My name is Kathryn Martucci on the director of policy and programs at the alliance for Health Policy at i had the pleasure of welcoming you all on behalf of the alliance to our Breakfast Series for reporters. For those who are not thinly withfo the alliance, we are a Nonpartisan Organization that is dedicated to convening and educating Health Policy community through a Balance Exchange of evidence. We are so thankful to bill pierce and Apco Worldwide for supporting the alliance and put it on this syrians with that support weve had the privilege of hosting many 15 guests and Panel Discussion over the past couple of years, including joe grogan and we are honored to welcome back to be properly you have the decision being our first repeat guest picky joined us about a year ago when is an associate director at omb and to look for doing about your new role and healthcare priorities as a director of the Domestic Policy Council. So thank you for being here again. Thank you to all of you for being here and with that i will turn it over to bill to get us started. Again, welcome on i behalf of apco where along with the alliance we think these are important events to hold, the importance of important thing to hold since we believe strongly a well informed press is extremely important to the washington d. C. World and that a dialogue like this is extremely important so we really appreciate you willing to come here and subject yourself to the questioning of this group of folks. Im senior director at Apco Worldwide. Joe and ive known each other for quite some time. Worked in theit bush of ministry together and ask catherine noted this is the second go around for the first time most of it okay that i t guess. We appreciate you coming here today to joe has had a distinguished career in the private sector and thegu public service, and so we are welcomed come welcome you back again. The only admonition i would make as we turn it over to question and answers, that you state your name and what outlet you are for. We are live on cspan2, so welcome cspan2 viewers for its mostly for their benefit so they know whos asking the question and where youre from. That would be greatly appreciated. With that i would like to turn over to joe. Take it away. Thanks for having me back and its good to see some of you reported again and for those of you who i dont know, i look to the opportunity to be asked a few questions and share with you our views on health care in the trump administration, some of the ways the Domestic Policy Council functions and tell you a bit about some of the other issues we are confronting as well. Just to start with how the domestic policy functions and what it ista we do on a daily basis, other administrations perhaps have had a more linear defined area of responsibility for itsef senior white house officials picked this administration, this president has very entrepreneurial o styl, consistent with the way he has lived his life and he expects his Senior Leaders to pursue issues and an entrepreneurialer manner it requires us all to work in a very horizontal, collaborative fashion. A lot of times there is, there are stories in the d. C. Media about how theres tension in this white house or tension among Senior Leader. First of all, tension is not a bad thing, but to the extent that there are overblown factions or any of these things been reportedly on, it is wildly overblown. The Senior Leadership in this administration gets along extremely well. I spent a lot of time walking tie halls visiting Senior Leaders offices, giving a bind on issues before we go into the oval office. We have robust and open discussions in front of the president. I can tell you thiss week we had a meeting with the the presided we had i think 14 people and their two briefed him on issue for which she had to make a decision. We couldnt find a Senior Leader of the team who disagreed, so we went and found somebody else who could take the counter side so the the president would get the benefit of understanding a different side of the few and ultimately he made a decision. He works well when he watches people debate both sides of an issue and then hes able to make a decision. I love working in this white house. Its a lot of fun. I like the Senior Leadership team here that doesnt mean we agree and everything but thats fine. Found is if a team of people respect each other and work well together and has the best interest of the present and the American People first and foremost. Beyond that i would say my philosophy at the council is there some issues which we are lead, health care is one at a think is what we will talk about for the most today. We are lead on other issues as well. Labor issues, for instance, but where we are not lead we want to support so we want to be as helpful as possible to advance a policy agenda, for instance, larry kudlow at the National Economic council with the lead for tax policy. If there is something that crosses over into the domestic policy lane, say health care, a big achievement of this administration is tax policy and Health Care Policy is to fulfill the individual mandate. We would help make the argument to the present look, this is something that should be repealed, it makes no sense, its odd with our belts. There are other issues which i may not be lead on the issue but i will into the oval office with another principle and say look, this is in my opinion, what we should do. Comports with what the other principal wants to do or heres another take on it. We lead when we have the baton, and we support when someone else does and its all to move the ball forward for the president and the American People. One thing that people sometimes in this town struggle with, because mr. Trump is so different than the traditional politician is to say, well, what type of approach is he taking on this . Hes very nonideological picky did that come in with 50 years of Campaign Donation from particular vested interest, and a defined philosophy, except for this. He likes to solve problems. He will ask a gazillion questions to figure out the right answerr to something, and he stepped necessarily interested in somebodys opinion just because of their title or status. He wants to know from expert. I have watched him look over cabinet officials and ask a question of a 20yearold or a 30yearold staffer sitting on the couch in the oval office, and ask their opinion about an issue. Because he wants t to know the right of the payment and he wants to know keeping the people who are expert on any given subject. Hes told the story about being on the uss jerry ford and asking the Maintenance Crew whether their preference was for the magnetic launches for the aircraft on the Aircraft Carrier or the old steam launches. They said steam, and he said why . They said when it breaks we can fix it. Many went into a description description of how long it takes to load a plane into position and why the steam made more sense. I can submit to you i can think of a president in my lifetime that would go over and asked the guys doing the actual work each and every day what their opinion is. Now, that decisionno of the president to prefer steam im sure would anger a lot of defense contractors. It would anger a lot of procurement officers, anger a lot of project officers who were behind that, but this this is a president who doesnt really care about offending special interests or people based upon title turkey wants to get to the right answer for the American People and is willing to talk to anybody who has expertise in real world experience in it. I know theres this other impression that people who havent been able to hack it in thead Administration Come out ad they wilt under the president s questioning. Well, tough, to be perfectly frank with you. The president asked tough questions of a lot of people he puts people on the spot. Obote people can handle it so thats the president s style turkey wants to make sure you understand what youre talking about and that you have the courage of your convictions and its an environment that i enjoy and a lot of other people enjoy. Some traditional d. C. Dwellers cant really handle d it but thats not this president s problem. Its their problem. When they go out and whine about it to the media or give anonymous post after the fact, it should be taken with a grain of salt because they had left for a reason. This president is almost ive gotten calls at seven, 7 15 in the morning when i know hes been up very late at night the night before and he exhausts the people, many of the people rented are not able to keep up. Thats just the way it is. On health care, i think consistent with the president s of you, that are lots of problems that need fixing. This is can we taken an approach that is not bound by any particular special interest. It wouldve been easy forot the president to say im going to solve the drug pricing problem by throwing more taxpayer subsidies into the system and helping people do outofpocket copays. Instead he has challenged pbms, payers, manufactures, all publicly come rhetorically and with serious policies, we have three major legislative agendas as a close out the year. Drug pricing legislation is one of them. It would be easy to have gotten a deal to just appropriated more money and spend more taxpayer dollars to quoteunquote solve the drug pricing problem but thats not what he is wanted to do. He wants to lower list prices, clear out a lot of the convoluted incentives that drive prices up and expose patients and the American People to excessive costs. And consistently across the health care agenda, youve watched him and his team confront issues that other administrations have ignored. I worked in this country the Obama Administration. Ad you could not get a meeting in the Obama Administration with a senior official on health care subject that did not involve the aca. Theres 13 Million People in the Affordable Care act. Theres 100 million, 89 people nine people in the employersponsored market. On confronted and much of the Opioid Epidemic was fueled by taxpayerfunded programs. Medicaid and medicare and prescribing guidelines putout by the cdc that should have been addressed more quickly. The list goes on and on. Transparency will have hopefully anotherannouncement this month , maybe in december but im hopeful this month. There are a lot of people who do not want customers and the American People to see where the money goes in the Healthcare System. They thrive on opacity, on arbitrage created by the lack of transparency in the healthcare market. Theres a lot of money flowing through the Healthcare System and unless we get at confronting some of the vested interests that have been making a lot of money yearoveryear on this, theAmerican People will continue to be exposed. But other problems, the Kidney Health initiative, that program had not been modernized since Richard Nixon created it, modernizing the developmentof influenza vaccines is another example that we are doing. Back to opioids, weve got yearoveryear declines in opioid deaths which is significant. On drug pricing we also have yearoveryear declines in races for medicines. First time in 50 years and thats a direct result of the president throwing so much attention to this issue and forcing companies and manufacturers to negotiate more aggressively so i love working on these healthcare issues. With this president , because it is a wide open picture. It isnt one issue. He hasnt concentrated on one problem. He says give me a problem and you guys figure out how to solve it and i will back you and i dont care what special interests or what lobbying group we may offend. Just Work Together and solve it and on healthcare last thing ill say before i open it up, it is probably the best integrated team of any subject that this tadministration confronts and when i say best integrated being honest so on healthcare , when we have a meeting with the president you will have a lot of people in the meeting. Sometimes we have to have them in the roosevelt room because a lot of people are interested in the subject. Kelly and conway will show up, larry kudlow will show up, white House Counsel will show up, head of omb will show up and we worked well together on the staff level and principles level, we bring a lot of different views and perspectives. Thats why theres some issues where were leading alternative larry kudlow or some other member of the team, can you take the lead on this issue because your person is ideally suited to move it forward so its a great team of people. To work with confronts hard problems, hard challenges and its a pleasure to be a part of it. Thank you joe, i think that was a good overview. Im going to ask two quick questions and i will turn it over to you for questions and the two questions are one close out of what you just said which was then how do you work with the apartments . And the second question is are there, one or two issues that you the Domestic Policy Council works on and i dont need a detailed answer but one or two questions you work on that the public doesnt know a lot about that you enjoy, that you think are important, that you enjoy just to give a little more depth to what the dpc does. We do a lot of issues and maybe where not out front and center on a daily basis. Yesterday we had an event at the white house in the oval office with victims of communism to highlight, this is the first president who signed the proclamation to recognize the hundred Million People who were killed by communist regimes. We had a group of people who had suffered under other communist regimes tell their story to the president , the Domestic Policy Council on so co that event and spoke to the press and some were on television today to make sure that the American People recognize the importance of fighting for freedom and the struggle against communism that still continues today. Religious freedom is another issue where involved in that a lot of people dont see you this is a president who respects and religiouS Institutions and isnt contemptuous of them andwants to make sure people arefree to practice their faith. Human trafficking is another issue that were working hard on. Its an issue that exploded with the rise of the internet, the dark web. Some of the stories that are, that we here are prettyawful. Its not just labor trafficking, its also sexual trafficking, not just t international, its domestic. Its not Just International criminal gangs, its domestic gangs and Family Members often and its a tragic situation. Workforce development is another issue. I work closely with yvonne petrov on that. Education issues so theres a whole host of issues. Agriculture issues that we work on sometimes. And like i said, anything we can be helpful on that we have bandwidth you we can, we roll up our sleeves. How many staff is there dpc. Were over 20 right now including details so we take a lot of detail from departments to come and help on a specific issue. I got somebody from the interior department thats a talented attorney who is helping on some of their regulatory issues. We work with the office of management and budget on regulatory issues that the president s got a wonderfully refreshing view of regulation in that maybe we should pause on just constantly defaulting to regulation and solve every problem by regulation and clear out some of the underbrush and recognize that maybe some of these regulations are outdated or have created more harm than good and lets deregulate this administration it has been aggressive on area i hired somebody who had been at the department of justice and is a very talented attorney to help us work on that with the office of management andbudget. So we, and thats also about our relationship with the department. Eweve got a great relationship with the department. The white house drives policy but we have an open door as far as good ideas, they can bring it to us. Hhs for instance just unveiled a notice of proposed rulemaking to reform start and antikickback laws and that was not an idea that was generated at the Domestic Policy Council riyadh it took over two years of really hard work, thats another example of issues and other administration would say to talk, not interested lets do something else, lets do something x here, lets let industry continue to suffer under the onerous regulations but are outdated and they prevented a lot of creative contracting in the healthcare space. A lot of creative arrangements that would benefit patients and thats h why we moved it so we have a great relationship with the apartments. Its a lot of back and forth each and every day, theres a member of my staff thats on the phone with any number of departments and anybody, secretary will call me up swing by and say ive got an idea, do you want to help, do you think this is crazy and we move it forward and its a ngreat team area is a great cabinet to. Lets open it up for questions and remind you to please state your name and where you work. My names edward newman. [inaudible] the white house has expressed support on this and of course it remains hold up republicans are not in favor of the tax provision. Does the white house report swinging the provision and whining at this point wes and mark. Im glad you asked, we have always wanted a bipartisan solution to drug pricing. That even goes before the house of representatives was taken by the democrats, but its just a recognition of reality. Nancy pelosi is the speaker of the house, youre going to need democrats to get something on the president s desk that he can sign and you need 60 votes in the senate to get something that the president can sign. The republicans dont have 60 votes in the senate so youve got to get democrats there and youre right, we are very supportive of the Grassley Wyden compromise riyadh it is the product of a really good bipartisan collaborative approach to solving drug pricing. The caps, and we continue to work with their staff each and every day. Republican and democrat on improving the package that came out offinance, theres a number of Different Things were accomplishing. Make sure that premiums are kept low. As we align the incentives to drive drug prices down and give seniors a true test topic where they would pay zero after a catastrophic and they would pay no more than rate right now, its at 8000, we lower that to 3000 roughly thats a huge win for seniors area at a huge win. As far as the inflation cats are concerned they were not the administrations proposal. But they are the product of a bipartisan compromise and they are the roots a bipartisan bill in our opinion area Nancy Pelosis bill right now is unworkable. Its impractical and its hyper partisan and isnt it is not going to bask in its current form. The surest route to a bipartisan solution that would be a real win for democrats, republicans, the president and more importantly the American People is Grassley Wyden and were working very hard to get that done and get that moving area and ive been talking to pelosis people since theytook the house , before they were, before she was speaker. I got calls from her staff. I was at the Wealth Management and budget at the time and they called me and said we want to work on drug pricing and i said absolutely, door is open. We will work in collaborative fashion and i said theres one red line for us and that is to not take savings and plow it into the Affordable Care act for additional subsidies. That will earn a president ial veto and then a general directional approach is we dont want to punish market successes area we want to address market failures. So there are clear instances where copays are way too high. Drugs are allowed to command a premium price far beyond the original vision and spirit of waxman. And those are the things that should be addressed , not killing innovation or taking a product that somebody invented thats really valuable to a lot of people and just appropriately intellectual property or the value of it so we want to have new ways of innovation. We think were on the cost in this country of a huge, huge push of new medicines that we get that would bring real value to people. Genetic treatments coming online, theyre in the right now are amazing. The watch that killed would be a tragedy e. Yetheres plenty of ways to save money for people, payers, taxpayers, patients, companies and have them more a rational system without killing innovation. Over here. On two questions, first of all, what is the president S Institution and the other is on transparency. The ministration claims transparency similar to the insurers and consumers but a lot of employers would say it would help them and give them information they need to know, why not gointo the Pilot Program on that . First, im not going to get into what the president decided. But the transparency problem is not going to be solved in one step or one fell swoop. We will make a major pushon it on a number of different fronts. Frankly, its implausible to believe that more opacity, more confusion, more lack of clarity is going to help patients and drive costs down. We need to get, one of the problems with addressing drug pricing and why its so hard is because these programs are complicated and every time you want to make a change, frequently congress or regulators things worse. Its one of the reasons why the Grassley Wyden proposal is so important because it would dramatically simplify the Part D Program. So transparency is a big, it would be revolutionary if we had true transparencyin our Healthcare System. I find it bewildering whenever i get a healthcare bill on a personal basis. Im one of the people that ignores my Health Care Bill for a good 90 days becausethe first two are certainly not true. They tell me i hope 40,000 or my most recent trip to the hospital and then it turns out after three months we sorted out, you owed 280 and that doesnt make anysense. The medical billing were working on on capitol hill, thats another element to get more transparency in the Healthcare System performing part d is another effort. The grassleywiden proposal as a provision to require less basis to be attached to drug price adds so transparency should be first and foremost in everything we do in healthcare. Everything we do from a policy perspective as a government. Taxpayers, citizens should be able to understand these programs. We should get more data out there generally speaking. Not just in healthcare but in anything so transparency is very much a broad philosophical direction for this administration. We felt that the government knows better than the private market or american citizenry, as a matter of fact the d government knows less so if we have data lets get it out there. Right here. Do you have any announcements on what the transparency revelations will say it . Know. I think we wont have to, broadly speaking its going to be unclear but it could be huge. You look at the disparity and even in certain metropolitan areas among different procedures, some hospitals will pay 10 times as much with no improvement in outcomes for the same type of procedure and ambulatory surgical clinics versus hospitals, that type of differential, different sites of care so i think the key focus of the transparency hthing is to think about is it would be revolutionary if we had true transparency in healthcare pricing and it would open up huge opportunities for innovation to bring costs down. We dont have costs coming down as much as we should in healthcare with all the innovation that we got in computing, all these computers you have, the amount of power that in those systems that would cost how much 10 years ago, 20 years ago, 30 years ago. Why are we getting the same reduction in prices in healthcare with the same improvements in quality . A big part of that is government subsidies, lack of transparency and misaligned incentives. You look at where we get price decreases with the least government regulation at all, lasik surgery being the one thats referred to and its a great example so transparency would be revolutionary and as with all disruptive innovations, its unclear where it would end but its got to be better he than the current system. Theres no way you can tell me that the level of confusion that exist in our americanhealthcare is beneficial for taxpayers, patients or physicians. Im going to move around with this but just for the benefit of our audience, go ahead next. Is the administration going to release the [inaudible] and also on Grassley Wyden, what discussion has therebeen about adding a rebate provision . The International Pricing index is under review so i cant go into a lot of detail on it. As i said these aredifficult issues. We are very ifocused on making sure that any policy that we roll out is solid. Making sure the data is right, making sure that we through potential unintended consequences. Pricing is a difficultissue. We continue to make sure across all of our healthcare policies and policy generally make sure that they are e solid from a legal perspective, solid from a policy perspective and that we are not going todo something that were going to regret over time. Im sorry, the second question . Adding that provision to grassleywiden that would pass them through. There was a lot of talk about that being voted on in committee. I am a skeptic of the rebates , i have been from the beginning. The first couple of budgets the president sent out to capitol hill and i worked on the drug pricing reform revisions in our first couple of budgets. Were very, theres a great deal of skepticism of the rebate and also as with specific proposals for legislative changes to get the rebate problem. Its really hard. Weve probably spent more man hours on rebates and any other particular issue in healthcare. To be honest with you, the amount of resources, National Economic council of economic advisers, contractors , cms, hhs, trying to figure out the different modeling about what would happen under various scenarios. To be clear, the way the rebates are currently structured, whats set up in the end the Obama Administration and this is another example of an issue that should have been confronted or another issue that we have inherited. If somebody has an easy legislative solution to the rebate problem im all ears but i think theyre not going to get there, id much rather focus on the simplification of the part d benefit and going at the direct and indirect renumeration issue which congressman meadows had the bill on that we are supportive of and were willing to work with members on tweaking to make it stronger. Weve gotten a lot of good feedback from Senate Republicans on the dir issue and i think the transparency of some of this would help to you i would say this also, the restructuring the liability and the part d benefit to put taxpayers less on the hook and payers more on the hook will get a lot of njthese rebates to be honest and interject more competition and more aggressive negotiation in the private sector. Aso just restructuring the benefit that weve got without directly calling it rebate reform will actually be rebate reform. Go ahead. [inaudible] and some have also said that are going to be ways for Going Companies to contact around the importations, around in importation regulation, how is that planning progressing mark. Around the proposal, the president s been focused on this issue since he campaigned h. The differential between us prices and International Prices and of course members of both parties and that he will during when they have citizens crossing the border to buy drugs in canada bebecause its cheaper for them than it would be out of pocket here in the United States. And governors have come to the president to ask for the ability to import drugs secretary a czar has made it clear that his concerns around it can bealleviated because of the modernization of supply chains. Tools that can allow for importation through a mechanism like this to make sure that theres no alteration but what were not talking about his importing drugs from canada, from thailand via canada. Were talking about safe effective drugs that could be imported in the United States provided the state wants to do that so weve been working soclosely with states like florida and colorado and others on exactly how that could be achieved but i think it is i think we can do it and we will see. If its disruptive to the market and forces companies to contract around it, so be it. The Current Situation is untenable and its objective early irrationals and the president wants us to address it and this goes back to the point about the president not saying this is too difficult. Hes a disruptor, it makes some industries uncomfortable sometimes area it makes some vested Interest Groups uncomfortable but thats just the way it isand its refreshing to be honest. [inaudible]. [inaudible] is this an issue on the radar of the administration and if so are you encouraging secretary a czar to put it to the test. Its on our radar screen but i dont want to get into the deliberations and pricing instructions right now but it is an issue. I dont want to rule anything out or anything out. Administrator verma as said on multiple occasions of his addresses that the Health Industry has a choice between moving in a democratic direction or moving aggressively to the space payment. The program that you all have been moving on multiple pass and initiatives, one thing of the policy is of the ministration wants to aggressively push on this this would require all the hp plans to hundred percent about quality programs for commercial plants in that role and thats is that under consideration at all or is there more aggressive issues . We are looking at more aggressive valuebased arrangements and thats one of the reasons why were moving in a kickback to allow more of these things in both the number of different contexts. Its a delicate balance, we dont want to force anybody necessarily into a valuebased arrangements that when a patient doesnt choose to be there so preserving Patient Choice is front and center for everything that were doing. There are some patients we he believe would do better in comprehensive carevaluebased arrangements, others may choose not to. To use an example, the Electronic Health records debacle of the last eight, nine years is an example of what happens when we forget about where the patient is in all this. The Obama Administration promised 36 billion, 46, whatever that 3astronomical and insane number it was into the stimulus package to get the hr uptake that it was going to improve quality, bring costs down. All of it fantasy, none of it happened. None of it is einteroperable and now were working on finalizing our interoperable tool for the end of the year to make sure the systems and talk to each other but i dont know how many of you ehave been in the emergency room with a Family Member but the doctor comes in and doesnt even make eye contact anymore, theyre looking at the laptop and typing away and answering questions and its an example of how our system is so screwed up that we have allowed ourselves to not think of the Patient First and foremost and think oh, if we give the government and of power and with enough data are going to solve all of our problems , not true. These are human beings at the end of the day and its a human being that needs to be taken care of and we need to make sure that patients and physicians have the flex ability , have the choices they need to arrange their, to make their healthcare choice is going to make the patient healthier and weve been focused on that since we issued an executive order in october 2017 asking for a report on choice and competition. It allowedus to push out shortterm limited duration plans , hr 80s, Health Reimbursement accounts which is going to be huge booms for employers and employees to get different types of healthcare arrangements more economically viable for them. So were about choice and competition, about the patient being in control and the patient being at the center of this so anytime were talking about forcing arrangements, its something we would be skeptical about. We would want there to be more transparency, more data out there before we make the decisions that are best for them. In the corner. Where you stand with the beeping flavor band . Do you have a sense of timing and are there any concerns about vape shops being hurt economically . The vaping issue or more successfully eccentric is a complicated one and i dont know if you saw the la times story which was followed up with some other reporting about how this is an industry that would again first started to come onto the four of regulators and policymakers during the Obama Administration. The decision was made notto bring them into regulatory compliance. We have believed that e cigarettes are a viable alternative to combustible cigarettes. Everybody recognizes combustible cigarettes are a problem. They cause cancer,they are bad news, also to other health problems. Pulmonary and cardiac problems. However the option for adults is complicated by the fact that we got 5 million kids using these things and that is a major public challenge. Consistent with my answer earlier we want to make sure that we are datadriven on this and striking the right balance between adult choice and protecting kids and that has been our focus as we look to finalize our policy. Theres been latebreaking data over the past few weeks that we have been looking at so i cant tell you exactly where we are going to be or the timing, but we want to make sure the data is solid and we strike the right balance between protecting kids and getting adults the choices they need to stay off combustibles. [inaudible] its been important to recognize that the fda only hasjurisdiction over nicotine. So this is a world that i dont fully understand area i was too old i guess when the vaping stuff started but you go into a vape shop and you can spoke it without nicotine and people do that. You can also go into a vape shop and mix it with a flavor and thats fine too so what were focused on is the devices that have nicotine and the flavors mixed in. And making sure that adult have options they need to get up and stay off combustibles and the kids dont become addicted to something that they otherwise wouldnt be addicted to. Nobody knows how nicotine addiction plays out over the long term. Anecdotally cotheres very stories including personal stories i heard from parents and older brothers, older sisters talking about whats happened to members of their family, but the data is really in many instances early and that would is what makes it complicated and difficult issue to confront but we are very focused on it and veryfocused on making sure we do the right thing. Is there any discussion about whether the plan would be menthol flavors or adult only vaping shots and the man includes menthol, would juul and other companies beable to sell their meant flavors . I dont want to get into the specific details until its finalized and we would have to deal with extensive jew and day on it and you should anticipate that but its a difficult issue and its, fda regulation in this space is complicated and on a personal level i hate tobacco issues, i always have an fda should be regular eating this stuff in the first place. When i was in the Bush Administration and this conversation started i said this is a moronic idea. Fda regulates drugs that can help people and you balance safety and effectiveness. It regulates devices which help people and you evaluate whether they are safe and effective. This stuff, tobacco has no redeeming qualities and it shouldnt be regulated by a Health Agency like this. All the unintended consequences, sucking up bandwidth on tobacco issues is an incredibly huge distraction. The fact an fda commissioner like Scott Gottlieb or whoever the next ones going to be has to spend all this time on tobacco issues when they could be figuring out how to advance new therapies, cure cancer, solve cystic fibrosis, get drugs more approved more quickly, all the competition that they can bring stuff and trying to navigate all this stuff and when i showed up at omb i told my team the door is open. Anyindustry can come in, any patient group, anybody can come in with a problem. Bandwidth permitting. I dont want to do anything on tobacco and i got pained all the time. Tobacco, tobacco. Traditional, e cigarettes, everything. They want to explain were getting screwed by the fda, we dont understand what the standards are. This is not the way the law was intended. Im getting blown up by members of congress, on and on. Its a huge waste of time for a Regulatory Agency like the fda should be helping us, with the next cure to be sucked into the mud on this all the time and the unintended consequences of this law are just mindboggling. You think about all the time thats been spent on this issue. It sucks. [inaudible] i dont know. Thats mypersonal opinion. I have never had this conversation with the president about who should regulate tobacco but it has no redeeming qualities. What the hell are we doing with fda doing this . Its just awful so were wastingour time on this and youre wasting your time on this. [inaudible] do you have his books to takea test vote on health care and how do you get around that . The frustration level on the part of the American People with the drug prices, the outofpockets that they pay and the high drug prices, the frustration on the part of employers, health plans , i dont think theres any issue that we confront thats more front and center. You pull the issue, its the Top Healthcare issue consistently of what people complain about. This is an issue that both republicans and democrats should be able to come together and get done. And unfortunately there are some current complications on that front. I think everything is set up to do it. This is the right president to do it. This is a once in a Generation Opportunity to confront these issues and in a nonideological fashion. Were in our third year here, today the anniversary of the election three years ago so i guess were starting our fourth year. We can spend a ton of bandwidth pushing up policies to rationalize our system, protect patients and align the incentives, not have a bunch of Government Programs that are set up to drive high prices and i think it would be a win for both democrats and republicans. I think there are members who want to do a deal. I get calls from democrats and republican members who want to help on the deal and im hopeful we can get there so i dont necessarily see it the way you see it that its not in the best interests of nancy pelosi or leader mcconnell to get the deal done, i think its in everybodys interest to get a deal done. Back row. John wilkerson, inside policy. I just want to add part d for medicare, on rebate reform i know youre skeptical. I heard that last year but the finance committee is trying to do something on it and id like to ask you do you see any potential for pointofsale rebates for insulin specifically and what do you think of using sa aggregate rebates instead of pointofsalerebates . Like i said, idi is under review so i dont want to get into details on. Were out of time for ideas. Somebodys got a rebate idea, that train left the station. We need solutions right here, right now. This package needs to be wrapped up in the next few weeks. Like i said ive spent over two years working on the rebate issue. Nobody has come up with an easy solution. Its one of the reasons why the pelosi phone negotiation because its not really a negotiation on the house side, why that thing has got to get jettisoned. Its not just it has no chance of bipartisan support, its impractical, its unworkable. I dont know how that thing was supposed to work area its a whole new bureaucracy being created at is somehow helping define what a drugs value should be when you got academics, pdms, payers and Drug Companies and consultants all invested in figuring out how much a drug should be valued. Theres no way that provision works just like its not really a negotiation because its dictating a price at the end of the day. Its an offer that no company can refuse and white it would kill innovation so the opportunityto retool that is over. The opportunity to play around with the rebate stuff is over. Ive been talking with as i said, loc team since last year. Very open, collaborative. Conversations. Wide open as far as ideas. Were done with ideas. Weve got to get a solution area without getting scored by congressional budgetoffice and got to get a deal on the president s desk. Ive been hearing from frankly ive been hearing from the house side since january. Six weeks we will have a bill, eight weekswe will have a bill, two weeks we will have a bill. There were supposed to have a score and have it on the floor last week, didnt happen. They got to cut based on one of these thingsthat are not going to be , im not going to and up on the president s desk on the first place and would sink this opportunity thats tpresenting itself. [inaudible] what areas if its time to pull the trigger, what areas would still be to before they do that mark. The grassleywiden compromise was built, the money saved from the Part D Program it was not redirected into the benefits. I think if we redirected into the benefits you get an even bigger bang for your buck frankly. Its a bigger benefit for seniors. Its abigger win for seniors so those are the types of things that we are working on. I dont want to, and just making sure that its solid numerically, that you dont get unintended consequences on premiums but we really a stage on a bipartisan basis of dialing in on the final specifics on this and there are other pieces as well. A paper delay piece that creates, incentivizing bio similar to get the industry moving a little bit better, to bring costs down on the biologic market. There are a lot of pieces moving. Energy and commerce,ways and means, a lot of great bipartisan work there. Senate judiciary, and it health all have a lot of good stuff. Senator collins has got transparency efforts around patent listing for biologics that would be helpful. We need to look at some of the biologics that have these marine patents or mystery patents that pop up long after and protect the Market Exclusivity far beyond the original contemplation of what is rational. Her effort would be very well appreciated so theres a lot of things that are moving that could be tied together and that is where we need to beconcentrating, not on new ideas. Could you talk about this pending Court Decision on the Affordable Care act and if it were ruled unconstitutional but whats the next step from the administration on that . The Affordable Care act was rammed through in the middle of the night without any republican vote and its already been in the Supreme Court twice. It doesnt work according to its original billing. It was supposed to give us universal coverage and it was supposed to allow people to keep their doctor. Both central conceits, both central promises of the aca have not borne out so we spent 50 billion a year to drive the individual market from over 10 billion to slightly over 13 billion and we have 28 Million People who are uninsured in this country. That is a failure of the aca, so much so that the democrats have moved beyond the aca and you see the dominant debate on the airwaves about medicare for all and medicare buyin. Everybody recognizes that the aca is a failure. The central question at play in texas versus azar is a constitutional one. The administration thought it was important to stand up for the role of law. We will be prepared after that decision comes down with any number of the permutations that get decided. Its important to recognize though that nothing is going to happen immediately area the decision will be stayed pending a supreme Court Decision. This will surely go to the Supreme Court. It may or may not be decided, probably not decided before the election but even if it were i would imagine the Supreme Court would stay its decision but we need bipartisan approaches to help solve health care in america and when we do these things Just One Party ramming something through, thats not going to happen. As i started talking about in the beginning we spent eight years talking about the aca and avoiding all these healthcare issues that were percolating and in some cases exploding like opioids. Like theecigarette problem that was beginning to manifest itself. Ultimately, if democrats and republicans were to come together, we can solve the preexisting conditions problem in much the way that we solve medicare for seniors because theres a market failure area to everybody in the administration recognizes that people with preexisting conditions have a difficult time if not an impossible time buying healthcare coverage. The problem is theexchanges now are made up of people with preexisting conditions and people who are 100 percent subsidized, thats it. If thats what you want to accomplish, if you want to help the poor and you want to help people with preexisting conditions you can do that far more effectively and are cheaper than the aca. We would be focused on protecting people with t preexisting conditions and restoring the rest of the market to move on a lot of these other healthcare initiatives and addressing other problems in the system and not ignoring them by dumping more subsidies into the system. I believe that the protection of people with preexisting conditions is going to be the only lasting contribution of the aca. That is why you have bipartisan consensus on them. The present campaign on it, he said it consistently. In our efforts to think through what should happen on the aca, protecting preexisting conditions, we worked down from there. I think regardless of what happens with preexisting conditions will be protected and if the democrats are in a position where they can prosecute a legislative effort to get medicare for all and wipe out Health Insurance 480 million americans in the employer market, and totally eviscerate the Medicare Program for seniors and disrupt the industry it would be a disaster if they were ever in a position to do that. It wont work and it shows how bankrupt their ideas are to be frank. They dont understand the free market, they cant confront any of these issues, they go back to the mothership of Central Planning and they say heres a solution, lets give government more control. Is that going to work in any area mark its just crazy that were having a serious discussion in this country around putting the government in control of all our healthcare. It wouldnt work for the American People and it would be, it would take away so many options for people that employers like, employees like, seniors like and it would be a real disaster if it was ever to get moving. What do you think are the realistic challenges given that its november and the appropriations have been done and it feels like drug pricing is the top buyin. I think if we get drug pricing we can get surprised billing. If we get surprised billing and even so surprised billing has a lot of bipartisan support. I think there is an opportunity for compromise their were in regular contact with the senate and the house. Its really down to just a couple few issues. I do hope you can come together in the end. Its an easy issue for the American People to understand its an obvious one address and people shouldnt be going into the emergency room expecting ask price and they get, and with the understanding that they have coverage. They buy coverage for a reason and then they wind up sorry, this coverage doesnt apply in this instance and heres your surprise. Theyre not in a position to bargain, not in a position to fully comprehend in many of these instances whats going on and they need help. And unfortunately, the hasnt already been addressed but i think the opportunity is there and were close and i think it could come together with a bunch of care legislation at the end of the year. W or it can be standalone, i dont think its necessarily has to be attached. I do think there are a lot of healthcare pieces moving, with standards at the endof the year, drug pricing. That is attached to. So theres going to be a lot of big bills at the end of the year, hopefully we wont just do flash us mca down the drain. Thats ridiculous that it hasnt already been done area that would be a clear bipartisan wind, big win for the American People area the and the aa bill that passed every year for 57 years, that should be passed so that should get done, the Appropriations Bills should get done and we should get a good healthcare package for the end of the year its just a question of counties guys sit down and get it done . About 10 minutes left on going to ask you a question and we will come back on the side after i asked the question so try to if you can think of your question, short answers for joey. And you might not be able to talk about this joe but one of the other big issues that ive heard a lot about recently is the lawsuit regarding hivaids drug, truvada i believe it is and is that an hiv aids issue part of your plan to address this issue but it also has elements of drug pricing in it as well . You talk a lot about disruption, doing things differently, not ideological. How should we look at that issue . The president commented on the elimination of hiv transmission within 10 years. All the technology is there to achieve this, thesocial science data, pharmacological data ,testing data and all be done. Im a veteran of the hiv initiatives in the Bush Administration as you are, i ran the president s advisory councilon hiv and aids and its an incredibly exciting time. If you are a veteran of those policy fights to see the opportunity that presents itself. And to the president s credit, he saw it as well and said lets go for it and he raises it repeatedly. He raised and offhand comments, how excited he is about this. How this is somebody who lived in new york city during the height of the hiv epidemic and saw many people around him not live through the height of the aids crisis. The opportunity is there. A lot of experts, we deployed a lot of expertise. You look at bob redford at the center for disease control. Tony county, the team at hhs. Weve got a lot of great people working on this and it can be done. Congress appropriates the money. Thats another thing we like to see. It can be done relatively costeffectively and would be a huge win Public Health and for the American People. As for the lawsuit itself i have not been involved, i wasnt involved with my previous employer. I havenot done anything on it since ive been here and its in litigation now so its up to somebody else area. I appreciate it. Can you say what you mentioned in your opening remarks, the view that Medicaid Expansion might have helped further the Opioid Epidemic. A lot of people who were addicted to opioids have been on Government Programs whether itsmedicare or medicaid. This is something and we have treatment guidelines that encourage and star ratings that in medicare that encouraged aggressive Pain Management with opioids and frankly somebody was was not minding the store you look at these losses that have taken place on the state level , about what occurred with some of the marketing and i dont want to get into specific litigation and it looks to me like people were allowed to engage in conduct that is inappropriate and got a lot of people hooked on opioids. The Opioid Epidemic , it is an epidemic. Youre talking about tens of thousands ofamericans getting killed every year. By the epidemic, the president doesnt drink, doesnt smoke, doesnt do drugs and to his credit he said lets confront it t area and kelly and conway has been upfront on this along with jim carroll at mdc b and hhs. But to be frank kelly and conway deserves a lot of credit for focusing on this like a laser beam when she came in and the administration. We have yearoveryear declines in opioid debts. So its an achievement of this president but we have a larger addiction is in this country and its important to recognize that we cant just keep oureyes on one problem at any one time. We have to be open enough to confront problems that may be we dont want to confront. I dont know that anybody wakes up in the morning and is super quiet up to dive into the details of the tragedy that occurring with addiction in this country, but youve got to because its important to the American People. Its important for our country and this is a president who has focused on fighting for people who a lot of people have thought about in a long time or havent had them front and center whether their American Workers in the Manufacturing Sector or people in flyover country or families dealing with addiction. So its, its , theres a long way to go but we have made a lot of progress so far and changed a lot of the treatment guidelines and a lot of the incentives to drive opioid addiction and while thenumbers , i havent actually heard anecdotally again, we will see the numbers from people and specifically practitioners in various parts of the country thats in the opioid numbers willcontinue to trend down and were just seeing the beginning of the fruits of our efforts area. I havent heard that anecdotally from emergency room physicians, not everywhere but there is, theyre seeing something different. Which is good news. Go ahead. From the washington examiner, Scott Gottlieb office said that he expected deaths from opioids would start to decline again as data comes in between meth and opioids and cocaine and opioids. Sometimes by users who dont that the drugs have been mixed together. Ics . And talking about prescription opioids specifically what you start mixing them and we got a math problem in this country starting to really take off thats going to be difficult to get arms around. The fentanyl issue has been a big problem next and in many cases. Inappropriately with prescription opioids. Or sold on the street so its not easy, but id have to look at what hes talking about specifically and weve seen yearoveryear declines and thats the day im looking at right now. [inaudible] do you have plans to more effectively implement those things work the former director and is there a possibility that you get the religious conscience rule through initiatives addressing issues with it i dont know. The president agenda is often times awarded by activist judges, thats one of the reasons we have celebration in the east wing this week appointing over 150 federal judges who will interpret the constitution and not make policy to suit their own ends. We recognize the risk we run whenever we confront any of these challenges but the president respects religiouS Institutions and respects people of conscienceand some judges are going to be skeptical of that. We spend a lot of time to make sure that our rules and regulations are legally sound but at the end of the day you do roll the dice anytime youre going to be disruptive ecthat a liberal judge is going to come along but we will prosecute an appeal any case on any policy weve advanced because we believe in it and we spend a lot of time tomake sure that its solid. [inaudible] im just curious why the administration isnt interested in them even though they are neutral payments between household and house payment abilities and the discount program, those cuts still included. I know one is being appealed but why do they keep pushing programs that have been instructive. Because the policy is solid and we think we can win and were not going to apologize and if its an instance where a judge is going to , were not going to be able to get something done at the lease highlights a legal change should be made and we can go to congress and say listen, the courts are sticking to us here and there and you need to clarify the law because were on theright track , heres the policy where pursuing and its not going to be as robust and strong as it could be without a legal change so there is, if your going to be aggressive in policymaking, youre going to run the risk that a court is going to hold you up but at least then you expose an opportunity for legislation to fix the problem and that goes in healthcare. And we construe train from all these fights and make our lives a lot easier and i could leave at 4 00 every day thats not the way were e approaching it. Releasing part of the healthcare rates and they said they used that information in their own state to negotiate higher rates as they know that t may have lower rates because of ulthe transparency law. Is there anything in the coming rule which you can talk about to address that kind of unintended consequence . I dont want to get into what kind of pacific instance or packet we will have more conversations with. We recognize any policy may have unintended consequences and we work hard to think them through but you also have a Public Comment period for that reason. The public should have the opportunity to let us know youre on track, your offtrack area make this improvement and we have consistently pursued, found regulatory policy procedures to give the public the opportunity to contribute and help us refine our rules. I cant stress enough how important it is for members of the republicans to get involved in the regulatory process, to make sure the government is doing the right thing and put, make them respond to the approach thats proposed. So it will go out as proposed and we will elicit comments and we may make changes bythe time it hits file. We are out of time so what i want to ask you is there any subject and these cover a lot of subjects, is there anything else you would like to throw out there that you didnt cover where wasnt asked . Maybe just we saw jobs numbers just come out last week revised upwards of 303,000, above expectation on jobcreation at a record low unemployment in the africanamerican community. 3. 5 percent nationally, were in a robust economic period but healthcare specifically is an area that can contribute more to our gdp if we get more inefficiencies out and align more incentives and the way to do that is not the government more in control of the Healthcare System, is to inject more choice and more competition and again, stay focused on why were in this business in the first place which is the patient, the american citizen that needs healthcare and to be healthy. Thank you very much. Thanks to you all. [inaudible conversations] u. S. Senate will be back in session today at 3 00 p. M. Eastern and Senate Lawmakers will be working on a nomination of chad wolf to be Homeland Security undersecretary for strategy policy and plans. When the Senate Returns at 3 00 p. M. Eastern, live coverage here on cspan2. House Intelligence Committee holds its first open hearing of the impeachment inquiry against president trump. Lawmakers will hear testimony from william taylor, top u. S. Diplomat in ukraine and Deputy Assistant secretary of state, george kent. Watch live wednesday morning starting at 10 00 a. M. Eastern on cspan3, online on cspan. Org or listen live with a brief cspan radio app. For 40 years cspan has been providing america unfiltered coverage of congress, the white house, the Supreme Court and Public Policy events from washington dc and around the country. You can make up your own minds. Crated by cable in 1979, cspan is brought to you by your local cable or satellite provider. Cspan your unfiltered view of government. Next, look into u. S. Turkey relations with a focus on the agenda, turkeys president. This is 30 minutes. We would like to continue and break down what is happening in syria in recent weeks and turkeys involvement in the country but as