavirus, we were told by the experts, there is a very strong chance of an extremely serious outbreak of coronavirus in the United States. So i want to talk about the reparations of this administration and what you have been doing. You have had more than a month to prepare for the increasing likelihood. And i want to ask you, is our country ready . Hon. Azar our country is preparing every day and the effective aggressive containment measures we are taking has bought us time to continue preparedness. One is always advancing preparedness. Every day, one advances those activities. Sen. Murray let me be clear, i only have a few minutes, you sent over a supplemental that was not clear to me at all. You just mentioned a number of things from tracing, state and local governments needing their cares andes hospitals are ready for this, and youve talked about protective masks, you have talked about Surveillance System, but i did not see anything in the request that specifically says how much each of those are going to cost, and we have seen the outbreak in china now, and we know it is going to other countries. It quickly overwhelms a Health Care System and it puts patients who do not have the virus at risk, who suffer from other conditions we know medications becomes difficult. Did you stockpile any of these critical supplies that we are told we need masks, protective suits, ventilators . Is that stockpiled and ready . Hon. Azar we do have in the Strategic National stockpile ventilators, we have masks we would not be asking for supplemental to seek more to procure more of that for the circumstance. This is a very unprecedented, potentially Severe Health challenge globally and will require additional measures. Sen. Murray i did not see any numbers in your request. Hon. Azar we will be Briefing Committee staff and members. This just came last night. We will be briefing you want those details. Sen. Murray you gave a very long list of things that are needed, most of which we do not have, what you cannot just buy tomorrow. Which you cannot just buy tomorrow. And i am very concerned that this is not only inadequate in terms of numbers, but in terms of specifics of what we will need, and we need to know that from your experts. Health experts, including your own, tell us this outbreak could be very longlasting, and this is a very vague request for supplemental funding, and i just think it is a bandaid, and i want to know why. We know this is coming and we have been watching in china. Everybody has been telling us. What is the longterm costs of a sustained response . Do we know that . Including the manufacturing in terms of diagnostics. Hon. Azar we have the details and we will provide them to Committee Staff and we want to work with you to ensure it is an effective supplemental. This funding request is for 2020 money only at this point. It would have a permission to carry over into 2021 spend, but we would work with the congress and appropriators on adjusting any 2021 needs. We are really learning day by day and week by week the contours of this disease as well as the spread and potential impact. That will help inform the 2021 discussions we will have with the Committee Going forward. In the next couple of months. Sen. Murray i have to say, i am very concerned about this administrations attitude towards this. If a pandemic is coming and we are disregarding Scientific Evidence and relying on tweets and emergency supplemental without details, and we are not stockpiling those things that we know we might possibly need for this or any future pandemic, i am deeply concerned that we are way behind the eight ball. Hon. Azar we actually have been aggressively moving. It has been a month and a half since the situation arose, and we have enacted the most aggressive containment measures in the history of our country in terms of our borders. I have used the First Federal quarantine in 50 years. Quarantine authority in 50 years of an hhs secretary. Sen. Murray can you ensure every single american today that if this pandemic hits our shores, that we have everything available and we have stockpiled it and we are ready to go . Hon. Azar that is why we need to work with congress for additional appropriations to enable procurement. But right now, and we have been clear, we do not have a vaccine. One cant have a vaccine sen. Murray i am asking about diagnostics and the tests. We do not have enough, correct . Hon. Azar yes, we have a diagnostic. Cdc invented a diagnostic and historic time. In historic time, within one week of the sequence arrival. Sen. Murray but it is not available . Hon. Azar it is available now at cdc and 12 sites have been able to validate it. We are working together on a modified version of the test that would enable qualified control to enable further spread of the diagnostic. Sen. Murray i am told that the diagnostic does not work. Hon. Azar that is simply, flatly incorrect. The diagnostic works at cdc and at 12 sites, it has been validated. We are working to get them validated at other sites. This is a working diagnostic. In the areas of the 170 labs, there was a sent, problem in the third stage that led to inconclusive results. We are assessing whether the actual step is needed in the process with fda, and we have 70 private diagnostic manufacturers who are working to bring forward diagnostics. We will work with those. Sen. Murray but we are not there yet. Hon. Azar we are now, 50 days into it, this is historic. No administration, no cdc in American History had delivered like this. Sen. Murray i do not question that, but i do question our ability for a very small, unspecified supplemental and the lack of preparedness we have to be ready for this. Thank you. Senator shelby. Sen. Shelby i want to follow up on what senator murray is talking about. One, it seems to me at the outset that this request for the supplemental money is lowballing it, possibly, and you cannot afford to do that. I hope the administration we want to help the administration and we want to help you do your job. But if you lowball Something Like this, you will pay for it later. But you are not only dealing with the crisis, you are dealing with the perception and concern of the American People. Both at the same time. I know that you cannot develop a vaccine and immunize everybody in america from something that has just fallen on us all at once, and the world, really coming out of china. But what are you specifically doing what are your guidelines and this administrations to contain this in america . We do not want this to spread. If it spreads, it will be hard to contain. What are you doing, or what do you propose to do . And what is your message to the American People watching the hearing . Hon. Azar the steps the president has taken are the most aggressive containment measures in history in terms of travel restrictions at our borders, funneling passengers, restricting foreigners from coming into our country, travel restrictions and advisories, two to countries and in addition to the solid, state and local Public Health response, which identified all but one of the 14 cases in the United States. One of them was identified through our aggressive screening measures at the 11 funneling airports. That is part of it. But then, the aggressive measures we need now, we have a historic opportunity with a vaccine. We have developed a vaccine candidate, and dr. Fouchi, he talked about it in the washington journal today, is within three months of development, that would be historic. We are supporting manufacturers that could be potential therapeutics that could be cheers are mitigations cures and mitigations for individuals who can track this. We work to contain as much as possible, but at some point, if there is some sustained human to human transport, we hope to mitigate with traditional Public Health tools. Those are the steps we would take. I was very clear when we enacted containment measures at the border. We cannot dramatically seal off the United States to a virus and we need to be realistic about that. Life goes on in some forms. Hon. Azar it does. And we will have more cases in the United States, we have been very transparent about that and we hope to work to mitigate the impact of those. Sen. Shelby you say we will have more cases, i think that is logical. Are we over concerned . Is it because it spreads city to city . Hon. Azar we always look for sustained human to human transmission. Sen. Shelby we have to have these models. Hon. Azar we do. We do. We look for sustained human to human transmission, especially when it is unidentified, that is what is particularly is concerning about iran and italy right now. Is we have got apparently sustained human to human transmission with no connectione to existing cases. That is very concerning to see that. That is what we would look for here. Right now, it is important to remember the 14 cases we have that are in the u. S. As well as the 40 from the repatriated individuals from china and japan, in every single instance, we know why that person has the Novel Coronavirus. We know. That is a product of the worlds finest Public Health system that allows us to have that level of knowledge on this rapidly developing. Sen. Shelby what is the treatment . Hon. Azar one treats the symptoms as one does for other therapies there are some experimental products and Clinical Trials. One is a gilead product. Some individuals have been an ind protocol for a Clinical Trial. That is being tested at two person trials in china as well as in the university of nebraska, and i believe also in japan. Sen. Shelby i believe that this committee, that we will be of the mindset to fund this crisis, not to underfunded in any way, it in any way,d and i hope the administration would look at this as something that they cannot afford to let get out of hand or the perception that it is getting out of hand. Hon. Azar i want to assure you that i am fully supportive of this 2. 5 billion request, it is what i believe we need for 2020, but of course if congress differs, we will work with you to provide Technical Assistance to try to make sure it meets what you view as the needs are. Sen. Leahy thank you, mr. Chairman. Senator leahy. Ator sen. Leahy thank you, mr. Chairman. Like so many others appear both republicans and democrats, we are concerned with the budget and the administration has put forward for the Proper Health and Human Services. Obviously, you were involved with it, but it seems it has been drafted to slash funding without any realization of realworld impact of the proposed cuts. In fact, the move is completely confounding in the midst of the Novel Coronavirus outbreak, and you want to slash funding in fy 2021 to very programs to help us combat dangerous Infectious Diseases. We might talk about vaccination of the virus which is still about two years away. It has spread to 30 countries, it has infected more than 79,000 people. It has caused at least 2600 deaths. Hundreds of americans are restricted to u. S. Military bases under federal government quarantine, and that is the first time in 50 years. But you proposed a cut, 3. 1 billion in the National Institutions of health, roughly 700 million percent is for Disease Control 700 million nearly 100 million from Public Health preparedness and response programs, and these are the very programs that we will have to rely on to combat coronavirus and other Infectious Diseases. If Congress Went along and made the cuts that you and the administration asked for, you would not be able to keep the public safe when the next threat emerges, and one will. So why would you propose such cuts, how does it make any sense . Hon. Azar we have a tight budget environment, but we prioritized the Infectious Disease preparedness and emergency response. So for instance, at cdc, those three activities were prioritized and increased the proposed funding by 135 million in the 2021 budget. Sen. Leahy the cdcs Rapid Response reserve fund is running out of money, and now we see the increase of the number of infected people to 53 in the u. S. How was that being careful . And this has been going on for months, and last night, we get this somewhat vague request for emergency funding. If i was cynical, i might think it was rushed over just in time for your appearance before this committee this morning, and that is why it is vague. Hon. Azar the Infectious Disease rapid Response Funded fund at cdc was funded by congress in 2020 as well as 2019, so it is current twoyear money. We are running out of that money which is why we have spent over transfer and reprogramming, and precisely why we are asking for emergency supplemental. Sen. Leahy you would take a half 1 billion out of the money appropriated for the ebola threat . Hon. Azar those would be proposed tradeoffs if the appropriators do not want to do that, that is just an option for the appropriators. Sen. Leahy did you have any of your request for supplemental funds, where any of them denied by omb . Were any of them denied by omb . Hon. Azar i am not going to discuss internal sen. Leahy why not . Why is it not proper . I have heard that question asked during democratic administrations and republican administrations in my 40 years in this committee, and it is answered. Hon. Azar i would never discuss internal deliberations with the white house, but i am completely supportive of the 2. 5 billion request, it does exactly what i want, which is to focus on the five critical success factor areas. Sen. Leahy what you want is a proposal that would divert 135 million from other important programs, including 37 billion from one area, millions of dollars from substance abuse, 7 million from Medicare Medicaid programs so i will not ask you about the liberation, but do you want to kind of hold out on things of which you rely on . Hon. Azar those are options for finding half of the cost of the emergency supplemental, but of Congress Make a different but if Congress Make a different choice, Congress Makes a different choice. Sen. Leahy where does the other half come from . Hon. Azar that would be , new moneyl funding you would have to come up with. Sen. Leahy things you want from the nih funding, ebola funding, and your recommendation is to cut that out . Hon. Azar it is a proposal of how to find half of the that is of that cost. Sen. Leahy it is your proposal . Hon. Azar if there are other ways to get there. Welcome, mr. Secretary. Before i ask and get into the coronavirus, i want to congratulate senator blunt, and senator murray, shelby, leahy, and members of the subcommittee for the last five years of funding for the National Institutes of health. Over that fiveyear is Discretionary Spending, which is about 1 3 of our budget, it has gone up 20 , but funding for the National Institutes of health has gone up 39 . And i might add, the subcommittee that deals with the office of science in the department of energy, it has gone up 38 . One of the bestkept secrets in washington is the big increase for funding for Biomedical Research and science, and i want to congratulate this committee for its part of it. I think one of our responsibilities as members of the senate is to help the American People get a fair view of exactly how threatening to them individually this coronavirus is. Looking around the world, there is reason for alarm. 10 days ago for example, there were 49,000 confirmed cases in the world. 10 years ago in china, there were 48,000 confirmed cases. Today in china, there are 79,000 confirmed cases in the world, and there is 77,000 and china, in china, and we read about problems propping up in italy which could get across their borders, and then iran, and other places, south korea. And not only do we have the problem of a rapidly spreading virus which could jump into our country, we have to think about what items manufactured in those countries could mean for us. With 13 of our Prescription Drugs being many factored in being manufactured in china, for example, are we going to have shortages . And everything we use in this country being made in china, will we have supplies for our automobiles and other things we make in this country, and what will it do to our economy . Looking around the world, there is reason to be alarmed. But now looking at home, let me go through the facts at home. We have known about this about two months, about 50 days. Hon. Azar yes, about 50 days. 10 days ago, if i am right, we had detected 14 cases in the United States. Hon. Azar i believe that is correct. Sen. Alexander and today, we have detected 14 cases in the United States in addition to the 39 cases of americans who have been brought home from overseas and isolated in this country because they might have been infected there. Hon. Azar exactly, the imported cases. Sen. Alexander during that time, you have begun to develop a vaccine which will not be ready for a year or longer, but you are doing that more rapid than any time in the history of our country. Hon. Azar correct. Sen. Alexander my question with this alarming situation and the thed, in the in world, what have you been doing right at home, to cause us to see a situation where this huge country of ours we only have 14 cases, my guess is, 20 years of preparation by democrats and republicans on this committee and publicans and democratic president s to be ready for pandemics, number one. Number two, it is the extraordinary Public Health the state and local doing their job. And number three, it is the first and most aggressive quarantine requirements that you have done in 50 years, so if we are alarmed about what has gone on around the world, what can we learn about the last 50 days in this country that you have been doing right that makes us be able to say, 10 days ago, there were 14 cases, and today there are 14 cases at a time when around the world, cases are going up . Hon. Azar we are bearing the fruits of our pandemic flu preparedness activities, which i was one of the architects of in the bush administration, and that congress funded. We are seeing the Public Health infrastructure from that. One of the most important things that we did as soon as we had a genetic sequence and understood the nature of the symptoms of this disease was to alert our state and local Public Health partners and our Health Professionals. And that is why 13 of the 14 cases were identified by Health Care Professionals astutely seeing that these were individuals who had been in the Hubei Province and took advantage of the one week developed cdc test to get results, so that kind of Public Health infrastructure is the backbone of our response activities here. In addition, we worked on aggressive border containment measures, and we worked with china to try to get transparency and information. We still do not have unfortunately, solid information to take to the bank on severity, on transmissibility, on incubation period on asymptomatic transmission. Sen. Alexander i am out of time, but i think you would say you would do more of what already done, properly funded . Hon. Azar yes. Thank you secretary, for being here. Secretary, for being here. This committee has a long tradition of bipartisanship, and i know that secretary, you and i have had a couple of disagreements, and so i kinda want to see whether we can find some Common Ground in fighting the coronavirus. The president s budget cuts in the Infectious Disease Rapid Response reserve fund, the Public Health preparedness and Response Fund, hospital preparedness and epidemiology capacity program, so given everything that has happened over the last 50 days, i want to give you an opportunity, and given the context here, which is last night, you proposed a 2. 5 billion supplemental. Do you want to rescind those cuts to the base budget of your agencies that deal with this problem . Hon. Azar it is a good question, senator. As i mentioned to chairman blunt, this is focused on 2020 money. Not money to be spent hon. Azar i am not asking you about the sub. I am asking you about the president s budget, and the question is a simple one. I have a couple of questions i would like to get to. Those cuts,cind will you ask us to restore those programs or will you not . Hon. Azar as i said, we will work with you over the coming months as we learn more about this disease of whether to modify the 2021 a preparation request in light of that. We do increase around by 135 million around preparedness, emergency response, Infectious Disease, and Global Health security. Sen. Schatz i will not get too much into the weeds, but i would say, that is actually a shell game. There are four key programs that deal with this problem, and they are being cut, and the cdc overall is being cut by 9 , so you may have increased a line item or two, but that is not the fact of the matter, and this committee will very likely reject these cuts, but it is absurd to me that you are proposing cuts at the same time you propose a supplemental on the same topic. So moving on, how many masks do we need and how much will that cost . Hon. Azar we would need to determine through procurement what the cost would be of additional masks. I know that this morning in the briefing, there was a reference as 300 Million Masks needed for health care workers. Frankly, establish supply here in the United States as well as to find sourcing of active ingredients such as the filtration materials, and even the nickel and copper, and those nose joints that go on the end of the n95 masks. If we get the money, we can make that market and get capacity built here in the u. S. Sen. Schatz for the 2. 5 billion, the masks, the strategic stockpile, all of your five lines of effort, it seems to me that you do not quite know how much each line of effort is going to cost. Is that accurate . Hon. Azar we would have to do procurements to find out exactly unit cost would be on the mask. We would be scaling of production that does not fully exist right now. One does not know until they fully procurement. Sen. Schatz that as a yes. Hon. Azar we would be scaling sen. Schatz how do you get the 2. 5 billion without knowing how to compile . The first one im asking about, you say you have to go through procurement, and i understand that. How do you get the 2. 5 without any degree of specificity or reliability is 2. 5 billion pulled out of a hat . Hon. Azar not at all. Sen. Schatz then what are the major cost items, you do not know how much it is going to cost . Hon. Azar you dont know the per unit cost, but in the range, that would clearly be sufficient. Right now, acquisition costs of n95 masks tends to be under one dollar, so that gives you a rough approximation, but we have to scale up domestic production. Sen. Schatz do you have back of the envelope numbers that you have not provided to the committee . Because it sounds like you have ballpark numbers. And i got told by a staff person that the sup, and i have not gone through it with a comb yet, but i have been told that this is the least detailed supplemental that they have ever seen. Should we just consider this a marker and you will get us the details later . Hon. Azar not in the least. There is a letter that went up last night that has the basic numbers in it, and as i have told both the chairman and vice chairwoman, we will work with your staffs to get you the Details Behind that. There is the till behind that, just last night you got the initial letter. Sen. Schatz final question on test kits. They were deployed in multiple locations and they did not function properly. Why in the world do we have tests that operate in atlanta, but cant be and the country of japan has test kits that are reliable, and other places first of all, other states, but also other countries have operating test kits, and given all of the preparedness work that you say you have been doing and all of the extraordinary work of all of our agencies, why cant we deploy test kits that function and why does it have to be in midmarch before states and especially ports of entry have functioning test kits . Hon. Azar the cdc test was developed with historic speed. It has three phases on it, and the third one, it is unsure of whether it is necessary. Whenever it is deployed on the field or the cdc, one has to do the following control and validate controls. The validation failed at the third stage for inconclusive results against control and one of the 92 reagent slots. We are working on streamlining that process, and we hope to get those revised once out. Quickly. Revised ones out very quickly. Sen. Schatz thank you. Senator kennedy thank you, mr. Chairman. Thank you mr. Secretary. We have 14 active cases now excluding the 39 that were imported . Hon. Azar that is correct. We have 14, then at the moment are at a total of 43 imported. 40 from the diamond princess, three from wuhan. Sen. Kennedy how did the 14 contract of the virus . Hon. Azar 12 of them contracted from trouble in wuhan, china, and the other two were spouses of those infected 12. Sen. Schatz how was it transmitted . Hon. Azar it is transmitted generally by respiratory symptoms, but i would like to defer if i could, we would be happy to get you from scientists the best assessment. Assessment of transmissibility for the disease. Sen. Kennedy can it be transmitted through food . Hon. Azar we do not believe that there would be transmission through food, but we are still trying to learn of the sustainability of the virus on surfaces. That is what we call fomite transmission. Our doctor says that he does not believe that there is reason to believe it should survive more than it can survive a couple of hours outside the body. That is the working assumption. That is one of the things we are hoping to learn from the who team in china. How is severity determined . Determined is usually by fatality rate against the number of people infected. Right, obviously. That was not a very artful question. Let me rephrase that. Some people get really sick, others dont. Why the difference . We dont know. That will defend on the nature flu, it was1918 interesting your healthier, young, middleaged adult males that had the worst reaction and greatest severity. I dont want to get too far afield here. The short answer is we dont know. We dont. Facemasks do we have . Millionrrently have 30 and 95 respirators. How many do we need . We need approximately 300 million for health care workers. We have 300 million healthcare workers in america, do we . That would be assuming the need to swap out used ones. Ok. Abouto your models show how many cases we are anticipating . We dont know because we dont know the full attack rate in china. 30 on seen a high of the diamond princess, which seemed to be an incubator. In wuhan, china, it is hard to know what the total number of accurate cases are. Sen. Kennedy we dont know . Hon. Azar we dont know. Sen. Kennedy do you have models to try to answer this . Hon. Azar we can only extrapolate from the data we get from china. Sen. Kennedy is china telling the truth . Hon. Azar we are getting information from china we just dont know. Sen. Kennedy what is the mortality rate . Hon. Azar it is killing between 1 and 2 , but it is based on a denominator. There may be many, many cases in china are low symptomatic. Sen. Kennedy what is the rates for influenza . Hon. Azar . 1 . Sen. Kennedy so we are talking about a substantially higher mortality rate . Hon. Azar it could be, that is why many to take great caution in the severity of this. Sen. Kennedy how soon will you have a vaccine . Hon. Azar as i mentioned, the wall street journal today talked about going as a Clinical Trial amazingly within three months after discovery, so we could within the year, but we want to multiple vaccine candidates out there. We have 1 billion of proposed investment through the supplemental. Sen. Kennedy the secretary of the department of Homeland Security is charged with keeping us safe, and he just testified about 10 minutes ago, a month and i half, which is it . Hon. Azar one could not develop a vaccine and a month and a half. That has not happened in human history. Sen. Kennedy maybe you ought to talk to the secretary of Homeland Security before he spreads that too far. Are we getting the cooperation that we need from countries other than china, and obviously iran . Hon. Azar [laughs] obviously not iran, but from other countries, yes, we believe so. Sen. Baldwin thank you, mr. Chairman. Secretary, i want to tell you about a couple of constituents. Mary from franklin wisconsin attended a roundtable i had over the president s recess week on the price of medications. She works for Kenosha County for over 20 years, retiring as a Child Support case worker. She has diabetes and the cost of her medications including insulin are over 1500 a month. She said to me, i am just one of millions of people that have this problem. There are people who are not getting their medication, who are dying because they cannot get their medication. Who are deciding on food or medication or paying mortgages. At the same roundtable, i met a father whose young son had severe allergic reaction. He was treated at the hospital and then the physician prescribed epinephrine. Because of the childs tender age and weight, an epipen was not appropriate because it would contain too high of a dose. When he went to fill the alternate prescription that had the right dose, the outofpocket cost would have been 5,000. I was in disbelief when i heard that, and he explained a little bit more, and what he ended up doing was buying an epipen, and praying that his son will gain at least seven pounds before he next has any type of allergic reaction. How frightening. In december, the house of representatives passed a comprehensive Prescription Drug pricing bill that included my bipartisan fair drug pricing act. The fair drug pricing act as you recall passed out of the Senate Health education, labor, and Pension Committee last june. You noted in your testimony that the budget supports the bipartisan proposal, however, it does not support explicitly either the house passed bill or my fair drug pricing act. We have talked a lot about transparency in this industry. Do you think about pricing transparency would make it harder or easier for congress, the drug corporations, to enact sensible policy to bring down prices . Hon. Azar we do support notions of drug pricing transparency. I tried to get specific authorization to explicitly require that Drug Companies disclose their and rather astonishingly, litigate that issue in court. Their directing in to consumer advocacy. And now we are rather astonishingly having to litigate that in court. A fair drug pricing act, you issue a report to your agency, what justification and full transparency. We talked probably around a year ago about whether we are capable of showing a follow the dollar chart when you have a drug priced at 100. What peace does the manufacturer take. Takepeace does everyone along that . When they double it, what is the extra 100 go . We dont even know that. I urge you to work with us to pass a bipartisan fair drug pricing act, and i think it will so help our ability to reign in these prices. In my few seconds left, i want to switch gears and talk about the vast expansion of junk plans that has occurred under this administration. There was a Study Released just shortly ago that found these costs on veryose vulnerable populations. Those newly diagnosed with cancer. According to a study, a person newly diagnosed with lymphoma and covered by one of these junk plans could pay anywhere from 23,000 to 45,000 of outofpocket expenses in the first three months following their diagnosis. The other issue i wanted to point out is we are talking about coronavirus, we just had a reporting out of florida that somebody who had recently traveled to china presented for concerns that he might have contracted the coronavirus, and may be charged thousands of dollars in outofpocket costs for seeking care. Because he is covered by a drug junk plan. How does the expansion of junk plans by this administration help us during severe outbreaks like the one we are currently experiencing and is very frightening as we move forward . And how does it help someone who incurs cancer, who is diagnosed with cancer . Hon. Azar Short Term Limited Duration plans are not right for anyone. We have been transparent about that and they existed under the Obama Administration. Sen. Baldwin they were threemonth and now they are three years. Hon. Azar actually, no. In a midnight regulation, they shortened them to three months and we restored that. Sen. Baldwin because of the impact on the rest of the markets. Hon. Azar they are not right for everybody and we enhanced the Consumer Protection notices even from what the Obama Administration had, but some insurance may be better than not being able to afford any insurance. These are 60 off and cheaper than Affordable Care act plans for people who are not subsidized, so it is an option. But it is not the right option for everybody and we have tried to be transparent about that. Senator rubio . Sen. Rubio i want to acknowledge how difficult with this decision has been because of the lack of transparency and in china. Whatever the numbers they put out today, i can assure you the numbers are higher. As of today, they have not shared the original viral sample, and i know they put the code online but they did not share the sample. They have not been forthcoming about best practices on a host of issues. How response is complicated by the fact that we are dealing with a totalitarian government that is more interested in pr dealingr image, then in with the outbreak of this kind. That is impeding our ability to develop things like a vaccine and so forth. Hon. Azar we need full transparency and full cooperation from china, as well as every country. The who needs to hold every country accountable as they would the United States for that type of transparency and cooperation. Sen. Rubio do you have any view on what would happen if this virus makes itself to a underdeveloped country with poor or no Public Health . For example, haiti, some nations in central in particular. The impact that that would have on those societies, not to mention many nations in the african continent, what it would mean for migration flows and the Global Economy . Do you have any thoughts about how destructive it would be . One thing is that it shows up in italy or the canary islands, but the other thing is that it shows up in a country that already lacks basic Public Health and the ability to address it. Hon. Azar obviously, it would be concerning at the virus spreads to africa or other areas that have less developed Public Health infrastructure, because they will not be able to take the steps towards mitigation and containment that we would take here in the United States. It would spread rapidly. This is why it is so critical to china, so data out of we know the severity and what the mortality rates really are here, so we know what we are dealing with in terms of impact. Sen. Rubio we know that 80 of active pharmaceutical ingredients in the United States come from china. I wrote a letter about this to the fda commissioner, and i know there is a lot going on. But we have not gotten a response. I wanted to know a few things. Does the fda have tools and information to track potential medical device of pharmaceutical shortages . Hon. Azar we do hope to be able to track with pharmaceuticals. They have to report to us if there is any potential shortage, and we have not received any reporting at about potential shortages connected to the china situation. The medical Device Companies do not have to make those same kinds of proactive reports, and that is part of what we suggested in legislation. Sen. Rubio what would we do to mitigate shortages if we saw one coming . Hon. Azar it is a difficult challenge because the supply chains with drugs as with the rest of our economy are very much globalized and entwined with china and elsewhere. One cannot stand up a manufacturing facility for pharmaceuticals just overnight. If a drug company happens to have multiple manufacturing facilities that were qualified, they could transfer manufacturing. And we would certainly work at fda to expedite regulatory approval. Sen. Rubio have we sort of thought forward we are not dealing with the most transparent government in the world in china so what option would we have to work with nonchinese suppliers of these key ingredients . Hon. Azar we can work with any supplier that is fda approved. One cannot just secure fda approval overnight for either a generic or for the manufacturer of an innovative product. We would work with those companies that hold licensing and patent rights to be able to expand. Sen. Rubio have we done any work sort of putting that in place just in case this comes on . Hon. Azar we are aggressively and proactively working with all of the Drug Companies and Device Companies, and we have made it clear that we are available to help them. None of them have signaled any potential problems in terms of supply. There are a couple of manufacturers that do work in Hubei Province, the epicenter, but they report that they have large stockpiles of supply already, of product already, but we are aggressively working on this because it is, it is a concern. When one has this Global Supply chain that is intermingled throughout the world, including in china. Sen. Rubio this calls to mind that perhaps it is not the greatest idea for the health for americans and health care to have 80 of our active ingredients come from one place in the world, where it can potentially serve as strategic leverage at some point down in the future, but is vulnerable to this sort of disruption. At a minimum, you would agree that this is sort of a wakeup call that we are overly dependent on the supply chain so heavily concentrated in one place in the world. Hon. Azar it is and has been, and you have been at the forefront of calling attention to the issue. The challenge is what is the appropriate remedies of that. Because if we start dictating where Companies Make products, that could increase cost, which could increase health care and drug costs in the United States, but we are happy to work with you and congress on supply Chain Management approaches that we should take that Congress Wants to authorize. Thank you. Senator murphy. Sen. Murphy thank you, good morning. Mr. Secretary, we can agree that when you are dealing with response to pandemic, days and weeks matter, correct . Hon. Azar we try to take advantage of every day that we are able through our aggressive containment response, absolutely. Sen. Murphy you presented a briefing to members of the senate three weeks ago in which many of us expressed alarm that the administration had not sent a supplemental request to congress at the outset of this epidemic. We were told in that briefing that the administration believed that it had ample existing resources to handle this epidemic, and that did not make sense to many of us who saw what was coming. Last night, you sent word that you are now requesting that supplemental funding and we are hopeful to get some meat put on the bones so we can get to work quickly. That was a mistake now, in retrospect, to not request that funding weeks ago at the beginning of this pandemic, correct . Hon. Azar no, not at all. We had 105 million that we were infectiousom the disease rapid Response Fund. We have not even started on the 136 million of the transfer authority that i sent over it i think last night, we sent over the reprogramming and transfer plans we have for that. Three weeks ago was just two weeks into even knowing about this virus, which we have been very transparent in briefing and working with you on. One cannot know the contours or nature of the disease to even know what to request at that point and what that would involve, and indeed, today we saw one of your colleagues was questioning if we even know enough to make a request at this point. We are making the request and we believe we know enough to do that now. Sen. Murphy his point was in response to your statement regarding your inability to create a market until you have the funding, which speaks to the long process from the request of funding to congress to the creation of a market that would answer some of the concerns that senator rubio has. What was knowable three weeks ago was that when you make a request of congress, the money does not occur and be created overnight. It is a process to come up with that legislation and you acknowledge that even once you get the funding, you then need to go out and create markets for some of the products that have shortages. Many of us did see the need early on because we knew it would take a long time in order to get this funding through the process. And i think we have lost critical days and weeks, and there were many people in the briefing who were asking you to present this earlier. Can i ask you about a program that the cdc was running . I think largely with previous supplemental dollars. I have heard it referred to as an Epidemic Prevention account, Global Health Security Initiative operating in about 50 countries. Reports from about a year and a half ago suggest that that money ran out and the cdc did not replace it with other funds. The number of countries in which we were Forward Deployed were trying to train local Public Health staffs to identify pandemics and respond to them were reduced from 49 countries to 10 countries. At the time, you received a letter from about 200 different Public Health organizations asking you to backfill and request new resources to make sure that those programs remained open. You may not have an answer today, but can you confirm that that program is only running today in 10 countries compared to 49 that it was running in when that supplemental funding was Still Available . Hon. Azar what has happened is the ebola supplemental money was going down, and we were increasing the Global Health security agenda funding through cdc. For 2021 appropriation, we million, a 50 million increase as we sloped that up. The number of countries are focused and moved to try to have a regional footprint and as we have built labs and capacities in countries, they stand on their own. We moved to a regional approach. We can get you the precise countries where we are operating in now, but that has been the philosophy. It has not been a retrenchment, but to have a regional deployable force instead of permanent infrastructure in every country. The chairman isnt here, but i think the answer is that we are operating today and perhaps one fifth the number of countries we were in several years ago. We were operating in 50 countries, because we recognized we had a lot of work to do to train up staffs in developing countries to identify these outbreaks and to treat them at the outset, so they did not ultimately reach our shores. Many of them have been sounding this alarm for years that budget cut after budget cut, proposed budget cut after proposed budget cut to the cdc was going to have any effect. I do not think today that we could draw a Straight Line for the number of countries that have been cleaved off of the Global Pandemic Prevention Program and the outbreak we are dealing with today, but it is another alarm bell for us. We cannot continue to close our eyes to these developing pandemics. We are going to have to be partnering with many other countries and under this administration, unfortunately, we are going the wrong way. We are operating in less countries abroad. But i will appreciate hearing the more detailed information from you in the coming days. Thank you. Senator hyde smith. Sen. Hydesmith thank you. Secretary, thank you for being here today and i want to start by making a few comments before i go to my question. First, i know you have heard from chairman blunt repeatedly about his concerns of the livers allocation of for transplant. I shared that senators concerns. Our only transplant program in mississippi just completed its 250th liver transplant this past friday, which is a very important milestone for us. Since the program started in 2013, it has meant so much to mississippians to be able to get this lifesaving care close to home. I am worried now that the new liver policy will undercut that ummc program. I hope you will work with us to address these concerns and ensure the continued viability of new Liver Transplant Program just like the ones we have in mississippi. Secondly, i want to thank you for your focus on lowering the cost of Prescription Drugs for all americans. Whenever i am in mississippi, i constantly hear from constituents who are concerned about high, outofpocket costs for Prescription Drugs, but both you and the president have made this aan issue of high priority issue of high an priority and i think you for that. Third, i was very pleased to see your budget request include the legislative commitments to help expand the telehealth at Rural Health Clinics and Indian Health service facilities. As one of the six senators in the senate telehealth working group, i was one of the very glad to be able to introduce this bill and i am working to get it enacted as a law. Your support is extremely critical in that. At this hearing last year, you and i discussed a struggling rural hospitals in mississippi. This continues to be a problem not only in my state, but across the nation. The most recent data released just released from 2019 shows that nearly 50 of rural hospitals are still operating in the red. Last year, i was so pleased that you testified that in part of some efforts from my office, you had established a Rural Health Task force at hhs to find all of the ideas to help address the crisis and access in rural america. I have also been pleased to support some of the early work on the task force including changes to the medicare wage index. That meant so much to our rural hospitals in mississippi. But i know the task force has been working very hard in recent months to do even more. Can you provide us an update on the Task Force Work and specifically, how this subcommittee can help support you and your office in that . Hon. Azar thank you, senator. Yes, on the rural task force, we have now matured to the point that Rural Health Care is a centerpiece of the president S Health Care agenda and a centerpiece of the budget proposals. There are four pillars. The first is Rural Health Care has to have a Sustainable Business model. We cannot just patch over it. It has to be something that economically works and our Rural Communities. Second, we have to have prevention and Health Promotion in Rural Communities. Third, we have to take advantage of telehealth and other innovation. Fourth, we need Health Professionals such as pas, physician assistants, nurse practitioners, and others who are able to practice to the full extent of their training and licensure in these Rural Communities, where we cannot often find just doctors to practice. We have many proposals in the budget. One of them, which i am very excited about that would help with rural hospital closures, would allow critical access hospitals to convert to in both anacilities, emergency room and outpatient, and not having to continue inpatient bed facilities, and also get payment supplements on that. That could be a real lifeline to our Rural Communities if we can get that approved. We also have several provisions we have proposed on expanding access to telehealth both in rural country, and also indian country. We also want to modernize our payment for Rural Health Clinics. They can be an important backbone of our system, also. We have a whole suite of legislative proposals in there for rural health and combined with our budget increases that we would love to work with you on. Sen. Hydesmith thank you. Thank you. Senator shaheen. Thank you, mr. Chairman. Secretary azar, thank you for being here. I do not have any questions about the coronavirus, because i was at the briefing this morning. I appreciated your comments to clarify things. The question i have for you and whoever else in the administration or in the senate is, why the briefing was closed. I have met with a number of constituents, in fact, right after the briefing, who were very concerned that they did not have information. I think it would be helpful to the public to be able to hear what is being said and i did not hear anything this morning that i have not read in the newspaper already. So, i think to have some of those briefings open to the them would be a great benefit and im hoping there would be something on the websites to help companies prepare their employees and to help the public understand what is going on. I give that to you to take back. Hon. Azar my understanding is chairman of the Senate Intelligence committee asked at the briefing be held at the top secret level. To ensure complete transparency with members of the senate on any information. What was found in the discussion was we were not relying on classified information. We tried to have radical transparency and so by the end was realized nothing classified had been discussed, so that label was taken off of it. Yes, we tried to be completely transparent what we know. Senator shaheen that would be helpful. I dont want to cut you off but i am about out of time. My clock is running. New hampshires been really hard hit by the Opioid Epidemic, as you know, and its been very clear the Medicaid Expansion has been our best tool in combating the epidemic. According to the most recent data available, 23,000 granite staters have accessed Substance Use Disorder Treatment through the Medicaid Expansion. But your h. H. S. Budget proposal would slash medicaid funding by 920 billion, including 744 billion in cuts that appear to gut the Medicaid Expansion. On page 112 of your budget, it says that, and i quote, as part of the president s Health Reform vision, medicaid spending will grow at a more sustainable rate by ending the financial bias that currently favors ablebodied working adults, end quote. So the only way i can read that is youre suggesting that congress should eliminate the match that our that is currently provided to states who participate in the Medicaid Expansion. Am i reading that correctly . Secretary azar we do believe i have said this for a couple years that the enhanced match for Medicaid Expansion for ablebodied adults actually prejudices against pregnant women, children, aged, blind, and we think thats to be corrected. Yes, you are reading it correctly. Senator shaheen are you saying we should eliminate the match that can go to Medicaid Expansion for states to use for treatment for Substance Use disorders, for example . Secretary azar so what we suggested in the budget is an allowance that would have us work with congress to look at issues like that around what is the appropriate federal matching rate for expansion compared to traditional medicaid populations . What is the Sustainable Growth in that expansion population . As well as, what flexibility would states require . Its meant to be collaborative working with congress, but there is a problem here which is there is a real prejudice in the medicaid system now in favor of ablebodied adults and state support of them because of the 90 match versus the average 60 federal match for those core it is a real disparity in the system that we need to address. Senator shaheen i think eliminating the risks puts people at risk in people like states like New Hampshire and across the country where they are getting treatment for opioid disorders and without that medicaid they would not be getting treatment. There is no alternative in a place like in states like New Hampshire for providing that treatment. So i i am not going to ask you to comment on that but just i hope thats something you will think about and you will share with states like New Hampshire before making any changes. And im sure congress will want to weigh in. Secretary azar i dont believe we suggested eliminate but regularize it compared to traditional medicaid. Senator shaheen i want to go now to the issue with ecigarettes and vaping because i have been very disappointed at the flipflop that we have really seen from the f. D. A. And from the effort to try and scale back on what evaping products are available to young people and to the public. I thought initially the f. D. A. Was pretty clear it would take all favored vaping products off the market, including menthol, and yet, they have failed to do that. So i wonder if you can talk about what youre seeing in addressing vaping . Secretary azar so i share your passion on the ecigarette challenge and keeping these away from kids. Just to explain why there was a change in what we initially announced on september 11. With, with our original data set we had, the National Youth Tobacco Survey, had tobacco flavor in one category and menthol in another showing menthol as a group was being used by kids. That troubled our people because we have menthol combustible users and we want to make sure there is an exit avenue available. We got to monitoring the future survey that finally gave us a breakdown of menthol, showing it was mint driving it and menthol was comparable to tobacco flavors and so we were able to leave menthol on the market, go after the mint there, and so that was the basis for why we made that change. Senator shaheen well, my time is up. As you know, there is legislation that would mirror whats in the budget with respect to fees on ecigarette companies and i hope we can enact that. Secretary azar and we support that also. Senator shaheen thank you. Senator shelby thank you, senator shaheen. Well go to senator merkley. On the comment about the briefing this morning. As the secretary say the, the said, the request for a briefing, topsecret briefing was made at the request of the chairman of the Intelligence Committee and other senators who wanted to make sure that senators knew there werent any secrets we werent being told. And we were both there but as a result of that, i think what we learned was that everything we were told had already been available to the public. Senator alexander so that was the motive. That was the motive for it. Senator merkley. Senator merkley thank you, mr. Chairman. And welcome, mr. Secretary. The administration has proposed a rule that was the flores agreement that sets humanitarian standards for the treatment of refugee children. And one of those changes instead of requiring 72 hours to move a child to the least restricted setting would allow the indefinite detention of a child. Isnt it indefinite imprisonment of a child a human rights abuse . Secretary azar so senator, i appreciate your concern there. That would be a d. H. S. Regulation. The h. H. S. Flores regulation i believe largely tracks our requirement under the flores settlement agreement. I can speak to that. I cant really speak to the d. H. S. Regulation. Senator merkley well, ok. Well leave that there then. Ill follow up with you. I want to switch to my team alerted your team, i was going to ask you a situation where a child has been trapped or in custody for six years now. Originally it was approved for her to go live with her aunt in 2014. She finally after six years signed an agreement to be deported without ever being informed that her family, extended family was still waiting and happy to accommodate her. Many things about this bothers me but, one, is that six years in detention is an incredible impact on a child. Just its a whole childhood disrupted or destroyed. Second is, essentially by not informing her that her family wanted her, it was extraordinarily misleading on top of Everything Else shes gone through. She should at least have the basic information for that decision. Im not asking you to comment on this individual case but im asking you outside of this hearing to put this case on the top of your stack because its just every now and then a situation arises thats so horrific where someone has fell between the cracks and been treated in such a manner that none of us would want for anyone we know or any child anywhere at anytime. Would you be willing to take a close look at this case and try to make sure we dont continue this that we get some perhaps really highlevel attention and fair treatment for this child . Secretary azar absolutely. In fact, thank you. Im glad i have not seen the media report until you and your staff raised this to us about this and i, of course, cant validate anything in the media report. I asked the team i want to find out whats going on. I completely agree with you. We dont want a children to be with us for that length of time but there are sometimes and i cant speak to this individual circumstance. There are cases where sometimes there either is not family. Family may not be willing to take someone in. There may be an unsuitability there. The shorter time a kid is with us we talked about this before the better it is for the child. We want the kid to be with us as short as possible. I want to dig in personally. I want to make sure shes treated fairly and her family is treated fairly. Senator merkley id like to get weekly updates where this case stands if theres something i can you can commit to. Secretary azar well get information about her to make sure shes treated well. Senator merkley i want to turn to the flores agreement. One of the proposed rule features indefinite imprisonment is to replace a hearing before an h. H. S. Officer but only if the child requests is. How would any child ever know that they could request such a hearing . Secretary azar well, all of our kids have the right to Legal Counsel and i believe there actually are phone banks as part of the counseling, Case Management process at the grantee facilities to ensure connectivity with counsel. This is one of the this is one of the changes that was made in the regulation compared to the way its set up in the flores agreement and i believe it has to do with modification. We can get you more information about this, but a modification in terms of the Justice Department and what they believe theyre actually legally able to do in terms of administering hearings. But were happy to get you more information about that. It really was i think a response to where d. O. J. Felt they had to be on these hearing processes. Senator merkley ok. I have visited the children in the internment camps. I visited the children in the child prisons. They have no idea that they would have this kind of right. Most of them did not have access to counsel. Many of them dont speak the same language as yet, its a fantasy to think a child would except in rare circumstances know to request such a hearing. That disturbs me because it strips a fundamental protection in the system away from these children. My time is expiring so ill just note. This is the thing that the flores settlement said it could be replaced by a regulation that implements the flores settlement but this regulation scripps it, scraps it, it doesnt implement it. As you can imagine, on behalf of these refugee children, ill be opposed it opposing it in every possible way. If youre studying it you might come to the same point of view. Senator alexander thank you, senator merkley. Mr. Secretary, senator blunt has indicated we should go ahead and wrap up the hearing at this point, which i will do. In just a moment. But i want to ask you a question and make a couple comments and then well conclude the hearing. Youre familiar with the lowered Health Care Cost bill that passed this committee 203, and i think youre very well aware that the house energy and Commerce Committee and this committee worked on an agreement. We pretty well came together between the house and the Senate Committees on a version of that bill which includes ending surprised billing and about 40 more provisions that would lower Health Care Costs, focusing on competition, transparency, and Prescription Drug costs. The house education and workforce committee, chaired by bobby scott, with virginia foxx, the Ranking Member, came up with basically a similar proposal and now the ways and Means Committee in the house has also come up with a version thats a little different on ending surprised billing. So we have two house committees and this committee in agreement. We have the ways and Means Committee headed in the same direction. We have the president s support, which is the question im coming to. So when you have this committee 203 with the chairman and senator murray, when you have chairman pallone and Ranking Member walden, when you have bobby scott and virginia foxx, all agreeing with the president s support and you have the ways and Means Committee headed in the same direction, it seems to me thats a good candidate for action to lower Health Care Costs, especially since ending surprised billing, the other 40 provisions or so that would encourage competition, transparency, and lower drug costs and save enough money to fully Fund Community Health Centers for five years, that could all be done by the end of may when the Community Health Center Funding expires. So my question for you, is this high on the president s priority list, and will you continue to work with this committee and the three house committees to get a result on ending surprised billing, which includes the air, ambulance, and other provisions as well as the Community Mental Health Centers Community Health centers . Secretary azar as you know, this is a very high priority for the president , ending surprised medical bills, and were very happy we actually have consensus about the core, which is protecting the patient from surprised medical bills. What were just trying to do is work with the committees on who then bears that cost, insurers, providers, hospitals, etc. , and the back on the backside. And we want to work with you to try to bridge that. Youre right, it does need to get through. We want to get a bipartisan, bicameral solution passed. Senator alexander thank you. Hear are my comments and you dont need to respond to these. I see the chairman is here and ill let him have his own committee back. He made the mistake of giving me the chair. Genomic information about newborn babies, blood taken from them, is used importantly in research. And many members think parents should give informed consent of that. Some of the researchers are afraid that will limit the opportunity for research. My own view is i think the researchers are wrong about that. I think when parents go into the hospital and fill out all their forms and one of the forms says, can the blood that we get from your newborn baby be used for research, i think overwhelming theyre going to agree to that and i hope you would take a look at that and try to help us balance the privacy right and the research opportunity. I think it helps the researchers to go ahead and do this because that locks in the steady supply of that blood for research and avoids coming up and having a big problem with it sometime later. And the other issue is, interoperability. We dealt with that over in our authorizing committee. We had a whole lot of hearings about medical information blocking and make it easier for patients to get their own health care data. And the two things id like to ask you to focus on is the one area where we had a lot of concern, had to do with third party people getting information from these things without us thinking about that very much. And the final rules need to balance Patient Access and the privacy needs to be addressed. In other words, we dont think the existing federal rules really dealt with that issue expertly. We want to make sure that we deal with the privacy question. And then the other and this is my own bias about interoperability. I tried to get the Obama Administration to slow down on implementing the various rules expanding about medical Health Care Information because i thought it involved too many people and they were going too fast. We all want to get to the same place, so i hope you will not try to do too much too fast. I think our goal with interoperability is to get there but if we try to go too fast to get there we may create more problems than we than we saw. Thats just admonitions from having dealt with this for several years. I just wanted to take this opportunity to mention those two issues to you. Ill ask the chairman if he wants to have his committee back. Senator blunt thank you, senator alexander. Secretary azar my pleasure, senator blunt. Senator blunt if you were going to pick any individual on our committee to have a wide enough range of interest to keep answering questions for the time everybody was gone youd start with senator alexander. So thank you. We got a few people that may come back. Were not going to go a whole lot longer here, secretary. Let me talk a little bit about Mental Health. One of the things ive been interested in, as you know, is try to get Mental Health on a truly even basis with all other kinds of health. We have a pilot that senator stabenow and i worked establishing a few years ago in eight states. The f. Y. 2020 bill included 200 million for Certified Community Behavioral Health clinics. Youve actually proposed that be increased by 25 million. I was pleased to see that increase. Also, something that we asked for in that bill, it was more information about what changes were seeing in Overall Health costs when peoples Mental Health is being treated like all other health. My goal with this pilot was not to have the federal government take over Mental Health but to try to create the kind of whole Health Information that would make it more easy for states to determine what this really meant. Are they spending no money extra when they treat Mental Health like all other health which i think may be possible . Are they saving money, which may be possible . Are they spending only a little more money when they treat Mental Health like all other health . It always seems, mr. Secretary, totally logical to me if youre dealing with somebodys Mental Health problem that youre more likely to be able to deal with any other Health Problem they have in a much more costeffective way. I do know that on the opioid effort in our state and the other seven states that have excellence in Mental Health pilots that the ability to have Mental Health assistance unlimited by 14 days or seven days or whatever it would have been, certainly make a difference in peoples ability to deal with their opioid problem. If you dont have a Mental Health problem when you become addicted to drugs, you certainly have one after youve become addicted. So what i really need from you all is a more is Quick Response you can give. We asked for a response to that in 30 days. Its been about 67 days, i think, now. The reason id like to see that is to see if were headed in the right direction and if theres another need we need to be compiling information so that you and i both have and the congress and state governments have what they need to look at to know the difference it really makes. You want to respond to that a little bit . Secretary azar we certainly agree taking care of Mental Health is critical to Overall Health and well work on getting you that information as soon as possible. I think you alluded to this, the president s budget proposes a major change here would be to live the state lift the state option for serious Mental Illness of inpatient Mental Health facilities beyond the current limit. As we have done for Substance Use disorder but actually make it a state option to get into that. That would make it i think it would be exempted from budget neutrality and other restrictions we have. Very excited for that change for Mental Health in the United States. Senator blunt i dont know if you had a chance to talk about the president s h. I. V. Initiative much today with Everything Else thats going on, but we did fully fund senator murray and i worked together, we worked with our house colleagues, we worked on the number that was needed last year. What kind of progress are you making there in end h. I. V. Initiative and what should we be looking at when you asked the number this year . Secretary azar what the number we gave in december was supporting the preparation activities. We have most of our new half of our new cases are occurring in 57 target jurisdictions so we worked there to get their plans in place and ready. We had four jumpstart jurisdictions that we were able to start moving on. Now you funded it, were now implementing the initiative in terms of diagnosing, treating, preventing, responding. The new money, so for 2021, would be year two of the full initiative. That would be 716 million for year two. Thats the scale, the 450 million scale after we implement those plans. Thats expanding the Community Health centers that are in the 57 target jurisdictions, expanding their ability to treat as well as to prescribe prep and get people on prep. It involves outreached individuals and adherence programs to ensure people take their prep, get on it, stay on it. Individuals that are diagnosed get on their antiretrovirals. Expanding ryan white capabilities in the target jurisdictions. Also at c. D. C. Having the Rapid Response team able to go and deploy into clusters where we see new clusters of h. I. V. Coming out. So really across that at c. D. C. And hrsa, now its implementation. So with the money you got us in december, were beginning that statebystate implementation and this is the second year of full scale into that. Senator blunt the meeting in my office yesterday, the topic of h. I. V. , get on their prep and stay on it, where this might be an area of this time released medication where you took it once a week or once a month, then it released on its own would have some real potential . Secretary azar certainly, any long acting prep would be great. I dont know if the manufacturers are pursuing that. I havent seen that formulation they are working on. Monthly, for instance, that would be fantastic. Senator blunt senator durbin. Senator durbin thanks for waiting with the roll calls. We had conversations with the issues of vaping and ecigarettes. The president and the first lady in the oval office mid september last year made some strong and encouraging statements dealing with this. Unfortunately a few months later when the policy was announced, there were concerns. The president s promise to remove all flavor ecigarette products from the market within weeks didnt happen. Instead he decided to exempt cheap disposable flavors like mr. Fogs bubble gum flavor. Puff i cant keep up with the name. Puff bars with g flavor. And sticks mango bomb flavor. Not a product for those who are hardened smokers trying to quit. Its a product attracted by kids. They end up with a nicotine addiction. I think it was not good to end this from the flavor ban. I am concerned about his decision to exempt more than 15,000 flavors in the open tank vaping system. Id like to get on the record what you told me personally and privately about monitoring whats going to happen next and what the response would be from you and the f. D. A. If it turns out that the extent of the ban, the extent of the restrictions are not adequate to stop this youth epidemic. Secretary azar yes. First, senator durbin, thank you for your partnership on the ecigarette issue. Its been wonderful to work with you to keep this focus on keeping these ecigarettes away from children. In terms of the disposables, as we talked about, njoy did pull off its favored disposable products from the marketplace, respecting the spirit of what we were trying to do here. These other products, if theyre targeted at kids, and if we get data showing that kids are using these products, were going to go after them with enforcement, with the full weight we got. Weve even talked to Companies Like google to use advanced analytics that they have to help us get even earlier warning signs than the National Youth Tobacco Survey which is more retrospective so we can see trends there. Senator durbin let me ask you this. By court order in may, the f. D. A. Is going to have to is going to receive applications from those who want to keep their devices and flavors on the market. Do you believe that an ecigarette application should be rejected by the f. D. A. Unless the company proves with scientific and medical evidence that the product actually helps adults quit smoking tobacco cigarettes, does not cause youth to start smoking and does not harm the user . Secretary azar so on the first part of your question which is Smoking Cessation, that would be imposing a drug approval criteria in there because, of course, Smoking Cessation device is an n. D. A. , new drug approval, a different par what the control is. I believe the standard is, it promotes Public Health. I believe its Something Like that in terms of the standard for f. D. A. Senator durbin not appropriate for the protection of Public Health is at least one reference. Secretary azar right. Senator durbin but of course, isnt that the marketing message . Secretary azar if it is senator durbin ecigarettes and vaping, you quit smoking. Secretary azar if they use that messaging without drug approval, we will enforce against them. We did issue a warning label against a manufacturer that was putting Smoking Cessation claims or those claims to their products. Senator durbin thanks for your kind words on d. T. C. I want to talk about the zero tolerance issue and the fact i joined with senator murray and others dealing with what happened to the kids who were forcibly separated from their parents at the border and there was a study done at our request but it came back and said we cant even find many of these kids or their parents. Can you tell me at this point how many children are currently still separated from their parents pursuant to that zero tolerance policy . Or the preceding policy which had the same impact . Secretary azar i want to make sure and ill ask if i can get you for the record i want to be sure of this, but i believe that we do not have in our karat o. R. R. Care at o. R. R. Any children that remained as a result of the zero tolerance policies. So i believe that to be the case. I thought we were down to zero of them, but i want to well make sure and get you that information for the record. Senator durbin and so as you sit there, you believe that every parent whose child was taken into h. H. S. Custody have been reunited . Secretary azar or they have not been parents or not fit for reunification. I want to be careful because i know there was one instance where there was an individual i think in guatemala we had trouble finding the parent but i believe that was resolved. Thats why i want to be careful to get back to you on the record to make sure i get every bit correct. Senator durbin i hope were sensitive to this. The remain in Mexico Program which is now involves thousands of people and children, there have been reports from human rights organizations about terrible abuse, including sexual abuse of children and adults who are on the mexican side of the border waiting for some sort of resolution of their status here in the United States. Do you accept some responsibility to monitor that program in terms of its impact on these people . Secretary azar so i am not involved in the d. H. S. Mexico migration policy. Thats not our authority. Doesnt go to our authority. Really its just the unaccompanied children. If they come across by themselves or if a parent leaves a child here on returning to mexico side of things. Senator durbin i understand the jurisdictional thing. I know you are a caring person. You understand it. When we turn away asylees, leaving them in mexico, we have at least have some role in this and should accept some moral responsibility for the outcome. Thank you, doctor. Senator blunt senator durbin, we are going to wrap up. Senator murray. Senator murray mr. Secretary, i want to follow up on what senator durbin brought up because i am really frustrated by the departments failure to protect Migrant Children against harmful policies, especially when it comes to sharing information with the department of Homeland Security. Over the past couple months, we have learned from news reports the white house hatched a plan to embed i. C. E. Agents within the office of Refugee Resettlement and use information from unaccompanied childrens potential sponsors to target them for deportation. And then we heard reports that i. C. E. Is implementing a widespread policy to fingerprint unaccompanied children who turned 14 while theyre in h. H. S. Custody without legal representation present. And now we are hearing another bombshell that h. H. S. Has been sharing Migrant Childrens confidential Therapy Notes with i. C. E. Who has then used that to weaponize it to deny asylum claims. I am extremely worried about this. In the past the care and protection of children was purposely separated from immigration enforcement. This is really alarming to me these actions are being taken. So just one question and ill follow up with you later. I understand children were told that the conversations with their therapists were confidential. Is the department making clear, anything children say in these sessions will be shared with i. C. E. . Secretary azar those notes from therapists or Mental Health counsellors talking to children should not be disclosed absent the childs consent or limited the most limited information possible in the event of a threat to themselves or others thats disclosed. Senator murray who does that . Secretary azar the therapist. The sharing of information, we discovered this in august, 2019, that there had been a problem since a guidance that was issued in 2016 where therapist notes were being provided over. What should happen is limited information about the childs protection or the childs threat to others should go into a serious incident report in the system. That should be the minimal thing needed. Grantee therapists were putting them in the s. I. R. Senator murray are you saying that are you telling therapists you should not share or are you telling children secretary azar as of august, 2019, we clarified our instructions that these notes should not be shared with anybody absent a childs consent and that any and any of course senator murray is it ok i share this with somebody you never met, yeah. Secretary azar no, they dont. I wouldnt hang up on that. They are not being shared unless a child were to consent. The information in the serious incident report threaten themselves or others, that would be put in the s. I. R. Senator murray saying to a child this may be shared Means Nothing to them. Secretary azar no. We are not saying it may be shared. Were saying its the standard mental Health Professional requirements if you threaten yourself or others, that fact is disclosable. That would be disclosed. We stopped this. This was in error that those notes were going over and that was stopped in august of 2019, long before it became a media story. Senator murray i hear that. You also said that if the child consents then it will be shared. How can it be consent . Its been a long time since i practiced law. If you are a child and dont have a capacity, how are you going to make this consent . What does it mean to a child . Secretary azar our children have Legal Counsel and so we pay for and so at the would be working for them on it. Secretary azar the most important issue is this was a mistake. It should not have been happening as it was identified, it was stopped. We do respect the privacy of these Mental Health conversations, as chairman blunt knows, i am very passionate about access to Mental Health care. We want to make sure this happens and that kids are protected. It was a mistake. We fixed it. On a Going Forward basis it should not be happening. Senator murray can you get back to me and mr. Durbin. Secretary azar you bet. Senator blunt secretary, thank you for staying with us. Thank you for your leadership at the at the agency. The record will stay open for one week for additional questions. Id like to be included on any response on that last question. I think that probably is something that when you look back at your answer, we need some clarification on that. The committee will stand in recess. [captions Copyright National cable satellite corp. 2020] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org]