Transcripts For CSPAN2 Health Human Services Secretary Confirmation Hearing 20180111

I think we better get it going. The committee will come to order. To this mornings hearing. Today, the committee will consider the nomination of alex to servee in the as the secretary of health and Human Services. I would like to welcome him this morning. I want to thank them for being here. Thisillingness to serve in capacity, as well. He has his work cut out for them. Health and Human Services is a massive, Sprawling Department that oversees trillions of dollars in spending and liabilities, encompassing all areas of our Nations Health care system. Confirmed, his decisions will impact the lives of every single american. Knowledge, experience, and most importantly, strong leadership. Our nominee brings all of this to the table after nearly do decades of experience after nearly two decades of experience. Hhs, mr. Azare at played key roles in implementing policies, including the Medicare Advantage program. He was also a leader in hhss response to the anthrax attacks shortly after 9 11, the monkeypox crisis, and hurricane katrina, just to mention a few. Ar will beed, mr. Az congresss prior contact. He will be integral in providing access to care and giving nations giving patients more choices with regard to coverage. When we are talking about modernizing programs like medicaid, innovating the chip program, and reforming the will bemarket, mr. Azar the administrations primary policy driver. He has made clear his intentions to address the growing opioid that continues to ravage communities across the country, including in my home state of utah. This crisis is robbing families of loved ones, employers, and able workers, as well as securities of the safety they once enjoyed. This is an important issue to everyone in this issue, but particularly to me and other members. I look forward to working with to figure out how hhs can save lives. Coauthored an act which is recently come under scrutiny with relation to the Opioid Epidemic. This law requires hhs to submit a report to Congress Regarding the obstacles to legitimate Patient Access to controlled substances. , so today i report would like to impress upon mr. Of gettingportance this to congress so that we can make any necessary changes that may help to turn the tide of this epidemic. I hope to get this commitment to produce and release this report as soon as possible, once he is confirmed. He has expressed his commitment to succeeding in this important endeavor, and i believe his record shows that he has more that he is more than capable. There are some on the committee who have made up their for the high profile nominees that are coming for in this nomination. His experience or his qualifications. Instead, we are hearing talk about supposedly Revolving Doors and nonexisting conflict of interest. I would like to take just a moment to address some of the more prominent attacks we have heard. His work in the pharmaceutical industry and where he has been a Senior Executive in the last few years, has disqualified him from serving in this position. I would hope that my colleagues standardsd setting that somehow working in the private sector is a knock against a nominee. Apply to this one. Azar is committed to fully adhering to requirements. In addition, he has committed to divesting any Financial Holdings that could present a conflict of interest, or even an appearance of such a conflict. We are not talking about anything unethical. We are not talking about a nominee looking to profit. Experience in the private sector and dealing with the policies and regulations that come from marknment agencies, are a in favor of a nominees qualifications. Himazars work will give important insight. Add that knowledge and background to the years he spent as a senior official at hss, you have an extraordinary resume. Azaragain, i believe mr. Is more than capable. Mr. Ny objective standards, azar is wellqualified to serve at hss. I want to thank you once again mr. Azar to be willing to go through this and to the willing to appear here today. I personally look forward to your testimony. I would like to reemphasize my support for the Childrens Health Insurance Program and my commitment to making sure that it gets reauthorized. It is one of the most important programs that i worked on and got through. We have a bipartisan agreement. I believe it improves things for the longterm. The time for a shortterm solution is over. It needs to be extended. I am going to do all i can to do everything to make sure it gets done. Children, states, and families are counting on us. Thank you very much mr. Chairman. I very much appreciate you convening the hearing. This is the first time that we have been together since chairman hatch has announced his retirement. I would just like to take a publicly what i mentioned to you over the phone. First, you have always been a gentleman. Every member of this body feels that. We know about your passion. We know about your dedication. We know about the fact that you have always had an ear for your colleagues. Youn when you and i talked, wonder what your friends are up to. You are always there with an ear. I would just like to note something that i do not think everyone knows. Boxer tch was a chairman hatch was a boxer and best ballplayers know a little bit about endurance. Just boxer picture 40 years in e ring. 40 years as a boxer. That is real endurance. Im sure we are going to have other colleagues talk at greater length but since this is the first time we have been together publicly, i would like to note that and i also appreciate the fact that you mentioned chip. As you know, we have teamed up on this now for quite some time. That theike to think fact that we came out of the resulted in not everything becoming bipartisan. We have got to get it done quickly. The American People said to me happenede break, what at the end of the year is that the kids got a patch . We are better than that. As chairman i just want to say that i am looking for to working closely with you. Unanimously inve this house. We ensure that families across this country do not go to bed at night in near panic about the prospects of an emergency. I look for to working with you on that. Todays is now, to this. Business. Donald trump said almost exactly one year ago that drug hiking Drug Companies price hiking Drug Companies are getting away with murder. Now, he has nominated someone with a documented history of raising Prescription Drug prices. Mr. Azar is now here with the committee. It is my view that the issues if confirmed are going to be defining issues. Defining domestic issues in 2015. The American People heard a lot of promises two years ago about how great their health care would be under President Trump. About how the era of sky high drug prices is over. Americans are going to want to know come this november, if all of those big promises and pledges they heard in the wall 2016,6 fall of actually happen. Mr. Azar was the president from 2012 to 2017. He chaired it u. S. Pricing reimbursement which gave him a major role over price increases for every product he marketed in the United States. Hatch chairman noted, that our staff did a fair amount of homework and i want to spend some time looking at the record. Drugs used to treat osteoporosis more than doubled under azaras watch. Another drug used to treat adhd, more than doubled. , used to of humanla treat diabetes, more than doubled. These are just some of the drugs under mr. Azars preview. Zar told they, mr. Aa never signed off on a decrease on the price of a drug. This morning, the committee in my view is likely to hear from mr. Azar and his colleagues. They will blame the system. Is that there is a few fair amount of validity and that. The system is broken. Was part of azar the system. Azar has come up empty. He has confirmed that it will not be the first time that the president and their Health Care Team broke their promises. Health care officials have come before this committee and have promised to uphold the law with respect. Right out of the gate, we itember tom price telling us would be his job to administer the law at hss. The track record does not look so greater. Great there. Seems that it sure the sabotage policy kicked in. Advertising budgets were slashed. It became harder for people having difficulty signing up for coverage to get in person assistance. They attacked a rule that says women have to have guaranteed access to contraception. Unfortunately, that has been removed and held up in the courts. What has been particularly troubling to me is that the Administration Made it easier to sell junk insurance. All in all, the Trump Administration have made millions of Peoples Health care worse and there does not seem to be a serious plan to undo the damage. Mr. Azar today will have to explain if you will continue that policy and he should not because his stance is an stark contrast with what he did when he was a member of the bush administration. Promotingme to medicaid Prescription Drug benefits, which i was one of the it, hets that voted for toured like he was in the grateful dead. Now he has tweeted less about open enrollment than about thanks giving safety. Told me he azar believes that medicaid counts as welfare. Thecomment thread to republican talk here is pretty obvious. To programscuts that are of life i lifeline. Support for struggling families. With respect to medicaid, for millions this program is at the heart of health care in america. It spans generations from newborns to 2 3 older people in nursing homes. Today medicaid is built on a guarantee. The trump team says, it wants to end that. To make motions in plan it harder for a lot of people to get the care that they need. Sometimes, it is folks with disabilities. In other cases it is adults with limited needs. Is, kind of my background so i am interested in hearing what mr. Azar has in mind with respect to seniors. To me, risking the medicare guarantee, i want everyone to know that that is a nonstarter here. Furthermore, my view is that you cannot get ahead in life if you do not have your health. Lower in the health of income americans is the absolute wrong way to go. There will be it other issues that fall under the welfare umbrella. I am one who feels that people with business backgrounds, those be viewpoints can meet welcomed. But it has to be in line with a set of values that i have. That is my sense of where we are and i would like to wrap up this way mr. Chairman. The leaders on both sides of this committee previously, have had regular meetings. A whole host of democratic representatives did the same thing. When i wrapped up the meeting with mr. Azar yesterday, he noted that he would not go along with the last secretary. Azar without any prompting said that he was interested in having those kind of meetings. Beingar, thank you for here. Thank you for our meeting yesterday and we look for to your statements. Here to introduce mr. Azar are two distinguished secretaries from hss. It has been quite a while since i have seen you. You served as the head of hss from 20012005. Servedo that time, he four terms as the governor of wisconsin. The longest tenure of anyone in that states history. As governor he was the pioneer of a number of initiatives including welfare reform which gained national prominence. As the secretary of hss he said initialaw the limitation of Medicare Part d. Next, we are going to hear from a very personal hear from of my mine. Before that, mike served as the administrator of the Environmental Protection agency for two years, as governor of utah for almost a decade. He had a number of National Leadership positions. As secretary of hss, he sounded the alarm about medicares longterm fiscal difficulties. Both secretaries are a wellrespected Public Servants. Their opinion should carry quite a bit of weight around here. I know they mean a lot to me. I want to thank you both for being here with me today. Well start with secretary thompson and then we will hear from secretary leavitt. Thank you very much german hatch. Chairman to thank you for this opportunity to appear before you this morning. Before i start i would like to echo something that the senator said. Mr. Chairman, you have always been a friend, a distinguished member, a mentor to me personally, and always a great leader. I feel that todays meeting is somewhat bittersweet for me. Sweet because i am endorsing my colleague, bitter because i have found out that you are leading leaving. Pleased or the more prouder to introduce my friend and colleague, mr. Azar. Alex is an outstanding individual with a great family. Well as,y is here as his father. Im here to provide my strongest personal endorsement and to tell you that he has the capacity, the capability, the until it to be an incredible secretary the intellect to be an incredible secretary. Academiccredible credentials. The only thing i have against him is that he did not go to the university of wisconsin. I was privileged to have him as my general counsel when i had the honor of serving as hss secretary under george w. Bush. Excellentecretary counsel who developed a great understanding for hss. Result, he deeply respected and passionately was respected by the Civil Servants with whom he worked for. From his tenure as general counsel, he went on to serve as secretary of hss. It is important to live up to responsibilities. He successfully led a large and Successful Health care company and this country. The basis of my recommendation likability, he is one of the most important attributes. I know from personal experience that he is a very honest, dedicated, passionate, and trustworthy person. He says what he means any means what he says. He is quite simply a man of great integrity. If the United States and its were to confirm him, the members of this Great Committee would have a double partner who truly understands the complexity of our Health Care System and Human Services program. Further, i believe because he wants to take on these challenges, he would work you thereive we with collaboratively work with you. Will do it, ie can assure you that he will. Mr. Chairman and all members of this committee, thank you for giving me this opportunity to help introduce alex azar. Thank you. Those words are very strong and very good. And members ofch the committee. Tom joint with my colleagues expressing gratitude. I joined as well today with secretary thompson and want to be completely associated with his comments about alex azar. I too, and equivocally recommend that he be confirmed as the 24th secretary of the health and Human Services. He is supremely qualified. Too, along with secretary thompson, feel well equipped to be able to offer an evaluation of alex azar. Counsel when il became secretary. Hss is a large, very complex federal agency. It not only looks after the Nations Health care system, it looks after all of the Human Services that we provide as a country. Much of the National Medical and scientific research, it carries out a significant amount of responsibilities related to disaster recovery. Mr. Azar secretary, auctioned as the coo of the department. I delegated much of the daytoday operations to his supervision. In that role he demonstrated a skill as a collaborative leader. Managementush had a agenda to improve the efficiency of the federal government. They had developed almost three areas of evaluation. Have hssset a goal to to have every major green. He organized an effort among hsss 27 different operating centers and he met that goal. Mr. Azar is a man of good judgment. As secretary i delegated oversight of the departments administrative rulemaking responsibility. And impartialerly way, he oversaw the rulemaking process and made recommendations to me as secretary that i learned to have great confidence in. He is a man of great judgment. Ive missed i have seen mr. As are under fire azar under fire. He is a stevie steady leader under fire. We were parent for what appeared to be a potential pandemic influenza. We were implementing medicare. Mr. Azar was measured and responsible. He establish priorities. He accepted responsibilities. Should you choose to confirm mr. I want to assure you that you will find him as i did. I believe you will see bipartisan communication rum mr. As are from mr. Azar. He is a person that brings unique expanses from the private sector. Something that i believe will be of immense importance over the next several years. Lastly, i will close with two final observations. The first is, alex azar by my experience is a very good person. He is a man of compassion. In myis an attribute opinion that is critical. Based on his previous expanses, i do not know if there has ever been a person nominated before who is in the position to hit the ground running like alex azar. He will serve the people of the United States while. Well. Thank you both very much. Mr. Azar we will turn to you right now. I have had a long experience with mr. Azar. I cannot have a higher opinion than what i have right now. I am pleased that he has this nomination. Thank you very Much Research airman. If you would not mind mr. C hairman. I am joint on my family joined today by my family. Unfortunately, my mother could not be here today and most tragically, my stepmother just passed away. Hank you all an opportunity like this just does not happen without Family Guidance and support. Members of the community, a committee, thank you for this opportunity. I cannot tell you how to shyam to hear the words of the touched i am to hear those kind words. Sherrod i simply cannot think of two gentlemen from whom i have learned more. Alex it just means so much to be sitting here with you. I never thought that they would happen. I also think President Trump for the confidence that he has the on me. On me bestoewed my grandfather who spoke not a out andenglish, stepped completed his long journey from lebanon to america. He met an individual who is wearing a military uniform on ellis island. Tot person possess the power admit him. That person was a member of the United States Public Health service. It is a testament to all that i love about this country. Just 97 years after my , with note discernible prospects, his grandson might be in charge of that very same Public Health service as well as, all of the other will world renowned components of hss. Through its outstanding leaders and career staff, hss is primed to meet that challenge. The task is humbling. Marshaling and leading the incredible resources of the require innovating. Through the subsequent anthrax furtherthat prepared us for any nuclear attacks. In the implementation of our completely novel prescription benefit for seniors, and helping , andild flu preparedness our response to threats such as sars. Through innovation in the private sector, to bring life improving their peace to our people. Finally, in harnessing the power of big data and analytics. Department decides the scope of hss, it becomes difficult to prioritize. I do envision focusing my personal efforts in four areas. First, drug prices are too high. The president has made this clear. So by. Jj so have i. Believe i bring skills and experiences to the table that can help us tackle these issues while still encouraging discovery. Second, we must make health care more affordable, more available, and more tailored to what individuals want. We all share a common concern for our fellow americans. Even if we do not necessarily agree on how best to go about addressing the challenge. Under the status quo, premiums have been skyrocketing your after year and choices have been twiddling. We have got to dwindling. must harness the power of medicare to shift the focus in our Health Care System to paying for sickness to paying for health and outcomes. We get better channel and leverage what is best in our programs to ensure that the individual patient is at the center of decisionmaking and his or her needs are being met with Greater Transparency and accountability. We must heed trumps call to need aggressive prevention efforts to stop overprescribing and overuse of these legal and illegal drugs. We need compassionate treatment for those suffering from dependence. These are serious challenges. If confirmed i will work with the super team at hss to deliver results. I think President Trump for this opportunity and i think this committee. They give her a much. You are really thank you ver y much. You are more qualified than most people ive seen. I am pleased that you are willing to sacrifice to come here and help turn this mess around. Let me just ask this question, as you know i have fought hard toextend the chip Program Support the 9 million families that rely on it. I think we will get this done as soon as possible. Will havehappens, hss five years of runway to work with. What should they be doing to bolster chip and ensure its continued success . The Childrens Health Insurance Program is such an important part of your personal legacy and i look forward to the reauthorization so we can secure that program for this year and years to come. It really serves as an important bridge and stable force for the children of our country and i look for to looking into any ideas that you may have in terms of implementation. Anyways that we can make that program more responsive. N. Thank you mr. Chairma particularly, i want to welcome your dad. In maryland and his father is a distinguished physician. I had a chance to work with him when i was in the state legislature so it is good to see that his family is here. The first question i want to ask you is going to be a colloquial one with maryland. That is protecting some of the initiatives out of maryland. Many states have come up with innovative ways to try to open our Health Care System. We just urge you to Pay Attention to these types of initiatives and be understanding that we may need some special attention to preserve this type of access to care. Senator thank you and thank you for this wonderful meeting. Alex if confirmed, i would love to come home to maryland and spend some time with you and learn more about the ireland pproach. Maryland a are all kinds of innovations and improvements available at the state level. No one person has the right answers so i want to be supportive of you and the state of maryland. One of the major accomplishments under the Affordable Care acts was to elevate Minority Health and health disparities. Also, to establish Minority Health offices. It is important that the secretary get directly involved in these issues. Do we have your commitment that you will pay particular attention to this particular priority to make sure that we do right for Minority Health in america . Thank you for your line longstanding commitment to that area. Skin, where ones one lives, should not matter. We should be doing everything at hss to ensure that everyone has access to care in the United States. I want to talk about one area that the Trump Administration has deviated. The socalled gag order that deals with services on contraceptives and other areas. I disagree with this policy because i think it comprises Womens Health in america. And compromises our ability to work internationally. The manner in which this was administered under the Top Administration has compromised our ability to work with International Health organizations. Are you willing to take a look at this to see whether we can get a more rational way . Again, i disagree with the policy to begin with but the way it is being recommended now is counterproductive to Global Health priorities and really does require some attention of the secretaries. Senator, i am not deeply familiar with the ways under any ways that the implementation have changed. As i know, there have been some differences and i want to learn more about that and would be happy to discuss it with you. Overarching you the view that the United States needs to have the International Health in mind. Id be happy to look up at issue and learn more and more about any changes that were made and learn more about that. You mentioned drug prices are too high in this country. We all know that. Globally it is even more out of step. Tell me how you intend to address this issue of ringing down the cost of Prescription Drugs . They give senator. Thank you senator. Anyone else coming in a secretary, this is such a complex area the learning curve for any other individual would be so high. We need to deal with issues of competition. We have robust competition. I want to make sure we create a very viable market to compete against branded companies. That is critical. I also want to make sure we go after any type of exploitation of exclusivitys. I thought it guesses when i was general counsel, i developed a rule that would change regulations that saved 34 billion for patients over 10 years. There is no Silver Bullet here. There is not one action that all of a sudden fixes this. I want to hear ideas from others. The most important thing to figure out is if we can reverse incentives on list prices. Work with this committee and anyone who is smart and thoughtful about if we can create incentives that can pull down the list rises so when a patient walks in needing to pay out of pocket, they are not stuck with that kind of cost. That is one of the ardor issues to solve but i am deeply committed to work with you on that. I have some obligatory questions. First, is there anything you are aware of in your background that may represent a conflict of interest . No mr. Chairman. Ofill follow the advice officials to make sure that i manage any potential conflict that come about through the ethics approval as part of the confirmation process. Alex no mr. Chairman. Do agree it without reservation to respond to any reasonable summits to appear and testify before any committee of congress if confirmed . Sherrod yes. Do promise to provide a prompt response . Alex yes mr. Chairman. As i promise you in my office, you will know about the questions that i will ask. Ill have two questions. The first involves the sunshine act that i worked hard to pass and is part of obamacare. The background to my question, and march of 2017, the university of iowa reported a growing crisis of prescription opioid use and overdoses in iowa. While lower than some states, iowa has seen rates of Prescription Drug debts quadrupled since 1999. I also think it is important to protect Patient Access to needed medications. One strategy to achieve that balance is to ensure that decisions are made in the best interest of the patient and not fromresult of influence drug care companies. The affect on opioid prescribing practices. To sunshine act was designed provide transparency regarding payments from Drug Companies. This law created the open payment data base at cms. Wrote a letter to your department thinking for the thanking you all for the support. In that letter, we further encourage the prioritize asian of the open payments database. You may wonder why i am asking you this question. One year ago, i think it was in , and we prevented that. Will you commit to continuing to collect and post all of the Data Currently Available on the open payments website . Alex yes. As you know, i am a big supporter of the sunshine act and your work there. I think that transparency is extremely helpful. My second question. The misclassification fiasco, i focused a lot on the medicaid rebate drug program. Id because of my oversight, found that during the Obama Administration, cms did not properly oversee the program which resulted in billions of taxpayer losses. Lost outyers may have on more than 1 billion. Doj recovered 475 billion. Why they did not go after the other billion, i never get an answer. Was mber 2017, the hass released a report on the Rebate Program and found that hundreds of drugs were potentially misclassified. For example, out of a sampling 2016,st 10 drugs from 2012 medicaid may have lost billions in rebates. We do not know how many billions of dollars may have been lost. By the way, i would also like to have submitted a letter that i have from a former cms administrator on the record. This question, there is a lot of taxpayer money at stake here, how will you approach fixing the medicaid drug Rebate Program so that it is properly overseeing and taxpayer losses are kept to a minimum . I was very concerned to see the media reports on the rebate rogue ramp. Rebate program. I will work hard to ensure that the row graham is improved. Alex one of the key issues i think to ensure is that the regulations are clear. If necessary, moving to enforcement to ensure that they understand that these are obligations that need to be held up. Thank you because during that you can save a lot of taxpayer money. Im going to ask you questions about these price issues. Certainly, if you have any questions we welcome your comments. During the five years that you directsident, you had responsibility for pricing strategies of the bio addisons unit. Biomedicines you also chaired the u. S. Pricing committee. Im going to quote from a written statement to the committee. Asaid to the committee, as a leader for the biomedical business industry, i approve pricing recommendations. During your time in these positions, based on the committees investigative team, the companys annual report shows the annual revenue 70creased 58 , reaching 7 2017. N in each year the company told shareholders that revenue increased because the price went up. You have told the finance committee that you are responsible for fixing the price. This chart that we are holding up shows the wholesale package price. , we show thetch red line of the price going up. The blueline, is before you became president. The price more than doubled on your watch from a little more 27,000. 0 to the wall street journal recently showed how these guys affects consumers price affects consumers. Mr. Azar, this certainly indicates the wholesale price in fact, morestates in than doubled on your watch. Yes or no . Alex i believe that data is correct. Now atme take a look another drug under your purview. Attention to treat deficit hyper disorder. This chart shows how the price of the drug changed over the year. Again, the price before you became president , is blue. , while you were president was read. Was red. This was another big jump in uprising that began shortly after you became president. If these were isolated incidents, it could be written off as an anomaly. Financial report shows that during your time on the committee, when you ran that, higher prices drove u. S. Revenue for drug even when demand for the products fell. One more question in this line of questioning. U. S. Pricingf the committee for this company, did of aver lower the price drug sold in the United States . Drug prices are too high. That is not the question. Did you ever lower the price . Alex i do not know. Every incentive in the system is towards higher prices. That is where we can do things together. No one company is going to fix that system. That is why i want to be here working with you. Let the record show that when that specific question was asked , he said, no. Let the records show that that is what we were told. Now, we are going to have to make some judgments about how you are going to approach issues of helping to shrink pharmacy receipts. I have talked about legislation that ive introduced that would ensure that the consumer got the price reduction at the window. Ing doucette legislation so i will have to ask if you will urge the president to support it . You mr. Chairman. Let us move the nomination of mr. Azar to the senate. It is a role that should not sit vacant. There are too many vital priorities in health care that need immediate attention and i appreciate you moving forward. I also appreciate mr. Azars willingness to serve. In my meeting with you, i was pleased to get your Top Priorities. Appropriately, he will be focusing on the affordability of Prescription Drugs. This is something that everyone around here knows about and mister azar coming in my meeting with you after your nomination i was pleased to get your Top Priorities for your time as secretary of conferment. Appropriately you will be focus on affordability of Prescription Drugs. This is something everyone around this day is know about and heres from constituents about. The problem is complex and doesnt have a simple solution encouraged to hear his commitment to taking this on and to know he has real expertise and understanding of the manufacturing side of the equation. That is something we really need, something that can and should have bipartisan approach and i hope to hear that kind of commitment from my colleagues here as well. Mister azar, you have listed and now restated your priority regarding drug prices, Insurance Market affordability and choice, working toward a valuebased system in healthcare and the Opioid Crisis. I completely agree these are where the secretarys focus must be and i look forward to working with you to get that job done. Mister azar has been before the senate before but this environment this time around is very different. Im impressed by his willingness to go through this very difficult process and appreciate his willingness to serve. To get to a question, wyomings department of health has had a medicaid 1115 waiver application sitting at the center for medicare and Medicaid Services for over two years. Is a tribal uncompensated care waiver. I understand the waiver is under consideration but i encourage you if confirmed to take expeditious action in making a determination on this longawaited application. This is something you have discussed before in which i know you not currently being in the position are not able to comment on. I would appreciate your commitment to examining this application as quickly as possible. Thank you for taking time to meet with. I dont know the parameters of the waiver but i am concerned about the time you mention that has been pending. I want to ensure if im confirmed as secretary that cms works with the state on any of these demonstration projects or waivers as a good partner and it is responsive and timely. I will if confirmed to get on that right away looking at that. You also talked about your priorities on drug pricing and that seems to be the topic here and i appreciate your willingness to take on that very serious and complicated issue and appreciate the background you bring to that issue. Im sure you are familiar with the announcement of the discussions with cms to think differently about how they price the new leukemia drug kim ryan. It is not a finalized agreement and i know there is not a longterm data showing how these arrangements work but it seems like an interesting approach and one that is worth exploring further. What is your view of value or outcomesbased contracting in the private sector and possible applicability to affairs like medicare. Outcomesbased contracting in the Healthcare System but especially with medicine can be vitally important and some of the regulations we have in medicare get in the way of that but when i was doing this in the private sector, i want to put if it works pay us, if not take a greater discount but some of the rules around government price reporting and other rules, fairly broad bipartisan support to open the doors to get real valuebased value and paying for outcomes on these medicines so im excited to think that could be part of how we think about drug pricing for customers. Appreciate the expertise that you bring but also the record you have been working in the government in the past so thank you for being willing to serve. I yield the balance of my time. Thank you. I want to thank you for your commitment on the Childrens Health Insurance Program. I want to thank you for your leadership over the years. You have indicated welcome, welcome to your family, you indicated you hit the ground running and my question is and what direction will you be running and i share the concerns of senator wyden in terms of when you were at eli lilly, the fact is, i will talk about another drug and that is insulin, the fact that particular product which is so critical for people with diabetes, from 1996 to 2017 went up 700 and during that time you were at eli lilly it doubled in price. I am wondering, when you say drug prices are too high do you agree the 255 for one file, multiple files are needed, do you believe 255 for one file is too high. Acrosstheboard drug prices are too high including for any product like this. Insulin prices are too high, the increases, this is what is so bizarre about the way the system is organized that those price increases happen and my former employer said this publicly, during that same period the net realized price by the company stayed flat yet the patient walking into the pharmacy, just to cover increased rebates the patient walked into the pharmacy, his insurance may not be paid for that is absorbing the cost and that is what i want to work with you to solve. Mister azar it was approved 100 years ago. Any recouping in addition to a taxpayers paid for would already have been done and i appreciate that you say it is too high and yet in that position with the system you doubled the price. You were taking advantage certainly of that system. That was a choice you had as president which is of concern to me because i am assuming the price of manufacturing insolent and double. Is that correct . I dont have the data. I didnt run the diabetes unit, i dont know the date on the price of manufacturing but the system works for those players in the system but doesnt work for the patients. Lets talk about how to make it work. Donald trump has been back and forth on this but he has said in the past that he supports negotiating Prescription Drug prices. Do you believe the government should negotiate Prescription Drug prices . I where the government doesnt have negotiation it is worth looking at that. One i talked about is in part d we do significant negotiation through pharmacy benefit managers get the best rates of any commercial payers. We dont do that in part the which is where we have physician administered drugs, we pay sales price plus 6 or some other number. The interest of time dont mean to be rude but in the interest of time, you are saying yes to negotiation of Prescription Drugs . Where we can do so that preserves innovation and access for patients i want to look at anything that will help us with drug pricing so if we should be looking at those approaches. National academy of science, engineering and medicine has indicated buyers in the biopharmaceutical sector often appear to be in a weak position with little alternative but to purchase the drug had the price and they recommend the effects of not allowing hhs to negotiate Bargaining Power further in favor of drug manufacturers. Part d is originally passed prohibited on the side of the drug company saying you cant negotiate. Do you support changing the law so that under Medicare Part d you can negotiate on behalf of seniors and the American People to bring prices down. Negotiation is happening, get the best rates out there. The National Academy are wrong on that. These are incredibly powerful negotiators who get the best rates available. When they say you are in favor of Drug Companies they are incorrect . For the government to negotiate we would have to have a Single National formulary restricting access to all seniors for medicine even cbo, the only thing that could change. We dont want to restrict Patient Access. Combating drug addition and Opioid Crisis recommended using Emergency Powers for naloxone, a lifesaving drug related to the opioid addiction problem. They just recommended negotiation be used for that lifesaving drug against opioid addiction. Would you support negotiation for that drug . I want to learn more about that bit if the government is the purchaser, if we are buying that as part of the Opioid Crisis program and we are supplying it to First Responders theres nothing wrong with the government negotiating that. I did that with secretary thompson during the anthrax attacks, theres nothing wrong with the government negotiating the purchaser for value and if we are supplying that out i look forward to learning more about that issue from with the government. Thank you for being here today, mister azar, thank you for the willingness to serve and your family for putting of the demands the come with being involved in public life. I think we all share your priorities of lowering the cost of healthcare and Prescription Drugs. I hope based on your past experience you understand you can help us with suggestions about how to get those drug prices down because that is an incredibly important part of healthcare today and an incredibly costly part unfortunately. I look forward to working with you on the use issues. We discussed this previously but we have providers in south dakota working to innovate and ensure access to care and in Indian Country a lot of challenges that exist. 4 years being in Health Service facilities in south dakota found to have serious deficiencies and poor quality of care. Pineridge lost its ability to build medicare and medicaid for failing to meet cms standards. This has to change. I have been working on restoring accountability in the ihs act to give Greater Authority to get ihs back on track, specifically the bill would give hhs the authority to terminate poorly performing employees, streamline the hiring process and create incentives for quality providers to remain on the job. Is this something that you agree you could work with congress to achieve . Absolutely. I look forward if we could get additional authorities and also look forward to any ideas you have. It is unacceptable not to provide highquality service. I appreciate that i look forward to working with you and your team. I have been supportive, i share this with you on finding solutions to address the application of medicare Competitive Bidding rates, noncompetitively bid areas, an issue radical equipment providers report cost supplier closures and Medicare Beneficiary access. Hhs was supposed to issue a report to congress came through the 21st century cures act on beneficiary access by january 12, 2017. Im not aware the report has been completed so i request that once confirmed you would work to have that report completed quickly. Additionally if confirmed, would ask that you commit to working with the office of management and budget to improve the final rule and provide relief for rural providers that have been pending since october 2017. I would be happy to work on those issues. In the face of provider shortages south dakotas Health Systems decreased access to care in rural areas through telehealth and as you may be aware several senators working on the connect for health act which would further expand the use of telehealth and remote patient monitoring and medicare. Import only one provision of that legislation would provide the secretary of hhs the authority to waive restrictions in current law where telehealth would reduce spending or improve quality of care. If confirmed would you support congress and acting that provision to provide you to expand access to teleHealth Services. As we had the opportunity to discuss together in our meeting im a big supporter of telehealth and alternative means of providing care especially in rural communities. We can be penny wise in those areas. I look forward to working with you and your team on that as well. It is something that has tremendous potential to deliver benefits to areas of the country for which in many cases it is difficult to get delivery of Healthcare Services at a timely and costeffective way. Thank you for your answers, we will hold you to that and follow through and look forward to working with you once you are installed and it is a big job with lots of moving parts, a lot of challenge, lots of opportunity to make a difference in the lives of people who need access to affordable Healthcare Services. I yield the balance of my time. I want to reiterate what senator stabbynow said about your service, the Health Insurance program can hopefully get that done in the next couple of days, by the 19th but we are grateful for that. Mister azar, thank you for your service in the federal government, good to see your family. You and i have common state routes, scranton and johnstown. Despite those commonalities we have disagreements on healthcare policy and i want to explore that. First and foremost, appreciate the time you spend in our office going back a couple weeks ago before the Health Education Labor Pensions Committee of which i am a member. At that time we talked about healthcare policy, in particular medicaid, which is a program Many Americans appreciated over many years but never more so or never with greater urgency than this year when proposals which in my judgment, the judgment of a lot of folks who follow healthcare policy for their whole lives a lot of concern that medicaid would have been decimated by some of the proposals this year that were put forward. I tend to focus on it not only in a programmatic sense but a people sense when we get letters from families that are very concerned, i got a matter of a letter last year from pam simpson from southeastern pennsylvania talking about her son rowan. This is the letter she sent me, pictures you cant see from where you are, she concluded the letter by making a plea to me to protect medicaid because her son rowan she described in the letter what his life was like with medicaid which we call medical assistance in pennsylvania, how much better it was, all of the treatment and therapies and benefits rowan received, she ended the letter talking, pleading with me to take steps to protect, saying we should her and her husband, their inability to make legals meet without medicaid, to focus on rowans life and give my daughter, luna, little girl who is younger than rowan, only 5 years old saying she will have to care for him because of his own circumstances. The last line of the letter she said we are in need of rowans medical assistance and would be devastated if we lost these benefits. That is what she said about her family and circumstances. A broad question, if the proposals put forward in the republican healthcare bills this year were enacted into law and or the administrations proposals on medicaid that you support would become law, would Rowan Simpson lose his medical assistance . From the same state, we actually share a lot of the same goals for access to care, access to insurance, access to quality. We may differ about the role of women, size of programs, techniques or whatever but we share that commitment and i share the commitment to the Medicaid Program as a vital safety net program. I dont know that individuals particular circumstance, how they qualify for medicaid but obviously for so many families medicaid is a vital bridge to independence eventually or longterm need for them and if confirmed my job will be to make that program as efficient, as effective, as responsive, available to everybody, as possible. Under current law there is a guarantee. As long as you are eligible, some are eligible, some have a guarantee by way of their disabilities and even people of significant means with jobs and healthcare coverage can avail themselves of medicaid because of disability. My question is will that guarantee remain in place not only for children with disabilities but adults as well. What we do in medicaid, we have got to make sure it is doing its job. For an individual like that with disabilities it needs to be categorically we have to make sure it is funded and supported to do its job. I also ask in the context of adult, we are running low on time. If you have an individual relying upon Disability Service provider, someone who needs a wheelchair, they continue to get their services. On any type of reform those are the situations we have to look at to make sure we are able to deliver for those individuals. I will try to come back in the second round. I have the pleasure getting to know alex azar in his previous roles in government, i got to see him in action and i can tell you from personal experience he knows his way around, a lot of integrity, friends and allies on the hill from his days in those jobs. You wouldnt know from some of the comments made today but he has been confirmed twice by the United States senate as general counsel and deputy secretary both times by unanimous consent. Not a Single Member objected, he has the experience, the background. I am glad someone with his experience, we have gotten a lot of challenges, big complicated department. We spoke about the Opioid Epidemic and what can be done in addition to what is being done and there was progress in the last couple years but hhs plays a central role, the comprehensive recovery act through cdc, medicaid and medicare, medicaid in particular and this is all going to be part of your bailiwick should you be confirmed. There is an issue, i want to get your views today, not so we talked about this in our meeting and that is improving access to care. This is something many of you worked on over the years, senator durbin and i have a bill called the medicaid care act which would lift his medicaid institution for mental disease exclusion otherwise known as the imd, it is crazy to me that there is a of 16 beds on some of the good successful residential figure programs i visited and they literally turn people away because they dont have the ability based on taking medicaid and being involved in the program to have access and it makes no sense. I understand why was put in place in the first place, trying to fight back on institutionalization but needs to change so my question would be knowing cms tried to be supportive, the 1115 waivers had been accepted and in some cases there are still a lot of restrictions, would you support legislation raising the cap from 16 to 40 and we have something we are working on. Would you be supportive of legislative efforts . As a nominee i cant commit the administration, we dont understand the restrictions in the face of the Opioid Crisis and demand for treatment, i would love to work with you on that. I appreciate that answer, not something you expected me to raise as much as other issues having to do with prevention and treatment but you for that comment and another reason you would be good in a job, we need to get that raised. We have to pay for it and understand we have some thoughts on how to do that and it is crucial right now in my state and so many other states getting hit so hard by this Opioid Epidemic. The other issue is wellness and prevention and you touched on that in your comments and think about how we approach to health care in this country, paying for good health, includes providing the centers for better wellness programs, senator wyden has been a leader in this who introduced legislation in the past called the better rewards bill, it basically says for Medicare Beneficiaries they would be given an Incentive Program to be able to help them with whether it is Smoking Cessation or Heart Disease or Diabetes Prevention things that overtime will save the government some money but most important to me to make their lives more healthy and so they can live longer, healthier lives. It has worked in the private sector, no question. The clinic in ohio, the best case of that where they put this in place for their own employees and seen enormous improvement in Peoples Health and it is a modest incentive and i know it works because it works in the private sector. Among seniors it will work even better so my question for you since we are looking on trying to make some changes to reintroduce the legislation because the Congressional Budget Office hasnt given us the score they should in my view but what is your view of this legislation . Would you support it . Dont think it should be limited to medicare, medicaid has application for this Prevention Wellness program. I have long been supportive of these wellness and prevention programs even when i was general counsel and deputy secretary of hhs as we looked around our regulations to enable these programs. And happy to work with you. It comes up so often medicare and medicaid were designed in a 60s, 40 or 50 years later we can be bullish as i said before without saying what we wont cover because it fits in a category even if it is better for the health of our people and save us money. Im happy to work with you on that. My time is expired and i look forward to your confirmation. Thank you, mister chairman. Congratulations to you. It is also thank you for four decades of Extraordinary Service and thank you for your personal friendship. Mister azar, there is a lot of chatter up here, we have 1 trillion hold, additional budget deficit over the next ten years added to the national debt. There is a lot of chatter among our republican colleagues that we need to make up for that. There is specifically looking at Social Security, medicaid or medicare under the guise of socalled, quote, welfare reform end of quote. Tell me. Do you think in welfare reform that it ought to be medicaid, medicare, and Social Security that would because . Im not involved in discussions. Im a private citizen. Im not in fault in discussions of what is being contemplated so im not aware of cuts in any way being supported by the administration. So im asking you for your opinion. You dont have to comment on what republican senators are saying, your opinion. Would you consider in order to make up all of this huge budget deficits cutting medicare, medicaid and Social Security . The president has stated his opposition to cutting medicare, medicaid and Social Security and remain steadfast in his views on that and the secretary would be to enforce that. Would you advise him to keep his word . I would stick with keeping his word on that. I dont have the broader context of any discussions going on. Im here on the sidelines of this. He made that commitment and i will live up to that of confirmed to keep his commitments. What was the last hhs secretary made some interesting statements about what he preferred. I am curious as to what you prefer. Do you support raising the medicare eligibility age . I have not voiced support for that. That would have to be considered in the context of everything else. What we have to do is make sure medicaid is sustainable for our beneficiaries over the long run. I know you agree with that. We need to come up with the right approach. I would like us to run medicare more efficiently and effectively driving value and outcome and stretching that program and making it more sustainable over time by how we operate it and as a result lead to great transformation to the Health Care System. That is where my energies are. Let the record reflect that the witness did not reject increasing the medicare eligibility age and i might say if you get out among the people you are going to run into people that did into their 50s and 60s and they are just holding on for dear life because they dont have any Health Insurance until they get 65 because they know they get medicare and they dont want it extended. Do you support turning medicare into a Voucher Program . Im not aware of any proposals to turn the program into a Voucher Program. What i want to do again is make sure our Medicare Advantage program which two thirds of new enrollees are signing up for Medicare Advantage and i played a role in helping to launch, a great option for seniors as they come into the program, getting high Level Satisfaction so i really want to make sure we are doing what we can to make sure it is a robust alternative for our seniors. That is where my energies are. Do you support closing the doughnut hole in medicare . Closing the doughnut hole . The Affordable Care act did have some funding that helps Senior Citizens when they arrive at the pharmacy, up to 75 coverage in the doughnut hole. Which im very supportive of. Of keeping all of that. Yes. Tell me about medicaid. What is your idea about medicaid . I want to make sure we enables likability for states to run those programs in ways that beat the needs of their citizens. I want to make sure in working with the states who have on the ground responsibility is a we are being a responsible and responsive partner of theirs and looking at likability trying new things. Excellent. Your time is up. Puerto rico. Medicaid for puerto rico. A block grant, it cuts off. We all need to Work Together on that puerto rico issue. We need to Work Together to find solutions. Mister azar, you for being here. I know drug pricing is very important. And beyond drug pricing, the issue of Health Insurance costs as well, very important, south carolina, 120 increase with last years 31 increase with policy exchange the no doubt we have to find a way to rein in prices our consumers are being impacted by in the Health Insurance arena. One of the ways we do that is through section 1332 waiver is giving states more flexibility in looking at the aca is the foundation, the catastrophic plans limited to 30 years old and below. I have legislation cosponsored by senator carver, warner and cassidy that would allow for the catastrophic plans to cover anyone who needs the coverage or once the coverage. One of the things i have often criticized the aca is the design plans are not suited for the individuals who want to buy the plans. As our next secretary, what would you do to expand Consumer Choice and encourage americans to make healthy proactive decisions . In terms of the Affordable Care act i am glad you raised the issue of increasing premiums and lack of choice that you are experiencing in south carolina. I believe if im confirmed as secretary i have an important obligation to make sure whatever programs im interested with work as well as possible. What we have now is not working for people. It is not working for the 10 million who are in the individual market. For many of those people it can be a false insurance card, very high deductible, not having access to providers so it is unaffordable use of care. I want to solve the program as you just mentioned for the 28 Million People who sit outside the market, dont have access to the individual market and by not being in that market causing premiums to go up for the people in it. Can we make those offerings, create more choice and make those offerings more attractive to create a better risk for that will help the taxpayer and people in the market, i share that commitment and want to work with states on the 1332 waivers and our authority to make that Health Insurance more affordable, make it real insurance and give people what they need. Next question on the Opioid Crisis throughout this country, through 2016 there were 64,000 deaths related to opioid. That is a crisis. In south carolina, 616 folks lost their lives, 9 increase. I would love to hear your commitment not only to address the issue from washington but lets get outside washington. Lets go to the rustbelt, lets go to the places where people are suffering today because of opioids and create remedies that actually work, that are not topdown but bottomup. Evidence suggests the best remedies so far have been created through a collaborative effort starting at the local level, moving its way up. I would love to hear you commit to running the hhs, going to places in West Virginia where they have the highest per capita with 41,000 deaths associated with opioids, places like orie county, myrtle beach where we have the highest level in south carolina. If we are going to understand and appreciate this issue in a favorable way we have to do so by putting a face on the issue not in washington but around the country. Are you committed to going to those places with us . Absolutely. I am a hoosier so im right in the epicenter of the crisis also and i do believe there is not necessarily especially when it comes to prevention and treatment programs there is not a 1sizefitsall approach and we need to get out there and see what is working, what different programs, not just to support them but replicate and make them available elsewhere at the epicenters in addition to we can do things at the center with regulatory authority, Education Programs that have to drive solutions on this crisis. Only 30 seconds left so i will make a statement encompassing my last two points. Number one, your expertise in valuebased arrangements would be helpful. Looking at opportunities in the future, there are a lot of innovative opportunities that will improve the quality of life every day americans and ways we cannot even imagine five years or ten years ago. I would love for us to find ways to make that access to lifechanging opportunities affordable. Second, as we through drug pricing i also think we have to understand the necessity of nonaddictive alternatives and the pipeline to get there. I hope there is a plan in place you are thinking expeditiously, approaching nonaddictive remedies as well as things that eliminate abuse. The last decade is a core area on publicprivate partnerships to try to drive nonaddictive pain a trip treatment therapies to replace legal opioids getting us into this mess. Senator warner. Let me join my colleagues in acknowledging and recognizing your Great Service to this committee and the people of utah. We are going to miss you and appreciate our Work Together and the fact that when you had a chance to keep me on this committee i kept on this committee so im grateful for that, great to see you again. I know my colleagues are asking about drug pricing. One of the areas i felt when there were specific policies we can implement, i have been concerned in many ways americans pay for drug pricing and part of the way is making programmatic changes here but some of this has to be dealt with in trade policies, we pay the highest percentage of drug prices is recognizing that you bring more than a little experience in this matter, your role at lily was involved in the pricing issues, what do you think about how we bring down americas americans cost of drugs, all the other industrial nations of the world . Thank you for meeting with and raising the important question. I talk about this is a critical issue for over 15 years when i was in government, that europeans, canada, japan, are not paying their fair share. They started investing through the framework basic program at the European Union and any ih primary research and funding but on the commercial side they are not paying more and able to have social systems with singlepayer socialist systems with single formularies, take it or leave it pricing and i we have to address that through trade agreements as well as trade negotiations with these trading partners, the fact that they are not paying but that doesnt solve the pricing here. That helps with relieving some of the burden of r d abroad. We have to address that here with measures i talked about but other measures am i would love to hear ideas you or others half because we are going to solve this with a list price level and the net price systemic savings level. How much more transparency should we have as Companies Raise prices in terms of rationale . Seems like a mishmash that is a bit arbitrary at this point . Im generally in favor of more transparency in the system. It is generally very helpful. We have to be careful with around pricing to make sure we are not doing something anticompetitive or counterproductive in what we are trying to do but if you have ideas i do think transparency can be part of the solution as we understand where the money is flowing in the system, who is getting the benefit from it and what is the benefit or harm to the consumer. As someone who for a long time did accept the premise we needed to do the r d here, that argument is runs in with me as we have seen americans bear this burden and we need more radical thinking and we have in the past. Touching on two other items. In your statement use that medicare shifts focus in the Healthcare System from paying for procedures in health and outcomes, that, everyone makes those comments. One of the things that came out of the Affordable Care act was cml i. I hope, it is not been as productive as i would like to see at times, it is still a tool that is useful and i would like your comments on the role going forward. I agree with you and i believe cmi will be one of the important legs to drive this transformation through medicare. We need to pilots, test and generalize. I hope we realize some of those pilots mac, you might have a disagreement on this, because too often those in the voluntary system have already been able to bring about efficiencies and we need to force more into the system. We dont disagree. I believe we need to test hypotheses and i want to be a reliable partner, i want to be collaborative, transparent, follow appropriate procedures but to test a hypothesis around changing our Healthcare System it needs to be mandatory to get adequate data. We have been working for a long time on advanced Care Planning and end of life issues. And put coding in for that consult. I would like to be on the record in terms of recognizing we dont want to limit anyones choices but we want to honor and respect choices about Care Planning. It is a very important part of our personal Care Management as we think about our life and health. Family members that we engage in that thoughtful planning of what we desire. None of us talk about imposing anyones view, to respect that individual. Enabling fat is important for us. Welcome. Congratulations, glad to have you in front of the committee and welcome your family, being very patient through this hearing and some questions already been asked because i have been to the Banking Committee going back and forth. Apologize if anything i say is duplicative. I was proud to work with my colleagues on this committee as we work through the historic tax reform bill. As you are aware, portions of that eliminated the individual mandate tax penalty. The obamacare individual market was the most unpopular element of that law and its penalty. Disproportionately affected, hardworking nevadans and americans across the country that were struggling to get by. Individual abilities to make their own choices about their Health Insurance and prevents the federal government from penalizing these individuals who cannot afford these. In my office, and what we discuss here, where will, under your leadership, hhs, what are you looking for with quality of access, Affordable Care, some of these issues move forward. I am pleased to see you taking time to answer these questions as we look at affordability and access and allamericans. The way we do it now, is not working for everybody. That is an unconfirmed, my job is to take whatever i have got so the Affordable Care act is there to work as best as it can. Part of that is driving a system that is more affordable, more affordable insurance, more choice of insurance, that gets them access, not a meaningless card for them, and insurance, what they should have. I work with states like nevada and others to come up with different approaches, no 1sizefitsall, not necessarily one right answer. This is very complex. We share the goal, we want people to have access to affordable insurance. We want to work on that. I am one of the authors of graham capacity. Have you formulated an opinion or decision of the direction of what you do like or dislike on that proposal . With the Graham Cassidy heller legislation, the elements that are positive are empowering states to run their budgets. The way we run the medicaid system is the matching system. It also means in running that program it is not all their money. They dont always exercise creativity or fiscal fraud, waste and abuse stewardship as if they owned 100 of that money so the incentives can be reoriented in a positive way by more state empowerment as you see through the Graham Cassidy health. You talked in your Opening Statement about access and competition. One of the proposals is competition and that is access across state lines. You can get Car Insurance, you can ensure anything except healthcare, you can even a Car Insurance from someone in connecticut, the way it works now. Have you advocated for this . The president has pushed hard to allow this competition, this access and this is the next step in the administration agrees with that. What is your opinion . I am supportive of those efforts and anything that can increase choice, access and choice, more options to patients and consumers of what they can buy the more likely they will find something affordable for the man that works for them. I only have a short time left with the chairman. We are looking at a shortage in american medical colleges. And 100,000 positions by 2020. How do you anticipate will be needed to cut those shortages . We have problems that help with physician shortages and support training with medical education or Health Professions programs, for instance tuition subsidy and reimbursement programs and those are directed more towards underserved area, the most rural and remote areas, and if you have anything, how do we address that shortage . With senator nelson, the residential positions shortage reduction act. And an opportunity to look at this legislation with residency of 50,000 in the next five years. I appreciate your chairmanship in this committee. Thank you, mister chairman. Senator brown. Thank you for your earlier comments. I know you werent there at the creation, you can convince Mitch Mcconnell who has resisted moving on chip, september, october, november, december, now it is january, you can use your gravitas and hard work to convince him to do the right thing. We will get it done. 2016, 4000 ohioans, one of your home states died from opioid overdose, 11 people in the state a day. You say if confirmed one of your Top Priorities will be addressing the Opioid Epidemic, i am appreciative of that. We are in a state of war. My question is yes or no, will you commit to prioritizing this issue . Absolutely. We need Stronger Leadership than we have seen. The secretary of hhs engaged in this comprehensive approach. Will you commit to protecting the integrity of the Medicaid Program including Medicaid Expansion as it currently exists . If we look at any changes to medicaid if congress were to look at any changes to medicaid, how do we address people suffering from Substance Abuse that are currently Getting Service under medicaid, something we would have to look at to meet that need. Let me stop you. You used the term ablebodied adult when speaking about medicaid, and you were given medicaid reform and work requirements in medicaid, a great deal of thought. Does an individual diagnosed with severe Mental Illness or Substance Abuse disorder, is that person ablebodied . I dont have addition in hand. It is something to work on with congress that i share your concern. Would seem pretty obvious. You have no definition of ablebodied, appropriate for differentiating between and among medicaid recipients who share with us. Philosophically i would like us to work in the programs to avoid any clips we have in benefit to smooth out the approach so individuals have an incentive. You can understand our skepticism and concern that we hear top elected officials and appointed officials talk about ablebodied adults and disqualifying them for medicaid and we realize in my state, 200,000 people right now are getting opioid treatment. Mostly through medicaid and i was with a gentleman in cincinnati sitting next to him and his 30yearold. Com he turned to me and said she wouldnt be alive without medicaid. You spent with 6 years working at hhs many as general counsel, looked at definitions of medicaid and much else. Confirmed he will be in charge the regulations. That is why all of us want to know how you could rationalize requiring individuals struggling with an illness whether it is cancer or opioid addiction or severe Mental Illness. And struggling with those illnesses to remain eligible. Special and requirement in direct contradiction to the objectives of the Medicaid Program. If you consider someone with cancer to be ablebodied what about an individual diagnosed with depression . I would like you to please submit your proposed definition of ablebodied to this committee included in todays hearings before this Committee Votes on your confirmation. I dont have a proposed definition. You are imputing to me a desire that i have not stated. I want to work on are there ways to make the program be customized to different types of beneficiaries. I never singled out i have sat here and seen members of this committee, all of whom had insurance by taxpayers trying to strip medicaid away from in my state we have got to keep medicaid in place, to the expansion in place. To Medicaid Eligibility, 200,000 ohioans getting opioid treatment who get it because the formal care act Holding Government insurance themselves ready to take away. I apologize perhaps, but excuse my skepticism, you are not there yet. They thought about the definition of ablebodied, senator nelsons comments, blown a hole in the budget, we have to close that who told. And generally conservatives dont like, medicare, Social Security, medicaid, Unemployment Insurance to cover this, what happens to these people . My time has run out but i hope you will think those 200,000 people in the state you lived in for part of your childhood, how they will lose their opioid treatment, Addiction Treatment coverage if this administration does what it tried to do. You said donald trump is living up to his promise not to touch medicare, medicaid, Social Security but the fact is he isnt because he wanted to sign a bill that would strip medicaid from those 200,000 ohioans. I need answers for them. The company you worked at, welcome. Which was larger . The last year you were in charge, the budget for research and development where the budget for advertising. The budget for research and developing, the budget is approximately 5 billion out of 20 billion revenue. How much was the budget for advertising . I dont know the exact number across the board, it would be less than 5 billion. Could you get that figure . I wouldnt be able to, that is proprietary information. The cost of advertising has dramatically gone up for pharmaceutical companies. Everybody knows it because you cant watch an hour of tv without being told what you should ask your doctor to prescribe. Do you believe the american taxpayer should be subsidizing Prescription Drug advertising . It can be helpful where it causes an individual to think about a disease condition to assess that and a call to action to address that. I share your concern. There is a lot of drug advertising on television. I share that view. I could be thin, happy, i could even, the one that kills me is for erectile dysfunction, i have two bathtubs. How crazy is that. I do not understand why the american taxpayer is subsidizing this gross overuse of television advertising, not for overthecounter where you need information but to tell your doctor you want it. We have taxes for business expenses across the board and everything we do in business. I agree that there are a lot of other consumer advertising, it does seem there is so much of it. I would love to work with doctor gottlieb, the balance to how we authorize and approve direct consumer advertising. The have data, is it not working and patients taking the right message . It is working. People are the most heavily advertised and prescribed. My question is should taxpayers be helping foot the bill by it being deductible . Do you believe in capitalism . I do. And freemarket . I do. One of the most basic tenets of freemarket is negotiation for prices based on volume. Walmart became the behemoth they are because they negotiated with their suppliers, got lower cost to that which they passed on to the consumer. Yes. You said earlier today the, quote, every incentive is towards higher prices in pharmaceuticals. Do you believe negotiation would be an incentive to lower prices . They lower net prices off of list price, and it succeeds quite well. That would be incentive that in your testimony there is no incentive to lower prices. That is unfortunate. It is not incentive on list prices which we have negotiation that pulls down whether taxpayer pays and the individual pays but that list price i am aware there is a lot that goes on behind the curtain. Im very aware that for most folks that are getting their drugs, getting more and more expensive and we do not have the ability to negotiate for lower prices based on volume. Incentive mccaskill i am very aware there is lot going on behind the program. Im very aware that for most folks that are getting their drugs, theyre getting more and more expensive and we do not have the ability in the federal government to negotiation for lower prices based on volume. Remove the provision that prohibits the federal government from negotiating for lower prices. That is what the Congressional Budget Office has saidas you would not get better pricing by removing that. Thats crazy. Thats just nuts. Theres something wrong with thr system. What you telling me with a straight face is if we remove the provision that prohibits negotiating for lower prices, that its not going to make any difference in the price . There is no provision for negotiating for lower prices. That is happening now. The government has these entities that do that negotiation and they are the government could do it directly. You have all wouldnt that save us money . It wouldnt do any better. Theres a middleman now. Theres a middleman now thats doing that negotiation. Its not the government. They do it better than the government. The government benefits. You were saying because of private sector we should pay somebody to do it in the middle because the government cant do it . What we should be doing is those techniques that drive such good net pricing, what can we take from the learnings into part b where we, i would focus, part b which is physician administered drugs where we pay Sticker Price plus a markup, nom negotiation out of the governmented or any other entity can we take learnings from how we are managing to be under budget in part d on her expenses and managing a Program People enjoy have High Satisfaction and take some of those learnings into part before taxpayers and if we can drive prices down that hits the patient, the Senior Citizen outofpocket because they always a percent of that medicare reimbursement for drugs. I will work with you on part b but i refuse to acknowledge what you you are saying, that e pharmaceutical industry wanted that in the law for a reason. They lobbied for the the guy who helped get t it through went to run pharma after he finished getting through. It wasnt average consumers that want to make sure it was illegal to negotiate for lower prices. It was pharma and there were powerful and the did it. I refuse to believe that they didnt want that therefore a reason. Thank you, mr. Chairman. Thank you, senator vitter senator cantwell. Thank you, mr. Chairman. In light of your news of your decision, i wanted to thank you for your work on the low Income Housing tax credit, not just issue buffers over years in making sure the Program Continues to work costeffectively. Thank you so much. Could i i make one comment before you begin . I believe having listen to senator browns questioning, idly senator mcconnell is supportive of our chip agreement andom i hope that our colleagues are near the side, especially help convince senator schumer to support this as well. Mr. Chairman . I i havent seen so far. All i can say is i havent of very few seconds. I appreciate your interest in getting this done. I spoke on chip on the floor yesterday senator schumer came right after me and said he was very much committed to our legislation, our bipartisan legislation, so thank you for that. Okay. Senator cantwell. Thank you, mr. Chairman. I would be remiss not to mention i met with my Provider Community this week and on the chip issue, and the level of anxiety in making sure we have continuity, notices that patients are getting is starting to definitely cause anxiety. But anyway, i wanted to go back to medicaid ifef i could. Our expansion was over 600,000, and our uninsured rate was cut by 60 , uncompensated care was slashed. So to me the expansion has been a success. Do you support and and or sunset or curtailing of the Medicaid Expansion . I want to implement the program weve got. If we end up but looking at in changes on the Affordable Care act Medicaid Expansion i dont believe that the proposals the president or i would support involve cutting medicaid or cutting the expansion. Or rather slowing the rate of growth over the next ten ten ys in the interest of sustainability. Thats my understanding of the math on that. So youre saying you support the block granting . Whether its a block granting or other changes to block granting, the devil there is in the details comee is her enough money for the program, you would have to figure out appropriate formulas and approaches around whats theth matter of money there. There is a lot that can a few from notions of block granting because it helps align incentives the states have empowerment and the accountability to manage those dollars as their own, and as washington does, really deep creative and customize the use of the program and stretch it for their citizens. I doth think theres much they n be appealing. Listen, i get you are a nominee by those in f the decisn by want to be really clear on this point because myha status been with a clear. The proposals that a even considered a block granting an percapita cap, my providers have been very clear, very clear. It is no innovation. It is simply a budget mechanism to cut medicaid. And the cbo saying that it would end up cutting onethird over the next two decades, i think, is supportive of that. My support of you is going to be based on this, not because of politics of who you are or any of that, is going to be on whether im casting a a vote to continue these policies or not. They are working and my state would be the first, the first to innovate because we already are and we had some conversations about that. I want to be clear that i view the previous proposals of block granting and percapita cap as cats come as my Provider Community has made very, very clear to me. Theyve also said that with that kind of approach they expect a private markety insurance rate o go back up, that they seem downward pressure on those prices giving expansion, and didnt want to see those go back up. So okay. Do you support the delivery, another example of that is the Delivery System reforms we were able to do to get the population to move off of longterm care to communitybased care. Impo assuming you support those kinds of efforts as a true way downforming and driving costs . As we are spoken inn your office i am completely supportive of notions. Sometimes institutional care for some individuals make sense butt alternatives homebase, of the care, im completely supportive of these kinds of innovations. What could weca do to drive that took faster implementation . Because we incented states to do it under the Affordable Care act but if we took a more aggressive approach that what you would see some savings. I dont know what the berries are. I dont understand it. It seems so attractive to me. I dont understand it. So i would love if confirmed to get your ideas if there are things that hhs is doing that are getting away that i would want to do that because im 100 committed where you are on this issue. Do you support medicaresat move from feeforservice actually depicts one of the priorities that i would try to focus on as secretary. What about the basic health plan which is part of do support the concept of allowing some states to bundle up their low in the population try down costs . It seems to me and i would like to learn more about from our meeting. Seems to me a very attractive notion of . How one helps in the transition between the Medicaid Eligibility and the subsidy elements of the affordablee cae act. I want to learn more about it but it seems to be very attractive. Thank you. Thank you, mr. Chairman. Senator wyden. Thank you. Thank you very much. Mr. Chairman, a couple of questions. I want to make too unanimous consent request of the might to put document into the record at this point because i think mr. Azar has come in response to colleagues, given incorrect answers. Senator nelson, for example, asked whether he was supportive of the president position with respect to these issues, medicaid, medicare or salsas goodie. Mr. Azar said the president promised he would not cut it and he is s here to that promise. That is simply untrue. The president s first budget proposed cutting medicaid by hundreds of billions of dollars for proposals like block grants. Id like to put the budget into the record, not the entire budget, but the part that indicates the answer to senator nelsons question isnt great. Also, we have just gotten information will be happy to do that but we should let mr. Azar respond to that. This is just a request to put information into the record. Your earlier statement, i wonder if he has any comment about that . I think this has to do with washington speak, that a come slowing the rate of growth of a growing program is simply not a cut in my mind for the president ste might. We are talking about hundreds of billions of dollars, and the state medicaid directors point pointblank said no flexibility is going to make up for the fact were talking about hundreds of billions of dollars worth of cuts. I also asksk unanimous consent, mr. Chairman, that we put into the record documents from the pew trust and global data that certainly suggest the answer to senator mccaskill with respect to advertising in r d was incorrect becausewi in 2013 according to these documents only spent 5. 7. On sales and marketing, and 5. 5 billion on r d. And he said that these budgets were not remotely close to each other. So i would without objection. Let me know if i couldho just mr. Chairman, i would clarify. The question was the advertising budget which was about direct to consumer and theres no way that to even remotely close at 5 billion at lily. Not overall sales general administrative expenses. I dont have a Balance Sheets inferno means i cant speak toet that but i know there is no conceivable way in the advertising budget at eli lilly was remotely close to the r d spending. We will that people evaluate that data. You said that you were far apart. Thats thats not the documents. Let me go to my two questions quickly and appreciate the chairman on this. Affordable care act weeks before at the h. E. L. P. Committee you said you supported proposals that would wipe out the medicaid guarantee for our Senior Citizens. This is the guarantee that picks up the tab for two out of three older people in nursing homes. 4000 changers in oregon each day and you would wipe out that guarantee by folding medicaid into a block grant. Id like to know whether you still support walking back the medicaid guarantee for these older people, and again, as i indicated the nonpartisan medicaid directorec stated, quo, no amount of flexibility, their words, not mine, are going to compensate for the types of cuts. Would you like to walk back your earlier position is with respect to that commitment to all the people who did everything right, thought the worst, that they will still have a guarantee of nursing home covered . I believe what we talked about at the h. E. L. P. Committee hearing was around the fact that block granting, that i i can fd a lot of appeal and block granting. As i said to and there, the devil is in the details how one stretches the notion of any type of block grant both in terms of the dollar amount and what strings from the government are attached to, in terms of who needs to be covered, who is eligible but not necessary to cover. E that all we need to be worked out in legislation whichch we ae far from. Why dont you amplify this for the record because the chairman scooters and going to do this last and quickly. It looks to me like you still want a block grant which the state medicaid directors say no amount of flexibility is going to be able to compensate for the cuts. Lolast question, we havent tald to to her, title for a of Social Security. Of course what people know as welfare, afdc, a hugely in port and programs help families escape poverty and find work. K. Right now it looks to me like a measure of success, the major measure for success is reducing caseloads at that program. Id like a different measure and would like to see if you would work with us on it. Id like a measure of success to be finding jobs for people so you can get out of poverty. So the question is, thats not the measure today. Would you work with democrats and republicans to change the measure, to actually change the program so that the measure is not reducing caseloads but it is having people find work to get out of poverty . Thats a yes or no. Absolutely. Thank you. Thank you, mr. Chairman for the extra time. As i understand senator casey is one question and then we will wrap it up. You have one,ch too . Mr. Chairman . A goahead. Thank you ver y much, mr. R. Chairman. Mr. Azar, i wanted to ask an additionalai question regarding the approach the administration has taken t with regard to implementing the Affordable Care act making our Health System work, Health Care System work. It came to my attention at a think the attention of people across the country from a store in politico of the efforts made thero administration to what i would argue the sabotage the Affordable Care act. I have report coming out the outline some of those actions taken in restricting enrollment is one come , canceling coveragl kinds of efforts undertaken that resulted in us pushing to get a document from health and Human Services. It took months to get. Now we are told that theres a new document that wee referred o in a letter that we said december 21 to the acting secretary. We stayed, and im quoting from the letter, hhs has developed a list of hundreds of other actions to sabotage healthcare for people nationwide. We go on to say reference a spreadsheet. We conclude by saying please provide the spreadsheet list ised above which lists more than 200 regulatory actions the administration is planning to take to further undermine healthcare. Thats our request. The response from hhs january 5 fifth said they will not turn that over. In our h. E. L. P. Committee hearing, you said the following when asked you about a thought in permitting the Affordable Care act, you saidke quote, my b is to faithfully implement the program thats passed by congress, whatever they are. That would include the Affordable Care act asth the law of the land and remained such. To implement it as faithfully as possible, unquote. So my question is in light of this recent history, not theory, history of what i would argue is sabotage, do you commit to providing that document that i referred to in the letter sent on the 21st detailing the more than 200 planned regulatory actions that was developed and maintained by hhs . Would you provide that and provide in ama timely manner and without redactions . Ill be happyul to look at that. As of nowme many i cant commito governmental action that i dont know if that document was prepared during the Obama Administration or drink the Trump Administration. All i can tell you is if i am confirmed as secretary, i am a problem solver. I wantmi to work with you and every member of this committee and other committees to make this program work for people as best it can. I do think changes are needed. I think statutory changes are underway. Whatever we can do i want to make insurance affordable, i want to make it work, and so you have my commitment. I appreciate that but this document was developed under this administration, more than 200 actions, and its hard to square your statement in the h. E. L. P. Committee and some of the statementsou stay with faithful implementation with this undermining of the Affordable Care act comeod with your support which is evident from some of the questions for legislation that would further undermine it, especially on medicaid. I hope that the American People will have the kind of transparency that they should have a right to expect when it comes to this kind of sabotage. Thank you, mr. Chairman. The last question, senator carper. Thank youesna did you have one more question . I had questions, yes. No, let me first go to senator mccaskill and then on, do you, senator carper, and yu are going to be last. Senator collinsas and i did a long afterto investigation in te committee on last year on price spikes. A couple of really good poster children for hedge funds found a drug that was being sold for pennies and they managed to spike them upug the thousands ad thousands of dollars. You have a chance to read the report from our investigation . Ive only seen summaries of it but i do want to look at that and get any ideas that you all were able tom come up with ther that we could do if im confirmed that hhs to work on these issues. I would appreciate that. We spent a lot of time looking at it. Its obscene. Really, nobody was happy when he was convicted. One of the things i know, i dont know if you work with dr. Gottlieb on this yet, hes very concerned. Theres this issue of these generics and competition more and how can we build competition and invited in. I very committed on that. Deeply the patent system is being abused . I believe there are abuses. Do you believe the orphan drug law is being abused . I do think we need, i dont know if i want to call it abuse. I want to look at it more because i dont know enough to use that word. But i know there are issues around contingent exclusivity across all indications or expansion where this an orphan indication. I want to look atwa that. It may be simply what the law provides in which case if we dont like that thats a legislative question as opposed to manipulating lupo. I dont know. I would love to learn last weekgi it was announcedt went from zero to 15,000 a bottle. That drug is been around for decades. For decades and they just slapped 15 15 grant on one bote of it. Theres something really volunteer. Im going to take you att your word. We all skeptical over because of what weve been throughhe the lt 12 months, but i hope i can come i hope if im confirmed i can earn your trust and your confidence of my treatment on his issues. Me, too. Truck prices are huge problem right now. I i want to work with you and hope you for now you will say, you know, you proved me wrong. I hope so, too. Thank you, mr. Chairman. Thank you. Senator carper. Would you just briefly tell us that evokes are right behind you. Was yes. Thank you thank you very much. Im joined by my wife jennifer, my daughter claire, my son alex, my father doctor alex azar who was in newark downward when he worked at dupont when i was a child and growing up. My sister stacy and her husband, nick. Welcome one and all. Glad you areeyus here. When i was governor one of the things we focused on we set up Family Services Family Council that about half of my cabinet and we focused on the basic Building Block of our society families, i do strengthen a stabilized family. We started with a statewide campaign on teenage pregnancy. Delaware had one of highs teenage pregnancy rate. We put together a bunchf of kids in the state to tell us what we ought to do in a comprehensive statewide approach. And we did it. The teen pregnancy rate in delaware is a lot more than it used to be, still too high but the unplanned pregnancy rate in our state come in a a country still about 50 . Think about that. Around 50 . One of the most reliable forms of contraception available something called long acting reversible contraception, most reliable form of contraception, less than 10 of all women take advantage of in uterine devices or implants but they work. That work for a long time to get out on it without taking them everyday or stopping what youre doing and get ready for making children or not. But at any rate, what are the policy and economic barriers to expanding the uset of these log acting reversible contraceptive contraceptives . Ex the steps do you think we could take to expand access to them and lower the rate of unplanned pregnancies in the United States . Again, roughly half of the pregnancies are unintended. A lot of them really young people who were involved. I am not as knowledgeable as i would likend to be and would love to learn more about it from you. I am assuming we provide that to title x at hhs but if there are barriers i would love to learn more from you about that. Obviously if you study this than i have. Im one who believes in going after root causes. The problem, one of the problems in our society is poverty, and i think was Marian Wright a human who used to say you take a 16yearold girl who was in high school, she becomes pregnant, as a child, drops at a school, doesnt marry the father, her child has an 80 likelihood they will live in poverty. Same 16yearold girl does not become pregnant, does not drop out of school, waits until to one to have a child and marries the father of the child. I likelihood that and it will end up in poverty is 8 . 80 on one hand, 8 on the other. When i found out that, i get serious. Last year massachusetts under the leadership of governor charlie baker, very impressive leader, they passed legislation for all Health Insurance plan to cover all forms of Birth Control without costsharing. I want to ask, again this may not be fair but if not you can say so, but do you agree with the massachusetts requirement that all Health Insurance plans in the state should cover all forms of Birth Control without costsharing . I have no issue with states making those choices. Thats exactly competition states making choices like that. Thats what it ought to be doing is making the choices about how to run their Health System. All right, thank you. Senator mccaskill was asking questions. I can in the room on drug pricing, and hope im not good to same territory but when asked this question nonetheless, so if you will bear with me i would appreciate it. Current administration has repeatedly promised to tackle high druged prices. They have neglected to back up the rhetoric with meaningful results, at least to this point in time. Several Drug Companies have tried to address the challenge of high drug prices with more Price Transparency and proposals for valuebased pricing. What regulatory and statutory barriers impede the use of valuebased pricing to lower drug costs . How would you bring together the Drug Companies, one of which used to lead, how would you bring together pharmacy benefit managers, health insurers, other stakeholders to put together a valuebased drug pricing proposal that can be implemented quickly to bring some relief to consumers . Its a great question. You put your finger on one of the key issues, is the van valuebased pricing, how can we have outcome based, valuebased, pay for the value you were getting on the drugs. One of the Biggest Barriers is the price reporting regulations that hhs task. It really has h to do with how u reportpo over time because of course your striking an agreement and paying for a drug here, but then it might be several quarters later into you get the on the results, and the problem is and youd end up having a true up or a change on past price reporting which is generally not viewed as a good thing. I do believe this is within hhs jurisdiction that if i am there, we can fix at an address that to create pathways or you can put your money where your mouth is and support the value on the drug. If it doesntt deliver, then py more discounting or rebates in return. So i actually think this is very actionable, senator. Thats great. I want to commend you on your choice of people to sit up there with yet the beginning of the hearing. Mike succeeded me. Tommy thompson from wisconsin who precedes all of us as chairman of the nga, one of my favorite people, loved being there colleague. You could not have to find people sitting next to you. I think you got some good when sitting behind you as well and i would say one of him who worked for the pot for many years, my wife retired from dupont went to work there gosh, over 35 years ago and had a great career. We love dupont in our state as know. Thanks. Thank thank you, good luck and congratulations. Okay. Well, we finally got got to th. I want to thank you for what i consider to be a very elevated testimony. There are still question in my mind and that shouldnt be in anybodys mind of your competence and your abilities to be able to handle this very, very important job. In all the time i have served in the United States senate, i have e worked with hhs and other agencies as well, and i have to say that you are one of the best Public Servants that ive seen in the whole time that ive been here. And i think you handled yourself very well in front of this committee, and hopefully we can get you up and out as soon as we possibly can. So with that i just want to welcome your family and thank them for sitting through this. Come back andto say vote everybody, but god bless you and with that, we will recess until further notice. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] sunday night on after words Georgetown University law professor Peter Edelman looks at the way court penalize the poor through excessive fines and fees in his book not a crime to be poor. The criminalization of poverty in america. Is edited by georgia congressman hank johnson. Was poverty an issue in terms of the war on drugs or the victims of the war on drugs . Sure. How did poverty play internet . What happens to families, what happens to the men who have been locked up and all the collateral consequences so they cant get jobs. They are not allowed to live in public housing. 45,000 laws across the country, collateral consequences of one kind or another, it destroys somebodys life. If they were not poor when it went into prison, there definitely poverty stricken for the rest of their lives. Its totally connected to poverty. Watch after words sunday night at 9 p. M. Eastern on booktv on cspan2. This weekend on American History tv on cspan3, saturday at 8 p. M. Eastern on lectures in history Lebanon Valley College professor on the lead up to the american revolution. We will have a tax on things the colonists import, paper, lead, class, he picked and we will collect it at the port. Nobody else has to be bothered. Thats that. Big surprise. Where outrage, more anger and more fear. Sunday at 4 p. M. On reel america, in 1963 film assignment i ran. He learns techniques to sustain himself in distant reaches of the jungle, or an arctic wasteland. Above all he knows the ultimate alternative faced by the special forces man in action, adjust or die. And that six on american artifacts, a preview of collections for the use Diplomacy Center museum set to open next year. Benjamin franklin, silas deane and are thoroughly who are really Americans First professional diplomats conducted these two treaties in this treaty of commerce was essential. Granted france most favored nation trading status. The french were very excited about being able to get into the economic trading war with Great Britain after the war was over. This treaty would remain in effect for several years afterwards. American history tv every weekend on cspan3. We are live this morning for a forum on the cost of building a wall among the u. S. Mexico border. Texas democratic congressman Henry Cuellar represents the border district will talk about its potential impact as well as the implications of the Trump Administrations broader immigration policy. This will all begin with a presentation about security on the border featuring drone footage. It should get started in just a moment. Live coverage on cspan2. [inaudible conversations]