Human services. The Health Committee holds a courtesy hearing on the nomination of the secretary, the finance committee receives paperwork, it will vote on the nomination. Senator murray and i will have an Opening Statement and former secretary and former governor of utah Michael Leavitt who we welcome today, good to see you and have you back and senator young who is a member of this committee will introduce alex azar after his testimony then senators will each have five minutes of questions. We have a lot going on in the senate today but we have a good turnout so i anticipate a good, vigorous questioning period. Alex azar, if confirmed will be did the of health and Human Services, you will be running 1. 11 trillion organization, that almost equals the total of 12 Appropriations Bills Congress Passes each year to Fund Everything from National Parks to National Defense to national laboratories. You will be overseeing medicare and medicaid, the nations government run Insurance Programs for the poor and elderly, Mental Health and Substance Abuse where you will have to address the Opioid Crisis among many other issues, the National Institutes of health where with francis collinss excellent leadership the United States is leading efforts to lead a cure for alzheimers, new nonaddictive painkiller to prevent opioid use and treatments for cancer, the fda, where we have gotten a start speeding up approval of generic drugs working to spur innovation and access to Regenerative Medicine and you will be faced with skyrocketing premiums in the individual Health Insurance market that are currently a nightmare for 9 million americans who dont receive a government subsidy to pay for their Health Insurance. We also have an opportunity to implement what the majority leader of the senate called the most important piece of legislation last year, the 21stcentury cures act which senator murray and i and members of this committee agreed upon and gave broad new powers to the fda, National Institutes of health, included the first major organization, worked on that, Mental Health programs in a decade as well as significant new funding for the Opioid Crisis which virtually all of us support. I believe you are an excellent nominee for this job. You have been confirmed by the United States senate twice, you have offered to meet with every member of this committee and have met or spoken with 15 Committee Members, you served in the Judicial Branch for Supreme Court justice antonin scalia. The executive branch, having been hhs general counsel for four years and deputy secretary for two years, you know the private sector, you spent decades in a leadership position at one of the Major Pharmaceutical Companies so you know how drugs get the manufacturer to patients. With all of these prospectives you should need no onthejob training to lead this department and should be able to take advantage of this exciting time in Biomedical Research to speed safe drugs through the system to patients more rapidly. I see your brought experience as one of your principal assets, experience in healthcare to me is an obvious asset for someone called upon to lead the nations most important healthcare agency. One reason doctor gottlieb, the fbi director has done so well so rapidly as he knows the agency. Having been deputy commissioner, he knows the private sector having worked in it. Doctor collinss knowledge of an eye agent leading the human genome project made him an effective leader at the National Institutes of health. Im glad to know people like you and doctor collins have the experience on the issues you will be dealing with 3 day. Healthcare costs and drug pricing are issues this committee has studied to better understand existing challenges and find solutions which we plan to hold a third hearing on how the supplychain effects what patients pay for Prescription Drugs on the server 12, and hear from the national academies. I would welcome your input as we examine the price patients pay when picking up their prescriptions. Healthcare is much broader than Health Insurance was only 6 of insured americans purchase their insurance in the individual market but that is where we have had our debate and discussion. 9 billion in individual market dont qualify for a subsidy and are hammered by skyrocketing prices. Tennessee premiums increased 176 in four years, an additional 58 for this coming year. Both congress and the administration need to act to provide relief for these americans which members of this Committee Work on an agreement cosponsored by 11 other republicans and 11 other democrats which the congressional offices will prevent a 25 price increase in premiums by 2020 by paying costsharing subsidies, decreasing federal dollars on aca premiums and the deficit. The agreement would give states the authority to use the innovation waiver already in the law to find other ways to lower premiums. Alaska created a Reinsurance Program and lowered premiums by 20 with new federal spending. Yesterday the president said he supported the Alexander Murray agreement becoming law by the end of the year. Our agreement has so much in it that appeals to so Many Democrats and independents hard to imagine our not passing something prevented 25 increase in premiums by 2020 and offers states flexibility to further lower rates. The democratic leader called it a good compromise, the senate has the support of all 48 democrats and the senate, chairman of the Democratic National committee tom perez tweeted last month Alexander Murray has widespread bipartisan support. As a secretary there are many other steps you can take to lower premiums and stabilize the markets such as approving innovation waivers which would increase access to lowercost plans and incentivize younger and healthier individuals to purchase insurance. The Opioid Crisis that is ravaging this country is a priority for the president and every member of this committee. Having hearings on the state perspective on the Opioid Crisis tomorrow. You will be coordinating a departmentwide effort to combat the opioid drug abuse, Drug Overdose deaths in tennessee went up by 12 from 201516, in particular overdose drugs related to fentanyl, synthetic opioid have dramatically increased 74 from 169 in 2015 to 294 in 2016. Congress has passed legislation to streamline programs, provide funding to states and communities on the front line of this crisis including protecting our infants act comprehensive addiction and recovery act, the 21stcentury cures act. We have included 816 million in fiscal year 2018 appropriations bill to address this growing and tragic crisis. As you implement these laws we want to hear from you what is or is not working, we stand ready to work with you if you have additional tools for authorities that need it, some are saying we need an opioid czar. I hope you will join me advising the president this is a bad idea. You need to be the czar, the federal government does not need a new czar. Once confirmed you need to be the one to take charge of leading the federal government response and letting us know how to help. I mentioned we have an exciting opportunity to implement the 21stcentury cures act as we continue oversight hearing on cures i hope your work with us to take advantage of all this law offers including president obamas Precision Medicine initiative, Vice President s cancer moonshot, the brain initiative, cures also gave you in the fda new authority to hire the scientists it needs to make sure these exciting new advances are safe and effective for americans which we all thought that was a big priority. I hope you use these authorities to make sure we take full advantage of this exciting time in science. The committee will perform oversight on drug quality and security act. A law we passed to help ensure the safety of compounded drugs. Also hope we will continue to look at how to lower healthcare costs including the cost patients pay for Prescription Drugs and how to keep people healthy. Looking at next year the committee will have to reauthorize the pandemic and all hazards preparedness act which provides the authority to ensure our nation is prepared for and able to respond to Public Health emergencies such as hurricanes, Infectious Diseases like zika and bioterror attacks. Another important bill to fund the fda, the one focused on animal drugs, the animal drug engineering animal drug user fee act. There is a lot to do. I look forward to working with you on this and hearing more about your priorities today. Thank you, chairman alexander and thank you to our colleagues for being here today. Alex azar, thank you and your family for being here and your willingness to serve. In november 2016, people started emailing me and calling, coming up to me in the Grocery Store editorials with tears in their eyes wondering what the future of health especially for their healthcare and it hasnt stopped and because these worries and challenges are what this congress and the department were discussing today is supposed to be focused on i am going to start my remarks with a few examples of the stories i have been told over the last year. My constituents julie from Mercer Island in four time cancer survivor, she said she would not be able to afford her medical expenses or stay alive without Affordable Care act protections. Kim shared her story about her addiction to opioids and her ability to overcome it with the right comprehensive treatment. Christina said before going to planned parenthood she struggled to get Birth Control regularly given her unpredictable schedule and the fast food industry, those are just a couple examples, there are many others and so many pressing Health Problems this administration could be solving. Instead of solving problems that developed health and Human Services under donald trump so far has been determined to create problems. That permit has not attempted to help people get high quality affordable coverage. They made it harder by stopping payments for outofpocket cost reduction, letting insurers cover fewer benefits, cutting this years open Enrollment Period and cutting funding for Consumer Outreach and a lot more. Rather than allowing women to make their own Health Care Choices the department has tried at every turn to impose rightwing ideology on women and even prevent them from getting care from a provider that they trust. Donald trump went to states like New Hampshire and ohio and said he would confront the Opioid Epidemic head on and called it a tremendous problem. People believed he would make sure hardhit communities get the resources that they need at this administration and its Health Department did the opposite and propose getting medicaid which offers critical Wraparound Services and Substance Abuse Disorder Treatment to people who otherwise could not afford it. Experts say that would cripple response efforts and all it took was a meeting with few pharmaceutical executives for donald trump to go dark on the skyrocketing cost of Prescription Drugs despite a president s promises about bringing prices down. In fact it is hard to find the healthcare problem the leadership at hhs is not only failed to address so far but actively made worse. That obama has proposed using Public Health funds to close nearterm budget caps rather than to prevent costly illness and disease down the road. And utterly failed to see the urgency of the Public Health crisis still unfolding today in puerto rico and the Us Virgin Islands in the wake of hurricane maria. The administration is even rolling back protections that prevent discrimination against people who have been historically denied equal access to health care. It shouldnt have to be said that the absolute last thing our nations healthy permit should be spending time on is encouraging more discrimination in our Healthcare System. That is wrong. Alex azar, you and i have some stark disagreements but your nomination still could be an opportunity for hhs to reset, to put aside the extreme politics that are actively endangering people nationwide and start focusing on that the permits mission instead of Donald Trumps ideological agenda. People across the country would be far better off if you took this opportunity but i have to say with concern my review of your record leaves me with serious doubts that you will. As a pharmaceutical effective you need to raise drug prices year after year, eli lilly currently under investigation for working under your tenure with other Drug Companies to needlessly raise the price of insulin and you have said many times you oppose government efforts to lower drug prices. You made it clear on questions of Womens Health you side with ideology over science and rightwing politicians over women. Although conservative experts and governors and even some members of congress have rejected Donald Trumps attempts to sabotage the Healthcare System and jammed trumpcare through, you said this legislation would undermine protections for people with preexisting conditions, gutted medicaid, cost tens of millions of people their healthcare, defunded planned parenthood and more, you said it didnt go far enough. This leaves me very concerned about whether you would faithfully implement the bipartisan agreement chairman Alexander Just talked about, we reached earlier this year should it become law. And finally in light of Donald Trumps profoundly underwhelming followthrough on his Campaign Promises about tackling the Opioid Epidemic it is deeply disappointing that yet another nominee for the role of secretary of health hasnt supported committing the new resources we need for this effort. I worry about your professional history and statements that point to a continuation of some of the extreme damaging and approaches we have seen so far from this administration so let me return to the stories i mentioned at the beginning of my remarks to make my final point. Right now, dewey is traveling around the country raising awareness about open enrollment to help more people sign up and get access. Kim is now pursuing a masters in social work and helping people in Central Washington to get the necessary treatment and services they can overcome their addiction. Christina has become a vocal advocate for helping women in washington and nationwide to give care that works for their needs, jillian, kim and christina are doing more than their part to keep our communities healthy so my question is why isnt the nations healthy permit doing the same . People should have a secretary of health who will work for and with patients and families, not against them and who is committed to making policy based on science, not ideology. Alex azar, i am looking forward to your thoughts on the many serious concerns i have raised and how you would be an appropriate choice for this position but im concerned that donald trump has sent us an extreme ideologically driven nominee to pick up where secretary prices left off and that women and children and seniors and families deserve a lot better. Im interested in your responses today. I hope i am pleasantly surprised and i do want to say if you are confirmed i want to make it very clear i have not and will not let this administrations approach so far lower my expectations for any of the departments this committee oversees and i will continue doing everything i can to hold hhs to the highest possible standards of accent service for people in my state and across the country. Thank you for being here and i will turn it back over. We now welcome the nominee, Mister Alex Azar and we welcome your family and friends, we all for being here, a pretty good group of them, you may want to introduce them when you begin. Alex azar, first, introduced by governor mike leavitt who served as george w. Bushs secretary of the department of health and Human Services from 2005 to 2009, he worked closely with alex azar zen. Alex azar served as his deputy secretary. Then the nominee will be introduced by his home state senator and member of this committee, senator todd young. Please introduce Mister Alex Azar, and welcome. Thank you, chairman alexander and senator murray and members of the committee. They have very ably described the complexity and importance of this role and it is my privilege to introduce and unequivocally recommend alex azar. He is up to the task, he is supremely wellqualified to carry out this important work. As mentioned during my service as secretary of hhs, alex azar was deputy secretary. Innocence, he was the chief operating officer of this very large and complex department. Prior to his service, he served as general counsel under secretary thompson who i believe later will also introduce and robustly recommends him to the finance committee as they consider his nomination. That places experience in the private sector that has been mentioned leads me to conclude there may not have been a nominee to this office of secretary better prepared to hit the ground running then alex azar. It was mentioned hhs is a large and complex place. Deputy secretary, alex azar was essentially the manager of daytoday operations of 90,000 employees and 1. 1 trillion over budget. A brief example will illustrate his capability. President bush had a management agenda that laid out a criteria of several dozen different objectives and had a dashboard of green yellow red. Alex sent an objective to have every criteria green and he was the first deputy secretary in the federal government to achieve that. He was also delegated oversight of much of the regulatory process and a skillful lawyerly like way, he managed to carefully and equitably adjudicate administrative rules process which is robust at hhs. He is a worldclass policy anchor, Good Community person, you will see that today. I can assure you if he is confirmed as secretary you can expect good communication on both sides of the aisle. He is an experienced diplomat. Experienced, i think, is a word that will be underscored here. I have seen him under fire. 9 11, he was part of the response. There was a point in time when katrina, pandemic influenza and the rollout of Medicare Part d was happening at the same time. This is a person with great experience in a complex department. Most important, can i say he is an extraordinarily good human being. He has the kind of compassionate heart it requires to lead the mission of this Important Department and i commend him to you and urge the senates confirmation of him as the secretary of health and Human Services. Thank you for joining us again as you have before to help this committee. Senator young. Thank you, chairman alexander, Ranking Member murray and fellow members of this committee, i am grateful for this opportunity to introduce a fellow hoosier, alex azar, to be secretary of the department of health and Human Services. Donald trump made an outstanding choice in selecting alex azar to lead this Critical Agency which happens to be the largest civilian Cabinet Agency and the us government. Alex azar is, as has been said by a couple of individuals, and extremely qualified nominee and he is a wellknown expert in the healthcare industry. His previous leadership experience as general counsel and deputy secretary of hhs and as president of indiana base lily incorporated which is the largest affiliate of one of the largest Healthcare Companies in the world, will collectively be an effective combination as we work to solve our nations most significant healthcare challenges. Former hhs secretary Tommy Thompson said that alex azar is one of the most competent people i know. And experienced leader with deep, substantive healthcare knowledge. I agree. In addition to his impressive academic record which includes degrees from dartmouth and yale, alex also worked for the late us Supreme Court justice antonin scalia. He first began his service at hhs in 2001 when the United States Senate Confirmed him to serve as the general counsel. Since then alex azar has been a leading voice in healthcare reform and Healthcare Innovation with reputation as an effective leader. He has been outspoken on the need to lower the price of Prescription Drugs sank patients are paying too much. If anyone can help solve this problem it is alex azar. He is the right person to help reform our broken Health Care System and to ensure the department succeeds in its mission to enhance and protect the wellbeing of the American People. Alex was confirmed to both his previous positions at hhs with unanimous bipartisan support, confirmed twice by the United States senate for positions at hhs with unanimous bipartisan support. I am hopeful this time will be no different. I know alex is a good man with a heart for service, got to know him personally over the years would i look forward to supporting his nomination and working together to ensure all americans have access to highquality Affordable Care. Thank you, mister chairman. Alex azar, we invite you to give your opening remarks, your full statement will be incorporated into the record, welcome. Thank you. If i could take a second to introduce my family that i have got here today, i am pleased to be joined by my wife, jennifer, my daughter, claire, my son alex, my father, doctor alex and my sister, stacy, and her family. Unfortunately my mother linda could not be here today, most tragically my stepmother wilma died of cancer in july. I am very sad she could not be here for this moment. Having an opportunity like this does not happen without the support of family and their guidance. Thank you, mister chairman and Ranking Member murray, members of the committee, for the opportunity to appear before you as the president s nominee to be secretary of health and Human Services. Senator young and governor leavitt, thank you so much for those extremely kind words, your friendship, your mentoring over the years. I think donald trump for the confidence he has bestowed on me in nominating for this position. 97 years ago my grandfather, and impoverished teenager who spoke no english stepped out of steerage on the ss argentina completing his long journey from lebanon to america. He met an individual in the military uniform, that person possessed power to admit him or send him back to poverty and uncertainty. That person was a member of the United States Public Health service. It is a testament to all i love about this country that 97 years after my grandfather went to his 6 second physical on ellis island with no prospect of political, economical religious freedom america offers his grandson might be in charge of the Health Service and all the other worldrenowned components of the department of health and Human Services. The mission of hhs is to enhance and protect the health and wellbeing of all americans. And every single american in some way, every single day. We are at a historic time in terms of delivering on that mission through innovation. Outstanding leaders and career staff. Hhs is primed to meet that challenge. Marshaling and leading require innovating, never being satisfied with the status quo and anticipating and preparing for the future. I gain these skills in the dark days after 9 11 as we face the health and Human Service consequences of the attack, and the anthrax attacks and preparedness for potential future, further biological, chemical, radiological or nuclear attacks. In recognition of our part d description drug benefits for seniors by helping build global, national, state, local, pandemic flu preparedness programs and our response to the threats of monkeypox and efforts to reform welfare programs to make as empowering as possible for the individuals and families we serve. Through innovation and the private sector, to bring life improving therapies to our people and the people of the world, harnessing the power of big data and Predictive Analytics to make us more efficient, more capable of serving our fellow americans. With a department the size of hhs it is often difficult to prioritize. Nonetheless should i be confirmed, i do envision focusing my personal effort in four critical areas. First, drug prices are too high. The president has made this clear, so have i. My experience, helping to implement part d and my extensive knowledge, how insurance, manufacturers, pharmacy and Government Programs Work Together i believe i can bring skills and experiences to the table that can help us address these issues while still encouraging discovery so americans have access to highquality care. Second we must make healthcare more affordable, more available and more tailored to what individuals want and need in their care. Under the status quo premiums have been skyrocketing year after year and choices are dwindling. We must address these challenges for those who have Insurance Coverage and those who have been pushed out of left out of the Insurance Market by the Affordable Care act. Third we must harness the power of medicare to shift the focus in our Healthcare System from painful procedures in seconds to pay for health and outcomes. We can better channel the power of Health Information technology and leverage what is best in our program and in the private competitive marketplace to ensure the individual patient is the center of decisionmaking in his or her needs are met with Greater Transparency and accountability. Finally, we must heed Donald Trumps call to action and tackle the scourge of the Opioid Epidemic that is destroying so many individuals, families and communities. We need aggressive prevention, education, regulatory and enforcement efforts to stop overprescribing and overuse of these legal and Illegal Drugs and we need compassionate treatment for those suffering dependence and addiction. These are serious challenges that require a serious minded sense of purpose and if confirmed i will work with a superb team at hhs to deliver results. I think donald from for this important opportunity to serve the American People and i thank you for consideration of my nomination. Thank you, alex azar, we begin 5minute questions. I will just ask one questio. Id like to reserve two minutes askhe end so i can questions later. During the nomination process for the secretary ofagriculture, of agriculture, there are concerns about his close ties to the agriculture industry. While moving treatments and cures through that agency. There was concern because he had worked with pharmaceutical companies. You have worked with a Major Pharmaceutical Company in a major position for ten years. My own view is my own view is that the big help because having some familiarity with the drug pricing is such a byzantine situation that someone who did not know anything about that or much about it by the time they came in they would be gone before the even figured out 5 of how we a might lower drug prices. So i think its a plus but what do you say to the skeptics who criticize you for that especially for those who question the increase in insulin prices while you were part, while you are a leader at eli lilly over the ten year time frame . Mr. Chairman, thank you for that question. As you and others have mentioned i the honor of serving as general counsel and then deputy secretary of hhs from 06 years in the Senior Leadership there. So for me if i will confirm this is returning home. This is myy place data want to be. After hsi did spend ten years at eli lilly where i was a senior leader, eventually the president of the u. S. Affiliate directly leaving the sales and marketing of all nondiabetes, nononcology drugs in the United States. , as the geographic leader also supported operations for those otherr business units. I do believe as the chairman mentioned that these public and private sector experiences do prepare me very well the role of secretary. Xp i think this is especially true in the case of drug prices. S has risen substantially. In particular, insulin. The Current System of other medicines may meet the needs of many stake holders but that system is not working for the patients who have to pay out of pocket. We have to recognize that impact. Thats why the president and so many members of this committee on a bipartisan basis and i have talked about the need to fix this system. I do think through my experiences in the Public Sector and at lily my expenses in the private sector, understanding how the channel works, how the channel sees these issues, how manufacturers, payers, pharmacy benefit managers, all distributors all Work Together. I believe i can hit the ground running to work with you and others and we can work to identify solutions here. I will reserve the plans of my time. Thank you. Sen. Murray let me just follow up. I think the cost of drugs is something i hear about more than anything else. It affects somany people in a negative way. And im assuming that you agree with the overwhelming majority that drug costs are too high. Do you agree that congress and administrative actions are needed . Mr. Azar i absolutely do. Sen. Murray as we know you are president of a Major Pharmaceutical Company when it got worse. Tell us how you would approach this as secretary . Mr. Azar thank you to my senator murray. And i appreciate the chance we had to sit down together. I really enjoyed that discussion. Also in terms of your opening, i hope if im confirmed, i hope i can earn your trust and show you this is the job of a lifetime for me. I would approach this not for any industry or past affiliation, but to serve all americans to improve their health and wellbeing. I think there are constructive things we can do but id also like to hear ideas from the committee, from people at hhs, and elsewhere, but let me throw a couple things out that are worth focusing on. We need to crease generic and branded competition. The more drugs we get to the market, the more competition we have. That can bring down costs to the system. We have to fight gaming in the system of patents and exclusivity by Drug Companies. I have always been an opponent of abuse and gaming of the patent systems by Drug Companies. I led an effort to get rid of filing multiple patents to delay. The exclusivity saved 34 billion for consumers through the efforts that we pushed by reinterpreting. Why are americans paying more than those in europe and japan and is that fair that we are baring the cost ofother nations. And im running out of time. I will just say this. The skepticism comes from, you are in the world of pharmaceuticals and prices didnt drop. How are you going to do that as secretary . We can talk about it later. How is the fox guarding the hen house. A lot of skepticism you will do it from within the agency when you stated before you dont believe government should be part of the problem although you just said something different. I know others will ask about that. I wanted to take a ask a question about Womens Health because so far under President Trump leadership and former secretary price, a number of detriment of were taken that undermine Womens Healthcare. Including appointing multiple extreme antichoice ideologues, undermining title x, keen prevention programs, and critically rolling back protections for women to afford coverage for Birth Control from their Insurance Plans. I wanted to ask you, if we commit between sides and accident of their first rather than ideology and extremism . Senator murray, as we discussed in your office if i am secretary i am second for all americans. I am there to enhance and protect the health and wellbeing of all americans, men and women. We a have programs that this congress has created and that hhs is it a little bit. I would faithfully implement those programs. We mayim differ in different elements of how those get implemented, but i firmly believe in following evidence and sites wherere it will take , in that it is programs. Do you believe that all women should have access t to health care their doctor recommends for them, yes or no . So if the issue is for instance, the conscience exception that hhs has come out with, i do believe we have to balance of course a womens choice of insurance that she would want with the conscious of employers and others, that the ballots that sort of an american value, trying to balance those at very small group i think speedy the women despicably the employer has the president over that . Just in terms of come not in terms of access but in terms of insurance, to force those very few, i believe it is less than 200 who have come forward, very few employers that would be impacted by that, by the conscious exception to respect frankly the rights asth well as respecting womens access to the insurance. I disagree. I think womens access to healthcare their doctor requires for them should take precedence, but we disagree about. Let me go to a critical question that senator alexander and i raised, if confirmed, we youou commit to implementing it as intended and working with us to improve affordable, accessibl, trepidations . Absolutely. I know that some people today are climbing the bill we designed will fix of the problems that are being proposed. Do you think the costsharing reduction payment will be sufficient to make p up for chas if other tax cut proposal to cut . The work of this committee on a bipartisan basis, frankly its a wonderful model for dressing. It recognizes problems with the Affordable Care act, problems with its implementation. There are going to be some new authorities in the package that youre talking about. Those will be useful, but i do want to caution, i dont believe it is a longterm solution to problems that are just inherent in the Affordable Care act that it think we still need to work to address in terms of getting to affordable interest for People Choice of insurance. That insurance to live in real access to healthcare for people so not just a card but actual access to physicians. Many insurance that lets the people get the insurance that they want, not what were telling them from the center. I do think its an important stopgap to help along that way. I have a lot more questions but im wayay over time so i wasnt other members ask at this point. Thanks, senator murray. Senator paul. I think most americans dont disparage or dislike people who achaemenid will. We are fine if people honestly accumulate wealth. If youal ask americans, sam waln who built this great store and sold inexpensive things and we can very wealthy. Most americans dont think hes a terrible person or he somehow abused the system. I dont think americans have the same big warm fuzzy feeling for big pharma. I think many of us proceed to use our economic might to manipulate the system to maximize profits. Sat like theyre selling a cheaper product to more people. Theyre using government to profits. Their do you acknowledge that the Current System, under the Current System big farm uses the economic clout to manipulate the patent system, to increase drug prices . So there are clearly abuses in the system thats why one of the steps that t are mentioned o senator murray that of liquid to go after is a gaming of that. Ive always believed we have there should be a a moment certn when katie by the door there should be full generic competition and that is a gift to this country to the system and to patients when you walk in the pharmacy. I will say this is a huge problem thats been going on for decades. We find insulin since the 20s. 50, 60 years or more with production of insulin by pharmaceutical companies have no generics. Everybody says theyll fix it and theirli nonspecific, but bi tend to be at outer because these problems go on and on and on. When you look at the drug problem one of the things people proposed is to allow us to buy drug some york, allow us to buy drugs in canada, allow us to buy drugs from mexico or a silly. In fact, this was the president s positionally said allowing consumers access to imported seat and dependable drugs and overseas will bring more options to consumers. We that legislation on this. We passed itro several times and yet it never happens. Youve taken a position against reimportation. How does it jibe with the president s position . I before publicly state a position against unsafe importation of drugs into the United States and the president has said the same, reliable and safe. The drugs in europe are unsafe . We have a succession of democratic and republican fda commissioners who have been unable to certify underf the lw have they been wrong and beholden to the companies frankly. You would have to sit theresid d say that the European Union has unsafe drugs and would be unsafe forwo americans to buy drugs and European Union or from canada or from australia. It just frankly is not true. Its a canard and its been going on year after year after year and we have any knows bob people say well fix the drug problem and it never happens. What i think its important for america to know, this is an capitalism. Walmart is capitalism. L gates was capitalism. They pharma, its not really big farmers fall. Theyre trying to maximize their profit using government but we are letting to do. We had this terrible system or to get an epipen, you have for 20 years, you manipulate one little thing in the spring and all of a sudden they get another five years and another five years. One of the things we could do that would dramaticallyfi change this is if you have a patent on the epipen for 20 years you get it. If you change a g make it bette, you get a patent on the new epipen but guess what, we can of generics on the old. Currently you can have that with all these impediments. Why dont wen. Have generic insulin . He will take someone who believes it and i told you my office youve got some convincing to make me believe that youoi could represent the American People, not big pharma. I know thats insulting at a meeting to be because im sure john honest and upright person but we all have our doubts because big pharma manipulate the system to keep prices high. It is not capitalism and its Big Government that weve got to fix it. S we cant happily go at it with to really fix it, and you need to convince those of us are skeptical that you part of fixing it and wont be beholden to big pharma. Senator, as a sit inrm the office with you yesterday, that issue of the multiple filing of patent is, a t modification of a manufacturing process or delivery device, i completely agree with you. I think thats one of the important avenues that we ought to be pursuing because again, there should be a time certain when competition begins, with genetics, and you shouldnt be able to simply make a change their and evergreen your pain. I fought against one thing in myas last few seconds. On the drug reimportation will give you a question that you can think about and write. And but he says its not safe. I want you to determine why the drugs are not safe from the European Union and have it make it safe. If theres restricted says where to go through one committee, im fine with that. Vote Audit Committee for the european drugs as a come through, needs to be expedited. Everybody says its not safe so we never do it. Thats bs and American People thinks its bs that you cant buy drugs from the european or canada or mexico are the places. We always say its unsafe. You will have to convince me that you at least open to the idea of the present is, that was his position and campaign, if youre open to it and not just say its unsafe will say this is how i would do it and is how i would reimport drugs and make it safe. Thats an honest reform. If you cant do that i cant support you. I i hope you come back with an answer that says this is how i would make reimportation safe. Thankk you. Thank you, senator paul. Senator bennet. Thank you, mr. Chairman. And i would say just following on my colleagues comments another option would be how to figure out how to make our price is the same as the prices in these other places for people in america didnt have to go to the ridiculous contortion of how to import drugs from overseas could just have drug treatment wantt o congratulate you, mr. Azar, on your appointment and your willingness to serve during these difficult times. When president clinton left the white house he left behind projected 5. 6 trillion surplus. And thats what he gave to president bush. And then we fought two wars and we didnt pay for those wars. We enacted Medicare Part d which you mentioned a couple of times in your testimony which was not paid for. And then wepa had the worst recession since the great depression, and when president obama became president we had a 1. 5 trillion deficit. He became came to office. President trump ran for office, and this is one thing i will say he is consistent on primary, and Republican Party nominee came in the American People elected him. His promises were these. He would eliminate our debt quote over a period of eight years. He would deliver quote a a gia, beautiful, massive tax cut. He would pass quote one of the largest increases in National Defensemen in American History while also saying quote, im not going to touch Social Security and im not going to touch medicare and medicaid. Those are the president s solemn promises to thein United States. In the 90s i been at this congress has disgraced itself year after year by not enough to pass a a budget, by having 30 continuing resolutions, by not being able to establish a set of priorities to the American People. And we sit here today collecting 18 of our gdp in revenue and spending 21 of our gdp and expenditures. And on the floor this week, disgracefully, is a tax bill that would reduce that 18 to an even lower number below at least the 1. 5 trillion additional deficit in our balance sheet, and as much as 2. 5 trillion. And the concern a lot of people have in my state is that after this incredibly unpopular tax cut is jammed through with no hearings, that the administration is then goingbr o break the president promised toa not touch medicare and medicaid, and instead exploit the deficits that republican majority has created in the time that george bush was president and now the time that donald trump is president to go after medicare and medicaid. And i wonder if you could assure this committee that the president will work for you a set of hhs will honor the promises that he made on the campaign trail to make sure that hes not going to get medicare and medicaid, which was, which is what he said . I apologize for the long wind up of history has been forgotten by myyo colleagues, and i think its important. Thank you, senator. A pleasure to see under pleasure to meet with yesterday. I hope well have a chance to Work Together. As i mentioned in my opening remarks, the third of those four guys are really want to focus on is about strengthening our Medicare Program. Because theres so much mistake, fraud, waste, abuse in the program, efficiency in that would pay for healthcare procedures and sickness. If wes. Can tackle that and if e could move to a more value driven system of healthcare, we will do two things that are really important. One of them is we will stretch out the resources in the Medicare Program to keep its allow itlonger and to to serve its beneficiaries especially as we face the baby boom generation. It will also serve as a catalyst for change that the entire Healthcare System because so much of Healthcare System just really free write off of whatever medicare is doing on payments, et cetera. I think its a unique opportunity and think the president is fully committed around this both the strength, strengthening making medicare, medicaid as effective as efficient as possible for the people that we serve. And hope we could can do thh way that is affected by the idiotic politics about healthcare without over the last ten years. I completely agree thatt instead of disincentives in the program are misaligned. We need to online thing. On the other hand, it is also true the reason why we are paying one dollar and for every three dollars where consuming in medicare is largely because of Medicare Part d which was not paid for when it was enacted by this congress and under president bush, and because of the drug profession which is a double whammy which is caused us to blow the soul. My fiscal concern what you dont think for some reason is share today by my colleagues on the other side of the outcome white house on the concern that beneficiaries in my state are going to pay a price for the fecklessness of washington, d. C. I dont think thats fair. I hope we will be able to proceed on a shared understanding of this fax and Work Together to congress that. Mr. Chairman, thank you. Thank you, senator bennet. Senator collins. Thank you, mr. Chairman. Mr. Azar, i very much enjoyed our discussion in my office on drug pricing, an issue that is very important to all of us, as you can see. I want to follow up on a couple of issues. There was a recent nbc investigation that found that a wide variety of Prescription Drugs on certain Insurance Plans were actually less expensive when the consumer paid outofpocket that if the consumer used his or her Insurance Plan. An example of that was a customer who had a copay of 43 for it, cholesterol drug where, itl should used her, not used or insurance, she wouldve paid less than half ofha that, 19. Ive been met with a group of pharmacists in the state of maine, and i was outraged to learn that there under gag orders that prohibit them from informing their customers that there is this differential in price and that they be better off not using it insurance and paying outofpocket. Do you support prohibiting those kinds of agreements that prevent a pharmacist from giving to transparency on the drug pricing to their customers . Senator, first again thank you for the many. I really enjoyed our discussion, and how can you not hear about that and have your jaw drop recs honestly, how can you not just find that just writing that that could go on. So, yes, i think, those are the types of issues across the entire channel in Drug Distribution payments that i want to bring the expertise i have to the table to work with you and others and hhs to try to resolve. That shouldnt be happening and our many of the things i shouldnt happen in the channel. In how the system works. I think we can Work Together to come up with solutions that will have patience when he walked in the from is a pay as little as possible. That absolutely should be our goal. And i cant tell you how frustrated these pharmacists were that they were unable to give that information to the customers who think they were struggling to pay in a high copay. A second issue that a want to explore with you today has to do with the investigation that the senate t aging committee undertk into sudden price spikes in off patent drugs. And we found that the risk evaluation and mitigation strategies or the rim system which were intended to manage drugs with increased risk factors were instead being abused by certain Drug Companies to block potential competitors from accessing a sufficient amount of the drug once the patent has expired to do the bioequivalence he exams that the fda requires. And ive had extensive discussions with deputy officials about this. Doctor Janet Woodcock testified that the fda has referred 150 cases of potential anticompetitive behavior to the ftc. The ftc claims it doesnt have enough authority. The new fda commissioner has suggested that they could b opportunities with the fda could partner strategically with medicare to prevent a deliberate blocking of genericme competito. From your perspective, how can we address this issue . Senator, i am aware of issue also as one of the abuses that occurred up there, full generic competition in the market. I would look forward to working with you and dr. Gottlieb to get to real solutions. Just how rem programs could be abused to block entry and once we get to the end of life we should be looking at, to the rem program doesnt make sense . Are the legacies, august the required for safetyey when twity the potential for generic status . There may be statutory changes needed. I do not know, but i but i thie need to solve it. Thats one of the things that has to be solved. Thank you very much. I assume when you refer to the endoflife speedy the indepth, yes, sort, and a patent life. Make that very clear. Thank you. Thank you for clarifying that for me. Take you senator collins. Senator warren. Thank you, mr. Chairman. Mr. Azar, ill getat right to te point. Your resume reads like a howto manual for profiting from Government Service. About a decade ago you worked in government helping pregnant the nation of profitable Drug Companies. When you left you went straight through the revolving door and became an executive at eli lilly company. Last year they paid you about 3. 5 million for doing that. Not bad, now you want to go back to the revolving door and once again regulate the same Drug Companies, at least doco it and they decide to go to the revolving door again. I dont think privatesector experience should disqualify anyonen from serving, but i thk the American People have a right to know that the person running hhs is looking out for them and not for the own bank account or for the profitability of their former and maybe future employers. So i have some questions along that line. The first is you grief when a drug company lies aboutdr its products or defraud taxpayers they should be held accountable by the federal government . Of course. Good. Because right before he went to work for eli lilly you worked at hhs while the help the Justice Department with an investigation of eli lilly drug zyprexa. It was proved by the fda to treat schizophrenia and bipolar disorder. But you decide to boost its profits by pushing the drug on Nursing Homes for uses like to mention an alzheimers, with no proof that it would work. The word for that is fraud, and it cost thell government and taxpayers billions of dollars. Eli lilly was still under investigation when you left Government Service and went straight to work for eli lilly. And then as the Companies Top spokesman you help manage the fallout in 2009 and the company was forced to pay the largest criminal fine ever imposed in a prosecution like this, or then half a billion dollars. At that time eli lilly ceo said quote, doing the right thing is nonnegotiable ati eli lilly. Do you think that settlement represented adequate accountability for eli lilly criminal behavior . So senator, i want to be really clear the conduct in that case occurred and endeded up log before i ever even left the government or thought about going to eli lilly. I was not involved in the case when others in the government. I think i actually learned about even the investigation fort firsttime author think think itd been in media i have not seen that. I think of and about actually when i was interviewing and i learned about it and i wanted to do my own inquiring because and you begin the spokesman. I became thehe head of Global Corporate affairs. The conduct that occurred was unacceptable and there is not a leader that would say differently. It was a nasa learning and transformational experience for the company. So was the settlement adequatey accountability for ei lillys unacceptable behavior . It was the largest, as you said that the largest, i think about a and then there was another company had one. Do you think it was adequate . Thats my question. It was certainly the largest ever. What i will. Take the most was adequate . K it senator cohen what was important about that was that it changed patterns iors. Sen. Warren im sorry. What is important is the and that is asking whether or not there was adequate accountability. Mr. Azar i do believe so. I dont have any reason to believe not. Sen. Warren lilly made billions of dollars off this scheme. And they paid a half a billion dollar fine. And they said thats a huge fine. The truth is it is a huge fine. But they made far more money than they actually paid out. And for me, thats just not adequate accountability. Your ceo got to keep sleeping in his own bed at night. At the end of that year he was paid 1. 5 million for his troubles and another 3. 6 billion in socalled performance bonuses. I think the message was clear to other Drug Companies. Within eight months, pfizer was caught doing the same kind of marketing. And slapped with a criminal fine. Since then there have been four more drug company settlements in excess of these settlements have 1 billion. Become a cost for doing business for the Drug Companies. And as we speak, eli lilly is the subject of multiple lawsuits and investigations accusing the company of conspiring to illegally raise its prices of its insulin products. But were supposed to believe that this time around, youre going to be willing to hold them accountable in a way thats going to make a difference. Shouldou think the ceos be held personally accountable when Drug Companies like eli lilly break the senator, there was a period of time where across the pharmaceutical industry that were various practices that then got resolved to litigation, and what im actually quitera proudf is the fact that i was not there as general counsel, i did not negotiate the settlement of that case. But the attitude that i saw top to bottom globally around that was one of how do we make sure this doesnt happen again . How do we make sure that the processes, the culture, the oversight im out of time and understand that im outut of ti. I just want to make it clear for the record. I asked the question of whether or not you think ceos ought to be held accountable when the companies they are running rake the law. Im just trying to get a little accountability answer. If you have a yes or no answer ill take it. Satisfied with our discussion. Thank you. I will take that asou a y knw you would not hold them accountable. Thank you, mr. Chairman. Thank you, senator warren. Senator cassidy. Stepped up. Young. Thank you, chairman. Mr. Azar, youve been caricatured by some as a predatory avaricious big pharma executive, and in response to i like to give an opportunity to actually say a few words here as opposed to my giving an extended speech. Can you talk about what you did in your previous tenure at the agency around the drug pricing issues . . Senator, thank you for asking about that. You know, back in the Bush Administration when i was general counsel, there was a very clear abuse that was occurring where pharmaceutical companies were taking advantage of a a loophole in the drug laws to allow them to have longer longer longer patent periods. What do we g do is get to the e, they would file a new patent and then get another extension. And what i said to our legal team was this is unacceptable. Nobodys ever thought of a way to do with this without legislation. Let us see how we interpret the statute in a way that prevents that. Drove that, drove that, drove that and we actually got to the point where we put out a role that allowed only a single whats called a 30 month stay in litigation come basically you get one shot at the apple instead of these multiple four, five, things that could cause a drug to last years and years longer. When we put that will make it out the Economic Impact of that rule was estimated to save consumers 34 billion over ten years, and that rule was later enshrined in the leadership of senator mccain into statute and the medicare modernization act. I would just like you to repeat that for a second for those who may not be paying attention and who may want to fuelel false narrative that youe not sensitive to drug pricing. You had a process by recognizing an anomaly in the law that led to a regulatory change that saved how many billions for consumers and Prescription Drug prices . 34 billion over ten years. Okay. My constituents will be happy to know that. Thank you. Mr. Azar, you participated last year in a symposium at the manhattan institute. Do you recall that . I do, yes. At that symposiumst you statd we are i on the cusp of a golden age of pharmaceutical breakthroughs but the problem is outdated system for paying for Prescription Drugs is threatening to squelch Patient Access to this recent and revolutionary burst of innovation by shifting a crushing burden directly on to individuals. A lot of hoosiers, a lot of americans pay for the drugs to help savings accounts. Do withmething we could hsa or otherle vehicles to up wh drug costs . I do think there is actually. So one of the things when you have a high deductible plan, and thats one way or two, three, four, 5 6000 just to pay outofpocket before the engine starts paying, the law says you cant use, that the plan cant cover during that time of deductible unless its something of a a preventive service. But the government has a a putp a good guidelines about what can be covered as Preventive Services so that patients could have first dollar coverage in that deductible. So their Health Savings account could cover those prevented services. And so, and also changes that would allow more money to be put away in the Health Savings account, more flexibility for use, anything that lets the Patient Access to more money for lower copays when you walk into the pharmacy i think has to be part of what we drive towards. Ive asked you to questions come one about your past professional history with respect to drug costs. You able to cite an example where you actually catalyze or processed to lower drug costs. As joe about any ideas you might have revolving around a new issue Health Savings account. You put forward an idea that could help reduce the cost burden on consumers. Im encouraged by that. I hope others are as well. I have roughly 40 seconds left. I will note President Trump is indicated welfare reform will be a major priority for his moving forward. Its a priority of mine. E. Much of the policies that fall under the category of welfare reform are under the jurisdiction of hhs. I look for to, i will submit a question for theon record for yu but of what to see what kind of changes you anticipate hhs making through executive order as the administration is pursuing in other areas to improve our welfare systems. So with that, thank you, mr. Chairman. Thank you, senator young. Senator hassan. Thank you very mu ch, mr. Chairman, and Ranking Member murray. Good morning. Congratulations on your nomination congratulation to your family. This is Family Affair and were grateful for their willingness to support you in this work. As youou know, New Hampshire has been ravaged by the fentanyl come here when an opener to crisis and are in need of real resources to help those on the front lines combat it. Hhs used a flawed funding formula to allocate resources on the 21st century cures act. So the hardestst hit states like New Hampshire didnt get adequate resources, and now even though weve asked them to change the former hhs has declined to do that to update the formula for thehs second yer of funding. But another big problem is the Trump Administration has refused to request additional funding to fight the crisis. Which has prompted many to question whether the president is truly serious about addressing it. We need thisab administration to send a supplemental funding request to congress for Additional Resources to combat the opioid addiction epidemic. So mr. Azar, yes or no, if you are confirmed we commit to me today that you will and courage the Trump Administration toll ak congress for at least a 45 billion in new supplemental funding to fight this crisis . A number that has had bipartisan support. Senator, thank you and im glad were ableaz to have a discussion about this terrible Opioid Crisis and impact in New Hampshire. I dont know the number, but what i will commit to you is if i am confirmed i am going to work across the government to assess do have the resources we need . If i do not believe we have the resources we need to address the problem, work with the president and called us to do. I will tell you i dont know a governor of either Political Party who believes we have the resources we need. I dont anybody on the front light of thisel crisis who thins with the resources we need. Will you also commit to examining all substance issues Funding Sources and pointers and directing wherever possible under your authority more funds to the states hardest hit by the crisis . I dont know the precise issues around that formula, how much is in statute and how much of it isw discretionary but absolutely, i know you are concerned about the money going to New Hampshire and i certainly find confirmed with work with you to look at that and see what flexibility is there are an do we think its the right approach. The issue is the money has been distributed basically on population as opposed to the overdose death rate in particular per capita in particular states. Lets move onto another issue. The drug company has recently engaged in unacceptable behavior to shield the patterns of its dry eye doug restasis from review in order to prevent generic process and deny consumers more affordable alternative. In September Allegan announce it paid a native american tribe to take ownership of the patent and then allegan licensed the patents back from the tribe can continue to sell the drug as usual, exploding the doctrine of tribal sovereign immunity to protect its profits. Allegan is renting the tribes travel sovereign immunity in order to protect its products. The move ultimatelyy is meant to stop generic version of restasis and come to the market which would be cheaper for patients. This outrageous first of its kinds do you was called up for recently by Federal District court judge. So i would like to know what you think about this deal, yes or no, should Drug Companies like allergan be allowed to rent out tribal sovereign immunity in order to shield their patterns from review . So i do not know as secretary if i would have any actual enforcement issues that i do want to be careful about any particular situation but i would say i which share your concern about any type of abuse around extensions of patina protecting whatever legitimate processes are for evaluating validity of patterns. I appreciate that. If you are confirmed i hope you will work with me and others on this issue, understanding there are multiple agencies that have some jurisdiction. I wanted to touch on another issue. The country recently learned the case of jane doe a 17yearold young woman who is forced to continue practicing against her will for over a month while in the custody of the shelter that contracts with hhs overseeing unaccompanied minors. Jane doe was eventually able to receive the abortion that she decided was necessary for her and the court confirmed was necessary for her but because of this case it has come to light that the director of the hhs office scott loyd use very disturbing tactics to block d Abortion Access for the young women in the shelters. He prevented minors seeking abortion care for meeting with attorneys. Ar he suggested placing pregnant minors with sponsors who would override the minors choice about a pregnancy rather than placing her with family members and he personally visited pregnant minors to pressure them to continue their pregnancies. Political appointees in washington, d. C. At hhs should not be imposing their own ideology on these young women, nor should they be coercing them or shaming themno for their choices. If confirmed do you agree that you have an obligation to follow the constitution and allou the laws of the United States even those you may not personally agree with . I am a lawyer and a take the obligation of following the laws and constitution as interpreted by the courts as a solemn obligation, absolutely. Mike leiter that i know im running over, and i will follow up with you. Thank you. Thank you, senator hassan. Senator cassidy. Mr. Azar, nice to see you. Enjoyed ourur conversation yesterday. Im a physician. I worked in the Public Hospital system of louisiana taking care of the uninsured and a poorly insured which is the same medicaid patients. Theres a lot of data out there that patients coverage through medicaid oftentimes have worse outcomes than those who are covered through other forms of insurance, even when correcting for Disease Burden and socioeconomic factors. Clearly we should have a bipartisan interest in havingan Outcomes Data that shows whos doing a a good job and whos n. If someone is doing a good job, rewarded, and if not figure out why and try to prove it. First david . I couldnt agree more. Any thoughts about the data setscrew available . Im told c for medicaid and chip right now there is in theory a structure for this Outcomes Data to be a cumulative and compared, but in practice it is not. Thoughts on that . I do not know the data sets, but if confirmed, i will gladly look into that because i do agree not to always be evaluating our programs to see what works, what doesnt work, are there certainin programs to work better than others. Our goal is people have for walker, access to care and one approach is better than the other in delivering quality for that we ought to be using any data we have to find that. Yesterday you were opening meeting formally whiston from both sides toto go over certain issues. I would just ask at some point because our Ranking Member and chip in very good about convening that. N we do as the federal government that better data sets so patient lsaps can be monitored . Its an old maxim of healthcare, if you dont measure if it doesnt improve. I think we measure that. I appreciate your invitation and event i am confirmed to any kind of convening bipartisan process to work through these difficult issues. I hope if i am confirmed i hope what you find is my style is one of complete got the answer to every problem. These are complex and vexing issues, and i want to have an open dialogue, back and forth. Im a problem solver. My brand is if theres a program is not working i can be made better, i want to work on solving a problem and i want to get the best input and the best ideas from the board of directors. From our perspective there something you do administratively we dont have to mess with what is this something you did legislatively and we should devote our attention and i would be the purpose of this. I appreciate the ideas. If there are ideas of what can be done administratively i want those also if confirmed. Public health, theres been a problem, isea working with senar schatz and others as regards how to have a Public Health fund so we, if we get another seek it doesnt take a special corporation, just to give you and my thoughtss on that and i can bear to katrina. Congress had to come in an appropriate money for fema to go to respond to fema and that we figured out no, before i i camn the ticket lets just put the money up front so beckoning me to try it out. From my perspective we should be doing the for Public Health as well. What thoughts do you have as regards how we can y help you better respond to Public Health emergencies . Well, i was actually back in the Bush Administration with the architectural project bio shield. I really see preparing for Public Health Emergency Response the benefit of having predictable funding and the ability for the government to be a reliable partner in that develop and process. So i would be very happy to work with you. I cant speak for the administration but speedy how to safeguard from the money being frittered away on things which are not Public Health emergency or being used as a slush fund to cover shortages elsewhere . One would have to draw the line very clear. I would share that concern. We need to make sure its built into a Development Response program for Public Health emergencies like zika, ebola, or frankly as we have the countermeasures. Levy also say this may just be something encourages your monitor Sheldon Whitehouse and i have i like to say sheldon, if i say white house they think 1300 pennsylvania avenue. In the cure is built with report something for health i. T. My physician colleagues are retiring at age 55 55 because theyre just sick of Electronic Medical records and the dampening that his ban on their ability to interact as well as their productivity. In the 21st century cures the health i. T. Act was included that gave some directives supposedlyly progressing well bt nonetheless trust but verify. Any thoughts about that and how we can ensure that health i. T. Becomes an enabler of patient physician relationships as opposed to implement . I need to be careful because my father may jump to the table and start telling about all the problems of exactly the problem youre talking about. Im with you. I think that when secretary leavitt was secretary and we went down, he started to turn on health i. T. He was adamant. Electrification of Health Records without interoperability isn not useful. Thats just moving files to a different place. Im afraid weve done a a bit f that what weveve electrified or record systems but we havent gotten interoperability. We have made it too complex at the point of entry with the doctor. I would love to work with this committee and i will if confirmed work within hhs to strive towards interoperability and reducing physician burden because it should be an enabler, that something that detracts. The doctors eyes should be on the patient, not the computer screen. Fantastic, amen brother, and i just back. During our 21st century chairs, we veered off to the side and held six hearings on Electronic Medical records. All of us are interested in it. We made some progress with the last administration that we might set up ill talk to senator murray roundtable, and less formal way thats bipartisan to try to continue that focus over the next couple years. Senator baldwin. Two, mr. Azar. Theres been a lot of discussion about experience, insights as well as potential for complex. Already in this hearing today. Obviously, experience and insights can be extraordinarily helpful, but weve heard from the president that he wanted to drain the swamp. Referred phrases like foxes guarding the hen house weve heard and the revolving door. So noting that perspective that you would bring p having servedn large pharmaceutical corporations, in a leadership post, brings a very specific perspective, especially as we tackle one of the critical problems of our day, the high cost of Prescription Drugs, oftentimes lifesaving and life extending medicine for our constituents. We had a hearing recently in this committee on drug prices. And i felt that there was a lot of fingerpointing from the folks who were at our dais, toggle whether they were from the perspective of big pharma or pharmaceutical benefit managers, or all of the other players in this system. And citing complexity, citing its their fault, not ours. But because of your background in the pharmaceutical industry, id like to not hear fingerpointing what can be done. I have many constituents who share their very personal stories about their challenges with the increasing and skyrocketing costs of, again, lifesaving or life extending medications. Great from stoddard wisconsin sons, both with type i diabetes, and they are now extending over spending over 1000 a month just to maintain insulin and test strips. When youre president of eli lilly, you were thereer during a time that there was really radical increases in insulin prices. It increased more than 1000 since 1996, and over 200 during your tenure. Can you tell us, and more specifically, greg and his two sons with type i diabetes, white eli lilly and other companies are systematically increasing the list prices of drugs that are already on p the market . So senator baldwin, thank you for the question and also thank you, i fully enjoyed our discussion the other day, on this and other issues. So first on the fingerpointing, ive actually been really clear, even when i was at eli lilly on the speech of drug pricing, fingerpointing is not constructive enterprise avidly owns a piece of this. Everybody in the p system owns a piece of this and i think the government owns a piece of this and thats why i want to serve because i think the skill and experience can help you with the government on fashion of one company cant necessarily i appreciate that but my question specific is what would you tell greg and other constituents about eli lilly is role . And insulin prices have been significant as increases have been significant for all drug prices pretty much, and the problem is that system, the system makes it so, and greg, greg and his kids do i tell them its the system . Thats the problem. What about drug manufacturers are the starting point. They set the list price. What should i tell greg about the 200 increase during the time you were there in the price of insulin . That what we need to do is work to fix s so that great and his kidss have insurance that covers that insulin so they have low outofpocket, the Drug Companies, so we got to get the list price of that also. We need to come up with speedy that starts with the drug manufacturers and thats reminiscent of the hearing we just had. Its a complicated system and this and that. It starts with the manufacturers setting the list price. We talked, i see i am hitting my time and i have lots of questions can maybe we will have a second round, but you talk about generic and branded competition. Youve talked about biting the gaming of the patent system and exclusivity. Theres a bit of q a about reimportation. Two things i wanted to talk about should get a second round or i may submit written questions as the role of transparency and getting the pharmaceutical companies to justify their increases in price. I have a bill along with senator mccain to require that for Companies Planning on increasing the prices. Andn secondly, the role of negotiation, somebody in your role directly with the pharmaceutical manufacturers. Thank you, senator baldwin. Senator isakson. Thank you, chairman alexander. Oakham. Glad to have you. I look forward to our meeting to order im glad we did have a meeting before this. Havingng listened to your testament, having heard ms. Ward over the years, having been pt of the reimportation debate over the years, being a Senior Adviser a lot of pharmaceuticals myself, the cost tobu pharmaceuticals, pricing for pharmaceuticals, a gaming of the system is referred to is a a he issue. So id like to s give you at the risk of being presumptuous, give young a homework assignment that help chairman alexander and senator murray will back me up on. Will you come back to us in six months with the recommendation of what youre going to do to help and the gaming of the system in terms of the pharmaceutical . Absolutely. I think you are uniquely qualified having been a ceo of a Major Pharmaceutical Company, knowing what you know and taken the responsibility about to take on. Too forthright account us and and say these are the things that are being abused by either the Pharmaceutical Company or manufacturers or whoever it is, im not interested in blinker im interested in solutions. Lets try and end the gaming of the system because oftentimes these debates and in response e questions we ask indepth obfuscating solutions otherwise might be talked about because we dont do the would you be willing to do that . I look forward to the opportunity. Secondly, to return the favor i live in atlanta, georgia, represent the state of georgia and the United States sin and have been a representative for 20 years in the congress of the United States. Its the home of cdc which is the World Health Center which got very low notified but, in fact, solve the evil the problem with when it contain an outbreak and ended its threat, same thing with zika. Did it in part in partnership with four institutions run the country that had builtlt isolatn chambers at Emory University in atlanta being one of them to get people under care, isolate th, treason and by the way all four of them went to annemarie survived the ebola infection emory. Thats a typo partnership with our to do. I want to commend you continue to advocate for cdc and its fun and its stability to meet the joseph one percenter that we dont yet know what they are here when of the solution. Senator, the cdc and its leadership and its career staff are the envy of the world, and i sure that you. And they are saved a lot of lives and so many tragic from happening that itches unbelievable what they have done. Last, this may seem to be a silly question. I was a salesman all my life, a Commission Income all my life. Medical ratio in Affordable Care act includes the cost of a Sales Commission as a part of the medical loss ratio point of which in effect puts most people who sold Health Insurance to encourage a bot in the market out of business because the commission they would be paid, although very modest, would throw it over the 85 the 85 t ratio, therefore they didnt do it. Most americans today are buying, go to look to try to find a way to get insurance, personal financial interest or anybody, no Financial Sector do for anybody to offer it to them because they are priced out because the medical loss ratio sinners. Weve introduce legislation for years and about to end that by taking out of the calculation for medical loss ratio to typiy expand the access and exposure citizens in need healthcare can get there would you help us with that and see if we can get that trip . Senator, id be happy to work with you. Y look at that its an issue i had not focused on. Im glad youre educated me today on that. I had not known of the concern before. We would use some of our timetomarket. Thank you, mr. Chairman. Er thank you, senator isakson. Senator franken. Thank you, mr. Chairman here congratulations on your nomination, mr. Azar. Ask you a few short yes or no questions, if thats okay. Mr. Azar, are you aware that the aca required health plans to cover evidencebased preventive Health Services free of charge . Those are part of the essential Health Benefits, if i understand the framework correctly. Sen. Franken are you aware that hhs commissioned the institute of medicine and the independent Nonpartisan Organization of experts on health and medicine to review what Preventive Services are necessary for Womens Health and wellbeing . The institute of medicine recommended coverage for all fda Birth Control methods free of charge. I believe thats the case, yes. Do you agree with the institute of medicines conclusion that access to free Birth Control is vital to Womens Health and wellbeing . Senator, separate from the issue of any Birth Control or which ones should be covered, one of the principles that we have thinking around the access of insurance, it ought to be insurance that the individual wants to acquire and the level of coverage that they want. So, if i have concerns, my concerns are actually at a much more precedent level, not about this coverage, this drug, that product, this one or the other, but rather, should there be flexibility for the individual to choose the type of insurance package they want. No animus toward one or the other, ours should have flexibility in there that does not exist with the current framework. But you agree that the institute of medicines conclusion that free Birth Control is vital to Womens Health and wellbeing. I couldnt speak, i havent studied the iom report. And we at hhs have to provide Family Planning and services. Do you agree with the institute of medicines conclusion that access to contraception free of charge reduces pregnancy which in turn reduces abortions . I havent studied seems to make sense as you state it. Do you agree with the institute of medicines conclusion, this is their conclusion, that reducing unintended pregnancy also reduces the Health Risks Associated with such pregnancies and that contraception helps women to increase the length of time between births which reduces maternity mortality and complications. We all share the goal that unintended pregnancies, especially by teens, is something that we want to work to prevent and educate and use our programs to support that. In light of this, do you agree with the Trump Administrations actions to undermine the access to Birth Control. On that issue, that is a balance between the essential Health Benefit and the conscience of the organization involved. As i mentioned earlier, i think it was close to only 200 organizations where the actual obamacare Affordable Care act implementation there around the contraception mandate actually even excluded tens of millions of people who were in grandfathered plans. This conscience exception has much smaller impact, i believe. I just want to focus here on the science. The law requires the Preventive Services be evidencebased and this is evident evidencebased. Will you take steps as secretary to make sure that women have free access to contraception. I will follow the law. If the law requires the coverage and the follow the law there, but i also will, as the president has done, and has to try to balance the conscience objections of organizations and individuals there. A number of my colleagues have expressed concerns regarding your track record and eli lillys track record on drug pricing and i want to tell you i share their concerns, especially with regard to eli lillys actions to spike insulin prices, but i wanted to move im running out of time so im not going to be able to, but i wanted to get into medicare drug price negotiation. The president said he is for medicare, being able to negotiate in part d for with the pharmaceutical companies on the price of drugs. Do you agree with the president that medicare should negotiate for lower drug prices . The president has generally spoke been medicare is negotiating and getting the best price for drugs. And part of the negotiation through the three or four biggest pharmacy benefit managers that negotiate and actually secure the best net pricing of any players in the commercial system. I sat on the other side of that, i can assure you of this. What id like to think about. How can we take learning from part d maybe into part b. Part b does not have negotiation. When a physician p prescribes an expensive drug, sales price plus 6 . How do we take from part d and bring lower costs to the system, but also lower costs to the patient because they pay a share of whatever medicare reimburses in part b so thats a double win. It could lower for the system and lower for the patient on their out of pocket. Thats the kind of thing i would have energy to see. Where we can actually really save money and improve things for our parentients. Im out of time, but the va is able to negotiate prices for their drugs and i think that in Medicare Part d, we should be able to do the same inge this that they do in the va. Thank you senator franken. Senator roberts. Thank you, mr. Chairman, and mr. Azar, alex, thank you for coming. Congratulations on your nomination. And thank you for being here today. Its already been stressed by governor levitt, my colleague and fellow marine, captain young, senator young, about your prior work at the department of health and Human Services, as well as the confidence shown by the senate. Sometimes we have to do a multitask here. I apologize for that. But at any rate, the confidence youve shown to your senate to unanimously confirm you to that agency twice already. And highlight the strength of your qualifications. I appreciate the chance that we had to chat, i think it was monday, on some particular areas of interest for me, improving our Rural Health Care Delivery System as well as continuing to mature a food supply and basing deficient policy on sound science. You are a hoosier, but you did find a kansas girl to marry and as the folks in Overland Park kansas know, theres Nothing Better than a Shawnee Mission south way, i want today make sure you understand that and thank you for bringing your family. As both a member of the Health Committee and chairman of the agriculture committee, and a member on the finance committee so well get another opportunity to walk and particularly at hhs and more importantly, the fdas work on food nutrition and policy and we talked about that, a common message i hear is the need for regulatory certainty. Just a moment, i beg your pardon. Will you turn that off . More importantly the work on food and nutrition policy. A common message i hear is the need for regulatory certainty, in particular, on the biotech front, which is a critical tool for agriculture today. Back in january, both fda and the usda proposed rules and guidance on biotechnology, recently as a recent stake holder comments, the usdas animal plant and Health Inspection service decided to withdraw the proposed rule, reengage stake holders and comments a new rule. If confirmed, what steps would you take to engage and coordinate with other agencies involved with the regulatory review of Biotech Products to harmonize future rule making efforts. So, senator, im not familiar on that particular rule making with the pullback, but i can assure you i would share both goals that i think youve articulated. The first, its the job of the government when regulating to give clarity. So many want to comply and know the rules of the road. Can we give clarity. The second is a special in the area of food safety, the level of coordination between hhs and the Agriculture Department is absolutely essential, theyve got to work in the shared space because of the shared jurisdictions there and i would commit to you to be an excellent partner, along with, im sure, dr. Gottlieb, working with ag. I have one other observation, ive been watching your children and watching these youngsters over here and watching your dad. Your dad is very proud of you, he office is very proud of you. I want to tell young folks, welcome to polysci 101. Were asking questions on their mind and very important questions, i want you to be proud of your dad. s done a good job in the past and he will do a good job in the future. He will be confirmed, in my view, and not only by this committee and not only by the finance committee, but also on the floor of the United States senate, and then also by the president. Thats a long process. And sometimes it gets a little tough. We ought to be handing out selective earmuffs for young people to put on earmuffs if it gets tough for you and take them off. Be proud of your father, hes a good man. Thank you, mr. Chairman. Thank you, senator roberts. Senat senator. Welcome, mr. Azar, i dont think theres much that you and i are going to accomplish today on the question of drug pricing, but i hope very much that in office you will take the side of the American People and not just the pharmaceutical industry or worse yet, the investors who have raided the industry with no pharmaceutical background with the sole issue to jack up prices on pharmaceuticals and extract money with monopoly authority. We know how to deal with that ordinarily and i want you to help us deal with that. I want to talk about something for bipartisan political process. Two stories, you know what a medicare hcos are. I do. And one is an early one, coastal medical over four years saved medicare 28 million relative to its benchmark while maintaining a 99 quality score. That makes it one of the very best in the country. Its average per member per year expenditure is going down, while the satisfaction and health of its members are going up. Similarly, intergra Community Care network, over two years saved 12 million relative to benchmark, achieving a 95 quality score. I say this not just to brag on rhode island providers, but i think its an answer to a much larger question that we face, which is here is the graph of health expenditures, more or less, in my lifetime for the country. 27 billion to 3. 2 trillion. Its a curve that is breaking the bank. Weve got to figure out how to fix it. One of the ways that we can look at fixing it is to look at oecb chart i use all the time which shows lot of our competitor nations here and theres the usa, a big outlier. This maps Life Expectancy and cost per capita. This puts us the highest cost per capita for Health Insurance in the world and gives us Life Expectancy comparable to the Czech Republic and chile. My third and final graph, were seeing a little progress here. Let me explain what this is. This top line, the red line is what cbo predicted for federal Health Care Expenditure back here when it made the prediction in 2010. Then, events moved forward, postthe Affordable Care act and got to here and sure shuf enough coming in below. In 2017 the baseline was rewritten by cbo and predicted and the difference in the 10year budget period what cbo predicted in 2010 and what it predicted in 2017 amounts to 3. 3 trillion dollar in savings. So the case that i would make to you is that if we want to take on the Health Care Cost problems weve got to take it on through editing like the a it. Os, theres a sweet spot where we can bring the cost back from our outlier position in the United States while improving the quality of care, i have seen it happen in rhode island. The reason that the cost is going down for coastal medical patients, because they get home visits when theyre sick, and the telemedical. And house check to make sure there arent slippery rugs in the hallways that might call a fall. Over and over again, its better, humane engagement that reaches the patient where they are to that is had wonderful twin benefit of improving health and the Patient Experience while also bringing costs down. Were not seeing less increase in the cost curve from integra and from coastal medical, were seeing cost per member going down. Promise me that youll work with us on that. Promise me you will not get ideological when it comes to solving this problem and that you will work to solve it in a sensible, bipartisan, thoughtful way. Senator, i would just say, amen. You know, just hearing those stories is exciting to me. It is, i think, one of the great legacies of secretary burwells tenure, the alternative payment models that we have out there and id like to keep driving that forward. That was that third leg of my priority, if i am confirmed as secretary. I just, i think for those of us who care so deeply about improving quality or reducing costs in our Health Care System, improving integration, coordination, just thinking of ways we can deliver better for our patients than our beneficiaries, theres just so much opportunity for bipartisanship here because we share so much of the same goals on this, and what we have is in medicare, its a central role. Its the only payer, that sits there with enough consolation of lives to change the system. Correct. I think, you know, United Health care, as big as it is, i dont think theres a market maybe that has more than a couple of percent of patients, it has to follow what medicare does. I would be so excited to work with you on im going to invite you to rhode island and see this. I would love to do that. And i look forward to that visit. Thank you, mr. Chairman. Thank you, senator whitehouse, mr. Casey. Mr. Chairman, thank you. Excuse me, senator murkowski is here and i failed to go to that side. Thank you, mr. Chairman. Thank you, i apologize. I know im at the end dias and came in later, but theres added benefit to being one of the later ones and having the full opportunity to not only hear most of your opening comments, sir, but to hear the questions and the inyearries and your responses, again, congratulations on your nomination. I will also be curious to hear your response to senator pauls inquiry, regarding i mportation of drugs. I think for those of us in alaska where our neighboring country, our neighboring state, if you will, is canada, many in my state wonder why we are not able to do more when it comes to safely importing. So, i, too, am curious to know what you might propose in that area. Senator baldwin mentioned the hearing that we had some weeks ago about drug pricing and i think, a general level of just confusion and bemusement that many of us had, those who were here to provide testimony, were engaged in a fair amount of finger pointing. When you dry to drill down to how we can do more when it comes from a transparency perspective. I think this is something that we all recognize we can do a better job with and again, i look forward to more detailed response from you. Were going to have an opportunity to meet tomorrow and so, i will probably hold more of my alaskaspecific questions for that time, but one of the other discussions that we have had in this committee recently, as we have been discussing the aca and some of the requirements within it. We had we had recommendations from some who had suggested that the Navigator Program that is currently in place no longer needs to be funded, the president really axed it, not too many months ago. And it was pointed out that not all parts of america are equally situated. We dont have a drug store on every corner in alaska. In most of my communities, we dont have a drug store and so the role that the navigators have played in helping to walk, many alaskans through the intracassies of insurance have been important to us. Nobody has really asked that question today. So i would ask for your views, your plans. What do you see the role of navigators moving forward . How can you provide assurances in an area where we simply dont have the professionals that could assist individuals, that they know what their options are. So, senator, thank you and its good to see you again. I think the last time was in anchorage i got to see you when i was serving as deputy secretary and look forward to seeing alaska issues, and doubt there have been as many in alaska and your focus on Behavioral Health is something im interested in exploring some more. Absolutely. In terms of the Navigator Program and just outreach, my view, as it is with so much of the programs is what works is do what works, and im not at the department, i dont have the data, i havent seen everything. My understanding is changes in the Navigator Program were focused on Navigator Program elements that werent working in renewing and funding navigators able to result in work. I dont know the specifics about the alaska situation. I can only tell you that i do genuinely get it in the sense of understanding the uniqueness of the very frontier nature of so much of alaska, and would be very happy to work with you if im confirmed to see what are the ways to deal with that. Its really what works. Whats effective, what works, what delivers for the program. And i think ive said pharmacies, and its not only pharmacies, but its also those who help us navigate through the insurance side. We dont have Insurance Companies on every corner as well. Ill look forward to discussion on that. Very quickly, theres been a lot of focus, also, on Womens Health care, Preventive Care, eliminating the risk of unwanted pregnancies. I happen to believe that the more we can make contraception available and affordable to women the better off we are. I wondered why we are still this many, many, many decades after prescription Birth Control was made readily available, why we have been so reluctant to move to overthecounter products for Birth Control. And it not only, it makes the product more expensive as we continue to see, just kind of a flat amount out there, but you also have the requirement for a medical appointment in order to get that prescription. Do you see a way or an opportunity for us to reduce the barriers for more affordable Birth Control pills, contraception and in a way that can really help women in gaining greater access to contraception . So, the overthecounter regulatory regime, as you know, is this otc monograph procedure na commissioner gotleib im glad has said is out of date in the 70s, needs a lot of work weather legislatively or fda to really speed the approval of products overthecounter as you said for cost availability and standards. There are scientific and legal standards that have to be met by the sponsors of a product in terms of ability, to selfdiagnose and selftreat and their user studies that basically need to be conducted so it would be driven by that would be my view on any product that the fda would have to decide on, but i think the regulatory system really needs a close look at and ill be delighted to work with commissioner gotleib how we think of over the count products for people. Well have an opportunity to talk. Mr. Chairman. Thank you, we had an opportunity to talk in my Office Yesterday and grateful for that. Grateful for your willingness to put yourself forward for in this work thats difficult. I want to thank your family and extended family, as much as Public Officials work hard, their families often sacrifice more and i appreciate that commitment your family has made. You and i have a home state in common in erms it of where we were born. Not where we were raised, but i know youre a johnstown native and im a scranton native and still live there. We have disagreements especially on health care, i want to get to those. I want to start with something fundamental, i wish we didnt have, but because of the interaction between dr. Price, secretary price and this committee i have to ask this question. When dr. Price came before this Committee Prior to his confirmation, members of this committee submitted a number of questions to him for to answer on the record in writing, and he didnt provide a lot of responses. Im going to be very precise in this question. Do you commit to provide answers to all, operative word, all, all the questions you receive following appearances before this committee . Ill certainly be happy to comply with the senates nomination procedures and the nomination setting and of course, in ongoing appearances before the committee with the protocols and procedures of the committee and the senate. But do you agree that anticipating questions for the record posed by Committee Members during the nomination process is part of that compliance . What i senators, what i do not know what the protocols are between the Health Committee and the finance committee there in terms of questions for the record. I apologize, im not im just not familiar with the customs. When i was general counsel and as deputy secretary nominee, the hearing before the Health Committee did not occur there so im just not knowledgeable, but id be happy to get back to you on that question, i dont know the protocols, im sorry. Ill take that as a tentative yes for now, but i hope you familiarize yourself with those rules and respond accordingly. We should not have to engage in a back and forth on basic questions for the record. I wanted to ask you about, in light of the debate on health care, the substantial debate that has been undertaken over the last number of months on the Affordable Care act, and especially medicaid, at least from my point of view, especially medicaid. And in addition to that debate, some of the statements youve made, i wont catalog the statements youve made that have been critical in one form, and commenting on the process, and now youre seeking appointment, a confirmation vote on hhs secretary and that, of course, would conifer confer on you responsibilities you dont currently have. I want to ask you this, do you faithfully in committing the Affordable Care act. If the Affordable Care act is the law of the land, to implement it and my hope to implement it in ways, if it remains, i obviously believe and administration believes that the statutory my way that it leads to affordable insurance, choice of insurance, access and not meaningless insurance carted and insurance that has the benefits that people want not what we say in d. C. For them. Let me ask you as well about an issue that frankly doesnt get enough attention, its the efforts that have been made by the administration to undermine the Affordable Care act, thats my view of it. I use the word sabotage and i think thats an appropriate description. Let me define more specifically what i mean. When i say sabotage of the Affordable Care act, the following, drastically cutting funding for advertising and outreach. Cost reduction payments. Spending funds meant to promote enrollment, promote enrollment on a pr campaign instead to undermine the law and repeal the aca. Dollars should not be spent on that. And spreading falsehood about the health of the marketplaces. Its one thing to be critical and concerned about it, but another thing to spread falsehoods. Number five working to roll back Health Insurance protections. Thats the predicate for the question. Would you oppose those efforts knowing you have a responsibilities to faithfully uphold the law. Yes or no. I would disagree theres any efforts to sabotage the program. People want to make the program work. The csrs was a legal decision that congress had not appropriated the money. Other elements, i can speak for myself how i would approach how about cutting funding on advertising or outreach activities. The advertising cuts actually put advertising for the program now many years into it at the level of Medicare Part d and medicare advance. At some point the Insurance Companies have to do their own job and youre not saying that the advertising was cut. . Theyre can ut to Medicare Part d and part b and i think the insurance should stand on their own two feet. Well have more time engage on this. Thank you, senator casey. Thank you. Mr. Azar, good visiting with you. Ill tell you what i said yesterday. What im looking for from you is a commitment to the Health Care Safety net broadly define. I voted against your predecessor because he had commented negatively, planned parenthood, chip, medicare Affordable Care act and his brief tenure at hhs proves he wasnt kidding. And i dont think we can have an hhs secretary that doesnt support the safety net. You say that drug prices are too high. As a member of the aging committee i became convinced senator collins was our leader that theres a new model out there, patience as hostages. Patients who need drugs who cant afford to go without them without risk to their life or health. Are treated as hostages by pharmaceutical companies in some circumstances. Theres a story in the Washington Post, why treating diabetes keeps getting more expensive in october 2016 and this is a quote accord to go the Washington Post analysis of truth and Health Analytics data over the past two decades elyle lilly and nova nor disc raised price on insulin closely in sync. Convince me that eli lillys was not part of this patients as hostages business model. As i said in my remarks to chairman alexander earlier today. Insulin prices are high and too high. And the system that weve got, it may fit for the stake holders behind the scenes, but for the patient youre talking about, weve got to recognize its not working. Do the individual actors have no culpability on this . Everyone shares blame here, everyone shares blame here throughout and what weve got to do, i want to be a productiven begin, if i can be secretary, to work with you on solutions to fix that. Let me ask you about your second goal. Second, we must make health care more available, tailored to what individuals want and need in their care. Amen, amen. They have a sense thats interesting, you cite challenges for those who have been left out or pushed out of the Insurance Market by the Affordable Care act. Aca. And its interesting you talked about people pushed out or left out by aca. The uninsurance rate has reduced following the Affordable Care act. Im not arguing that its perfect, but as you read your statement, it suggests that people are there are fewer people insured because. Aca. We have the Surgeon General from indiana hoosier just like you and said the uninsured rate in indiana has gone dramatically down because of the Affordable Care act, combination of Medicaid Expansion and premiums that help folks afford. So in looking to this question, are you going to execute or be part of the wrecking crew. I dont think thats an accurate or fair statement. Happy to explain, i believe we can do better. I believe and i do, too. And i believe that for the folks in the individuals market right now. Too many of them are paying too much for insurance. Too many of them have insurance that is was that your opinion before the Affordable Care act passed. I thought that would happen given how it was structured in statute, unfortunately. But the numbers of people uninsured in this country were dramatically higher than they are now when you were at hhs in i would always want to work with you, our goals are the same in the sense that we want to improve peoples access to insurance. The president wants this and we may only differ about tactics and approaches. My point was the forgotten man and woman who isnt in the individual market because the insurance isnt affordable for them and i want insurance for them. Sir, we must harness the power of medicare to focus shift to the Health Care System and why didnt you mention medicare . Medicaid is very important part of your portfolio and and i found it interesting in reading that sentence you didnt say a word about medicaid nor mention medicaid at all. The reason i dont mention medicaid is not a lack of commitment to medicaid. Its really that medicaid does not have the same kind of payment rules that medicare has at the national level. And that was my focus, im not a im a governor and i ran a Medicaid Program and an exgovernor. Its interesting, wouldnt you also agree that we can focus to paying for procedures and shift that focus and pay for health and outcomes. The Medicaid Program can be part of that as well. Certainly could. And the governors, if governors are willing partners to try to drive that, absolutely, medicare, the secretary has more levers in his or her control and would you try to do the same thing in medicaid. Absolutely, could have,. If we could make medicaid better let us serve more people. Thank you. Thank you, senator. Senator murphy. Thank you, mr. Chairman, thank you for your nomination, mr. Azar. I enjoyed our conversation and open to your nomination. Im very, very concerned about your answer to senator caseys series of questions and so i just want to state it to you one more time and give you a Second Chance here. This administration has shortened the open Enrollment Period by half, it has cut outreach funding by 90 . It has cut funding for navigators by 40 , it has pulled out of state enrollment partnerships. Is your testimony here today that this is all in service of an effort to make the aca better . Do you really believe that the goal of this administration is to help people sign up for the Affordable Care act . Im so, obviously, im not in the government and i dont have access to all data. My understanding, i cant validate this from the outside was the choices were about whats working and not, woulding and theres no sense funding any aspects of the program working well and also a policy decision around advertising its time for that to be regular lahrized in amount of finding in advertising. You think that President Trump is taking these actions in the goal of making the Affordable Care act work bet are. I think i dont know that President Trump was part of those decisions. Thats with a made at hhs or a matter of budgeting, but i think the goal is, with the program youve got, do as best you can. This one has a lot of problems in it, i am if the Alexander Murray bipartisan package here helps, its what does cutting the open Enrollment Period in half do . I dont know, i wasnt, again, involved more did i study the comments on the Enrollment Period change, but my understanding went from 90 to 45. And nonabout the senator, but most of us have 45 days to allow for beneficiaries and let the plans then know who is in their plan so they can plan predictbly for the following year. If you run up until the end of the year there, youre going to have its harder for the plans to set their abbing actuarial basis for the open Enrollment Period and pricing. If you run that right up to the end there, i know this from when we launched part d in Medicare Advantage the first year, the closer you ran up to january 1 on that one, its very hard to implement effectively and efficiently in the coming year. My understanding is this is not the insurers to be begging to be cut in half and you put that next to evisceration of the programs that would help people understand the fact that the open enrollment has been cut in half. I think its strange that im happy to look at that, i was not involved in that. In the individual marketplace okay, you said that there are things that the hhs secretary could be doing to make the open Enrollment Period work better or to what do you think that you could do in the face of these changes to make open enrollment work better, to make sure that people have the ability to choose wisely in the exchange. If you say these are changes that are made in the service of making the open Enrollment Period better, what else do you think can just i want to just to clarify, i dont believe i said that these are changes to make it better, but rather to eliminate what i think again, im on the outside not there running the program. I dont know the status of thinking on each individual element there. My point is, if something is not, woulding, why are we funding it. The view was Navigator Program, if certain of those vendors are not delivering, delivering one beneficiary enrolled and receiving a lot of money, say, why keep funding that . That would be my perspective. In looking at it and then using your resources to put it on whatever the effective outreach and Enrollment Programs happen to be, that would be the approach i would follow. I dont know, i wasnt there. I havent been involved. Ive been at hhs for the Affordable Care act initiation or implementation. I havent studied each of the individual programs there. Let me follow up on some questions that senator warren was asking. I agree with her experience in the private sector shouldnt be disqualifying. We want to make sure youre not simply bringing your advocacy on behalf of the industry you used to work for in the government. Pharma has a number of sort of major legislative priorities, faster fda approvals and medicare negotiating directly with the with Drug Companies, continued legalization of direct to consumer advertising. I know youve been critical of specific practices of individual Drug Companies, is there any major issue on pharmas legislative advocacy list that you disagree with . Well, senator, if i get this job, my job is to enchance and protect the health and wellbeing of all americans and not pharmas agenda. Give us an example. I dont have pharmas policy. Thats how little focus ive been gone for a year. I dont know what their list of agenda items is, senator. Thats not my area of focus. My area of focus is the president s agenda, and how i can work with this congress to try to make the programs of. Had h schls hhs better in the interest of americans, know the any trade group or company. This is the most important job i will have in my lifetime and my commitment is to the American People and not to anywhere ive worked in the past or any industry ive been connected to in the past. I thank you for that answer. Thank you, senator murphy. I think we have senators who want to ask additional questions. Well have a second round. Mr. Azar, let me begin. Senator cassidy asked, senator whitehouse would have and others too, about Electronic Health care records. We can do some things about that in the congress, but he think most of what needs to be done, youll have to do because its a matter of administration. I had urged the Previous Administration to delay meaningful use three because it was implementing it at a time when it was also changing the way that doctors and providers are paid. I thought it would be wise to slow that down and get it right and build confidence among the physicians and other providers about what we were trying to do. I said that based upon visits with hospitals like vander built university where they said meaningful use one was helpful. Number two was okay. And number three was terrifying. And i think, so we ended up with six, six different hearings and a lot of bipartisan interest in this. One thing that seemed to me to make some difference would be pretty simple. There was an ama ama study that showed that doctors believe theyre spending 50 or 60 of their time on documentation and it seemed to me that a good thing a good approach for in would be if thats true or not. At least these the perception. Might be for the secretary to work with the doctors in medicare, there are a half million of them, say, okay, if you think youre spending that much time on documentation, either youre not doing your job right or were not doing our job right. Why dont we Work Together, set a goal to bring that from 50 or 60 , whichever it is, down to some other goal in the next three or four years and change the reality and the perception over time. It would seem to me that some managerial technique like that is essential because inoperability is one problem. Excessive documentation is another. Its a big miss still. If youre even at a sophisticated hospital and you want to take your own medical records to some other place, the best thing you can do is xerox them yourself, put them in your briefcase, carry them over and carry them to the next doctor. Even in a sophisticated place after 30 or 35 billion dollars. Can you make it a priority ap use some of this skillful managerial and executive experience background you have to help us improve, a, interoperability, and b, reduce excessive physician documentation both in reality and perception. What are your thoughts on that. In both of those areas, thats a sensible approach. Mr. Chairman. Interoperatorability, its ridiculous if you have a system where you have to collect your paper records to go to a different facility. That is a betrayal of the vision that secretary levitt laid out when we originally were working toward that journey. He would talk about the Railway System and if you dont get a single gauge it doesnt work. And in australia you have three Different Railway gauges to get around and my brotherinlaw can tell you, thats where hes from. We need to get that fix. The regulatory burden, electronic Health Records with physicians, that would be my style how to, would, the affected individuals, they know whats wrong and whats happening and get the input from them and see if there are appropriate changes that could be made. Might get your father to help you with that. Some ideas secretary burwell actually changed something in her administration where she believed the reality was different than the perception. It was the Patient Satisfaction survey that many of us were convinced was causing doctors and hospitals to prescribe more opioids in order to get a higher score on Patient Satisfaction. She was convinced that that wasnt true, but it was true that people believed that. So she persuaded president obama to change the policy. I dont know exactly the amount of time that physicians are spending on documentation, but theyre really fed up with it and that, for a whole variety of reasons which you understand, we need to change that. So i would think some simple initiative working with physicians, especially, and hospitals, to say, lets if its 60 and the perception is 60 , lets agree on a goal. Lets particular it a step at a time and take it to 50 or 50, lets take it to 40. Or lets take it to 30 and lets see whats being done about that. We cant do that well here, we can monitor it and we can encourage you and make some changes in the law and basically its an administrative challenge i hope youll take up and let the senators here work with you and encourage that. Senator murray do you have additional questions . I do. Thank you again. I am very concerned about some of the responses particularly the senator casey and senator murphy who talked to you about what many perceive as in president directly and his direction to the administration hhs has been to make sure that aca does not work. The reason that we very adamantly support that is because many people are now getting access to care through insurance that did not get it before. Those are the harder to reach people. Lower incomes, tougher populations, and they end up, we all pay for them at the end of the day if they dont have insurance. The goal is to have as many people as possible insured, have access, get their Preventive Care and dont show up in Emergency Rooms and costing everyone. Part of making sure, a critical part of making sure that they get access is through the outreach and longer enrollment. Now, you answered a question about open enrollment to make it in half, had to do with actuarials. The exact opposite is true, Insurance Companies put their prices out, theyve alrea figur that out. It doesnt change their costs. What it does, making sure they have time for harder to reach people to get enrolled and they know what theyre doing. They havent bought that before and different access for problems, time to reach them and they understand what theyre buying. Thats the intent of longer enrollment, which this administration is cut in half and made it more difficult. The second thing is, the outreach. And i was surprised to hear you answer, senator casey, by saying that Insurance Companies should pay for that outreach. They have a very different goal here, theyre not looking for the tougher, sicker, harder to reach, more rural folks to sign up. They have a very different goal. As a country, as other people who pay for insurance see our premiums go up, we have that goal and thats why its so imperative. And in fact, in the Murray Alexander bill, which you have been asked about, we reinstate that outreach money for na exact purpose. You will be hhs secretary if confirmed, you will be responsible for making sure that outreach money is used effectively and the Enrollment Period work so that we reach that. Do i hear you that thats not what youre not going to do. Senator, i share your commitment. Any program hhs has i want it to run as efficiently and effectively as possible and serve the beneficiaries of the program, thats my style and my commitment to you how i would work. Any particulars here, im not there, i have not studied the particulars why changes were made around the Enrollment Period i simply offered hypothesis what might have been a reason around cutting in half to the 45 days to a more normal Enrollment Period. And before that implementtation afterwardsment i did see that with part d when you bump up generals january 1, getting Insurance Companies getting them carded and running. I havent seen that problem. Host . I want to be clear, i want the programs to, would with people and if your idea to make them work, programs to work, i want to make that happen. Do you share the goal as many people as possible who may be sicker or harder to reach in Rural Communities that havent been reached before should be part of what were working for. Of course i do. Awant to i want to make sure that everybody has affordable insurance as possible. Who do you think is equipped for that . The question you had asked around advertising. Advertising budgets, my understanding is at the level of part d Medicare Advantage, thats my understanding, i dont think thats your Rural Outreach or your hard to reach, that was just your Television Ad is my understanding and i may be wrong. That was my understanding there. So not about trying to reach potential beneficiaries, get people enrolled into the program, that, it may just be talking past each other on that issue or my misunderstanding the nature of that part of the program. Okay. Im confused by your answer, just say that. I want to ask one more quick question, i know my colleagues do as well. And that is will you advocate for women to make their own Health Care Decisions by supporting a broad Safety Network and ensuring all women are willing, able and qualified providers of their choice. Senator, the administration, i believe youre asking a question about a particular provider at issue. The administration has had a perspective whether that should be funded or not. If im secretary i will implement whatever congress has passed and the laws that we have there faithfully. My time that does concern me and i will turn it over to my colleagues. Thank you, senator murray. Senator franken. Thank you. Mr. Azar on monday the l. A. Times published an analysis of the Senate Republican tax plan which repeals the individual mandate or the federal requirement that americans have Health Insurance coverage. The Analysis Shows that repealing this provision, quote, threatens to derail Insurance Markets and conservative rural swaths of the country, and could lead consumers in these regions, including most of all, im sorry, most or all of alaska, iowa, missouri, nebraska, nevada and wyoming as well as parts of many other states with either no options for coverage or health plans that are prohibitively expensive. Mr. Azar, in your Opening Statement, youve said that you want to make health care more affordable and available to individuals. Given this new data, do you support repealing the individual mandate as part of the republican tax plan, knowing that it puts rural americans coverage in jeopardy . No, senator franken, what i do not support is forcing 6. 7 million americans to pay 3 billion in penalties to not buy something they dont want to buy through a mandate upon them and 90 of whom make 75,000 a year or less. That i do not support. Well, i think you understand the structure of the aca, which is that you guarantee that you arent discriminated against for having preexisting conditions and then if youre not discriminated against because you have preexisting conditions, then the motive for someone to get care, or to get insurance, buy insurance, we have to mandate it. This is my understanding of the logic behind this, that to mandate is, you have people dont wait until they get sick to get insurance, and thats just the way and then you give subsidies to people who dont have the means to buy it. Thats sort of the threelegged stool of this. If the individual mandate is repealed, the Congressional Budget Office estimates that 13 million more people will be uninsured and that premiums will go up by 10 . The Alexander Murray deal, which i work on those negotiations and thank the chairman and Ranking Member for that, those are helpful its helpful, but its a temporary measure that cannot offset these estimated price increases or coverage losses. And given this, and given that People Living in rural areas tend to be older and have Greater Health care needs than average populations, what specifically will you do to make sure that People Living in rural areas are not hurt by the all of these current efforts by the Trump Administration to undermine the Affordable Care act. So that as you arctticulatea i think you articulated well. The theory of the mandate was to pool insurance risks to create an insuranceable risk pool for the Insurance Companies to do abbing actuarial. And 20 Million People are not in the pool and eroded the risk pool. What i had id love to work with you and congress to work on them toe rural citizens can have Affordable Care and give them real choice. Half the counties have one plan available to them and i worry about that. The fact of the matter is under acc, over 20 Million People who werent insured have insurance and it feels to me that everything that this administration is has been doing is basically named at undermining the markets and undermining the way of the aca and undermining so that we can throw away these gains, but everything that is getting rid of the individual manda mandate, putting out plans, temporary plans, shortterm plans that will not cover the basic, you know, the ten basic health guarantees, it just seems that this is a conscious effort to undermine the health of americans and its just i think that as we go forward, we have to find ways to make sure that people arent discriminated against because they have preexisting conditions and that we have large the largest pool possible and we spread the risk and we make sure that people have as many people have health care and if you repeal this, 13 million more people will be uninsured and premiums will rise. He think we share so many of the same goals and just disagree with the approaches and tactics to get there. But my heart and my goal shares so much of what youre talking about in terms of Affordable Care for people. Thank you senator franken. Thank you. Well continue with our second round of questions and conclude the hearing after the second round, i think there might be one other senator who wants to go back. We go to senator warren. Thank you. I share concerns that the Administration Spent the first 11 months of this year trying every trick in the book to destroy the Health Insurance in this country. And youre to look at key parts of medicare and medicaid. I want to start by asking a basic principle. Mr. Azar, would you agree its important that we have a system that allows for every single american to have access. Sclooep to the kind of coverage they need . I think we all share the goal that we want all americans to have access to affordable insurance that they desire. So is that a yes . As i framed it, yes. Ok. Good. Heres the problem. Those are the exact words that dr. Price used during his confirmation hearing before this committee. He sat exactly where youre sitting right now and said exactly that. He pretended that he cared about people being able to get their health Care Coverage. And then he got confirmed, and spent eight months doing everything he could to take away Peoples Health Care Coverage and crash the Health Care System. So i think thats the reason were trying to be very specific about what it is you will and wont do. So i want to follow up on senator murphy and senator in utah may be there with the doing it, thatormu it was the fact that in some island had worked. So let me ask the question this way. Ifou you are confirmed as hhs secretary and there are no data showing that cutting theth enrollment. Improves enrollment, will you commit to going back to a threemonth long. For Health Insurance enrollment . My own view would be if it does not work for the efficacy of the program, for the insurers and beneficiaries, and i would certainly be open to changing if confirmed as secretary. I am not in the government. I cannot commit to Government Action not having seen everything there. Is the question im asking. Youve used it as an excuse. A Good Exchange with senator alexander about the importance of data. I agree with the right im just asking, if there are no data to support your hypothesis that cutting the time. Somehow might improve enrollment , will youou commit to going back to the threemonth Enrollment Period . Or that of the data and if the data drives in that direction, im going to push to ensure the program is the fact that. I dont know if counterbalancing factors there may be. Im not on the inside. So as not all about data for you. You there is data but i do note the elements ill take that as a no. And secretary price was in office, he supported republican bills to repeal major portions of the Affordable Care act. If confirmed as secretary, will you oppose suchwh bills . Senator common i supportto legislation, various forms of legislation that would have a system that leads to more choice and more access. I asked a very specific question. Because im trying to get this is what price said when he was in here. Im trying to get a very specific question. Would you publicly oppose republican bills to repeal the aca like the ones weve seen so far thisne year . Are you saying we should wait and see what youll do . I will work with this congress and the administration to build a system that helps people get affordable insurance. You and i will differ fundamentally i guarantee you im at the contras or disassembly two. So you dont oppose the bill with the two so far . What about turning medicaid into a block grant . Secretary price push that idea while in office. Would you do same . I said before i thinknt lookg up a lot creating and empowering states to be fiscal stewards they aret can be dead can an effective approach. The contras to back him the amount off funding i supported as a concept to look out. One needs to t look at law granting of finance tract. The question isnt that what is the precise program. The notion of running the program and having all the incentives if you could own up to the fact you want to cut medicaid and got the Affordable Care act like every other member of the Trump Administration, that you want to smile and pretend otherwise until you get the job and yet you say exactly the same thing that would let you pick up right where tom price left off in trying to get the Affordable Care act. Tom price lied through his confirmation hearing and now you come in here and say the same things he said. No one should be fooled. Thank you, senator orrin. Thank you, mr. Chairman. I wanted to pick up where we left off on the question about the case of jane doe, the young woman i asked you about. At the end of that question, you said you agree that you have an obligation in the United States, even if you dont personally agree with it. Is that correct . That is correct, yes. Im glad to hear that. Under the Supreme Court decision in roe v. Wade from the women a constitutional right to make their own Health Care Decisions. Yes or no way you or no we are committed to upholding those Constitutional Rights as well . I would always work to ensure implementation of the constitution mosque currently interpreted by the courts, yes. Thank you. Im glad to hear that. I want to return to y the issuef essential benefits for a second. You have said he would make the opioid addiction crisist a priority if confirmed. I appreciate that, but we need a lot more than lip service to make a dent in this epidemic. One of the key tools to combat this crisis is the set of 10 benefits of the aca requiring that insurance cover Substance Use disorders. In october, cms proposed their 29 t. Notice that benefit parameters which are finalized about state seriously erode the benefit come include the Substance Use Disorder Service benefits. Estate developed their own benchmark, the row with at the ceiling on the generosity of benefit that states can include in theirng plans. Before the aca was passed him aca was passed to make your plans on market did not provide coverage for Substance Use Disorder Services. I am very concerned under the rule proposed now, states would decide to limit this critically important benefit. Given your stated commitment to addressing the Opioid Epidemic, yes or no would you commit to rejecting harmful changes to the essential Health Benefits in proposed rule . I believe states are most effective in determining the benefit packages for citizens and circumstances you describe the unique circumstances of each state is a problem when they do that the Insurance Companies come in and charge much more for the benefit and thats one of the advantages. Nobody in my state plans to get an illness that their insurance doesnt cover. Nobody plans to become addicted to Prescription Drugs after surgery, but say and says too bad i didnt buy Insurance Coverage for that treatment in the advantage of the essential Health Benefits is millions of millions of people not only got coverage of the aca the coverage that actually address their needs. Before when i was in the state senate, it was often the case that insurance can just get dropped the coverage for things they couldnt make money on and eventually the public picks up that. Cost. I ask you to look at that issue very closely because the essential health and if its under the aca has been critical to fighting the epidemic in our state. Last topic i wanted to touch on with you when you heard a lot about it is about drug pricing and some of it is about your past employment as president does billy eli lilly. I went to read the New York Times article because theres a reason people are skeptical about your commitment to lowering drug prices. This is what you were quoted as saying the New York Times. All wholesalers like mike tyson and cardinal, pharmacies like cvs and walgreens, benefit managers like express scripts, care market Drug Companies make more money winless prices increase. The unfortunate victims of these trends areri patients. So basically come in thatha quoe you are admitting thatth high lt prices are hurting consumers and creating profits for Drug Companies, but yet you continue and just last spring to push the blame. Here you said everybodys got a part to play. Last made the conference to push the blame on everyone but pharmaceutical companies for high list prices, even setting list prices is something that manufacturers directly control. You have also blamed Insurance Plan designs for high drug prices, but it is really the list price by manufacturers that is driving the increases in what consumers are paying because requiring lower costs will leave to increase premiums. Again, all at the expense ofiu consumers. I want to ask now that you will be taken off your Pharmaceutical Company hatpin will be responsible for advocating for consumers coming do you think its time the federal Government Take Action to limit the profit druggo companies to limit the insurers right now with the relationship you in early remarks i did not need to be suggesting that list the relevant for that pharma doesnt have a piece of this also. The challenge is as a think about the burden on the patient when they walk into that pharmacy, if the list price is 500 they have it. That 500 or if the list price is 250 they have to bear the 250 under a high deductible plan, both of those can be unaffordable for that patient. My point is and where you want to work rightofway over. My point is without some action will be passed on in the Insurance Premium will become unaffordable. Thank you. Thank you, mr. Chairman. Thank you, senator hassan. Senator baldwin. Thank you. I too want to continue along the same lines that senator hassan was asking you about and also what we were talking about enron one and you mentioned your example at 500 a month. I told you a story about greg from stoddard, wisconsin and mentioned dianne who lives in western, wisconsin who has ms has taken a medication for over 23 years to slow the progression of her en masse. When she became medicare eligible and therefore the way in which the family was insured and paying for medication, she and her husband had a heart raking discussion at the beginning of this year whereby she and he decided that she would stop taking a medication that had reached 90,000 a year. No change as far as i know in the ingredients, the manufacturing process or anything else. It just had crept up, cracked up over all of that time. This hearing available online, search azar at cspan. Org are really the remainder of this and take you live to capitol hill. Senate leadership is speaking to reporters and others. My colleagues who work so hard to get to the place where its accurate guide to Small Business administrator Linda Mcmahon with us as well as the Small Business Entrepreneurship Council president and ceo of karen cure again. Certainly, karen has brought a number of people here today who know they are going to be affected by this
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