Come to order. I just want all members to know that our Witnesses Today have to leave at 5 00 p. M. The questions for the first panel on the hhs budget with secretary, and, welcome, mr. Secretary, will be limited to four minutes. The second panel on the minutesl case, but only 10 members will be able to ask questions during that round. I will have to be strict with the gavel, since the witnesses have a tight timeframe. I know that you will all cooperate with that. Let us begin. Welcome, mr. Secretary. We are glad that you are here. We have a lot to take up. Every bit of it is, obviously, serious. The chair now recognizes herself for five minutes for an opening statement. Let me begin with mr. Secretary. I think that the confusion is the enemy of preparedness. Confusion is the enemy of preparedness. I believe that the administrations lack of coordination to the Coronavirus Response is on full display. We all know that. Markets are reacting, i think, at least in some parts, to the lack of trusted information amongst many other factors. Our government, across the government, has to speak with credibility and authority. Instead, it is like a great chorus champion on the side of the stage. One saying one thing, the president saying Something Else, and that adds to the confusion. I think there are key questions that need to be addressed for the American People. What is the plan . The overall plan . Should this virus affect americans in high numbers. What is the plan for increasing diagnostic capacity and what is the target number for that . Dysfunctional past have limited our opportunity to diagnose the virus. It could be said u. S. Bases could reflect limited testing and not that the virus has spread. It is up to our professionals to put out with clarity that kind of information. What is the plan for protecting our healthcare workers that are in the frontlines of this . What is the plan to increase Hospital Capacity . In my view, the United States of america has the premier professional Public Health professionals in the world. In the world. Our scientists, our doctors, those heading up the agencies, those that are part of the agencies. I think the problem rests more with administration people. One thing, one thing, other saying Something Else. I think the briefings down for the congress, if i might suggest, should be open to the public. There is no reason to have secrets about this. And i say that because it raises the element of fear with people. There is something going on behind closed doors that they are not telling us. It is a time for us, if i might use the expression, to give them an inoculation of confidence. Certainly, the virus triggers fear. I think the antidote to this is truth and transparency, including informing the American People of a coordinated, fully funded government plan to keep us safe. These are not things they can do for themselves. We are the ones, you are certainly in the driver seat on this. I think that the funding request, and later my questions i will ask you about that, is fully inadequate. Before requesting the Emergency Funding, the president s budget contained dangerous that weekend our frontline response. Cuts to Health Care Safety net and programs focusing on increasing our healthcare workforce. We are driving in the wrong direction. It is as if there is a fire in the fire engine is going down the wrong end of the road instead of going to the fire. We need these resources in order to care for the American People. As the author of the pandemic and all hazards preparedness act, i know the best way to fight outbreaks is preparing and investing in advance. Not by rushing after a pandemic hits. While the virus is spreading, the president budget cuts almost 700 million in the cdc, 430 million from the National Institute focused on Infectious Diseases, 3 billion from the governors Global Health program. This is a draw dropping 1. 6 trillion cut from the very federal program to cover one and three americans. This does not make any sense. The president s budget virtually ends the Workforce Development programs that trained more than a half million clinicians each year. I see them every week in my Congressional District at Stanford Medical Center and Lucille Packard childrens hospital. It weakens our Public Health safety net and it hurts our countries resiliency. The cdc, nih, all of these agencies cannot run on fumes. Cannot run on fumes. It is not even a tesla if it does not have a battery that will last. If americans are uninsured or underinsured, they will not seek care. That will contribute to the spread of the disease. I dont know what the president has often honest beautiful healthcare, i dont find beauty in what i just said. I am sorry, this is a part of it. With that, i will have questions. Thank you again for being here. The chair now recognizes doctor burgess, the Ranking Member of our subcommittee, for his five minutes for an opening statement. Thank you, mr. Chair. Thank you, secretary, for being here. Always great to see you and our committee. I hope you are grateful to be here in our committee. To weeks ago i was criticized rather severely for even suggesting we needed a coronavirus hearing. The work we were doing that day was a bill that would never become law. It was so important we did not need to do that hearing. We did need to do that hearing. Im grateful we are having it today. This hearing is also being coincidently run with the president s Budget Proposal for fiscal fiscal year 21. That is a lot of stuff to cover in one hearing. I guess we will do our best. Let me just say, i do appreciate the administrations commitment to. I appreciate the commitment to lowering healthcare costs and reducing the complexity of the system so that patients can more easily access their care. The administration and mr. Secretary led on was Kidney Health for americans. That continues in the Budget Proposal and the support for hr 5534, the comprehensive drug coverage for kidney transplant patients, as you know, mr. Secretary, this bill would extend Medicare Coverage of those drugs on a 36 month limit. A patient with a kidney transplant has to take these drugs or their body will reject causing the patient to return for dialysis treatment. A kidney transplant is indeed an investment of the future of that patient and this bill will help protect that investment. I worked on this policy for a decade and im happy its been highlighted as a priority by the administration. Time for congress to finally pass this common sense legislation. The budget also continues to work on the support act. Major piece of legislation passed in the last congress. Programs making sure the Opioid Epidemic and response programs are in need priority. We have heard from various states about the efforts they are making to help those with Substance Abuse disorder. Funding for the state opioid response grant is imperative to allow states to find the innovative ways to combat this crisis. I also appreciate the fact that the administration included prolife protections and all proposed funding language. It is important to ensure federal funds are not used to perform abortions and i hope as this subcommittee moves forward with reauthorization and the Appropriations Committee puts together the bills for fiscal year 2021 they will maintain those protections. Other important programs and policies receiving increased funding including the Maternal Child Health block grant, administrations Maternal Health in America Initiative and the 340 b drug pricing program. Funding increase for that centers for Disease Control and prevention, particularly important as we now face this worldwide coronavirus outbreak. Which brings me to the Novel Coronavirus. It has affected over 80,000 individuals worldwide. Proven to be more deadly than sars. I appreciate the Trump Administration vigilance and Rapid Response. Let me just say, i think it was for fridays ago when you came along and said there was a limit to people being able to come into this country from china and i thought that was important to the administration to say that. I believe that is one of the central things, my thesis is, one of the central things that has provided us at least a little breathing room as this virus erupts around the world. Unfortunately, not as effective as some other countries. Now its incumbent upon us to make sure we utilize that time wisely. There was a preparedness act. Worked on by this subcommittee. The last Congress Finally passed at the beginning of this congress. An important piece of legislation. I would have liked for us to have done real time he raised updating what was intended by this bill. Responding to the appropriations that we made. This is the type of information rather than the political rhetoric back and forth that we have heard. This is the type of information i think would be helpful and reassuring to the American People. You cannot ignore the fact of what has happened to the markets. Today we are grateful that they seem to have rebounded a little bit. China is not coming forth with information. It is that uncertainty that is driving, one of the negative forces driving the market. Mr. Secretary, i appreciate you being here today. We will have alterable questions for you. Thank you. I yield back. The gentleman yields back. I want the Ranking Member to know the following. On january 30, 2000, i requested that the following week that we have a hearing on the coronavirus with the head of the agencies. The secretary leaned in and say i head up the effort and i want to be there. Here we are today. This is not something that is just casually overlooked or lowered. That is far from the fact. I would like to recognize the chairman of the full committee for his five minutes. Thank you, chairwoman. Todays hearing serves to critical purposes. We will examine the Trump Administration proposed budget for the department of health and Human Services for fiscal year 2021. We will get a crucial update on the ongoing response to the coronavirus. I am disappointed, though not surprised that the Trump Administration Budget Proposal completely contradicts the promises that the president makes to the American People. When it comes to enjoying the American People have access to affordable and quality healthcare, the Trump Administration has failed them and this Budget Proposal continues that record. Two years after showering the corporations of major tax breaks , the president s Budget Proposal flashes 100 billion from the Affordable Care act. 500 million for medicare and more than 900 over the course of 10 years. The president also wants to make it easier for states to take away peoples coverage, undermine their care and cut critical benefits. This includes a health and wellbeing of tens of millions of children, parents and people with disabilities. It is unconscionable that the president wants to cut it to pay for tax cuts for millionaires. These budget cuts also fly on the face of President Trumps own words. He promised as president he would not cut at a care or medicaid he promised in the state of the Union Address earlier this year that he would continue to protect more than 130 million americans with preexisting conditions. As the secretary knows, this administration is doing the data records to strike down in all of its consumer protections. President trump is proposing a 12 cut to the budget. One of the largest cuts to any federal agency. Medicare, medicaid and the aca. The president s proposal cuts at the National Institutes of health by 3 billion. The centers for Disease Control and prevention by 675 million. Keep in mind that this is the very agency that is not responding to the coronavirus. The most concern to move tobacco regulation out of the fda authority altogether. The administration would create a new agency to oversee Tobacco Products while we are in the midst of a tobacco epidemic. The control act clearly and unambiguously assured that fda would regulate Tobacco Products with the protection of Public Health. Over the last decade, the agency has worked to develop the expertise, workforce and scientific base to regulate these products. I am concerned that this proposal would only serve to further politicize tobacco regulation by stripping away the sound, scientific and evidencebased approach and replacing it at the whims of political employees. Nothing more than a gift to big tobacco companies. Let me move to the second topic at hand. We will ask questions of the secretary another Top Health Officials on the administrations efforts to address the coronavirus outbreak. It is critical we get an update on the scale of outbreak, repercussions and how we can Work Together to ensure the safety of all americans. I think we have one of the strongest infrastructures in the world. More than capable of coming to an effective solution. We should be supporting that with all available resources. Again, adam chair, i thank you. Well, actually, i have time left, if anybody wants it. Everybody gets time . Anybody want my time . All right. Thanks a lot. I yield back. Gentleman yields back. Pleasure to recognize mr. Walden for his opening statement. Thank you. Mr. Secretary, thank you for being here today. Not the first time we have seen you. Here this year, probably. We certainly appreciate the work you and your team have done dealing with the coronavirus. I think ive been in every one of the roundtable and hearings that you and your team have provided for this committee and other committees. The comoderators of the first one in the Visitor Center where every member of congress was invited. I was at the last one and i was at the situation room at the white house before the break. You know, i think you all have been very forthcoming with the facts. For whatever reason, we have not had a hearing here, maybe wanting to wait until this one, i think it is important that we hear from you and the team that you are leading. I think it is important to recognize the work on reauthorizing the all hazards preparedness act in the last congress. We had big fights about that. Thank goodness it is in place because it is designed to do exactly what we are encountering today. A lead person in the administration that is you, designated by the president and a team ready to go. I have been to enough of those briefings that i so members kind of yawning and those closed door briefings. Hearing it for the third time. Gone a week and a lot has changed. We know what is happening in china is probably worse than we are being told. Supply chain as well as Public Health. We know that it is spreading around the world. We know, and you have warned us, other doctors have warned us, expected this could well mutate. It can well expand. We should be ready for that. We have a terrific Public Health system here in the United States. A lot of that is driven at the local level. It is important we have those communication links in place so when we identify something, someone coming into an airport, Health Officials know about it at home and we are able to deal with it. It is good to get this out in the public. I would just point out that we will hear from you and the cdc, fda, in asper and nia to give us an update on the sidecar hearing we have 80,000 confirmed cases worldwide. 2700 deaths. The outbreak has become a Significant Health concern. Yesterday italy announced 300 individuals affected by the coronavirus. Eleven have died. There is still so much we do not know about the outbreak. We will learn more after this Budget Hearing. It is, essential, that we do everything that we can and provide you the assistance. I know the meeting that i have been in, you have made it clear, if you need more money, you will ask it. We have made it clear, if you need more money, tell us and we will work with you. I know you have sent up a supplemental request for, i think a total of a little over 2 billion. Some of that is reprogramming. Some of that is additional money no sooner left your office and some politicians on the air criticizing you for not asking for enough. We will be interested to get your response to that. I do think it is also essential to look at perspective, in terms of what americans are facing today with the traditional flu. And that we probably lost, what, 10,000 or more americans have died from the annual flu, and we have vaccines for that, treatments for that. We have to think about that as well. And practice good Public Health. I was in japan with a couple of my other colleagues on the committee and you cannot go anywhere in japan without the Hand Sanitizer being squirted in your hand. It was a good lesson, i think, for all of us. We ought to be doing more of that here. It would probably help with the traditional seasonal flu. Theres a lot we can learn from you. A lot we can learn from your team. We look forward to hearing from you directly on that. With that, adam chair, i yield back. Gentleman yields back. I now would like to introduce our witness for todays first panel. One person, one person alone did the nations secretary of health and Human Services. Welcome to you, secretary azar. You certainly are aware with the lighting system around here. You are now recognized for five minutes for your statement to the committee. Thank you very much. Thank you for inviting me to discuss the president s budget for fiscal year 2021. Im honored to appear before the committee for budget testimony as the hhs secretary for the second time, especially after the remarkable result that the hhs team has produced. This past year we saw the number of Drug Overdose deaths decline for the first time in decades. Another record year of generic drug approval from fda, historic drops a Medicare Advantage, Medicare Part b and Affordable Care act exchange agreements. The president s budget aims to move towards a future where hhs programs work better for the people we serve. Human Service Programs put people at the center and where americas Healthcare System is affordable, personalized, puts patients and control treats them like a human being and not like a number. Hhs has the largest discretionary budget of any nondefense department. Difficult decisions must be made with Discretionary Spending on a sustainable path. The president s budget proposes to protect what works in our Healthcare System and make it better. I mention two ways that we do that. First facilitating patient centered markets and second tackling key impeccable health challenges. The budget healthcare reform aim to put the patient at the center colonoscopy a lifesaving services. Paying the same for Certain Services, regardless of setting. The budget endorses bipartisan, bicameral drug legislation. I want to thank this committee for your work to pass legislation to cut patient cost and save taxpayer dollars through lower drug prices. The budget reforms will improve medicare and extend the life of a Hospital Insurance fund for at least 25 years. We propose investing 116 million in hhs initiatives to reduce Maternal Mortality. Tackling americas Rural Health Care crisis telehealth expansion and new flexibility for rural hospitals. The budget increases investments to combat the Opioid Epidemic including Opioid Response Program. This Successful Grant Program grew out of this committees creation of the state targeted response grant. We were pleased to work with congress to provide flexibility on the grants for states to address stimulants like methamphetamine. We request 716 million for the president s initiative to end the epidemic in america by using effective evidencebased tools. Thanks to support from congress, we have already begun implementation of the initiative. It reflects how seriously we take the threat of other Infectious Diseases such as a Novel Coronavirus. By prioritizing the funding for cdc Infectious Disease program and maintaining investments in hospital preparedness. As of this morning, we still had only 14 cases of the coronavirus detected in the United States involving travel to or close contacts with travelers. Coming into this hearing, i was informed we have a 15th confirmed case. The epidemiology of which we are still discerning. Three cases already exist among americans repatriated from wuhan and american passengers repatriated from the diamond cruise ship in japan while the a meeting risk to the American Public remains low, there is now Community Transmission and a number of countries including outside of asia which is deeply concerning. We are working closely with the state, local and private sector partners to prepare for mitigating the viruses spread in the United States. As we expect to see more cases here. On monday, a request to make at least 2. 5 billion in funding available for preparedness and response including for therapeutic, vaccines, personal protective equipment, state and local Health Department support and surveillance. I look forward to working closely with congress on that proposal. This years budget aims to protect and enhance americans wellbeing and deliver americans more affordable, personalized Healthcare Systems that work better rather than just spend more. I look forward to working with this committee to make that common sense goal. Thank you very much. Thank you, mr. Secretary. We will now move to member questions. I will recognize myself for four minutes, which will be the limit for questions to the secretary. Mr. Secretary, we know that on february 24, the acting director of omb requested the appropriation of 100, 1. 25 billion for Emergency Funding for the virus. Is that what you requested of omb . The actual total supplemental authorization would be 2. 5 billion. I know, but new funding is 1. 25. I want to emphasize as i told the appropriators, that was meant as a suggestion, a way to fund half of it, if congress decides there are other approaches, we are not wedged to that. What exactly does that cover . Yesterday, the cdc said we need to be, essentially, we need to be prepared for a much larger spread of this virus in the United States. Is the, what has been requested in Emergency Funding to cover a broader plan or is it on the figures that you just gave us . To cover expenses we believe are appropriate for 2020. Through the end of 202020 fiscal year. We would work with the appropriators on any adjustments to 2021 in the weeks ahead we are continuing to learn about the disease. Expanding our Surveillance System. And some other questions. Sure. Im happy to walk you through. I read the entirety of your printed statement. I want to turn to the status of drug pricing policy proposals. You can just say yes or no. That be great. Have you finalized a policy ending drug rebates and medicare . We did not. Have you finalized a policy tying drug prices to the lowered cost reference pricing . An advance notice of proposed rulemaking. Not a formal proposal. Have you finalized a proposal to make drug factors we did. The farm industry Student Congress has not passed explicit operation for that list price requirement in the statute. Finalize or pursue any of these policies in the near future. We plan to finalize as soon as we can implementing section a. Allowing flow cost from canada. You know that the house passed hr three. You also know that the president said that we are going to negotiate, negotiate so hard, Something Like that. We will negotiate like crazy. Do you support direct negotiations . We do not. We do not believe the negotiation framework is either a negotiation or actually practical and implementable. It also has no chance of passing in the senate. Struggling even to get to the floor there. Capping out of pocket, as you know, prescription costs for seniors. Do you support the capping of outofpocket costs . We have an important. Yes or no. Reduce what seniors yes, we do. Well, i think ive asked let me just, well, hr three also limits drug price hikes to inflation. Do you support the inflation caps . That is part of the grassley widened package. We have made clear it is a package we can support. It is not the only bipartisan package, but the Price Inflation penalties are acceptable to us as the means of getting list prices under control. Thank you. My time has expired. I now would like to recognize the Ranking Member of the subcommittee for his four minutes of questions. The president signed two important bills into law that addressed Maternal Health and Maternal Mortality. Jamie Herrera Butler preventing death acts. States to establish or expand. The review committees. The other bill. Improving required Health Resources. How do you use these bills. Building on the success of those laws to assure access to quality Maternity Care and protect Maternal Mortality. And i thank you for your leadership on amino suppressive drugs. We put in the budget what you have long advocated for. Yes, you may say thank you. The work of Congress Focusing on this critical issue. Too many women are dial in childbirth, prechildbirth, postpartum. A serious part of the agenda with 116 million initiative, with 74 million increase. Focused on improving prevention, quality improvement, Postpartum Health and improving the data collection. Fourpart strategy that we look for. Thank you for that. Republicans of this subcommittee in 27 teen sent to your predecessor, secretary price and update on releasing the influence of plan. Previously had not been updated since 2005. Can you describe how you are using the pandemic influenza plan as a guide in preparing for your response to this current outbreak of the coronavirus. I was one of the architects of the original plans back in the bush administration. That work is foundational. It set up our entire state, local Preparedness Program for any type of viral outbreak for this. It is the blueprint for how we are operating today, including my role leading through the Emergency Support function under the National Response plan which is the doctrine we have in place for 15 years. Let me just say, this committee did do work on hr three last october. There was concern for many of us that the negative effects on innovation and development would really be profound. Now we find ourselves confronted with this coronavirus outbreak where we know we need new antivirals. We know we need new vaccines. Antibodies to help people who become ill. Can you just speak to the fact of, is innovation still important . We heard several times in the subcommittee and full committee, maybe innovation was not so important as getting cheaper drugs into peoples hands. Two of the key legs of the supplemental request are to develop vaccines and therapeutics for this novel virus. One of the challenges with hr three is the sheer amount of money we pull out of the system. I am not a believer if you pull money out of the drug industry is catastrophic or impossible. The sheer amount would impact the bringing forward of drug therapies for alzheimers, for arthritis, just go through the list of therapies that you need to and sent or you wont get them. Alzheimers drug that was withdrawn a year ago, i am reading is getting a new look at different dosing schedules. It will not happen if we dont value innovation. Thank you for being here. Look forward to the second part of this hearing. I yield back. Bio defense has also been cut. Glad to recognize the chairman of the full committee for his four minutes of questions. Thank you, chairwoman. Thank you for appearing before our subcommittee today. I continue to be upset by the Trump Administration decision to ask the court to strike down the aca and the republican lawsuit seeking to declare the entire law invalid. If the District Court ruling is upheld, the Trump Administration will be responsible for the largest coverage lost in history 20 million americans would lose their coverage making lifesaving healthcare unaffordable for American Families. It would eliminate protection for preexisting conditions, adversely affect the Medicare Program and Medicaid Expansion. Three letters now including one of april and last year requesting any analysis study assessment with reports regarding potential impact if the entire aca is founded unconstitutional. For almost two years now ive repeatedly asked for any documents relating to any contingency plans in place the event the aca is found unconstitutional. Only last week i received a one and one half page response that answers none of my questions, frankly. The documents produced so far, the committee answered none of these questions. I would like to submit madam chair the response in the record. I ask unanimous consent. So ordered. So really i have two and a half minutes here, mr. Secretary. I think the American People have the right to know what the plans are given the president asking that this entire law be declared invalid. Maybe you just have to answer yes or no. We will see. Has a department conducted an analysis to evaluate the impact on individuals with preexisting conditions and their access to Affordable Health insurance if the aca is found unconstitutional . It will not be left just like that. We would replace with something that would deal with preexisting conditions. Have you done any kind of contingency plan . What would happen if the court struck down the aca . We are always considering different options. Agreeing with striking down all or part. It does not sound like there is such a thing. Has a department constructed an analysis on premiums. Access to coverage in the individual market. Individuals with preexisting conditions if the aca is found unconstitutional. Yes or no. It depends on what would be struck down. All, part or none of it. We are years away. Any plans to ensure that the 20 Million People covered under the aca do not lose coverage, anything at all . We have been emphatic that we are changing nothing on how we administer this program. At the time, if there is a final Court Decision striking down all or part of it, it will depend on the context of that decision and the politics of who is in congress and what we can it sounds like the answer is no. You dont have anything yet. I would just like a commitment from you, basically, to respond to my request. Provide any documents to the committee that relate to contingency plans in the event that the aca is struck down. Can you give me that commitment . Deliberate process of some of the core is the internal executive functions. It sounds like the answer is no. I just think that it is unfortunate. Our oversight responsibility is to make sure that in the event we have this terrible situation, that there is some kind of contingency plan. I dont think that you have it. I dont think the administration has any plan. That will occur thank you appeared. The gentleman yields back. The chair recognizes the Ranking Member of the full committee for his four minutes. Thank you. Thank you for being here. I want to make a couple of points. The opening day of this congress i led the effort on the house floor, now in the minority, trying to move an effort to protect people with preexisting conditions, pending this lawsuits decision. Congress could act. This house could move legislation to put into law certainty to protect people with existing conditions in addition to the laws already on the books with preexisting conditions. My colleagues have chosen not to do that. They could. We would probably find Common Ground here on a preexisting language. A lot that could be done here. Second, a congressional budget office, independent, nonpartisan, eight15 new medicines would never be invented because of hr three. Speaker pelosi drug pricing bill. As you said, that could be a cure for alzheimers. It could be a cure for the coronavirus. We dont know. That is in the first 10 years. Further out you look, california life science, upwards of 85 of what they invested would go away. 80,000 u. S. Jobs. 80,000. We lose the r d. We lose the innovation. No president , ive been around republican or democrat, ever leaned in harder on issues of costs of care other than President Trump. I was with you and him when he announced the effort to get transparency in the hospital system. Before we got from the News Conference in the oval office, i think the offices hundred hospitals is that correct . I believe it is. You talked about the drug disclosure in advertising. What happened there . They sued us to conceal their list prices from their consumers. Then i want to talk to you about medicaid part d. We were all working together on this committee, which we have a great recommendation of doing. Occasionally we fight. We were working together to cap the outofpocket cost for seniors and modernized medicaid part d. All of that came to an abrupt halt. Driven i will say from the speakers office. But, we agreed that we needed to cap outofpocket costs. We put that in hr 19. They put that in their partisan hr three. We all agreed that it is time to cap the outofpocket costs for seniors and medicare. The Administration Support the cost for seniors and medicare. Absolutely. Did the administration oppose hr three . We do oppose hr three. Does the Administration Support the concept of hr 19 . We support the elements of it including capping outofpocket and saving seniors money. One of the big issues we try to deal with was a high cost of insulin. Not just for seniors, but for others. In our alternative, hr 19, all bipartisan legislation, we capped the cost of insulin i believe that 50 a month was the maximum. The administration, do they support that concept . I believe so, yes. Going forward, are you hopeful that congress and the administration can get to gather on a plan to president can sign that can become law, that would actually reduce the cost of the pharmaceutical drugs, in america , without driving innovation away . Yes. The most flexible party here. List prices under control. Lower outofpocket. Give the real incentive to get drug prices down. 80 or 90 of that grassley built. We think we are with you. We think we can get there. Thank you, mr. Secretary. I yields back. The gentleman yields back. Pleasure to recognize the gentleman from new york for his four minutes. Thank you. The state of new york was extremely disappointed to hear that cms has denied the request for its renewal of the Delivery System reform. The Program First approved insisting that new york include talk between states Medicaid Program that would incentivize providers to move away from fee for service toward value based payments. New yorks Health Care Community made progress doing just that. Receiving doubledigit reductions and Hospital Readmissions while saving the federal government billions of dollars. Their request for continued time of those savings was to move closer. Exactly what they have been saying. The federal government wants everyone to be doing. Why would cms and hhs want to stop supporting these successful efforts to achieve the very goals of the Trump Administration for the same it has for healthcare. Meeting with the state of new york to discuss how these reforms are sustained into the future . I would like a yes or no answer, if i could get it. Im not familiar with that particular program. We do support value based. I do not know the particulars. Yes, we would be happy to sit with new york. Okay. I would be happy to sit with you as well to discuss it. Mr. Secretary, we have mentioned it here. Other members have mentioned it here. You know it are too well. Skyrocketing Prescription Drug prices. My constituents always tell me they are having to make unconscionable choices to pay for food or filling a lifesaving prescription such as insulin. Taking bold Decisive Action to lower drug prices through hr three which provides common sense solution by allowing the government to negotiate drug prices. That is a policy that the president supported as a candidate in 2016 saying, and i quote, when it comes to negotiate the cost of drugs, we will negotiate like crazy. The administration has yet to deliver any meaningful solution to the health crisis. May 2018, a blueprint was released to lower prices, but many of those policies failed to materialize or provide relief to patients. Other ideas such as the International Pricing index has been shown. Despite these, President Trump claims to have reduced drug prices when a recent report shows on an average, drug prices increased by over 5 at the start of this year. Mr. Secretary, can you commit to me that you will deliver on the president s promise and negotiate your prices . I would like a yes or no also. Bipartisan legislation that would get through. Many principles that the president is supportive of it would have to pass both houses of congress. At the moment, hr three does not have the chance to see the light of day in the senate. We need to work on something getting through both chambers. Im sure if the president asked Mitch Mcconnell to put it on the agenda, he would. I dont think so. [laughter] plenty of things that we have passed in the house that the other body has not done in the president seems to be right along with it. I just think it seems to be another example of the broken health care promises to American People. I just think we need to get those prices of drugs down and we need to not have empty rhetoric, but true facts. I yield back the balance of my time. Gentlemen yields back. Please recognize the gentleman who was the former chairman of the full committee for his four minutes. Thank you. Welcome. As you know, this committee had a unanimous vote passed when i was chair. We expedited the approval of drugs and devices and i would suspect strongly that with your testimony, we had a Record Number of generic approvals as a direct result because of what this committee did. We also added some 45 billion in Health Research over a 10 year span. Frankly, we ask the question of the agency as we work on this legislation, what is it that we could do to help make sure you have these targets of fast approvals. Whether it was fda, cdc and others, the nih, obviously, they gave us an answer and we delivered. At the end of the day, for this crisis, we are going to find a vaccine to solve coronavirus. I know that we are. I would like to think that what we did in this committee and passed on the house floor will be a direct result of that. Frankly, it prompts all of us to ask the questions of what more can we do to get on a faster pace to find that vaccine and that you are. In fact, as you may know, diana and i are working on a bill where we can take these three years since president obama signed the bill into law and ask those questions to see what constructively we can do so that all hands are on deck. I know that you will help us with ideas to do that. The question that i have is, containment in the first, the very first step in responding to any outbreak of coronavirus. We have seen that around the world did i have statements from yesterday that indicate that the cdc says it really is not if, but when. A larger number here in the United States. Ive always believed and if you are going to do something, better do it right the first time because you will not find the second and you want to make sure pay me now or pay me later. We need to have the right numbers as it relates to this terrible disease. It is the two and a half billion, is that a floor . Is that a suggestion . At least 2. 5 billion for 2020 money and then work on 2021 money as we see the situation develop over the weeks and months ahead. I know we are waiting to see the precise details of where it is going. Are any of those dollars envisioned to include the continuance he of what china has done as it relates to regional quarantine . No. We do not envision that as a practical step here in the United States. As the doctor spoke about yesterday, in the event that we had Community Level outbreaks, which might be small, just a town or city, if we have that, we would take the pandemic playbook which is communitybased mitigation steps , social distancing. It is very rare that the efforts around cities, they usually provoke more panic and cause people to actually leave and spread. China is a different government and culture than we have here. Of the 14,000 americans that have died this flu season, do you know what percentage of those were not vaccinated . I do not have the numbers. Historically, our youth that i have not been vaccinated, which is a real tragedy. Any clearing of those 55 americans who have currently been diagnosed with the coronavirus . Did any of them have the flu vaccine . I do not know if that would have been asked. We do not have any evidence that the flu vaccine would have any properties related to the coronavirus. I do not know if that was asked as part of intake. I yield back. A pleasure to recognize the gentlewoman from california. Her four minutes of questions. Thank you, madam chair. Thank you for holding this important hearing. Welcome, mr. Secretary. I do want to express my deepest concerns about the medicare, medicaid and other cuts included in the budget. At a time with the coronavirus out break and addiction crisis a lawsuit threatening protections for preexisting conditions. Targeting the most vulnerable in our communities. Access to Vital Health Care services. We should be prioritizing primary comprehensive care, particularly, and the mentally ill and people with addiction. I believe Mental Health is an area where we have opportunity to Work Together and make progress. Mr. Secretary, i appreciate the strong support of the Community Behavior health clinic. As you know, representative and i are working to further scale the program with our bipartisan legislation. Mental health and Addiction Treatment expansion act. The eight states currently participating, we have studies showing that quality Mental Health services, Outpatient Care and Addiction Treatment provided at these facilities are saving lives and money. People are avoiding jails in emergency rooms. Getting the comprehensive care that they need in these communities. We have 11 additional states that are ready to participate in and expanded program. This bill has a bipartisan beard supporting this full expansion. House majority extending the program longer term. I am very pleased to see that the budget this year explicitly endorses extending this excellent demonstration. I believe that we all agree, mre resources around treatment will find the epidemic. Mr. Secretary, i have a question. Under the leadership of the money made available to hhs and fy 20 to help states prepare, how does hhs plan to obligate these resources . Thank you for your personal leadership on the certified committee to behavioral center. You are right. The data is showing positive results today. Thank you for that. In terms of your work with the chairwoman, now accepting applications from states for these grants to increase access to and improve the quality of Community Mental and Substance Abuse Disorder Treatment services through the expansion. The deadline for states to apply is march 10. Thank you. Making it clear that there is room to improve Mental Health and addiction care. In california, county hospitals and public Children Hospitals relying upon Financial Arrangements that levy public funds and partnerships. Essential needs providing healthcare to the most underserved communities and patient populations of the state. I have concerns about the administrations recent proposal to eliminate these sources of funding. Particularly, supplement payments. I worry if finalized, destabilizing the whole system of care provided under medicaid did payments components of total medicaid reimbursement that was provided to rely on reimbursement and financial stability. Mr. Secretary, have you waived the restrictions on supplemental payments against adequacy of these base payments . Are there plans to make any corresponding adjustments . We are hearing the very important feedback from you and others about that regulation. We want to take that in as we look at how and whether to finalize the relationship of these intergovernmental transfers to supplemental payments and if there are ways we can work with states to restructure payments that would be consistent with the law. Thank you. I yield back. Chairwoman yield back. Pleasure to recognize mr. Dash of illinois. Thank you for being here. Corona virus is a novel pathogen, as most of us know. Emerging microbial threat. Madam chairman, i ask to submit a record. This news release from the Health Organization on the 17th of january, 2020. I joined with jean greene on what we call the adapt act. Last congress, with the help of the now chairman of the subcommittee and Technical Assistance by hhs on what we call the revamp act. It is an attempt to address how we have these resistance. How public funding may not be the only way you can address this. Can you talk about that challenge . I am very concerned about the Drug Development about terms of creating a sustainable market. We have had tremendous success from the efforts you have led in congress has med and my agency have supported. Especially in this concern of as you put it trying to have something on the shelf that you dont want to use. Thats the key. Scott peters and i are also working on legislation that we call ending the diagnostic odyssey and it is an attempt to to help dna sequencing so that when theres a disease or some event, you dont have to test, test, test, you can go just through the sequencing aspect of that. Any thoughts on or comments on what you all may be doing that we dont know about in trying to push more dna identification . So ive not studied that particular issue. Were happy to get back to you on that. Its certainly at the fore right now as we deal with the Novel Coronavirus and have the cdc diagnostic but also hope commercial innovators will develop physician bedside diagnostics for rapid insite testing. Obviously this is timely because of the threat that were all concerned about now, but it is also rare disease week, and a lot of that community is, you know, looking for this as a novel way, especially on that what we call that diagnostic odyssey where they just and we see that with people who are struggling with just types of cancer and trying to identify the right treatment early versus what i would say sometimes is a trial and error method, that is very damaging to the health of the patient, and with 30 seconds, let me i wanted to just briefly and its been asked a little bit before. You all do support medicare d reform, is that correct . Oh, absolutely. It is a real opportunity for seniors. And how would reform lower patient out of pocket costs . Well, you would cap catastrophic payment, the limit at 3100. So a patient would never pay more than 3100, and then at least the grassley widen plan, the senior could actually opt into a program where they would pay no more than 258 a month for their drugs no matter what their expenses are. Amen. Gentleman yields back. The gentleman from maryland, mr. Sarbanes is recognized for his four minutes of questions. Thank you, madame chair. You certainly know the popularity of ecigarettess that recently has recently led to unprecedented surge of Youth Tobacco use and bringing back with a vengeance the tobacco epidemic in this country we have worked so hard to curb. It shows why we have to improve the law and something this committee has been working on. Unfortunately, the Trump Administration is now proposing as i understand it from the budget removing fdas oversight of Tobacco Products in favor of an untested agency that will take years to get off the ground which threatens to set us back even further. Im perplexed that the administration would decide to do this, remove fdas authority, alter the agencys Public Health mission, which includes making, quote, tobacco related death and disease part of americas past and not americas future and by doing so ensuring a healthier life for every family. This latest move is kind of breathtaking. It makes no sense. It is a crazy thing to do by the administration, which unfortunately hasnt taken significant action against big tobacco as more of our nations youth are becoming addicted. In january, after heavy lobbying from big tobacco, as we understand it, and the vaping industry and listening to partisan political consultants, like Trump Campaign manager brad parscale, the administration reversed course and we were on a trajectory where we thought everybody was on the same page. The administration reversed course, announced a policy which failed to ban all flavored ecigarettes allowing popular menthol cartridges to stay on the market and allowing all flavored disposable ecigarettes and open tank ecigarettes to proliferate through our Nations School bards which is exactly what they are doing school yards which is exactly what they are i think. I which is exactly what they are doing. When formulating the Budget Proposal to remove the fdas tobacco oversight authority, did you, your agency staff, white house staff, or staff of the office of management and budget speak or meet with any lobbyists or other representatives of the Tobacco Industry or for that matter political operatives who work for or are contracted by the president s Reelection Campaign . Well, i cant speak for others. Im not aware of any such deliberations. The idea was that if we move the Tobacco Center out from under fda, first, if it were a politically appointed a president ial appointed Senate Confirmed leader, they would be more accountable to congress. Second as a direct report to me or whoever is secretary, elevating the role of Tobacco Control there. Its always been a little bit of odd connection. Fda is about safe and effective, whereas the Tobacco Center is about regulating a product that is undeniably bad. So theres it doesnt make any sense, does it . [inaudible]. We are at this tipping point, this epidemic when it comes to vaping. There does reside however you want to sort of carve up what you consider the appropriate mission of the fda to be, there certainly exists, resides within fda now, significant expertise and experience in terms of dealing with this issue. Why you would propose at this moment in time when this epidemic in a sense overtaking the dimensions of the previous tobacco epidemic that we saw in this country, by zeroing out that authority and moving it to an untested new agency, which by the way, i think would be more susceptible to political influence of the kind i was just recounting than it is now. It doesnt make any sense to me. I urge you to reconsider that. We are in the midst of this crisis, and we have to use every tool available to us here in the government to respond to it. With that i yield back. The gentleman yields back. There is five minutes and 22 seconds left on the clock. Any member that would like to leave to vote, when we get to you can leave now. When the clock goes to zero, they will hold the vote open for those that have not arrived from our subcommittee, and at that point, well take a 20 minute break, but now i would like to recognize the gentleman from kentucky, mr. Guthrie for his four minutes of questions. Thank you, secretary. I look forward to getting to the coronavirus. That will be in my second round of questions. The support act we passed last year included my bill of comprehensive opioid recoveries act to establish Treatment Centers that offer fda approved medications, treatment all of them comprehensive. Currently the Grant Application is open for entities to apply. Im glad hhs is moving fast in implementing that program. My question is, how is hhs implementing other parts of the support act, and does hhs conduct any oversight on how the funds are actually being used . So first, thank you for the support act. And it is so comprehensive, we actually established a support act implementation Leadership Committee to track all of the different needed under the support act. It is enhancing all five elements of our strategy on opioids. Were driving forward, making progress on the Opioid Epidemic. The overdoses are down for the first time in decades as a result our collaborative bipartisan efforts here. Were implementing and using the support act authority so thank you for those. Also in 2018 Congress Passed my bill, the bipartisan bold infrastructure for alzheimers act. Can you please provide an update on how this law is being implemented across the country . So with that act, i would if i could get back to you in writing on that, i dont have all the details on that particular program. I apologize, if i can get back to you . Thank you. This is kind of technical from my role as ranking republican on the o and i subcommittee for this committee. This committee and o and i conducted extensive oversight cybersecurity at hhs including through technical audits conducted by gao of cybersecurity controls at hhs operational divisions. That sounds technical. Last congress subcommittee on oversight investigations held a closed hearing in part because hhs failed to properly identify and address certain vulnerabilities. We received preliminary results from the most recent audit of another hhs agency though i cant go into details in this setting. My question is, does hhs have a point person who coordinates corrective actions on cybersecurity among all hhs agencies, and if so, we direct that person to continue to work with the committee on improving enterprise cybersecurity at hhs and ensuring that mitigations applied in one setting are consequently applied to all hhs. Yes, we do. Our chief Information Officer who works directly with me absolutely is in charge of those issues. If i could go back to your previous question, i misheard on the bold act. On the bold act, yes. I apologize on that. For fiscal year 2020, cdc will have two funding opportunities for actions under the bold act. There will be the Public Health programs to address alzheimers disease and related dementias. Second there will be the Health Centers of excellence to address alzheimers disease and related dementias. We expect both of those funding opportunities to be out in the coming month. For fy 2021, the president s budget for cdc includes 3. 493 Million Dollars to continue to support these alzheimers activities. By 2050, thats when i will be 86, i believe, they believe it is going to be estimating a trillion dollars spent on alzheimers disease. Not only is it devastating to the individual, as the family that cares for that person, but also it would be devastating to the deficit and the budget of our country. So this is something very important. Thanks for your leadership and effort. I appreciate working with my colleagues here to move the bold act forward and address it. I yield back. Gentleman yields back. Pleasure to recognize the gentleman from new mexico, for his four minutes. I will wait right here with you and then well run over thank you, madame chair. Secretary, when donald trump was running for office, four years ago, he famously said that he wouldnt cut medicaid. He didnt say it once or twice, but claimed it at least five separate occasions that he would not cut medicaid, but in reality no president and no administration in the last 50 years has done more to undermine medicaid than donald trump. In fact, his first major legislative effort to repeal the Affordable Care act would have ended medicaid as we know it and put the healthcare of 70 million americans at risk. And if my colleagues from the other side of the aisle want to protect people with preexisting conditions, they should drop the lawsuit. That could happen tomorrow. After President Trump failed to cut medicaid legislatively, he decided to try the same thing administratively, even though the law clearly does not allow it. Secretary azar, theres been some misreporting that the block grant guidance is limited to adults in the expansion population. But under the administrations guidance, states could block grant medicaid for more than just expansion adults. Isnt that true . Congressman, i dont believe thats the case. I will ask the administrator to get back to you on that, but my understanding was that it would be an optional demonstration for adults only and it would actually not affect coverage for our most vulnerable or pregnant women, children, elderly adults, people eligible on the basis of disability, but i will ask the administrator to get back to you on that. That is not my understanding. Im glad you pointed that out because i believe that there is a concern here, and i hope that you would agree with me, if thats your understanding, that you do something about it, mr. Secretary, because the center or budget points out the center on budget points out that people that are low income parents, women who are pregnant, and people with disabilities who are covered through Medicaid Expansion could be included in what i will describe as the president s illegal block grant guidance. Is that something that you would agree with . If thats the case, would you stop it if in fact the guidance does allow for those vulnerable populations to be discriminated against . So, i have been under the view that it does not affect coverage for our most vulnerable populations. It doesnt allow them to strip benefits, eligibility, essential Health Benefits have to be covered. You cant change eligibility. You cant cap or limit mr. Secretary, if i may, just for clarification, because it sounds like were on the same page. What youre saying im not the concerns you are expressing i dont believe are in the hoa. We will get back to you on that. Let me ask you this pointed question. Yep. If in fact the president s medicaid block Grant Program does allow for those folks to be thrown off and get caught up in this, will you stop it . Well, were not going to approve plans that allow people to be thrown off because it cant eligibility. Let me ask the question one more time. It sounds like you are getting there. [laughter] mr. Secretary, if in fact vulnerable populations, like pregnant women, families, those that are disabled, are subject to this rule where they could be block granted, will you stop it . I dont believe i will not approve a plan that removes coverage for our most vulnerable citizens. Thats enough for me. You said you will not approve a plan with very low income parents, pregnant women, children, elderly adults, people on the basis of disability should not be affected in terms of their medicaid coverage is what im informed. I will get back to you to confirm those details. I want to make sure im right on that, but thats been my understanding of the h oa program. What im looking for is assurance that what if my comments are associated with being consistent with the center on budget points out, you in fact will not approve that plan and you will not allow for medicaid block grant cuts devastating cuts go into place that will be subjected to pregnant women, families, and those with disabilities. The categories that i mentioned before are ones that i do not believe are subject to it and plans should not be approved if they would harm eligibility for those individuals. So if the center on budgets assessment is correct, you will not allow that to go into effect. I dont believe their assessment or description of the program is correct. I have said i dont expect that i would approve any plan that would harm our vulnerable populations. It is a healthy adult opportunities under Medicaid Expansion. We will get you any clarification on that afterwards. Thank you. Thank you for raising that to me. Theres a reason that most of us in this congress have opposed medicaid block grants. These are devastating programs. Its another effort to undermine medicaid and to continue to cut the program which President Trump promised he would not. This is another example of where he is, and with that, i yield back. The committee will now recess for approximately 20 minutes, so hold on to your seats while you stand up and stretch, and we race over and come back. Sounded like the secretary said yes [inaudible]. This health and Human Services Budget Hearing take a break so representative cans vote in the u. S. House. While we wait for the hearing to resume at 2 35 p. M. Eastern, heres a portion of healthcare secretary alex azar in another hearing from this morning. Thank you very much. Chairman and Ranking Members, thank you very much for inviting me to discuss the president s budget for fiscal year 2021. Im honored to appear before this committee for budget as hhs secretary for a third time. Especially after the remarkable results that hhs has produced within the last year. With support from this committee this past year, we saw Drug Overdose deaths decline for the first time in decades. Another record year of generic drug approvals at fda, historic drops in Medicare Advantage, Medicare Part d and afford care act exchange programs. The president s budget et moves to a future where hhs programs work better for the people we serve, where Human Services programs put people at the center and wheres americas Healthcare System is affordable, person personalized, puts patients in control and treats them like a human being not like a number. Hhs has the largest discretionary budget of nondefense Department Agencies which means the difficult decisions must be made to put Discretionary Spending on a sustainable path. This committee has made important investments over the years, and some of hhss large discretionary programs including the National Institutes of health and were grateful for that work. The president s budget proposes to protect what works in our Healthcare System and make it better. I will mention two ways we do that. First, facilitating patientcentered markets and second, tackling key impactable health challenges. The budgets healthcare reforms aim to put the patient at center. It would for instance eliminate cost sharing for colonoscopies a life saving preventive service. It would reduce patients costs and promote competition by paying the same for Certain Services regardless of setting. And it endorses bipartisan, drug pricing legislation. The budget reforms will approve medicare and extend the life of the Hospital Insurance fund for at least 25 years. We propose investing 116 Million Dollars in hhss initiative to reduce Maternal Mortality and morbidity, and we propose reforms to tackle americas rural healthcare crisis, including telehealth expansions and new flexibility for rural hospitals. The budget increases investments to combat the Opioid Epidemic including Opioid Response Program where we appreciate this committees work with us to give states flexibility to address stimulants like meth. We this Committee Support has enabled us to begin implementation already. Today im pleased to announce that the Health Resources and Services Administration is dispersing 117 Million Dollars in grants to expand access to hiv treatment and prevention, by leveraging successful programs and Community Partnerships such as the Hiv Aids Program and community Health Centers to reach more americans who need treatment for prevention services. The budget reflects how seriously we take the threat of other Infectious Diseases such as the Novel Coronavirus, by prioritizing funding for cdcs Infectious Disease programs and maintaining investments in hospital preparedness. We still have only 14 cases of the Novel Coronavirus detected in the United States involving travel to or close contacts with travelers. We have three cases among americans repatriated from wuhan and 42 cases among american passengers repatriated from the diamond princess. The immediate risk to the American Public remains low, but there is now Community Transmission in a number of countries including outside of asia, which is deeply concerning. Were working closely with state, local and private sector partners to prepare for mitigating the viruss potential spread in the United States as we expect to see more cases here. On monday, a request was sent to make at least 2. 5 billion dollars in funding available for preparedness and response, including for therapeutics, vaccines, personal protective equipment, state and local Public Health support and surveillance. I look forward to working closely with congress on that request. Lastly, when it comes to Human Services, the budget cuts back on programs that lack Proven Results while reforming programs to drive state investments in supporting work and the benefits it brings for well being. We continue the fy 2020 investments congress made in head start and child care programs which promote childrens well being and adults independence. This years budget aims to protect and enhance americans well being and deliver americans a more affordable, personalized Healthcare System that works better rather than just spends more. I look forward to working with this committee to make that common sense a reality. Thank you very much. Thank you very much, mr. Secretary. Were going to step out of regular order for a moment. The chairwoman is chairing a hearing at 10 30, with a department of Homeland Security, so i want to say thank you, you know, for my colleagues, for your graciousness and allowing the congresswoman to ask her question before she has to excuse herself. Youre recognized, congresswoman. Thank you, madame chair and also thank you to the committee for the courtesy of being able to speak out of order. Secretary azar, since the initial passage in 2008 of my newborn screening saves lives act, it has helped ensure high quality diagnostics and lifesaving followup interventions for the over 12,000 newborn babies diagnosed each year with genetic and indoctrine conditions. As you know, the newborn screening act codified the Advisory Committee under disorders in newborns and children to help address the vast discrepancy between the number and quality of state screening tests. Because of this committees work, today 49 states and the District Of Columbia screen for at least 31 of the 35 currently recommended core conditions. Last september, the reauthorization of the newborn screening law expired. And we have passed a new reauthorization bill in the house, and we continue to push our Senate Colleagues to pass the bill out of their chamber. However, since october, your office has suspended the activities of the Advisory Committee, which is preventing it from completing its current work and commencing new business including a critical update to the recommended uniform Screening Panel nomination process. Meanwhile, you have the authority reinforced in the 2014 newborn screening reauthorization to deem the Advisory Council a secretarial Advisory Committee so it can continue its charter. Given the essential role that the Advisory Council plays in our nations newborn screening system, why havent you used this authority, and when will you extend the term of the committee until reauthorization occurs . Well, first, congresswoman, i would like to thank you for your leadership with respect to Maternal Health and co chair of the congressional caucus on Maternity Care. Maternal health is a Public Health challenge in the United States and our budget is investing in thanks to your leadership and both chair women of this committee by increasing funding, to reduce Maternal Mortality and morbidity. We will continue to fund the block grants to states which provides the states for flexibility with programs. We also have 126 Million Dollars for healthy start to Community Based strategies to reduce disparities in infant mortality and improve outcomes for women and children in high risk communities. With regard to the Advisory Committee, due to the lapse in the authorization, that committee has halted activities and im happy to look into the question of its work as we work with congress around reauthorization of course of the neonatal screening act. Okay, because you have to have authority to continue that committee. And you mentioned another issue that im concerned about, that in your 21 budget you proposed to eliminate the hrsa program that provides grants to educate providers and parents and to help states expand their newborn screening programs. Without this funding, how will the states fulfill these newborn screening activities and improve followup care for infants diagnosed with these disorders and who will operate, update, disseminate information from the federal clearinghouse of newborn screening information . Those are questions that im would like some answers to, but you did mention that you also rolled the newborn screening into the Maternal Health Child Health Block grant, is that what you just stated . I was emphasizing that we have within the Maternal Mortality block grant that does provide addition that does have flexibility to states for programs such as that, so they could use that block Grant Funding is my understanding to continue while were waiting for congressional reauthorization work on that. The concern is that number one you put less money into the block grant than was in the programs that you eliminated and then states are free to use the block grant money as they desire. So increasing funding for the mch block grant i think is an important investment, but it does not guarantee the money will be spent on improving state newborn screening programs. So maybe we can work a little bit on that and talk a little bit more about the possibility of reinstating the committee. Happy to work with you on that. Thank you. Thank you. Thank you. Thank you. Were going to return to regular order. I have a question for you, mr. Secretary. Just before you testified yesterday morning, before senate appropriatio appropriations, a supplemental funding request was submitted, as the chairwoman mentioned. We asked the request was submitted three weeks ago. While were glad the administration has finally done so, whats been provided to date is unacceptable. It lacks the fundamental components of a supplemental request, including proposed bill language, supplemental documentation and omb did not transmit a budget table with details until last night. To be clear, we want to be supportive. We realize the situation is evolving, and you are adjusting to shifting circumstances, but it is important for the committee to better understand the needs Going Forward. Can you tell us how much of the Infectious Diseases Rapid Response reserve fund has been used for this Emergency Response . As i think sorry. Has the 105 million that was available from that fund been exhausted . We are at the point now where we have used or where we have either committed or obligated the moneys in that 105 Million Dollars Rapid Response fund, and thats why i sent you the notice last night about the reprogramming and transfer on the 136 so that for future obligations we can continue our work. The 105 is gone . Committed or obligated, right. It is not there. Okay . Are you going to how quickly are you expending the funds . The actual run rate of the money going out the door, i dont know. I believe we were at about 20 million the last update we had given to the subcommittee, but i would want to defer to staff so we can check on that. I do want to make sure you are getting information on spend rate as quickly as omb will authorize the release on that. We are out of the 105 which were very grateful you all funded. Its proven to be vitally important. Thank you. Let me ask you to provide Additional Details of the supplemental request for the subcommittee. I have only seen a twopage letter from omb and a one page budget table. I was around when the Obama Administration submitted a supplemental request for ebola. They sent a 28page document outlining the intended purpose of each component of the request, and that was demanded by this committee. Every time they came with much more information. Let me ask you these several questions. How do you intend to reimburse state and local agencies for their expenditures on the ground . So weve got i appreciate your frustration with the two page letter being the documentation. We have been working with your staff to provide details by the way, this is the obama submission. We have been working with your staff. We do have plans that were going to work with your teams to make sure we educate on and Work Together to flush out. It is a very fastmoving process as im sure you understand. Within the at least 2. 5 billion dollars request, we would have the cdc have a major fund which would be through the Public Health Emergency Fund to allow them to work with state and local governments to reimburse for expenses around tracing, Laboratory Work we are going to reimburse state and local agencies . Yes, that is the goal is to have a fund that would enable the feedback weve gotten from state and locals, whether through grants or actual reimbursement and we would work with the committee on the appropriate structure of how you think that should be done. Okay. I would like to know what we think that is going to be, how much money is involved, etc. , so we can also respond. Absolutely. We are all getting those questions. So there are five key areas that werent quite transparent in the letter, if i could mention the key strategic investment quickly. My time is going to run out. Ive got the five areas. How much of the funding is designated for International Activities versus domestic preparedness . So i believe in the most recent document that i saw, the table that believe you have access to, there is 200 Million Dollars there of usa id funding that may be from existing sources. I dont know if thats new money or not, that may be existing moneys that would be dedicated on that. We have focused our 2. 5 billion dollars request at hhs frankly on u. S. Preparedness and response. And i would say, compared the ebola response, where getting that stopped in west africa or now in east drc is a critical element. Here our activities are really mitigation containment and mitigation preparation in the homeland because were not going to help the chinese stop this in china. China is going to do that or not be able to do that does it include replenish the Infectious Disease or Rapid Response reserve fund . Yes or no . I dont believe we used the Rapid Response fund. We would work on the 21 appropriation to ensure thats appropriately funded. The funding request was locked in december before any of this happened. We want to be flexible on 2021 funding to respond to that. Did omb reject any your requests of emergency supplemental funding to respond to the coronavirus . Im not going to get into back and forth with the white house or omb discussions. I want to let you know, this 2. 5 billion dollars request has my complete and full support. It attacks the five critical success factors that i made clear i needed to invest in, and it supports that. Its at levels i think are appropriate. And if not, if it doesnt fund it enough, well come back to you and work with you. Again, were trying to be flexible. We said at least 2. 5. We want to work with you on both Funding Sources as well as top line amounts. Well, the chair pointed out we will put together a supplemental that will address this issue. Congressman . Gave me a promotion there for a minute. Im sorry . [inaudible]. Shes got to get to the next meeting. I apologize. Thank you for allowing me to go ahead. Mr. Secretary, i was alarmed to learn recently that almost 90 of active ingredients used for pharmaceutical manufacturing originate in china. What should we be doing in the United States to ensure the safety of the American Drug supply . Well, chairwoman, as you know, this is really this has brought to light the issue of the complete internationalization of the supply chain, not just for medical products, but really across all of the economy. And so what were doing now is the fda is reaching out to all pharmaceutical manufacturers, Device Manufacturers, etc. , to make sure weve got visibility. The latest fruits of that work show that there are 20 pharmaceutical products we are awere of to date at fda where either the entire product is made in china or there is a critical active ingredient that is solely sourced within china. So those would be obviously the most targeted to be concerned about. To date, we are not aware of any expected shortages. And we have aggressively proactively reached out to manufacturers for that information. Im told there are two manufacturers in a province of pharmaceuticals, but fortunately the manufacturer has a large large stockpile supply of advanced production there. But we have to be very alert to this and we have to be candid that there could be disruptions in supplies. We already experienced that of course with medical shortages, generic shortages, due to sole source producers, manufacturing defects, inspection problems, and weve got an aggressive agenda for shortages that we have worked with this committee and authorizing committees on to help alleviate shortages. Thank you. Would you keep us informed . Of course, yes. Thank you, madame chair. I would like to recognize the chair of the committee who has a hearing. [laughter] well all talk fast. Thank you. First of all, i echo the concerns raised by the chair on the coronavirus. We really do need these answers right away. But id like to turn to another matter which is impacting Public Health. As you know, ive worked to restore funding for gun violence prevention since former representative attached his amendment to the spending bill more than 20 years ago. Some of us were there. The fy 20 spending bill enacted with bipartisan support in december, included 25 million for federal Gun Violence Prevention Research split between the cdc and the nih. And when you and i have discussed this issue, including at the Budget Hearing two years ago, you expressed support for this research and responded that were in the sciencegathering business. Well, clearly that sentiment isnt shared by the white house, as the president s budget would eliminate this Ground Breaking funding. Nearly 40,000 americans lose their lives due to a firearm each year. Hundreds of thousands more are injured. Why does the Trump Administration not believe this is a Public Health priority worthy of funding . Thank you for having funded that in the 2020 appropriation in december and were executing on the funding both at nih and cdc. A new Research Funding opportunity was put out Research Grants to prevent firearm related violence and injuries, with a deadline of may 5th for submissions of those. In terms of the budget submission and the continuation of that, as you know, with cdcs budget, we prioritized Infectious Disease, preparedness and Global Health security, and so that did mean cuts in prioritization away from chronic activities which included the Firearm Research there. We of course continue at nih to always be open for business as we have always been for Firearm Research within the peer review process of submissions. So that would continue a pace regardless of whether Congress Accepts the budget submission or not. We all due respect, the administration chose to make these cuts. This wasnt a tough choice. It was the wrong choice. With limited time, im going to go to another key issue. And i thank you, madame chair. As i mentd, at least 64 people died last year and nearly 3,000 were hospitalized with vapingrelated respiratory illnesses while many if not all of these cases were attributed to vitamin e acetate, the crisis raises serious question about how little is known about vaping particularly as concern grows that there could be longterm Health Consequences such as heart disease, stroke, cancer or more. This is particularly alarming as the youth vaping rates have skyrocketed. So i was optimistic when President Trump said he would clear the market of flavor ecigaretted, but after speaking to of flavor ecigarettes, but after speaking to his political advisors, he turned his back on Public Health for political gain and instead proceeded with an announcement that have left thousands of kids favor friendly on the market and allow disposable ecigarettes to flourish. How many more people will have to be sick or die for the administration to take this seriously and ban all flavors . Chairwoman, thank you for your passion around ecigarette and vaping issue and access for kids. I share that and want to keep working with you on this challenge. When the president made the initial announcement with me on september the 11th, we included all flavors other than tobacco in that statement because at the time we had the national Youth Tobacco survey data which had mint and menthol together as a single category of use. We were actually at that time concerned about including menthol in the immediate removal from the market given the fact that menthol combustible is a discrete legal category used especially in the Africanamerican Community and want to make sure that off ramp would not be immediately pulled away from folks. After making our announcement, we got the monitoring the future data out of nih that broke apart for the first time and showed that menthol was not being used by kids, it was much more like tobacco flavoring of the ecigarettes, and it was the mint that was driving it. Thats what led to the modification of the flavoring question there as we move forward to the submission deadline. With regard to disposables, we dont have data on disposables. The largest manufacturer did pull their flavors off the market is what they announced, the comparable kid friendly flavors off of the market. But were going to keep working and enforcing, if anybodys marketing to kids, we will enforce against them. We will watch the data in terms of enforcement priorities. They all have to submit by may of 2020 per court order at fda. Just a quick final question, frankly we need more resources to combat this epidemic, not less. So maybe you can think about why the administration recommended yet again to consolidate and then gut funding for the office on smoking and health. I guess i dont have any time. Why dont you think about that and perhaps answer. Just let me say in conclusion, this is an epidemic. You know, i speak to my grand kids, 6th grade, 5th grade, it is unbelievable whats going on out there. So we have to take it seriously, be tough and strong and respond to this epidemic thats growing. Thank you very much. Thank you, madame chair. Ranking member, thank you again for your absolutely, thank you. Madame chairwoman, the full committee, you have all the time you want whenever you need it. [laughter] im sure our chairman will make sure [inaudible]. [laughter] yes, you do. This is your committee. Thank you, but im going to go over to Homeland Security. Okay. We will miss you because we know were really your favorite. [laughter] we always have been. Let me start a couple things, i want to first associate myself very much with the request for the additional detail on the supplemental. Thats meant to try and help you, quite frankly because our job will be to sell the supplemental to our colleagues on both sides of the aisle and i know well Work Together to do that, so the more you can arm us with information, the better off well be. I do have a couple of quick questions on the coronavirus. My chairman made this point, i agree with her about ebola. I dont think you should sacrifice shortterm here this is bad dealing with coronavirus. If we ever had an Ebola Outbreak inside the United States it would be devastating. I dont think we should be you know, penny wise and pound foolish on that. I would hope working together we protect that funding Going Forward, and i just i say that just to advise you of that, and again, i dont have any problem with people being prudent, trying to stretch the dollars as far as they can. Thats a good thing. This is just one that i think were going to have to do something different. Now, i want to ask one question, and i know the answer to it, but i want to get it clearly on the record. If you do not have enough money in the 2. 5 billion you asked for, you will come back and ask for additional funds; that is correct . Absolutely. I have talked to our leadership and theyre fully supportive of that. They understand this is difficult to estimate, and that it could grow exponentially. I have to bring light from our side of the aisle to say look, if we have to go beyond this, please feel free to alert your colleagues on the other side that were going to work with you on that. The second question, and again, a compliment, i want to thank you we dont have the jurisdiction over funding on the healthcare service, but you do, and you had a modest increase in that this year in a tight budget, i appreciate that. Thank you. Will do my very best to give you more money than you asked for in that area, but i do want to also alert you, budget does propose the elimination of the good health and wellness in Indian Country program at the cdc. That aint going to happen. You know, that is a program that we work with tribal governments on. They are vastly underfunded in this particular area, and so again, i sympathize with you dealing with omb, but just to alert you that i certainly would be very opposed to that. If you want to comment on some of the things you are doing in tribal health, i would be very interested in listening to what you have to say. Absolutely. Thank you very much, and i think you know our passion, my passion around tribal health, and we have even in tight budget environments we have tried to ensure appropriate investment in Indian Country. While our budget does as everyone has noted propose an overall decrease of almost 10 in Discretionary Spending, ihs is funded and our budget request actually at 6. 2 billion dollars which is a 3 increase. So just by scale, i think that reflects the prioritization of Indian Health that were trying to make here. Discretionary funding for ihs has actually gone up by 24 between fy 2017 and 2020. Were working to improve quality, safety in our facilities. In fact, my deputy secretary is out there in south dakota this week, inspecting our facilities that were trying to get brought up to certification. Were working to as part of this appropriation, we want to really build up a whole quality Safety Culture and mindset throughout ihs, beyond just compliance with cms certification requirements. So thats part of all that were trying to do for Indian Health. Again, im very appreciative, and were going to work with you, where we can, and then occasionally stop you where we must. But let me move to another area, and you and i have talked about this recently. I think it is important for the committee to know. We have had some very legitimate questions in my view about reimbursement particularly during coronavirus for state and local people. But the reality is, the cdc provides i think 50 of all the funding for state and local Health Programs in the United States. I know my own state it is 60 . So its not as if you havent put a lot of effort out there already, and, you know, this is something that maybe state and local governments need to be looking at, not that im calling for any decrease in what we do, but maybe they need to be doing a little bit more themselves. But i want to ask you how ready you think these state and local departments are to deal with this as we go forward and what additional steps you think we ought to take to strengthen those without making them totally dependent on the federal government. As you mentioned, thanks to this committee, we through the cdc fund, approximately 50 of the Public Health infrastructure at the state and local level in the United States, in addition, theres connected to that is the Public Health emergency program, which funds over the last many years 675 Million Dollars a year to states to then give to locals precisely for this kind of situation, to be ready for Public Health emergencies. I have been impressed by most states and local governments degrees of cooperation and preparedness, but its also highlighted to me i believe there is a need for greater accountability and oversight with that money thats going out to ensure that it is in fact leading to readiness for Public Health emergency. Last quick question because i have about 30 seconds but i probably get more concerns about Mental Health in my district than almost anything else. I think thats pretty common for all of us. Could you address quickly some of the things in your budget that would help us deal with the Mental Health problems i know all of us face . One of the most exciting things in our budget for my perspective is the proposal that would allow a state option on whats called the imd exclusion, not just to have expanded in patient facility capacity for Substance Use disorder but also for serious Mental Illness. Weve seen where we have had imd exclusions approved, waivers approved, expansion and capacity, by bringing this as state option, which means it is not i think subject to the budget neutrality issues of a waiver, thats a major investment that could allow for serious Mental Illness. Just one example there. Congressman . Thank you very much. Thank you mr. Secretary for being here. Let me say your department is in the final stages of a regulation regarding the interoperability of healthcare data. Many of my constituents work in the health it industry. The outcome of this rule is very important to my district. I appreciate you listening to the concerns, comments, look forward to the improvements that will happen in the regulation and i want to thank you for your leadership. Ive tried ive worked directly with epic leadership in hearing their concerns. I think often they we put a proposal out, and we precisely because we want to get that feedback about operationalizing and everything, and so i hope that were trying to be reflective of the concerns there as much as we can. Let me try to get to the meat which may not be as pleasant. I would love to get to talk about the cuts to medicare, medicaid, the cuts to nih but i want to talk about the coronavirus. I need you to help provide some comfort to the American People that this administration and federal officials actually have a grasp on this, because let me go down a little bit of litany of what i found in the news the last few days. The secretary of Homeland Security yesterday say a vaccine was several months away. The president said were very close to a vaccine. And yet i think you and the cdc and others have said it is more like 18 months. We have heard from commerce secretary wilbur ross say that the coronavirus could be good for u. S. Business because it hurts china. We have heard larry kudlow say its contained. We have heard Rush Limbaugh saying it is no worse on that the common cold. And yet we have also heard from cdc officials not a question of if this will happen anymore but rather a question of exactly when. And a doctor who many of us really respect say it is inevitable this will come to the United States. We have those kinds of comments. Second, we know that this first started information coming around january 7th, in the budget that was produced by the president , on february 10th, provided a number of cuts that would have actually work to directly affect this from the almost 700 million cuts to cdc, 167 million from the office of the assistant secretary for preparedness and response, 18 million from the house preparedness response account and 200 million cut to project bioshield. We have seen recent reporting that 150 Prescription Drugs, this is from the fda, are at risk of shortage if this outbreak worsens and yet the fda commissioner is reportedly not part of the task force that is planning the u. S. Response to coronavirus. In 2018, the cdc cut 80 of its efforts as part of the Global Health Security Initiative to prevent global disease outbreaks because it was running out of money and it was reported that the department could go from working in 49 countries to just 10 countries. Also in 2018, the white house official that was responsible for leading the u. S. Response of the deadly pandemic left the administration and the Global Health Security Team he oversaw was disbanded. And finally, the tweet from this morning from the president , talking about low rating fake news, doing Everything Possible to make the coronavirus spelled incorrectly, im a journalism major look as bad as possible, including panicking markets if possible. Markets being the concern. Help me, is this contained . Is it a common cold . Inevitable . Two months in 18 months . Provide me some security that someone knows whats going on in this administration about the coronavirus. Thank you. Where shall i begin . A long list there. What we are trying to do and tried to do this with members of congress, senate, the public and the media is really flood you with information about this to make sure were being transparent about what were facing, what we know, dont know and what our plans are. The risk right now is very low to americans. We have been as larry kudlow said from a Public Health perspective, we technically are in a state of containment in the United States. We have had 14 domestically identified cases here from nonrepatriation thats remained the case now nor 15 days. For 15 days. But we have always been clear, number one, that could change rapidly, and from the outset, i and the Public Health experts have said we fully expect we will see more cases here in the United States. We have to be mentally prepared and also as a government prepared. If i can reclaim my time . That still didnt provide me the comfort i was looking for. Because the variety of statements i said are from two months, its nothing, it is a common cold, to inevitable, and i still dont think this administration seems to have grasp on it. Let me ask you this, youre looking for the funds. I also agree with the bipartisan concern around stealing it from ebola. I talked to a senior white house official last year not white house but administration official, one of his two main concerns he was dealing with was ebola. Taking money from that would be ridiculous. Let me ask you this. We have redirected 3. 8 billion dollars from defense for the wall. The wall is not going to stop any real or imaginary migration, and its certainly not going to stop the coronavirus. Would you be supportive of taking some of that 3. 8 billion dollars or any money for the wall and transferring it to take care of the coronavirus . So the ebola funding and all the transfers proposed in the supplemental, i do want to be very clear. That is simply a concept of how you could fund half of the supplemental. Were not wed to that. We wanted to give you ideas. On the ebola money, that in particular with ebola, it is thanks to the supplemental funding we had before, it is important to note we now have an approved vaccine from merck, and we have two therapeutic candidates. I have been daily involved with the eastern Ebola Outbreak that is coming close to being under control, on the epidemiological curve is looking more like that if the security situation stays. I want to thank this committee for the support on ebola we have had. We now have major weapons to use against ebola which is a revolution. Last part of the question, would you be okay with taking funds that have been redirected for the wall and redirecting to stop coronavirus . I dont believe the administration would be supportive of that, but congress will make the decisions about how to fund any supplemental. Thank you very much, mr. Secretary. Congresswoman . Thank you, madame chair. I want to commend you for your initiatives on advancing Kidney Health. 750,000 americans have irreversible kidney failure, and 90 of those patients are undiagnosed. So nine in ten people do not know that they are on this track. It represents and so then its too late to slow the disease progression. So thats medicare spends more than 120 billion, 34 of total spending, and end stage disease accounts for 7 of medicare spending despite representing 1 of medicare patients. This is only going to get worse. Ive been super excited about the initiative that the white house, that you have launched to go after several of the problems within our current system, both to educate and inform and help people become more healthy, also to make sure that were getting more solid procurements that people are getting the transplants needed. And youre also going after the big fear for most people who have transplants which is when is the immuno suppressive coverage going to end because i cant afford that. I want to say thank you. Its a breath of fresh air to have someone really taking on this issue. It represents a lot of hope for a number of us who have been laboring in this field. I wanted to ask, theres two things, you know, i have a lot of questions about the coronavirus, and i do appreciate i have seen multiple options for members that come for briefings from your staff, from your team. Thank you for keeping us abreast back to order. Thank you, dr. Azar for your patience. I would now like to recognize the gentleman from virginia mr. Griffith for his is it four minutes . Yes. Four minutes of questions. Thank you, madame chair. Appreciate you being here. Thank you very much. The president and your agency have expressed concerns with the middlemen in the drug supply chain, pharmacy benefit managers, pbms. Over time they have morphed into underregulated entities with opportunities to exploit their position in the middle of the drug transactions in the u. S. For example, according to a new report from exile consulting which is run by former express scripts executive, pbms benefit from a secure fee known as direct and indirect remuneration, dir, i know you are familiar with that at a rate exceeding 500 per prescription is compared the average administration fee. Last year, the Administration Proposed a rule to address these dir fees, but later withdrew it. Do you still have plans to implement Accountability Measures for pbms . If so, what does that regulation look like . I remain very concerned about the dir fees and their impact especially on americas Community Pharmacists as well as independent specialty pharmacies. So the reason that we did not finalize that rule, and were very transparent at the time, was the concern that by if we forced the dir fees to basically go through to the benefit of the patient, that that could cause an increase the middlemen would jack up the part d premiums for our seniors, that was the concern. The president has been adamant that he does not want to run the risk of part d premiums going up. So it remains a priority for the administration to deal with this erb shoe. If we ever could legislatively, that would be that would be useful, also. As you know, i would love to have a legislative solution, but we thought this might be a good test case to do it with that. Maybe even through if we could get bipartisan drug pricing legislation that might be a vehicle to have that in there. It might be. Let me ask you this, theres been some mention earlier today of hr 3, i raise the concern and then later it was raised by the Congressional Research service, that the bill as written is just blatantly unconstitutional. Have your lawyers advised you that thats the case in their opinion as well . Ive not had anyone study the constitutionality issues on hr 3 about the penalty amounts and whether that would work. So i havent seen any analytics on that. Any time they want a discussion on it, im more than happy to facilitate one. Lets talk about opioids. Over the past few years there has been a lot of talk how they are prescribed in america and how pain is medically managed in general. I will tell you that i thought we were on the track of getting our Healthcare Professionals to back off of giving out so many opioids for pain, but i have a friend who is currently undergoing some procedures, and we were talking yesterday about how they had given her opioids, how she took it in the initial day after some painful procedures, but that after that, she turned it away, but shes got it sitting in her house. What has this administration and hhs done to reduce the overprescribing of opioids . legal opioids to date, the present took office and we are making progress. Is going to take time but we cant just because we started to solve a problem, we cannot think that it is sold and we cannot take your foot off of the gas pedal to try to make sure that we dont over prescribe. Then we deal with this very serious issue. I yield back. The chair is pleased to recognize the gentleman from oregon. Thank you very much. Thank you very much for being here alex azar. We do it to make sure the cec is fully funded and a little concerned about the original budget. I would like to see some changes coming forward. My first question is on Medicare Advantage. It is a huge program in oregon and many states. Our federal tax dollars to maximum advantage. Most seniors, and a lot of their Prescription Drug from the Medicare Advantage pretty very concerned that this administration and others have didnt you try to merit Medicare Advantage programs, i think its foolhardy, whole goal here is actually make sure the savings are piled back in to make sure there are more benefits covered and better Prescription Drug coverage and expanding it to a larger universe. To give you some assurance, we will continue, this administration, you will try to improve the Medicare Advantage program and not take away the savings that will be plowed into more savings for folks. Im actually have direct orders from the president to protect that. More supplemental benefits, make sure those people have attractive options as possible. It. The guidelines in reducing caps and that sort of a thing made me nervous about the but was. Second question is on the proposed medicaid rule. You hear a lot about that back home. I was budget chair for my state back in the day. It seem like a great opportunity for states again, to leverage federal dollars with the state tax dollars, actually with private hospital dollars in longterm care dollars. It was a really smart use of taxpayers limited ability ability to finance programs they want. It really made great use of the dollars. Im very concerned with this new role, that all due respect, train and the kinds of transparency when indeed its back to take away patching funds and the ability for the provider tax be leveraged in many states including ours. Given the fact the executive order requires federal agencies to perform this Regulatory Impact analysis to determine the effect of the impact of the proposed rule who says that the implementation of the proposed rule is unknown. Consider that to be a Regulatory Impact analysis. I have not looked at the analysis. I dont know the specifics on that but certainly do want to assure you that we are hearing the feedback from you and others in governors, about this. We are looking at this to make sure those intergovernmental transfers are genuine state money that is being matched. Its not funny money or schemes. And also be more prospective, not looking backwards as much as we can. I appreciate getting the feedback. We are hearing a lot of it. With some people are calling funny money schemes some people other people would call it smart money. For maximum advantage. It really puts a huge hundreds of millions of dollars into the organ and state budget. So i urge you to back down on the a little bit earlys give it some more serious thought. I yield back. Is a pleasure to recognize the gentleman from florida. Thank you. Secretary azar, thank you first of all for your leadership. And thank you for your responsiveness to a lot of my constituent concerns as well. We began to make progress with her nations opioid crisis. And hhs has played a key role in that effort. Do you feel and this is a bunch of questions. Do you feel hhs has the necessary resources to continue to implement provisions of the 2018 support actin in 2019, hhs Pain Management recommendations. I do believe so in fact we have increased funding for the opioids in this budget. Also the centers, the Health Centers do a wonderful job is expiring soon. Weve reauthorized it for an additional seven years and that is a great thing. But how the community Health Centers serves as a gateway to integrated care for individuals with Mental Illness and Substance Abuse disorder. More than 28 Million People rely on community Health Centers to fully fund their critical part of our primary care network of Preventative Care for individuals and highquality services are delivered. Also using them in the hiv Epidemic Program to reach the underserved and people who need to bring into treatment treatment and prevention. More than 93 percent of our 1400 Health Centers provide Mental Health counseling and treatment. 67 percent of them provide Substance Abuse services. I think the number is 60 percent of the clients and the community Health Centers are ethnic and racial minorities. Im always just so impressed when i visit them, the quality of care and service. Absolutely. Do you have anything to add. Only give you an opportunity to add to this. This is a big issue affecting our constituents regarding the insolent price and pricing. If you could elaborate on that, i would appreciate it very much. I do want to clarify one thing. Its regarding a piece of legislation, i misheard, cap of 50 outofpocket for insulin. The administration does not have a formal statement of the position on piece of legislation yet. We want to get outofpocket down, so we want to deal with the insolent issue and get insolent pricing down for everybody. We dont have a formal statement yet on the issue. It has a lot of bipartisan support though. May could be such a benefit to people. Catastrophic cap of 3100, spreading the cap over 12 months, no senior would ever pay more than 260 bucks a month for the prescription they often into that. What an incredible thing we could deliver for american seniors. Bicameral by partisan action on that. Thank you for clarifying that and we will follow up with you because again, this is a big issue affecting our constituents. School safety. How does the budget address School Safety and the Mental Health needs of our students. We funded projects where in here which is a really important schoolbased School Safety program for those for Mental Health services. We have healthy transitions funded which improves access to mental Disorder Treatment and related Sports Services for youth. In the safe schools implementation toolkit to help educate teachers and administrators to identify kids in crisis. Who need Mental Health intervention. Thank you very much. I appreciate it very much. The gentleman yields back. Mr. Kennedy for his four minutes of questions. Thank you. This week, hhs issued for the immigrants. 4. 7 Million People from medicaid withdrawing, many of them are legal immigrants and the children of immigrants and Asylum Seekers and refugees. Nearly 5 Million People of fargo their Health Coverage. We do not believe that individuals who come to this country should be dependent on public taxpayers for healthcare or other services. We do not believe that individuals should cover the studys this country to be dependent on the Public Welfare programs. That is the basis for this. You frequently told us your story about your grandfather who was an impoverished teenager who spoke no member. Under this role, but youre and telling of the story come your grandfather would have been turned away. So i ask yes or no, are you with this pretty. So my grandfather came and worked his way up through the with his bootstraps. We have access to healthcare under this policy. Know he wouldve wanted to make his own way so he would not done that. I am proud of my grand father, 100 years ago he came here. I am im asking you if you are proud of this policy. Assuming people should not come to this country to comfort welfare. Are you aware of this. It. Slightly the numbers on the uninsured, require a bit more definition that. Whats happening on the uninsured is actually the eight steve eight, most of the growth of uninsured is because the a ca individuals are priced out of the individual markets. [inaudible]. Uninsured children have grown by 6 percent. Actually in terms of children and coverage, we have reauthorized that for a long period of time. We got the Medicaid Program. So in terms of the uninsured numbers there, the children that are uninsured are likely part of the coverage gap by the aca as well as pressing out on the subsidized monies. We held a hearing here of an epidemic represented from the department of health and Human Services of North Carolina said that if they had expanded medicaid, quarter 15 more people would be alive in North Carolina today. Do you believe that this Administration Opposition Medicaid Expansion, that according to that individual, is that a good policy choice. I am not going to validate a politician statement that i dont know who it was. The department of health and Human Services pretty. I dont know who they are on the basis for that. I have not seen the evidence pretty. You are you unaware that medicaid has saved lives. That is not what i am saying. I have not seen the evidence for that assertion you are making. Student one last question for you. He spoke with the Administration Efforts to cope that coronavirus. Recently can virtually try to be prepared after developing flulike symptoms following a trip to china. He was left of the bill of well over 1000 and demand approved the jury was trusted for was not related to a preexisting condition. Any was also asked to pay a few thousand dollars more. And your worried about fundamental changes. Millions of people who have signed up for junk insurance plans, do they really have a choice. So the Short Term Limited Duration plans are optional for very nice individuals. But they may not be the right choice for all. Thousands of dollars, but uninsured claims in the midst of a potential pandemic. Is that a good choice. If an individual, that is the choice between no insurance and some insurance, and 6 percent lower than what the Affordable Care has priced them out of the market for. I yelled back. Gentleman yields back. Thank you very much. Thank you mr. Secretary for being here today. I will switch years a little bit. 340b is a critical program, especially for rural hospitals. I am interested in what you think should be done if anything, to continue to ensure that the 340b program, even its significant growth, is helping more patients get access to care. You put your finger right out of there when you said image of the growth it has grown from 7 million of pharmaceutical sales to 19. 3 billion in 2017. We believe in the 340b program, we do believe those savings need to actually make their way to patients. Not just subsidizing hospital will make their way to patients. Imagine persistence, dinky this issue of insulin. Extremely low price, but they dont have to necessarily pass the savings on to the patient that they are serving as an outpatient. This partly why we have proposed the changes and try to implement the changes that would reduce what seniors have to pay for part d, would have to pay in the Medicare Program for the drugs. Do you think the more transparency in the 340b program 20 part of the solution. Absolutely. We support transparency in the program. We support giving the Regulatory Authority as part of our budget. And also requiring the hospitals who want to get the benefit of the savings by just walked out, to retain that in the program. They would have to dedicate 1 percent of the work towards delivering charity care. This seems a pretty low park. They probably need more authority. To grant the program. Would you agree. We need greater oversight, Regulatory Authority to regulate that. So that we can actually do audits and enforceable way and have that type of transparency. Suet i would also like to thank you for making improvements in Pain Management a key component in hhs in the opioid strategy plan. I firmly believe we will never successfully address this Opioid Epidemic unless we address the Pain Management. An ime physician. Critically fda medical devices. Which of the greatest opioid staring potential. Can you tell us what hhs is doing to promote best practices in the status of various actions to break down barriers for non opioid things for pain. It. That is what we developed internal opioid misuse with the mom model. We recently announced that mod model. That will address the fragmentation of care for pregnant and postpartum medicaid beneficiaries with opioid use disorder by supporting air ordination and better immigration. As part of that pretty. Funny in the hearing, youre starting to give some bullet points on a think corona. Does a fivepoint plan or whatever. In the last 50 seconds, can you expand on that predict. Our Surveillance System so we have comparable on the flu. Second, money to support state local Public Health departments that will have to do a lot of work. Third, vaccine, research and development. Fourth, Therapeutic Research and development, and for only, Strategic National stockpile acquisition especially personal protective equipment. Thinking for that. Do we have a knife access in china to get the data that we need to help solve this problem. It. That has been a struggle. They have not completed their mission. Waiting for the report. We are getting access to the information but i want to see the final results of that. Thank you night yelled back. They had existing oversight authorities of the 340b and is my understanding that they have conducted 1300 audits of the program. We do not have the ability to implement regulations. It. Without talking about that. Were talking about audits. So thats why wanted to get this on the record. Look at your audits and see what is in them. Its under the control of the department. I now would like to call on, or recognize the gentleman from california. Thank you very much madam chair. I appreciate the opportunity to have this oversight hearing. Secretary alex azar thank you for being with us. In fulfilling our oversight duties, some you were here, for a budget i asked you about your agencies and the horrifying practices of separating children from their families. Today i would like to ask you about other ways that the administration affects families both in my district and throughout the country. I would like to ask you about an issue that is fighting families my own district. Im talking about the forprofit companies, proposal for Detention Centers in my district. Approved by hhs and must use our federal tax dollars to put a facility thereto have children in a prison like setting. The company that received these funds from your agency, has a history of a of the stories of abuse within their programs right here in this country. They include inscriptions of excessive use of physical restraint, verbal abuse, food deprivation, humiliation and intimidation and even death. This is all about them having children in their care. As part of the Due Diligence of your organization, when officials within the office of Refugee Resettlement be aware of these types of violations to such a company like vision quest i dont want to endorse the statement that you made regarding the empathy because i do not know the particulars of that are the allegations that are being made there. So my be careful and not endorsing that. I would expect it would be part of any grant review of any grantee to examine their past history of the treatment of children i would absolutely expect that yes. Please report to this committee of any of the ones such as the lie was talking to, if theres any evidence, any valid situations with an organization such as one that would be entrusted with several funds to house children. Thank you. These funds you would be providing unless you were to have such evidence, he would go ahead and contract with an organization. That is how is you know, how it runs. We hire grantees run permanent estate license facilities and care for children until we can place them with sponsors. Thats really what the congress set up. The city of los angeles and solidifying theirs if they were going to allow private entities. Have another issue i would like to discuss. Impacting American Families especially Vulnerable Children throughout america. In your written testimony come you speak about the importance of promoting adoption, to give children the stability and love during their childhood. Is god prioritizing adoption. Cleaning neglect to mention the fact that right now in america, the agencies are turning away qualified potential parents because they are either lbd queue or a religious minority here in america. This is an spine that they are seven more times likely to foster adopted children and non lb you parents. My question is europe is to identify and address adoption, can you tell me Data Collections and reporting on Sexual Orientation are fostering adopted youth. Is it helpful to furthering at school. What you are referring to is the apgar reporting system. In the original relation contains 270 individuals data points in hundred 53 of which were new. In the states, no significant feedback about this year volume of data collection. All of which is money that if we add more and more questions, more and more Data Collections, the money cannot use it. And for the adoption and foster care placement so its really just an effort to streamline this data request in there. I think the gentleman. Its a pleasure to recognize the gentlewoman, and that she is from indiana, for four minutes. Thank you. Welcome sec. Alex azar, thank you for being here and thank you for going out this past june, the president signed the reauthorization of, which this committee worked very hard on unless congress, and we finally got it done. I worked hard with chairwoman and Ranking Members of this committee to try to make sure we readiness and response because the question of the pandemic is really not a question of if but when. They are acknowledging that. People are listening, to understand, the global security, Global Health security index, recently issued in the United States of america was first. In the world of a hundred 95 countries, for prevention and Public Health. I also want to commend the administration of the strategy that was put in place for 2019 to 2222, i commend you for leading network. But with respect to, im curious, how are you leveraging how is hhs leveraging of the new things we put into it. And i also would like to it address, because are so many good things in your budget but i am particularly concerned about it to her Million Dollar product. This brought forth so many incredible innovations in the partnership that they have with the private sector, what strategies are we going to put into place. If it is cut. So that was of course, in the budget before the coronavirus situation. Because congress and the appropriations in december added i think 535 million to the boiler funding in 2020, we were pulling forward zone for acquisition acquisitions especially vaccines therapeutic on it. I created some offset. Roomy need to relook at that. That was meant to be because we pulled forward some of those acquisition acquisitions pretty. But the private sector this developing the vaccines, and because the government is the customer for those products, is it fair to say then that they and all of the officials who are working in it are they saying that they should not anticipate what is happening right now because in the funding. We would work with the appropriators as to whether the absolute proposal on the 535 people and to be part of the funding of the supplemental if that happened. Anything from feedback this morning from the house preparations committee, unlikely. We still have a bullet in africa. But is on the downswing. What we would do is use that money for acquisitions. If the money remains there in 2020 the vaccines, and therapeutics that we have, but if not we can work with the appropriators and making sure that they are adequately funded. And are there any other issues or strategies or framework that we provided that you are using specifically right now to combat the coronavirus. Of the coronavirus, i cant trust directly to the authorities but for instance, vaccine strategies are very much influenced by that. , dna, the universal Vaccine Research that we are doing in the influence of case. As well as cell based technology to bring domestic Manufacturing Capabilities here. She has about that tune her Million Dollars cut to florida, and the secretary, responded. The administration, mr. Secretary, when on a budget ten days after not before, after declaring Public Health emergency. So your answer is really not correct. Some of them sure you understand that the budget is locked into december so is. By the date of the runabout virus outbreak. In the administration does not have the ability to call in a something out and say, we are not cutting the spread we need it. Come on. The gentleman from vermont. Recognize performance. Thank you. Impartation, we are very happy that youre preceding on that and as you know we have a republican governor in vermont who was extremely interested in getting authority to do this. They hope to have everything required for you sooner than the deadline. We think its a great opportunity, and our legislature they to take advantage of this. In one of the concerns that the governor has in particular but all of this, is including insulin, this one included. My understanding is been concerns raised with her that can be safely done. Really would make a huge difference in vermont. As you know a lot of people already drive across the border to get insulin. And even some companies do that. Our view is that the concerns about safety, are always legitimate. No matter where the source of drugs. Our real request is to accommodate insulin is one of the drugs that could be imported as long as done safely. I wish you could comment on that and tell us what we can do to give some folks in relief were desperate. It. They are expressly excluded. As a provision for the canadian impartation regime which we are using. We have no objection to it gone fact that second part of the impartation program or a drug company can bring a product in with a new drug code, and actually price it at a lower list price. They deal with their in the end, those minimum contracts. That is open for all products. Some images understand, this is couple. Youre saying it is of the statute spread concerned that hhs has. It was far as youre concerned, if this authority under the law, for insulin to included, you would see no reason to object that. Would be supportive of it. We believe it could be imported appropriately but the statute does not allow me to a private. So we did an amendment to the statute to allow for it, he would be supportive of that is unlike pretty stomach cant formally say the administrations position but i can tell you that the president wants to anyone that yesterday. We are delighted that the governor is working, the programs that when we finalize the role we can get to work on them quickly. Who would i followup with in the administration, probably you. About supporting that provision may need to be included in order to allow insulin to come in. That would be huge. The people of vermont. I am happy to work with you on that. Thank you. The gentleman from georgia, mr. Carter recognize work for minutes. It. Thank you. As you know, that premiums have squeezed out almost 4 billion out of pharmacies, with these fees. The sermon that was done by the national Community Pharmacists association said that 50 percent of the independent retail pharmacist in this country, dont be expect to be in business in two years as a result. It should be of concern to all of us and particularly, to hhs and the delivery of Healthcare Services in our country. I just wanted to ask you, i believe you responded, that you believe the concern is the premium with the Insurance Companys, they account for almost 80 percent of the market share in this country and all of it of the ppms are owned by Insurance Companies. How can we answer the question of whether those rebates, if theyre getting mediums, are going back to the Insurance Company and also owned by the same company. Thats one of the real problems we have. We dont have the transparency. We cant actually know where those monies are going. And would appear to me that actually is taking money out of one pocket and putting it into the other pocket. Is the same company. It includes the pharmacies as well. The vertical integration is something that has to be addressed but when you think we can do to address the fees. They have been associated with outofpocket costs. For recipients and that certainly is something that we have to be concerned about and i know youre concerned about and youve said in the past that you are. If we can lower outofpocket costs, would help to have the rebates at the pointofsale. Yes it would help to have rebates at that point of sale that would lower outofpocket costs and pushing through folks understand, the dir is basically a penalty provision that the middleman compose on the pharmacist. The patient is made to pay off of the full price when the by the drug in the pharmacy later makes this callback of the penalty but the patient does not get a refund of their outofpocket. And can take place almost a year afterwards are sometimes two years. The pharmacy is struggling from us. Close switch this from the coronavirus. If you can answer yes or no. At this time, you and others involved in preparing for a potential outbreak, doing everything you can to prepare for such an event pretty. He we are indeed. At this time, youre involved in preparing for this, it felt like you needed more money coming you have asked for it pretty stomach i wouldve and i have. And any time, if and others involved in preparing for potential in outbreak, the more money, would you ask for it. I will indeed. Absolutely sows out the amount of money, that is asked for is proportional to the effort this going to be put forth to prepare for this. This and the president has made very clear in my own discussions with him and publicly coming that we want to work with congress on the appropriate supplemental operations here. At least 2. 5 billion. We want to work with congress and get the money. One make sure that the congress is satisfied with the funding also. Has should be the case and again, if you need more, you will come back to us and we will want you to have everything that is available that you need to prepare for this and you will do this. Correct. That is correct. Thank you mr. Secretary. Thank you for being here today. As a father and a physician, i care very deeply but the physical and Mental Health of children. Also children while in the custody of the office of Refugee Resettlement. Im not mcculloch, but that up because im also dealing with a similar situation in my district. Our website says their unaccompanied children programs to take in consideration the unique consideration of these children when making placement. These decisions that are in their best interest of the child. Let me get this straight. I definitely want answers. When determining appropriate housing for children, do you give grants for Profit Organizations with people who have a child abuse background pretty. We would give grants to forprofit and nonprofit without discrimination. I recently learned that in addition to the facility in california, or is providing a grant to vision quest open a 130 bed shelter for unaccompanied sit children in california which i represent. This request is a forProfit Organization, and they focus is to make money rather than to care for the wellbeing of the children. Instead has a very long history of keeping children in abusive or harmful condition. Daniel of the way back to 1987. A report from the Rand Corporation found that the treatment methods used by vision quest for unorthodox and activities engaged closed o. Reported that the department of justice documented episodes of physical and mental abuse and is vision . In franklin pennsylvania including staffers pulling childrens hair and using harsh restraints, choking minors and even slamming them into walls. In 2017, the city of philadelphia and to in the contract with vision quest after state inspectors found that Staff Members and choked, slapped, and injured children in the facility. The providing federal funding to pay for Profit Organization with a long history of child abuse. Are you familiar with those reports. Some of the allegations that you raise, i am familiar with. Of course whether there are forprofit or nonprofit is not the factor but we want to ensure that any grants, look into pretty thank you. [inaudible]. Made the gentleman speak from the microphone so you may be properly recorded. Is a note from 1994. We will make sure that its appropriate. This way image in a history of abuse. It. In this way when you look and review these programs, i will ask you, what is the process, is there transparency. How do you determine and how do you open this up to communities to determine who will house children the safety of these children in mind. For these permanent facilities, at the request of congress, the grantees would actually have to be state licensed. So theres a state licensure procedure. It. They have denied them their ability to state take care of children because of that pretty. Than they would not be able to get the grant. So the question is, when you look at those reports, and you review the evidence. Would you be open to reevaluating these grants and your relationship with vision quest. I will ensure that all our has look at these, as part of the evaluation criteria and looking at the records pretty just because, all of the behaviors you described are absolutely unacceptable. I want to be very clear about that. Absolutely unacceptable. The gentlemans time has expired. We really need to move along because we have another panel and everyone knows some very important one. The state within her time. Mr. Long. Her minutes. Inc. You. And secretary azar. I want to thank you for being here today. As soon as we sat down, my phone started blowing up in my house was on fire. In missouri which turns out it was not. But the Alarm Company people seem to think it was. A sensitive part Fire Department over country remember that. But i want to thank you for working so hard to advance the administration itself. On behalf of the American People as you know in your testimony, rural americans face many unique health challenges. And under your relationship, integrated the role Health Task Force credit and is proposing a fourpoint strategy to transform rural health. As vitally important. Can you first speak to identifying the major rural areas and how to make those Needs Department wide. The task force identified four key priority trust. You got to do develop a sustainable model for rural healthcare. We can dispatch and over with money that is not underlying economically viable. Second, we have to have prevention and Health Prevention third we got to have telehealth and forth weve got to get the next generation providers out into rural america. We going to allow Nurse Practitioners and tea is to practice licensing rural communities. It. In one area has been seriously impacted of the past few years is Group Medical equipment. I was pleased to say that in the interim and final rule, in 2018, for medical equipment and rural areas and continued relief in the 19 an estate renal disease final rule. And it goes until the end of 2020. Can you tell me if cms plans to continue this relief after 2020. Im not able to discuss regulatory actions. We do know that there was a major priority to get the payment in place. To insert better equity for rural america. That remains very much and top in mind for us. Its not in the present fiscal year 21 budget, provision that would expand the Bidding Program for Durable Medical Equipment in the rural areas in 2024. We were many complaints about that Bidding Program over the years. Really since its inception. Can you tell how you would like to reform the program and how it would impact rural areas predict stomach flu would to do in the budget is actually a for Durable Medical Equipment under the competitive Bidding Program and move from a single payment amount, is based on the maximum winning bid to actually paying for fires on their own bid amount. And then expanding the Competitive Bidding to geographic areas including rural areas. That would enhance access to dme and rural areas by allowing competition there rather than something happy to depend on the payment result secured elsewhere. I can involve lot of the access challenges we saw that we had to work to fix the interim regulation. Outside experts, economists, consumer groups on this. And they considered expanding the competitive program. We do. We engage with stakeholders. We are making use to get that feedback. Would you go forward with a program without congressional approval. A. I believe, i dont know if or required statutory authority. I will get back to you in that. If its an Administration Action or a different action. Thank you. I know its been a long day. Its been nearly a month since youve declared a formal Emergency Response to coronavirus. Im for my second, youve sent letter to congress saying that you intend to use or transfer our program, authority to reallocate a actually under and 36 million from our programs. Yesterday we got the details of those transfers and i would like to request unanimous consent to enter it into the record. Yes. Thank you. 62 million, 37 million taken from the long Income Energy Assistance Program and 7. 5 million from the centers for medicare and medicaid. Given that you plan to take 37 million from the low Income Energy program, we have any estimates of how many people that will impact. And might go without heat this winter. For the transfer the allocation authority. Theres a change and we did that across the department evenly but then within different agencies, they selected various programs. We are now late in the season. Since the end of february. I dont have an analysis. Can we get to the record. But we think the impact will be. Worried about people who are not going to have heat. I dont mean to be that, i have four minutes. It took 62 million from nih, is that going to harm our our ability to do cancer treatments rated im happy with you that opioid debts have gone down this year pretty any other Public Health challenges. Whats going to happen to those programs. So the nih and during the reallocation and taking their allotment of the. 2 percent, they firewall off certain priorities including, i note Opioid Research and development is one of the priorities. And he talked about this yesterday be stated in your Senate Testimony yesterday that the u. S. Currently has about 30 million subfiles and 95 respirators with her breasts, which can help stop a person from inhaling particles. But that might required 300 million for healthcare workers alone. This does not include mask, gloves and protective equipment. We for about 900 worldwide and 60 more deaths. Yarn agencies, 65 percent of in 95 presbyteries are manufactured outside of the u. S. And china and mexico. Yesterday the Washington Post told us that a large Group Purchasing organization is sent they may only have two weeks supply. I want to frighten anybody, which in beat brushing off but hardly facing an intimate choi choice. I do want to clarify the numbers. I learned Additional Information about the number of mass we have pretty higher number. When 30 million surgical mats, with 12 million certified mask and find that are not my asked certified. 5 million. I just want to clarify the debt on that. Were transferring the money we discussed earlier is contracting to get contract started with domestic manufacturers in 95 mask so we can scale it production pretty. So how low will it take pretty. And that will take time. This is a National Security threat that 90 percent of our generics are coming from china. What are we going to do and im out of time to help bring the counter protection of these kinds of essentials to this country some are not dependent on anyone else. Time is expired. Thank you madam chairwoman. And also welcome mr. Secretary, i have to express my deep concern and disappointment and implementation of the Affordable Care act which is the law of the land. It appears that the department of health and Human Services has made it harder for americans to access and afford the vital Health Coverage that they rely on. Your department recently proposed rule that would discontinue the aca subsidies for low income families. Who do not actively reapply during the aca open enrollment. These are low income americans are currently enrolled in 0dollar premium plans. Secretary azar your departments analysis acknowledges that there are 270,000 americans who are reenrolled in these 0dollar premium plans. They could lose the coverage. And these proposed ending auto, auto enrollment for these individuals, thereby endangering the coverage. First a yes or no question. In deciding to propose this policy, did you consider the fact that it would result in American Families losing coverage. I want to get back to you for the record if i could. I dont know that we actually proposed it as opposed to asking for comment on whether one should allow auto reenrollment for people that are 100 percent subsidized and the aca exchange market. But i think we house, just for comment on that, proposing as a french pretty cement im assuming if youre asking for, it is something you are considering. Is under consideration if we should require someone to apply and getting 100 percent of the subsidy paid for the premiums. And if they affirmatively demonstrate the they continue to qualify. As opposed to just rolling over and paying them later if we find they need it. Can you guarantee that no individuals would lose coverage pretty spent what they dont qualify, and they would not retain coverage of the hundred percent subsidy. As mitch and if you change policy, they wouldnt qualify. I am particularly alarmed that your department would propose such a policy given that congress, they directed you to establish automatic reenrollment for all individuals. That provision was signed into law by the president. At the end of the year and this proposed policy goes against a congressional intent. Mr. Sec. , would you commit to the American People that you will not take away or take any action that would cause American Families to lose their Health Insurance. I believe the writer was in perspective to 2020 monies. In the request for information was regarding the 2021 plan year which is the subject to that writer. That is my understanding. Deep concern is the department now has a record of refusing to properly invest in advertising and outreach. In the department has drastically reduced funding for outreach and education activities. Its good of the navigator program. Limited time for enrollment is giving consumers less opportunities to make informed choices. Now the department threatens to disclose American Families subsidies to discontinue American Family subsidies to become accustomed to being reenrolled every year. Mr. Sec. , would you commit to working with me to ensure that americans wishing to enroll have will or will be well informed about the opportunities to enroll. Was happy to work with you congresswoman. We talked about it before. So just one putting on the record, this particular issue. It. Just in terms of open enrollment, we put out a billion reminder emails. Is just a yes or no question because my time is expired. Yes, i am happy to work with you. We will followup. The chart recognize the gentlewoman from california. Thank you. We have heard from you, our u. S. Government has implemented measures to help prevent the spread of the coronavirus. There has been missions, travel bands, airport restrictions, and additional trouble noted notice is issued. Many of these actions have impacted county, and particularly my district. In february 2nd, the president signed a proclamation, sitting for a national, travel to china and 14 days and not immediate families of u. S. Citizens and current residence. Over the course of the few weeks, 808 u. S. Citizens were throwback to the United States where there were quarantined for 14 days and military bases. And as of today, 37 countries have confirmed cases of coronavirus. Should we expect to travel bands from countries like italy. Who confirmed cases of transmission but are on a different continent than current travel beds. How sustainable are quarantines and travel restrictions and holdings the coronavirus. Thats an excellent question and thats why when we did the initial 212, china band that you mentioned, were very clear, thats the point that would spread in other countries. Measures like that would not be effective. With china and of course though the epicenter being in china, the aggressive measures taken in china, it was appropriate to do there. We will constantly look at other travel advisories, restrictions or surveillance and request for home isolation. I will gather more information. Its a very fair point. Following up on that, what resources are going to lead to the quarantines that are happening. And should these be expanded, extended, what Additional Resources do you expect. I would actually like to get us out of the federal quarantine business. But i do want to commend california there. Theyve really been a superb partner with us there. But it is quite expensive to maintain. Institutional quarantine. May really have implicated for us to scale up, this type of facility based quarantine, in the future as i think the doctrine mentioned yesterday. We envision more home or some home isolation activities. State and local based monitoring and quarantine activities. Monday hhs issued a statement about naval base in ventura county. American travelers coming through lax, who would be quarantined and monitored for symptoms of the coronavirus may slowly on the travel history. Based solely on their travel history. Mr. Sec. , what are trans for hhs plans based on solely their travel history. And when those be voluntary or mandatory. A statement that would be the province travel. They been in province in china, american or permanent residents are a Family Member would be subject to a mandatory quarantine. Were seen very few of those individuals. I think we had a family of three and than one individual is really all that i believe we have currently in quarantine. It is more of a backup concept there. We begin, works very well with the state and locals in california. Was really know the cdc has said that is not a matter of if the virus will spread that the matter of when. So Congress Wants to work with your agency on adequate and Sustainable Health responses. You cant do that without sufficient funding Going Forward to appropriate to the state and local partners. And especially had the majority proposal on that. Thank you. The chair recognizes the gentlewoman from new hampshire. Thank you. Theres a lot going on, both in your budget and with our concerns about the coronavirus. So i will move to this quickly. The key to a Public Health crisis as you will know is trusting credibility. And would be helpful for clear and easy to understand updates from this administration. To both us as policymakers and members of congress and to the American People. It would be even more preferable if the statements by the president of the United States, contradict statements of the scientists and physicians of the cdc in your department. My time is limited. On jump right in on the administration continuing efforts to undermine the Affordable Care act consumers protection for people with preexisting conditions. The administration and your Community Today claims to support the protections for preexisting conditions. But with all due respect, the fact speaks for themselves. If this administration has repeatedly taken action including Court Proceedings to undermine protections for people including my constituents, with preexisting conditions for your department finalize role to expand junk plants that do not provide protection for people with preexisting conditions. And issued 1332 waiver guidance creating new standards inconsistent with congressional. The guidance allows states to increase consumers cost for coverage and undermines protection. Simple yes or no question. Secretary, sec. Azar, are you aware that it could substantially raise costs for americans with preexisting conditions pretty. Actually in the 1332 guidance allowed me to approve waivers for 11 states causing ten to 30 percent decline in premiums. And the other states what was the state pretty. One of the scene i think was, maybe hawaii that we approve the waiver allowing them to not have the shop, i remember quickly, was a hawaii. Yes it was hawaii. At the request to not have the state i forgot the exact terminology but the technical aspect of the Affordable Care act. Trend nine. Those do indeed threaten individuals with preexisting conditions. Yes, sir no, you think its appropriate for states to direct money towards junk plans to that do not do not provide protectionsfor preexisting conditions . These are plans the Obama Administration allowed to 12 months. Let me dive right into that, under the Obama Administration the limited duration plans for work for just three months, and youve now extended it to 12 months with three renewals. Thats not the same condition. Thats not correct, that the Obama Administration has for 12months until the end of the administration when they passed a midnight regulation shortening it to three months. Right at the very end. My point is it was three months and you have allowed for extensions for up to three times, that is 4 years and we have people testify here that they did not even have noticed that there preexisting conditions were not covered and even insurers that sent to them and if they didnt know they had a preexisting condition, they should have known so this is something we need much more work on. I aim to protect consumers with preexisting conditions. One correction, its 12 reinsurance waivers, not 11. The gentlewomans time has expired, the chair recognizes the gentlewoman from illinois, miss kelly for two minutes and i want to instruct the members, we have 2 more to question and they agreed to limit their time to two minutes each. We will then take a very short break, maybe five minutes to reset the witness table for the next panel. And allow the secretary to take at least a few minute break. Now wewill recognize the gentleman from illinois , miss kelly for two minutes. Thank you mister secretary, i wanted to talk about two issues that ive paid a lot of attention to and have ravaged communities ofcolor across the nation, one is fraternal mortality. President trump has expressed concerns about maternal deaths and following mass shootings, last year called for Bipartisan Solutions to reduce gun violence. We in congress have come up with for Bipartisan Solutions. I worked with my colleagues on the other side of the isle on a goal to expand medicaid to provide postpartum coverage for a year and congress appropriated and President Trump signed into law 5 billion in funding for the cdc to stem violence, yet your Administration Seeks to slash funding to and block grant medicaid, to implement more restrictive Eligibility Criteria formedicaid recipients ,completely zero out funding for gun violence research. Secretary, are you aware yes, sir no budget contains a proposal that would allow states that impose an asset tax on pregnant women in medicaid, ages 112 to 113 of the hhs budget in brief . I want to look at that and get back to you, im not aware of that particular provision. We do have the proposal similar to what you mentioned for medicaid that would allow states and option to cover pregnant women for one year after birth if theyre suffering from Substance Abuse disorder so thats another part of the Maternal Mortality initiative. Proposal would cut medicaid funds by 2. 2 billion because it would cause a lot of people including pregnant women to lose their medicaid coverage. So maybe you can answer. Thats a spending provision, the one i just mentioned would actually expand, right now they can only get 60 days coverage postpartum, this would allow that coverage as a state option in a nonneutral way. My time is up. The gentlewomans time is expired. That legislation that we took up here is a waiting for approval. Of the gentlewoman has been a leader on this for, long before the rest of the members even knew that we had that horrible statistics in our country last but not least the gentlewoman from florida for her 2 minutes. The ministration is urging the federal courts to strike down the Affordable Care act and in its entirety. Including the protections for more than 130 million americans who have a preexisting health condition. I think my neighbors back home would want me to relay to you of dangerous, how dangerous that is, how angry they are about it. They do not want to return to the days when Insurance Companies could discriminate against them if they had asthma, cancer diagnosis, someother preexisting condition. They dont want to return to the days where an Insurance Company can cancel them if they get sick and i think the coronavirus now , shows the importance of consistent Health Insurance coverage. It has a Central Health benefit and it really shines a light on these junk plans. Your department has finalized a rule to expand the Short Term Limited Duration junk plan. They are not required to cover preexisting conditions. You acknowledged that in your last Budget Hearing in front of this committee. And a couple of studies have come out recently , Georgetown Health policy institute study, a one commissioned byleukemia and Lymphoma Society that channels , highlights the abuses here. Is the department conducting any oversight on the abuses of these junk plans, the abuses in marketing, false promises, are you conducting oversight . The Short Term Limited Duration plans are off exchange. Yes, sir no quickly, my time is short. We dont regulate subject to state insurance regulation. So its like handsoff, you said were going to promote these junk plans and you are notconducting any oversight , is that true . They are subject to state insurance regulation. You dont monitor the abuses in the junk plan market that are raising costs on everybody and excluding preexisting conditions . We do not regulate state insurance commissions. Gentlewoman yields back. Lets take a fiveminute break. And the staff can recess at the witness table. Then we will resume. Thank you. [inaudible]. [inaudible]. [inaudible]. [inaudible] the Sub Committee on health will come back to order. What were going to do is were not going to have our witnesses do their formal public statements. We had them all on the record. We thank you for them. I actively read them and im sure my colleagues have as well. I want to do quickly out of respect to each is to just give a quick introduction and then we will go to members with their questions. And first of all, thank you. For being here. I think that the United States of america is so blessed, so blessed to have i think the finest Public Health professionals in the entire world. And in the world, there is a reason why the world looks like this and its because we have you in our expertise so thank you to you. America cant live without you, really. Doctor hahn, welcome to you. I think this is the first time you are before the committee. And we will make it really pleasant for you. We wont do to you what we did to the secretary. Mistersecretary, welcome back to the table. Doctor pavlik, welcome to you. And to doctor redfield from the cdc, thank you for being here and thank you for collectively , for what youve done to help to brief the congress during this period now, is it my turn to ask . Okay. Let me start with the obviously with the coronavirus. I started out earlier today saying that confusion is the enemy of preparedness. I do not put confusion at the doorstep of doctor felty, doctor khan, doctor kadlec and doctor redfield. I think that you have done an excellent job in advising, breathing, congress and for the work that youre doing. I think we have some problems with the administration because the professionals say one thing and then theres confusion on the other side. I hope that Something Else will happen and that the briefings be held in public so the American People can hear you. I hope as we move through this challenge that the American People will come to know you the way we do and that we elevate the level of confidence and trust that i know you can engender, but i dont think its there now. Theres confusion, markets are roiling. Its not onlybecause of confusion , but there are many matters at hand. But you, the scientists, doctors , the American People couldnt be better served. Just couldnt be better served so thank you to you for your especially Important Service right now. What i want to get to doctor con, let me start with you is our drug comply. Our manufacturers being coming about potential shortages . Thank you for the question, we are being proactive in our discussions with manufacturers area as you know drug manufacturers are required to report to us when there are potential disruptions. How far in advance do they let you know thatthere will be a shortage . Typically those conversations occur in realtime. I think usually all of our conversations are in realtime. Im saying how much an introductory of time, if they were talking to you today, would they be able to tell when a shortage would begin . How much runway do we have . For example, china and manufacturing. So we have a problem with that. Just as an example i can tell you drug manufacturers are required to tell us when theres a potential disruption to the drug supply. When the applicants applied to the fda, they might provide for example five differentmanufacturers for the precursor to the job and five manufacturers for the final drug form. Let me ask you, is the coronavirus outbreak is continuing three monthsfrom now and i pray that it isnt, what do you estimate the American Drug supply will be . There are hundred 83 Prescription Drug manufacturers in china, 20 are solesource from china. As both precursors as well as the final drug form. Weve reached out to all these manufacturers. We have no shortages for those solesource drugs. Its the redundancy thats the most important and if we have redundancy we can ship to other manufacturing sources. The fda yesterday said that you mentioned this, the 20 drug products were either solely sourced for their active ingredients or finished drug products from china. Can you share that with us or is that proprietary . Thats a proprietary list, weare compiling lists with all the questions weve been asking any fractures. Doctor redfield, how many coronavirus tests does the us conduct as of today . How many cases . How many tests has our country conducted as of today . I would have to get back to you with the exact number. I kind of tease but i was serious to secretary azar. We have some deep cuts to these agencies, the people that youre sitting with and it was mentioned by i think the Ranking Member that the budget was printed and it couldnt be changed because of the print and all of that. I think secretary azar that 200 million in cuts, 700 million in cuts to the cdc and 3 billion of nih, are you willing to reconsider that given what our country is facing and what the American People need day in and day out from these agencies . They are the essentials. The proposal to the budget do not impact our ability to do novel Coronavirus Response. Cdc has 135 million increase in Infectious Diseases. In other words they deserve these cuts, these are healthy cuts. Its good forthem and its good for us. You asked us about impact, these will not impact functioning related to that and of course we have the emergency supplemental request on top of that. If you wrote it in decemberhow do you know that . Because the changes we make in the budget are not related to categories that will impact our ability to do the novel Coronavirus Response. So theres nothing to reconsider. I dont believe there is in terms of the existing Budget Proposal. Today is february 26, 2020 and i certainly hope you are right but i think that we are shortchanging the American People. Its time to recognize doctor burgess the Ranking Member of the subcommittee. I think the chair and i would point out we are the administrations representatives and bills originate in the house of representatives so it certainly is well within our power to provide the level of spending that you all request. The house is just now doing its budget. Several months after the administration did its budget area i will be testifying tomorrow and i think you people have concerns, ill bring them up to the budget committee, i just hope we will have a budget debate because we havent in several previous years but i do want to thank the panel for being here today. This is critically important. The chair is correct people do need to see and this needs to be public so thats why we have hearings because hearings are on the record and are public which is why several weeks ago i suggested we have this hearing and im glad were having it today area secretary azar, you were testifying on the budget before and you did take questions on the issue of the office of Refugee Resettlement. Just off the topic of corona, i say i have been fortunate enough to visit a number of your facilities provided by office of Refugee Resettlement and i think we are fortunate to have the men and women who are working in those facilities and would you just please convey to them my thanks because i do think they do a good job and we would be much theworse without them. I will and that will mean a great deal to them. You and i had talked earlier about the supply chain and the active pharmaceutical ingredients that we import from overseas and the fact was that there was an adequate stockpile as sort of the story began to involve several weeks ago. What are, or to the extent you can tell us, how are things looking now as far as the stockpile that companies have available as far as the activepharmaceutical ingredient . Thank you representative. As we discussed before we received no reports of shortages and found no shortages coming from china and we have discussed this with manufacturers and Pharma Companies and adequate supplies. Can i offer this observation, ive been on this subcommittee for a long time and weve had this discussion in other guises and other times and if theres any Silver Lining to this cloud, it may be we recognize we need to bring some of that manufacturing back within our own shores so we are responsible, we have the responsibility for the active pharmaceutical ingredients and i know this is something the president is focused on and one of his rebuilding of america, this is i think work that this committee has done in the past. I think its something we need to take seriously. We had hearings on Continuous Manufacturing a few to go and i think that is another aspect of this where perhaps some attention to the Continuous Manufacturing but the main thing is we can hear it so were not dependent on a solesource from another country whether it be in difficulty from an infection or just simply out of sorts of the United States at the time, does jeopardize our people and i do think we need to recognize that and thats not a criticism of this panel. We have known about that on this subcommittee for a long time and we have acted, now perhaps we will. Doctor redfield, i like to ask you the world Health Organization was able to assist them, now that report is going to be coming back, are you satisfied with the level of interaction you had with your chinese counterparts because the cdc was not allowed to go in, it was only part of the world Health Organization . We were able to have a representative on the team that went to china to do the investigation. Ive had regular conversations my counterpart, the head of the cdc in china and we had Good Exchange of scientific information and we have a cdc office in beijing china there and they continue to have good interactions with those colleagues. So you think there is working with state and local, there is good scientific interaction between us. Erica hahn, we will come back to you in a moment and thank you for the work you are doing on getting leverage to develop test, that is critical. They cant all be done at the cdc, were going to have to get those tests done rapidly in the field for our people on the front lines but to the extent, is there any evidence that theres any sort of bargaining behavior with personal Protection Equipment or pharmaceuticals . Is that something about which we need to become concerned . In terms of the supply . We have reached out to manufacturers and we are aware that shortages can and have occurred. However currently we know of no overall shortage related to pp but this is a dynamic situation as we mentioned at yesterdays press conference that we are likely to see some pressure, particularly on the demand side here but we are workingclosely with manufacturers on this. Is there anything you can do to prevent hoarding activity by people who might just be buying up equipment . The department has led an old apartment effort to communicate to providers and hospitals regarding this issue and have recommended following ddc guidelines with respect to the use of respirators seems to be the most pressure. Thank you. The gentlemens time is expired. Its my pleasure to recognize the gentlewomanfrom colorado , mister goetz for five minutes of questioning. I think the chair for including some of the other subcommittees. As for of the five of you well know, weve been having hearings in the oversight subcommittee for years on these issues. Its what keeps me up at night. The most recent hearing we had was on december 4 about seasonal flu and pandemic flu and low here we are and what im concerned about is we are still not any more prepared than we were on december 4 and so thats what i want to talk about. Back in 2005, we had a national bluechip for bio defense or 2015, some of you recognize this document. Our colleague Donna Shalala had your job mister secretary and in this blueprint for defense, what they did was they said we need to have, in case we have some kind of a pandemic, we need to have a clear line of authority make these decisions. Are you aware of that mister secretary . I wasnt aware of the secretaries recommendation. Are you aware of this blueprint . I was aware of the blueprint. I just got back from japan on monday so we were really looking at the diamond princess incident. And heres what i was concerned about his you had all these People Living in this petri dish of a ship for a long time. The cdc said that people, people should not be flown back to the us from that ship and then apparently the cdc was overruled by the state department so heres my question. You are the chairman of the president s task force on the Novel Coronavirus. Are you in charge . I am in charge but in japan the chief of mission, he made the decision has full authority of the president of the United States in any foreign country. Thats the problem. Ill tell you why thats the problem. Because you are the head of the panel to the Health Experts are saying you shouldnt be flying these people back in and then theres another agency that basically overruled what you said. If you have an outbreak in the United States, there are a number of other agencies that are going to have, that are going to haveother interests and ill give you a couple of examples. State department which wejust dealt with, hhs is you, the state Public Health department , various other agencies. Who is in charge of the final verdict . Is it you . It depends on the circumstances. Thats not what worked in a pandemic. Ambassador of the president is the final word. What happened is they flew back in 14 americans , maybe more who were infected with thecoronavirus, thats why someone needs to be in charge and you know what, i think it should be you. I just with respect, the vp of mission at a very difficult decision to make. I dont need you toexplain to me. What im saying is this goes along, there needs to be someone who can overrule Homeland Security and state , who can make these decisions for the American Public based on Public Health. And im going to, im hoping we can have some more hearings to talk about. Doctor redfield i want to ask you because the chair, chairwoman eshoo asked the question about the last chapter and you said you didnt know how many lab tests are available. We have lab tests that will accurately test for the coronavirus . Yes. What i heard was they are limited and people have to send their test to the cdc to be tested, is that right . Presently theres 12 jurisdictions that have to test up andrunning. 12 jurisdictions through the United States. Throughout the United States. People can send their test there . What are we going to be able to put that everywhere . Working with when are you going tobe able to put that everywhere. We are working with the fda now and hoping that later this week tests will be such that the first one and go, all the laboratories can execute the current test on themodification that we did with the fda. Doctor felty i know youre working on developing a vaccine if we gave you more money, could we develop a vaccinefor quickly . We would need more money to take it to the next step were in a phase i right now and were okay. How much more money . You think you could probably get bipartisan consensus that we would give you the money. How much would you need to get over the hill . About 140 million . Hundred 40 million. If you wouldnt mind the emergency supplemental would dedicate 1 billion or vaccine, just as part of the detail we will be working with the committee on. One more thing because my time is up and i know that congresswoman kelsey is going to ask you questions about supplemental. I want to say that even minority leader mccarthy today said we need at least 4 billion and we shouldnt be shipping money away from evil and other diseases into trying to deal with this coronavirus area we need to work on all fronts at once and i thank you for your comments and i yield that. The gentlewoman sign is expired, the woman from kentucky, Mister Guthrie is recognized for his time. Before all being here so Everybody Knows weve been having these meetings, bipartisan with several of you overtime and i remember when we first started needing it might havebeen doctor bassi , but we are going to prepare for a pandemic. Thats what the American People expect us to do, put things in place for a pandemic and hope and pray that it never comes with a get ready and as we prepare for it, people are going to see things, here and maybe react at this is imminent when itmay not be because were doing what were supposed to do. The other thing is i know the Administration Needs to reassure markets and marketplaces where we are and where we stand for everything that ive heard previously, from what larry comeau has said is it not consistent where we are but i know the cdc talk about a pandemic to be ready for and secretary azar, if youd like to explain i know the cdc warned americans should and i quote a pair for communities read in the United States and should be ready for significant disruption and would you explain what that means to the average person, what that means and whats the most Important Message you would like for the American People to know about the current state of american dealing with the coronavirus. Our messaging through the career officials as inconsistent striking a balance americas risk is low at the moment. Thats the change we. We are working to keep that risk low but we have always been transparent that we expect more cases in the United States with a rapidly spreading virus especially with what weve seen. For the average american there is no change in their behavior except what we would always abide which is to practice good public hygiene, watching your hands, not touching your face with unwashed hands appropriate preparedness activities at home and you can go to cdc. Gov or normal advice for flu season and others, good preparedness, good thoughtfulness. To be very transparent to people of the risks we face, even if we are at a low risk situation now people are surprised, so that they know whatwere dealing with and what uncertainties we are dealing with. Doctor redfield, for 50 days weve learned much about the coronavirus but much is still unknown. What is the current, i know people want to know at home is the current Scientific Consensus about transmission and how long once youre infected will you be infected, how long can you pass it on and what are the other remaining known unknowns . What other things that you know that you would like to know the answer to. First of all, we know its very transmissible. There are some viruses that are not efficient going from human to human. What weve learned early on and we are convinced now given what we see in china and other countries is a highly transmissible virus. Thats the firstthing. The second thing when you say how long a person is infected after they get infected , thats something thats up in the air and the way you get the answer to that is to try and isolate virus with what we call shedding for a tranny of time and we know that there are individuals who are actually able to transmit when they are without symptoms before they get symptoms. What we dont know yet and i think were going to get information from the group including the cdc individual and one of my people was in china with the who group, what the extent of that transmissibility is from an asymptomatic person. Is it minor . Part of the driving of the outbreak or is it significant . Thats going to be an important thing that is currently an unknown. I concur with doctor county, i think the biggest challenge we have right now what is the relative infectivity , whether before you get sick or you are infectious beforeyou get sick , are you more infectious after you get sick . We are tracking these patients you have in this country to see how long they actually have a virus thatcan be isolated. From their respiratory secretions. Its probably going to be longer than many of us originally anticipated area i think at this phase we have an individual about 18 days from the time theyinitially got sick. I think these are key questions and we continue to try to get the data to answer them. So are there other things youare looking to know that you dont know that youre trying to find answers to . One of the other areas from the cdcs point of view is understand methods of transmission. Is it all respiratory, for example candace virus survived on Certain Services long enough for somebody else tocome down, put their hand down and watch their face . Its not clear right now what the relative components of say droplet transmission is due for my transmission. I do, my time is expired and i will yield. The gentleman yields back. The gentlewoman from illinois , miss chicago is recognized. As all of you know the world Health Organization has declared the coronavirus outbreak of Health Emergency and our administration now has declared it a Public Health emergency. Secretary azar, we talked about this. The Trump Administration asked congress for just 2. 5 billion to combat the disease at the cdcs director nancy miss miss andre ward could severely disrupt daily life and good severely and could cause severe illness in the United States. And in that request did not as i understand include, were not specific about surveillance or testing kits that actually work, because not all of them have and for treatment. Instead, you suggested robbing 500 million from the United States response to ebola epidemic is actually still is raging in places. So i find it incomprehensible that you are asking for a molehill when what we really need is a mountain of support here. Secretary azar, yes, sir no, you agree the president of the United States that the coronavirus is very much under control in the United States and will quote, go away by spring. He did not say the last part that you just said. He said we hope it will go away with warmer weather. Iwould hope every one would hope it would go away with warmer weather. Virus in the United States has been contain situation today. But that can change. As doctor messier said he expect more cases and we expect he will see at least a little Community Transmission of the virus in the United States. Let me just ask another question, my hometown reported the first human to human transmission of the coronavirus in the United States and both illinois and cook county and Chicago Department of Public Health have money expertly i would say handled are two coronavirus cases, they have not received any reimbursements or Financial Assistance for what theyve done. I just met with the director ofPublic Health in chicago. Who said their spending hundred 50,000 per week to respond to this. Will you, will the United States be able in the 2. 5 billion be able to help local and state Health Officials who have already spent lots and lots of moneytrying to deal with this . That is actually part of the supplemental request to fund date and locals in addition to the 675 million money they already have received for many years. Illinois of course received each year 16. 3 million for exactly these activities but we want to give additional funding through the supplemental request for those activities. Thats good news, thank you. Secretary azar, will your 2. 5 billion be enough to help healthcare workers in hospitals and Nursing Homes or home care workers who have to care forquarantined individuals . In what respect are you asking . Salaries, because they are already paid. There are elements we need to add to our request. There may be additional cost that people that work in hospitals and they may have to hire more people. Is there any help is going to be for staffing mark. You mind if doctor responds . That is 350, 350 million dedicated for personal protective equipment can be used by healthcare workers in many different settings so we are stockpiling that to make it available should communities need that in addition to what they have on hand. Let me finally say this, last week 45 my colleagues and i sent sent a letter to President Trump and what we were talking about is going to have the guaranteed affordable treatments or vaccines that are developed. We are concerned that private pharmaceutical companies and having a role in this and raising the cost beyond the point that people could well afford. We absolutely share your passion around sharon Affordable Access to medicine the private sector must have a role in this area we will not have vaccine, we will not have therapeutics without the private sector candidates that they and we will have to invest in. We have paid for all the r. M. D. So far. Thats not accurate, the iliad has a product that was originally nih funded, basic research the diversity of alabama but they carried forward with development madera is using doctor county. Youre saying for sure, the affordable for anyone who needs it. Im saying we would want to ensure we work tomake it affordable but we cant control that price because we need the private sector. The gentlewomans time is expired. Thank you. I now recognize the gentleman from michigan, former chairman of the committee, mister upton. Ive had a couple questions that i hope to run through and i guess the first question what can be directed to personal you all. 24 seven for the briefings that weve had over the last couple of weeks as well area i guess this on to be directed first to doctor redfield. Theres a report just published now in the last hour or two, apparently theres a daily newspaper emporia called the june meeting daily and they reported that there is a Korean Airlines Flight Attendant who service a number of flights between lax and seoul. And he was confirmed to have coronavirus. We also, theyre not sure where she got rid theres discussion that she had worked on a flight to israel, with that apparent Tourist Group that came from corey on there. In the previous week. What you know about this, i hope you know something but i know its recent news but was published today in korea. Its thursday now so just wondering what you might know about this. I can say i havent been briefed on that. Normally what we would do if we had confirmed cases , obviously. This is a korean woman,24 years old. We are interacting and we send someone yesterday to embed in the korean cdc to help facilitate communications between koreas edc and our cdc but i can tell you i havent been read on that specific situation but i will look into it andget back to you. Second, does anyone else know anything more than mark doctor fauci, i know china in public thank goodness the genetic sequence which is allowed the rest of the world to try and pierce the ball here. Most are not therapeutics is one of the companies, i think they are out of massachusetts. That is actually working on i want to say a phase i but it may be wrong. Company working with the company on a platform called messenger rna. Were working on our Vaccine Research center and we did exactly as you said, as soon as the sequence was put on a public database we pulled the gene out for the spiked protein which is a protein you want to make an immune response against red there were several steps that determine the success or failure of what youre doing and weve been able to successfully express it in this particular platform that were going to use for vaccine. We have shown that its immunogenic in mice very soon within the next month and a half 2, its going to go into a phase i study but i think people need to appreciate because theresoften misunderstanding. A phase i study will be three months from the go which was about a month and a half ago will take about three months or four to determine if its safe and induce it to kind of response that you would predict would be protective. Once you get there, the question that i was asked before, then you go to a phase ii study. A phase i study as 45 people, the phase ii study has hundreds or maybe even low thousands of people. That would take at least 8648 month to show that it works. So from the time you push the button to go, from the time you even know what works, about a year to year and a half. Then as the secretary said, you have to partner with pharmaceutical companies to make millions and millions of doses which could also extend the time. That would be a vaccine or a remedy . A vaccine to prevent infection. Last question i have and ill save this for secretary azar, a couple weeks ago my colleague Debbie Dingell and i sent aletter to the administration. You were copied on it. As it relates to the supply chain of companies with operations in china, specifically wuhan province. A lot of us are concerned about products are made there weve got a lot of Different Things that are there. I know apple as an example, a fetch up their stock price collapsed and led to the market trouble that we had here this week. What type of outreach, have you directed, have you initiated outreach to companies, large and small , particularly on the shortage question as well because they may not want to tell you what they might not know. Where are you all on this. As chair of the task force we directed the whole government outreach to manufacturers and suppliers across not Just Healthcare but everywhere and doctor hunt and doctor catholic led the effort with regard to generic and biologic and Device Manufacturers in china and thats what doctor hahn was reporting on earlier, the result of that outreach. Im proactive as you know with drugs, they have to report to us essential shortages area devices, we dont have legislation so were probing that system. You dont yet know of any potential shortages but we are on that because we share your concern about the risk there. Just to follow up, secretary of commerce, early working other than beyond drugs and devices are. With their related entities their major manufacturing entities they are working to gather information about potential shortages as they might impact the economy, the National Security council, National Economic council are leading those efforts. I appreciate what mister upton raised overall but certainly the last part of it. The whole issue of our dependence on china. And 90 percent of the American People take generics and those generic drugs are manufactured in china and to a lesser degree in india. But china controls the Global Market on the api, active or mystical ingredients but i met with doctor catholic after i think it was a classified briefing. He came to my office and what i wanted to know was do we have an inventory, do we have an inventory of the manufacturers are, are any of these plants shut down . I know we asked questions about how long they can manufacture until they cant. Because drug shortages are a part of this whole problem the supply chain when i met with doctor catholic, we dont have that inventory. Is that in place now western mark. I believe thats what doctor on review on earlier. We do have an inventory . We reached out to the manufacturers, we do that proactively because there are not requirements to report to us. But they inspect manufacturing plants, dont know who they are . Yes we do. Whats the difference between that and the question i asked. We have a list of manufacturers given to us by pharmaceutical companies who manufacture both precursor products and final drugs in china. But there may be five or six for each of these drugs and they might be around in different countries. The gentleman from massachusetts Mister Kennedy is recognized for his five minutes. Thank you for being here, thank you for being willing to be before this committee i have some differences with some of you on our healthcare policy that im grateful for and i wish you all success so good luck to you and good luck to us all. First off, a bit of this, redfield if you can, ive got twoyearold and fouryearold and a lot of other parents of Young Children are nervous about this, the real answer is to parents of young kids, if there are any thing people should be doingor we should be concerned about . The secretary said the right now, the risk to the American Public is low. And we would argue that they go on with their life. Our containment strategy is been quite successful but that said, what was said also is in light of what happened in korea and italy and ran and japan and to be seen how fast this virus can move , we are encouraging people to just think about being prepared. Part of being prepared is trying to make sure theres as much clearer communication as to what we are confronting and how government is structured to be ready to meet this challenge i do think its obviously of my colleagues have noted despite to strengthen our pandemic preparedness this ministration did dismantle a Pandemic Response chain of command including Leadership Structure at the white house through the National Security council Global Health Security Unit so Flash Forward to this year and the coronavirus writing, there have been reports of this task force and you indicated you are in fact ahead of it, i would ask if you can communicate what that structure looks like so that people can have understanding as to what is backing that up just to get that information out would be helpful to all of us. So moving on a bit go to try to make sure that there is construction put in place but that communication is in fact clear. Mister secretary it would take a bit of an issue with the fact that the message is consistent, the message from you all so far has been pretty consistent area i do have an abc news story book enter for the record where it quotes the president from saying directly that its a problem that is going to go away. The president is also quoted by saying the virus were talking about, you know, a lot of peoplethink it goes away in april with the heat as he comes in. Glee that will go away in april. We are in great shape the. Doctor fauci, does this go away in april with theheat . The history of respiratory viruses and other coronaviruss tend to diminish and almost disappear as you get into the summer. Its just something that happens every year we see that with influenza however, underlying however, this isa new virus. We dont know what this virus is going to do. It acts like influenza, he will actually make it diminished and its impact but we have no way of knowinghow its going to ask. I would say theres different temperature gradients across this country by april, or not . Yes, and also in different hemispheres when we are having cold weather, our others are having warm and vice versa. You also stated we are very close to a vaccine, but doctor you just laid out that best Case Scenario we are still 18 months away roughly, is that right . He said and Congressional Staff briefed folks yesterday on a press conference that its not a question of if but rather when and how many people this country will have severe illnesses. Almost at the exact same time the president was saying that is going to work out fine and a problem thats going to go away. Doctor redfield, is does the cdc agree that this is a problem that is going to go awaywithout intervention . I think its important to recognize that from time to time new pathogens come from animals and get into the human species. Really this is one of those times when we got a new respiratory pathogen into the human species and i think its prudent to assume that this pathogen will be with us for some time to come. Doctor catholic. We dont know the cycle of it, we dont know if its going to be impacted by humidity and heat area but i think we should assume that this virus is going to be a virus that we are going to be challenged with similar to the other viruses that we have that are respiratory. About 10 seconds so yes, sir no, agree withdoctor redfield . I support doctor redfield you. The president expressing confidence, this theme of Public Health infrastructure a and local that we can deal with this, we will prepare for this, Work Together on this and hes trying to calm the public that we see in china panic can be as big an enemy as a virus so there is always that balance. Mister secretary i dont want to panic over this either, each trying to stop the stock market. These outright contradicting everything you all have just said, outright contradiction. I think hes expressing confidence. With no medical basis for it, thats what you explain. Hes expressing that the American People need to take a breath, that theres no change to anyones daily life, that the country has a plan, we have pandemic plans. Theresa playbook for this and we are executing that but we have to be realistic also transparent that we will have more cases. As the head of hhs you agree with the president s statement that it will goaway with the heat . The gentlemens time has expired, do you want toanswer that . I didnt think so. Youre doing a great job for the president mister secretary. Focused on the local populations like children and the elderly and we added a lot of new things to that. When the things im concerned about is the flexibility of the funding and whether or not we have a Rapid Response reserve fund of 85 million that was put into that fund. We have 705 million in Strategic National stockpile plus we have all these. How much flexibility is there or do we need to give you more very quickly to have more flexibility to be able to not focus on congress having to do supplementals all the time. How much more flexibility do you need . The Infectious Disease Rapid Response legislation was critical for us and the stock pile is critical to us. Emergency supplemental the most flexibility could give us there as we deal with the situation evolves we would appreciate that also the challenge was setting up longterm funding mechanisms that are indefinite as they can become slush funds for any other priority as opposed to concrete real Public Health emergencies. I think thats always been the challenge. And if you find you need more funding for any of these funds we come back and asked ask for more funding . Absolutely no want to emphasize the 2. 5 is for 2020 only people come back up any more and they will work with congress if congress wishes to give more. With respect to the strategic stockpile which i believe you will receive in conjunction with the cdc, is that correct . What is the status of our National Stockpile . Can you quickly say what those are . Is overrated countermeasures to deal with Radio Nuclear capabilities as well as pandemic influenza. We have a supply of personal protective equipment as the we have on hand. We are supposed to get more. Some of these are at undisclosed locations throughout the country are they not . That is correct. Is this point is the Strategic National stock piled sufficiently funded . At this point in light of what the requirements are in terms of what is in the supplemental request another 40 million would be of great benefit to help us with the shortfall. Last week when i was home i learned from a local Public Health official in indiana that an individual from this county had traveled from china and interestingly enough had come to the chicago airport. And the chicago airport official notified the Public Health official is this person is coming home to quarantine which i thought she appeared at this individuals home within 24 hours of that person coming through the chicago airport. I thought that was awesome and excellent in that that coordination happen. How did that happen and is that happening all across the country . This individual is going to quaff break with local Health Officials to provide their temperatures for a couple of weeks. Is this happening all across the country . Yes. How many do you have . Who at the airports are notified local Health Officials . When the original travel restrictions were put in for china and hubei if you had currently been to United States is a Family Member or permanent resident and hubei you were required to go in 14 days in quarantine. That quarantine could have been institutional or could have been in your home working with the Health Department. Thats how we have operationalized it but if you came from china the requirement was that when you came through you were given an education card that you have no symptoms telling about the risk and what the symptoms are and the Contact Information with your local Health Department and in conjunction with your local Health Department going into what we called voluntary monitoring and isolation. The woman who you gave is an example of did exactly as they were instructed and they were instructed as they went through chicago ohare airport. A local Public Health official was incredibly sub impressed and she had received the information in a. At like to enter into the womens csis produced a report in november about the u. S. Global Health Security making sure we are ending the cycle with a number of recommendations when i serve on a commission isf i affect the entered into the record and without i yield back yes man the gentlewoman has yielded back the gentleman from california is recognized for four minutes and for those that are left theres an agreement that is four minutes because the panel is getting nervous so id like to honor that. Thank you for being here today. I want to discuss a very important issue for local agencies and many other members are hearing as well funding and reimbursement for monies that are counties in Public Health departments have spent to help fight the spread of the coronavirus. Disaster trained emergency Public Health experts and in disaster or academic prepared his rapid reimbursement is a matter of readiness. I think we can all agree a lot of being outs from the Public Health infrastructure in their states. They are stepping up and they are coordinating and doing the right thing. On january 29195 americans from wuhan china came to fear airbase in the county my district is into the county responded efficiently and was effective in monitoring quarantining all of the passengers for 14 days. Over 40 county officials worked on this project and supplied food transportation housing and local Health Emergency management standby and support services for ambulances. All told the estimate is over 1. 3 million. The broader response continues in riverside in communities across the country. Receiving rapid reimbursement is critical to Capacity Readiness in the future but if you drain resources without replenishing them you want have the necessary resources to fight the Public Health crisis such as bedside diagnostics personnel to name a few and also having the resources to create preparedness plans quarantine plans for Rapid Transmission of this virus in the future but i want to ask a question whether the funds that are available to reimburse state and local officials for their efforts responding to the coronavirus . The secretary said in the supplemental the substantial youre telling me the last time we spoke you identified somebody in your staff mentioned a few and now you are saying those dont exist it would need to pass the supplemental to reimburse counties. Is that what im hearing from you . We have fund it california 41 million he put the supplemental has requested 747 million which would be state and local funding. There is no fund . But. No additional for each year. We are going to work on that and thats an issue because we were under the impression that there were and reimbursement is a matter of capacity. We dont rapidly reimburse local agencies will not be ready to deal with a potential rapid spread of the virus. Doc or kadlec inductor redfield can we get a commitment from both of you here today that you will reinduce these local municipalities for the costs associated with the spread of the coronavirus . We are clearly going to work to ciotta get that done. Dr. Kadlec . We are committed to work with you to do that. We need to reimburse because especially in rural areas where they dont have the resources, they dont have the hospitals and the quarantine space is the ability to get the supplies to those areas you are putting them in vulnerable situations if you dont respond. After redfield local and state Health Departments have used a quarter of their workforce produces the effect the nations ability . I think its one of the key core capabilities that we need to continue to improve our Public Health ability that is the modernization which you help with last year the Laboratory Capacity as you see with the current diagnostic test and the third point is the workforce. No discrepancy discrepancy anxiety that brings panic . Yes time has expired pitter wanted to get a commitment so the agencies dont lose the money they are losing interest in and to promise you even beyond where the cuts are. Id be happy but the congress has a job to do. These cuts are really shameful. We have such premier agencies people at the top that know what they are doing and they are being cut but the secretary said we did 125 billion everything is going to be fine. I dont think so. Dr. Bucshon for five minutes. Thanks for the 5 minutes i appreciated. Just kidding. In reference to the funding that congress provides funding for the agencies and the Budget Proposal so im not too worried at this Congress Wont provide the appropriate level of funding in i understand also if we get past that that would help. Secretary azar and all the people at this table do their job and give money to those people. I want to comment referring on the criticism of the president and what he has said. If the president of the United States and sites and sites a worldwide panic. They see see it is different for minor secretary azars or others and even though the president says what he said i do think having a calming effect in a situation like this is appropriate that allows professionals behind the scenes to do their job. I just wanted to say that. I agree entirely. Think the president s role has been critical in keeping the country column and the situation hes expressed levels of doubt and uncertainty with his words that we have but also tried to be reassuring to the American Public as we try to be transparent about what the risks are coming forward. We all have different roles to play in the president is a very important one in guide and in addressing the Public Health emergency. I guess we have this unprecedented containment strategy when things were in china. Now that we know their problems with persontoperson transmission in italy and south korea and maybe other places does that change your current containment strategy and you can address that. I would say we are maintaining aggressive containment. I want to say of all the strategies we have used in this multilayer strategy the most important when we have is the student medical Public Health community in the United States. Of those 14 cases originally that were diagnosed all but one, only one was picked up at the screening so we are now moving obviously to educate the american medical and Public Health community. Its not just china we have to worry about now. We have to worry about places like italy and iran and the republic of korea. We are continuing to look at our travel alerts. We put travel alert on level 3 for the korea and level 2 for italy iran and japan. I want the American Public to know this may not be the time. Again secretary azar do you have any think that to that . As far as the testing goes the cdc 12 other Public Health laboratories have the testing tg but they have some difficulty with the test and can you further explain the problem with the test. The test measured three different lets just say three different nucleic acid pieces and one of them had a control in the third one had a control with lowlevel contamination. There was never any question with there the test could say positive or negative. Had a group of individuals that would say we didnt know. It was. 50 to 550 samples a day in the question was asked earlier what we are running right now. We work with the fda have you conducted disease modeling for outbreaks in the u. S. . We do have Modeling Groups of global Modeling Group is looking at a variety of different models and thats in process. As tony said earlier there still a number of things we dont quite know about this virus to make those models available for primetime but we are working on it. Very much. I yield back. The gentleman yields back. That concludes the questions that we have for you today. Thank you to each one of you. Mr. Secretary u. Been here for many hours and throw a punch and take a punch, right . We are all here for our fellow americans and they think if theres anything that has come out of this today we want facts and we want to bring the temperature down. We want to bring the fear factor down and anything and everything that you can do in order to achieve that as we move on with dr. Faucis work and a larger distribution of the diagnostics through the cdc in partnership with what we have across our country will go a long way. Thank you to each one of you. Im not going to adjourn. You can get up and leave while i create a long record of items that need to be placed. Thank you chairwoman. Thank you. God bless you and your work on behalf of the American People. Thank you. Im going to request a unanimous consent request to enter the following documents into the record. June 28 letter before the House Committee to hhs and cms regarding the case texas versus the United States. In december 2018 letter to hhs and cms regarding the case texas versus the United States. April 2019 letter from House Committees to hhs and cms regarding the case texas versus the United States. February 2020 letter in response to the april 2019 joint letter for five House Committees regarding the case to the emergency in the United States. The committee is still in order. I want the witnesses to be able to leave it if anyone wants talk take it to the side room so i could read these and the record that if every 2020 letter to the hhs in response of april 29 joint letter House Committee regarding the case of texas versus the United States. In october of 2019 Washington Post article and Trump Campaign versus white house the proposed flavored vape van ben. A letter to hhs to congressional committees regarding the increased number of uninsured children in the United States. June 2019 letter from the energy and Commerce Committee examining hhs administration of the Medicaid Program. A statement from Johnson Johnson regarding the companys response to the coronavirus outbreak a statement from the American Society for microbiology regarding the coronavirus outbreak february 2020 article entitled quote bio farm industry academics push back against demands for price controls countermeasures unquote. January 2020 wall street journal opinion piece entitled quote pharma to the rescue unquote. Are there any objections . Without objection so ordered and the committee, the subcommittee will now adjourn. Thank you everyone. [inaudible conversations] ive studied at Morgan State University just down the road. A study for this. This is my vocation and not knowing i would be under fire for asking questions. I have asked questions of each president the same question except for one. Each president over the last 21 years but asking questions now im fearing for my life. We are not each others enemies as lincoln said. If we dont make this great experiment called democracy our Constitutional Republic we are succeeding in generations as i argue my book and we are going to expire but theres no guarantee. Things are looking great but when things are looking great its time to shore up the foundations