14% compared to 2019 and, in particular, cuts funding of the national institutes of health. secretary azar was also asked about the trump administration's support of a court case challenging the legality of the affordable care act. this is about two hours. the appropriations subcommittee on labor, health, human services, education, and related agencies will come to order. secretary azar, thank you for being here again this morning and for our efforts to work together. they could always be better. i think we're about to get you staffed up to a point that that will no longer be the excuse. so we'll think of what comes as the next reason this is not working the way it should, but i wanted to encourage you to continue to do that. obviously this is a difficult budget for us to talk about, and frankly i think it's a difficult budget for you to defend, and we'll see what we have to do here. the budget control act has impact on this. in the case of the budget that you have been asked to submit, there's a reduction of 14%. the budget control act would require an overall reduction in the non-difference discretionary spending of 9%. so this budget exceeds even that. i would say for the 9%, as i mentioned last week with the education secretary, you know, president trump didn't sign the budget control act. president obama did. and you didn't vote for it, and any of us -- most of us who were here when we did the budget control act did. so there's some shared responsibility in where that decision has led us. but there will be a number of concerns that i imagine you have to share about what this budget asks for. we made a top priority in the years i've been chairman of this committee, ensuring that medical research has the resources it needs at this particular time of real breakthrough potential to do what it does in a way that saves lives, improves lives, and frankly benefits taxpayers as we find more solutions. as an example, if we could find a way to identify alzheimer's and delay onset by five years, we've cut the projected cost for alzheimer's by a third between now and 2050. the cuts that you're proposing for nih would be an overall cut of 12.6% in research, or almost $5 billion. i'm sure that's not going to happen, but for that not to happen, we have to have a number to work with that you don't have to work with yet. and i believe we'll have that number. you know that we're not going to e limb night funding that provides 6 million households with heating and cooling assistance. that cuts resources that trained lots of people for medical professions and behavioral health and pediatric dentistry, and we're not likely to do any of those things. i understand you had to make difficult decisions here. i do appreciate the two new initiatives that you proposed, and i'll be supportive. i'm sure -- i believe the committee will be supportive of those. one, to eliminate the transmission of hiv in the united states by 2030. phase one of the ten-year plan would infuse the hardest-hit states and communities. missouri is one of those. with additional resources, additional expertise, additional diagnostic and treatment options, and i'm pleased to see that that's a new proposal as is the new pediatric cancer program to provide $5 million over the next decade to launch a major data project on childhood cancer. now, that runs pretty dramatically in the face of cutting overall nih funding, but i do think it gives us the opportunity to look even closer at pediatric cancer and factor that in as we continue to hopefully improve nih funding. in addition to these new programs, i believe that mental health treatment needs to be treated as any other health issue, and the budget request includes level funding for the certified community behavioral health clinics. missouri's one of the eight pilot states in those clinics and 200 locations in our state treating behavioral health like all other health. and we need to do more to encourage that. the head of barnes jewish hospital told me just last week, he said, quote, i can't treat a person's diabetes until their schizophrenia is under control. and i believe we're going to find that if you do treat behavioral health like all other health, you actually save more money on the other health care costs than you spend doing the right thing in behavioral health. finally, the administration's commitment to ending the opioid epidemic is well reflected in this request. according to the council of economic advisers, the total economic cost of the opioid epidemic in 2017 was $684.6 billion. the cost to our economy, the cost to families of the opioid epidemic was that. according to the missouri hospital association, this estimate suggests the epidemic cost the u.s. nearly $1.6 billion every day, $21,700 every second of every day through 2017. the past four years, this subcommittee has increased funding to combat the epidemic by more than $3.5 billion, and we have had great bipartisan leadership on this of people who really, on both sides of where i'm sitting, understand how this has impacted their states and have forcefully made that case. i appreciate what you had to do to try to prioritize limited resources. we will try to do things that make those resources more realistic, and i'm glad you're here today and glad you bring all the expertise and ability you bring personally to this job. and i'd like to turn to my partner here in this effort, senator murray. >> thank you very much, chairman blunt. welcome, secretary azar. people across the country made pretty clear last november that they want us to fight for their health care and make sure families get the care they need. that means fighting for protections that allow people with pre-existing conditions to get quality affordable health coverage. it means fighting to bring down the skyrocketing health care costs. it means fighting for public health investments that keep our communities safe and address crises like the hiv and opioid epidemics. and it means fighting for investments in research that can help discover new treatments, save lives. but instead of fighting to defend people's health care, president trump is fighting in court to take health care away from millions of people who are covered through the exchanges, covered through medicaid, and are covered by their parents' plan. instead of fighting to bring those costs down and help people get the care they need, he is fighting in court against protections for over 130 million people with pre-existing conditions for bringing back annual and lifetime caps on benefit, even for people who get their insurance through their own job, and for letting insurance companies offer plans that don't cover essential services like maternity care and prescription drugs. and president trump's budget before us is cut from that same cloth. it bulldozes right over the concerns of families with proposals that would make it harder for people to get care and cuts that would undermine the well being of families across the nation. overall this budget proposes a deep $12.7 billion cut to the department of health and human services, slashing it by 14%. i always say a budget is a reflection of your values. well, like many of his actions, this budget tells a very different story about president trump's health care priorities than his empty promises. despite claiming time and time again he would fight for people's health compare and despite his recent claim republicans would be the party of health care, president trump is continuing to push for harmful policies that would weaken patient protections, tame coverage away from people, and put needed health care further out of reach. this budget includes trumpcare, which the congressional budget office estimates will kick tens of millions of people off their health insurance. when it comes to curbing the hiv and opioid epidemics, president trump promised to fight the fire, but his budget actually fans the flames. it would make these crises far worse by cutting over $1 trillion from medicaid over the next decade and repealing medicaid expansion. medicaid is the largest source of insurance coverage for people with hiv, covering more than 40% of people with hiv in care. and the 37 states that expanded medicaid show how it can play an important role in addressing the opioid crisis as well. in some of these states, as many as four out of five people receiving treatment for opioid addiction are insured by medicaid. the centers for disease control and prevention also plays a very important role addressing these public health crises and many others, yet the trump administration proposes cutting its budget by a tenth. this proposes cutting immunization efforts by $78 million even amid an alarming measles outbreak in my home state and several others. it proposes cutting work on birth defects and disabilities by $44 million and proposes cutting efforts to combat antibiotic-resistant pathogens and emerging infectious diseases by $103 million despite the world health organization labeling amr, quote, one of the biggest threats to global health. and when it comes to medical research, this budget is a small step forward and a marathon sprint back. i do applaud the administration's call for more pediatric cancer research. for every new penny president trump proposes for pediatric cancer research, however, he proposes cutting a dollar from the national institute of health. kutsing medical research by 13% as he proposed would slow our universities to advance our understanding of alzheimer's disease, develop vaccines for hiv and flu, and treatments and cures for every other kind of cancer. and at a time when our nation is facing a health professional shortage, it's proposing to cut almost $800 million from health care workforce training programs that support tuition assistance, loan forgiveness, and training for several hundred thousand health professionals annually. this budget also continues the trump/pence administration's harmful trend of putting ideology over women's health and reproductive freedoms. its language specifically excluding planned parenthood from federal funding is just one of the many alarming steps backwards for women's health care from this administration. another is the recent announcement stripping title x family planning funds from several qualified planned parenthood affiliates. despite their proven record, helping millions of people struggling to make ends meet, get birth control, cancer screenings, and other basic health services. another example is the administration's gag rule, which will push planned parenthood out of the program altogether, interfere with patients' ability to learn about their full range of reproductive care options, and prevent people from across the country from getting the care they need with the providers that they trust. once again, the trump administration proposes eliminating safety net programs that provide critical assistance to millions of vulnerable families like the low-income home energy assistance program, which helps families afford heating and cooling, and the community services block grant, which gives states resources to address the challenge of poverty, and eliminating funding for preschool development grants, which provide high-quality preschool to tens of thousands of families. it's clear that we are facing a child care crisis in this country. parents struggle every day to find and pay for high-quality programs. we need more investments in that, not cuts, in early childhood education. and this budget continues to show disregard for families fleeing violence and extreme poverty in central america. this budget proposes a gimmicky $2 billion contingency fund on the mandatory side for the unaccompanied children program in addition to the base discretionary appropriation. let me be clear. i want to make sure that every child in hhs custody is well cared for. but i have been deeply disappointed in president trump's treatment of migrant children from heartlessly separating children from their parents to attempting to undermine protections for migrant children. and i have been frustrated with your department for failing to sound the alarm on the lasting damage that family separation would cause, sharing information with the department of homeland security so they can target potential sponsors for deportation, and relying heavily on unlicensed temporary facilities which are three times as expensive as permanent beds in licensed centers, to say nothing of my concern that the office of refugee resettlement was tracking young women's reproductive health and that former director scott lloyd was personally interfering with young women's decisions about their bodies. finally, mr. secretary, i am concerned by a recent proposal you outlined in a letter to my office to restructure the office of the assistant secretary for health. that restructuring would impact programs that serve adolescents, women, low-income communities, and more. and i'm very concerned that that proposal, much like this budget proposal, would serve very little purpose beyond prioritizing ideology over the health needs of families in this country. mr. secretary, finally i just want to note it is inaccurate to claim the budget control act requires the president to submit his budget at sequestration levels. in fact, just two years ago, president trump's budget proposed an increase to the caps for defense spending. so i hope you don't rely on that excuse for decisions in this budget. thank you very much, mr. chairman. >> thank you, senator murray. so secretary azar, you and i have talked about the -- oh, i'm sorry. we want your -- i'm sorry. i'm so eager. i have so many questions i want to ask here. maybe you want to waive your opening statement. go ahead with your opening statement. >> well, thank you very much, chairman blunt and ranking member murray. thank you for inviting me to discuss the president's budget for fiscal year 2020. it's an honor to have spent the year since i last appeared before this committee leading the department of health and human services. the men and women of hhs have delivered remarkable results during that time, including record new and generic drug approvals, new affordable health insurance options, and signs that the trend in drug overdose deaths is beginning to flatten and decline. the budget proposes $87.1 billion in fy 2020 discretionary spending for hhs while moving toward our vision for a health care system that puts american patients first. it's important to note that hhs had the largest discretionary budget of any non-defense department in 2018, which means that staying within the caps set by congress has required difficult choices that i'm sure many will find quite hard to countenance. i know that members of this committee have delivered strong investments in hhs's discretionary budget in the past, especially at the national institutes of health, and i want to be clear that hhs appreciates this work over the years. today i want to high light how the president's budget supports a number of important goals for hhs. first, the budget proposes reforms to help deliver americans truly patient-centered affordable care. the budget would empower states to create personalized health care options that put you as the american patient in control and ensure you are treated like a human being and not like a number. flexibilities in the budget would make this possible while promoting fiscal responsibility and maintaining protections for people with pre-existing conditions. second, the budget strengthens medicare to help secure our promise to america's seniors. the budget extends the solvency of the medicare trust fund for eight years while the program's budget will still grow at a 6.9% annual rate. in three major ways, the budget lowers cost for seniors and tackles special interests that are currently taking advantage of the medicare program. first, we proposed changes to discourage hospitals from acquiring smaller practices just to charge medicare more. second, we address overpayments to post-acute care providers. and, third, we will take on drug companies that are profiting off of seniors and medicare through a historic modernization of medicare part d, we will lower seniors' out of pocket costs and create incentives for lower list prices. i believe there are many areas of common ground on drug pricing where we can work together to pass bipartisan legislation to help people. the efforts we proposed around taking on special interests in the medicare program are so sensible and bipartisan, in fact, that even "the new york times" editorial board praised these ideas last week. we also protect sen yoiors by transferring funding for uncompensated care for medicare to the general treasury fund so that all taxpayers, not just our seniors, share these important costs. finally, the budget fully supports hhs's five-point strategy for the opioid epidemic. better access to prevention, treatment, and recovery services. better targeting the availability of overdose-reversing drugs. better data on the epidemic. better research on pain and addiction. and better pain management practices. the budget builds on appropriations made by this committee and provides $4.8 billi $4.8 billion towards these efforts include the $1 billion state opioid response program, which we have focused on access to medication-assisted treatment, behavioral support, and recovery services. the budget also invests in other public health priorities, including fighting infectious disease at home and abroad. it proposes $291 million in funding for the first year of president trump's plan to use the effective treatment and prevention tolls that we have today to end the hiv epidemic in america by 2030. hhs also remains vigilant on other public health challenges, including the current epidemic of teen use of e-cigarettes. in fact, i'm pleased to announce that today the fda is issuing warning letters to companies for making, selling, or distributing liquids used for e-cigarettes that have misleading labeling or advertising that resembles prescription cough syrups. the trump administration supports a comprehensive balanced policy approach to regulating e-cigarettes, closing the on-ramp for kids to be addicted to nicotine while allowing for the promise of an aoff ramp for adult smokers -- this will advance america's health care and help deliver on the promises we've made to the american people. i look forward to working with this committee on our shared priorities. and i look forward to your questions today. thank you very much. >> thank you. now we'll get to those questions. and i'm hopeful that we can get through most of our questions by the vote and leave some time shortly after 11:45. but if we don't, i'll come back, and there will be a second round of questions for anybody that wants it. so i would ask everybody, including me, to stick with their time limit. so the first question i almost got into a moment ago is just about the new liver allocation policy, the solid organ allocation policy, something that senator moran and i have been very interested in. we had one meeting with the organ transplant procurement network group, and frankly our view of that meeting was very different than what they finally did. both the university of kansas and washington university are really among the leading stakeholders in this in terms of the transplants that they're part of. i guess the problem is that states in the midwest, states in the south, states that have lots of small communities tend to be much greater organ donors, and obviously as long as we had a regional view of this, that was a benefit to their neighbors. there has been a dramatic decrease in availability of lung and liver transplants at barnes hospital at least since the new policy went into effect, and it's my question -- i think there will certainly be a lawsuit filed here. will you commit today that you'll ask optn, the transplant group, not to move forward with this controversial policy until that lawsuit has been dealt with? >> well, mr. chairman, i am concerned about the liver allocation policy issues you raise. frankly, any transplant organ allocation policy issues are quite difficult politically and as a matter of public health. and i actually received the letter from you and many others about the most recent organ -- the liver transplantation allocation policies out of optn. and we requested of them to think again and to ensure -- i believe it was -- was it the kansas and missouri providers, that we wanted to ensure especially that comments that came in at the last minute or perhaps came in late were fully considered by optn. we recently received a letter back in response to my challenge to them, which i believe your staff has access to, where basically they said they went through the procedures. they considered all of the comments, and they remain steadfast in their conclusion regarding the science and technical aspects of the allocation decision they made. i do believe my cards are played out here. congress deliberately set up the optn system to keep people like me from actually dictating the policy allocations, but i'm happy to work with the committee on any other solutions here to look at and ensure that the fair and scientifically valid treatment has been given here. >> well, i would think that one of the reasons the old system worked was that people were more encouraged to be donors if they believed that people in their community would benefit from that. on liver transplants, under the new policy, we think there would be 32% fewer transplants in missouri. i think barnes hospital's number four or five in the country in transplants, and they have told me since this started, they're now having to send teams of doctors across the country to have -- to get organs that would have been available under the old policy locally. i think it's further complicated and added expense and precious time to the system. but we're going to continue to watch that. let me ask one more question here on a big issue, and that's your role in providing security and taking care of unaccompanied children. you have nothing to do with border security, but you wind up with great responsibility. would you talk about how that's changed in the last few months? >> absolutely, mr. chairman. we're in a tremendous crisis at the border right now. we are getting 300 to 350 unaccompanied alien children crossing the border and referred to hhs every single day right now. these are 10, 12, 13, 15-year-old kids. they're not coming with parents. they're coming across the border by themselves. and these are historic levels for us. that's a 97% increase in february from the previous year february. it's just not sustainable at this rate. i know the ranking member raised in her opening statement concern about temporary influx facilities. i will work with this committee to do anything we can to take care of the children appropriately. any ideas you have how to ensure that we're doing that well, i would love to enhance our fixed permanent capacity. it's cheaper. it's more economical. we've been working on that. it's slow to do. government procurements and government contracting around leasing is slow. we need help. we need help, and at this rate, the funding even for this year will not be satisfactory, and i want to be transparent with this committee in particular about that. we are working with omb on what those total funding needs could be at the current rate, but it would exceed where we are even with the transfer and reprogramming that i notified the committee about. this is just -- it's beyond belief the level of children that are coming across the border right now. >> in your case, the unaccompanied children -- >> these are unaccompanied children. these are kids just coming across. they don't have a parent with them. they're coming by themselves. >> all right. i have more questions on this, but i'm going to stick with my time restraint. i have a feeling they'll be asked by others. if not, i'll ask when we get to another round. senator murray. >> thank you. thank you, mr. chairman. mr. secretary, despite continued assertions that your budget guarantees affordable health compare and protects people with pre-existing conditions, the fact is that the administration is doing everything it can to actually sabotage health care, and this budget appears to be just more of the same. this budget continues to push harmful policies that undermine health care for millions of people across the country. your budget calls for repealing and replacing the aca with the failed trumpcare bill, which was rejected last congress. and in his clearest message yet to patients and families that he sees their health coverage as nothing more than some kind of political football. last week president trump sided with the ruling that all of the aca should be struck down, all of it. now, according to reports, you initially opposed president trump on that and issued a statement of support. so i wanted to ask you today, did you initially object to the president's decision to side with the texas court because you know the impact that this would have. it would be devastating for so many families. >> as you can appreciate, the advice of a cabinet member to the president of the united states is highly confidential, and it wouldn't be appropriate for me to comment on that. what i would say the position the administration took in the affordable care act litigation is an appropriate position. it's supporting a district court's decision. reasonable minds can differ on this question of legal issues. this is not our policy position. that is a legal conclusion about the aca, and that litigation which we did not bring -- we are party. i'm the party in the litigation. but we want to protect pre-existing conditions. if the litigation ends up in that position, we want to work with you to secure better care for people and make sure all the types of issues you've raised are taken care of in any kind of new legislation. >> well, let me just ask you as secretary of health, do you agree that if this ruling is upheld, as the administration is arguing for, it will result in tens of millions of people losing their coverage and allow insurers to discriminate against people with pre-existing conditions if it's upheld? >> well, the burden would be on us to work together to actually come up with a better care plan. >> that's not the question. the question is if the court goes through with the ruling as you have requested them to, will it result? nothing else happens. >> well, you wouldn't have medicaid expansion, and you wouldn't have the exchange subsidies, and we would work with you to come up with a better decision that we hope delivers better care for people. >> i've heard that before. but it would mean that people with pre-existing conditions would lose their -- >> the president will never agree to any legislation that doesn't protect people with pre-existing -- >> i'm not talking about legislation. i'm asking about the court decision. >> a legal interpretation of a court case is not a policy position about what we want to have happen for people with pre-existing conditions. we're going to fight for people with pre-existing conditions under all circumstances, but a legal judgment filed by the justice department is different than a policy position to work with you to protect people with pr pre-ex. >> it's pretty clear if the administration goes after this in court and wins, people will lose their pre-existing conditions at that point. so let me just go on. i wanted to ask you about title x, and as you know, i am really concerned about this administration's constant efforts to undermine the historically bipartisan title x family planning program. it's the only federal program dedicated to contraceptive health care and family planning services and actually helps 4 million people annually get services like cancer screenings, contraception, crucial preventive health services. your title x domestic gag rule will take effect very soon, and it will bar providers from talking to their patients about all the family planning options. the american medical association has actually called that, quote, a violation of patients' rights under the code of medical ethics. you also announced the grant recipients for 2019, dropped five planned parenthood affiliates, and instead awarded funding to an ideal logically driven organization that doesn't even offer fda approved birth control. and you notified, as i mentioned earlier, your intent to reorganize the offices that administer both the title x and teen pregnancy prevention. so i just have a few seconds left. if you can answer yes or no, i wanted to ask you is birth control an evidence-based family planning option? >> we support the full range of family planning. that's why we fully funded and kept it flat -- kept the title x program flat funding even as we cut other parts of the budget. so we do support access to contraception and birth control and the full range of family planning options. >> and you do believe birth control is an evidence based family planning -- >> it's part of the title x program and we support that. so the one entity that you're referring to is part of its grant application as required to have -- there are going to be seven federally qualified health centers. these are always done with a program with a grantee and sub grantees. so they have to offer across the program the full range of family planning alternatives required by statute. >> including birth control? >> yes. so they will have other providers in there, the 7 fqhcs. >> it will make it harder for women. they have to get pushed around. i get it. my time is up. >> senator alexander. >> thank you, mr. chairman. welcome, mr. secretary. let me first pass a compliment to senator blunt and senator murray, the ranking member, and other members of the subcommittee for three consecutive years of significant -- four consecutive years of significant increases of funding for the national institutes of health. we see the results of that everywhere, and i fully support it, and i thank you for your leadership, senator murray, senator durbin, and you have been consistent supporters of that. second, to the president and to you, i'm proud of the initiative that seeks to reduce hiv infections by 75% in the next five years, 90% in the next ten years. i hope you will focus especially on those parts of the country where that's a special problem. african-americans account for 43% of hiv diagnoses. in 2016, more than 84% of the people in memphis with hiv were african-american and have estimated diagnosis in tennessee, more than 25% were in memphis alone. and i want to call your attention the medicare area wage index, which i won't ask you a question about, but that's continuing to be a reason why hospitals, especially in rural tennessee and other parts of rural america, closed because of the unfairness of that index. now, mr. secretary, i heard the question by the senator from washington about the affordable care act. i think it's a pretty farfetched case in my opinion, but i'm not the judge. i'm pretty sure that if there were any decision that resulted in the affordable care act being overturned, that the court would stay the effect of the decision giving congress and the president time to do whatever they wanted to do. let me ask you this question. have you made any changes in the way you are administering the affordable care act as a result of the department of justice's position on this litigation? >> we have and will not make any changes to how we administer the affordable care act in light of the lit galgs. it could be a year, two years before we get any final ruling by a final court of jurisdiction. i have instructed my team, my organization. we continue to implement the affordable care act faithfully and fully across the board without regard to litigation positions taken by the administration in court. >> so whether you like it or not, you recognize it's the law? >> absolutely. >> on a separate question, the committee that i'm chairman of and senator murray is the ranking member, the health committee have been working with the finance committee, senators grassley and wyden for the last several months to see if we could identify a series of steps to reduce health care costs. testimony before our committee is that up to half of health care costs are unnecessary. we're working on that the same way we worked on opioids, which means democrats and republicans working together, various committees working together, staffs working together. so far, so good. our goal in the help committee is to see if we can produce a recommendation, a markup for the full senate by june or july. are you and the administration willing to work with us and support our efforts to address these issues like surprise medical bills, prescription drugs, direct primary care, transparency, rebates, other issues? if we're going to work in a bipartisan way, is the administration willing to support our efforts to get a result in this way? >> we are fully supportive of the efforts of you, senator murray, chairman grassley, senator wyden, working together on a bipartisan basis across all of those issues. >> on opioids, president trump asked the president of china to make all forms of ethanol illegal, and china has announced -- in china. and china has announced that it will do that starting may the 1st. i want to congratulate you and the officials of china for that because our drug enforcement agency has told us that one way or the other, most of the fentanyl that come into the united states starts in china. i don't have time for you to answer a question, but as we think about opioids, i hope that you will keep an eye on the effect it's having on people with pain. while we're getting rid of opioids that are used inappropriately, we want to make sure that they are used appropriately by doctors and the cdc guidelines, about which there will be a report in may, and the fda report in august should be seen as advice and guidelines, leaving the decisions in the hands of individual doctors, and i hope you'll help us do that. thank you, mr. chairman. >> thank you, senator alexander. i want to say that having you and senator murray on this committee on things like the health care issues and things like moving forward on nih research makes a real difference, having both of you here who also have the authorizing committee, and your leadership has really mattered, particularly on what we've been able to do at nih. and nobody has been more involved in that than senator durbin. senator durbin? >> and congratulations to you and senator murray. this four years consistent 5% real growth at nih is saving lives. the president's recommendation of making a cut in medical research, i believe, will be roundly dismissed by both political parties, and i hope that that's the outcome soon. i thank you all, including senator alexander. so, mr. secretary, i have so many questions, so little time as they say. let me go to this unaccompanied children issue for a minute. when i asked the inspector general to investigate the zero tolerance policy of the trump administration, which forcibly removed over 2,800 children from their parents when they came to the united states, we were told that, in fact, the public announcement of this program actually post dated the initiate by as much as a year, that there could have been thousands that had not been disclosed prior to the announcement. when did you first become aware, mr. secretary, of the president's zero-tolerance policy? >> so i became aware of the attorney general's zero-tolerance initiative basically when he announced it in the public. i learned of it in the media in april when the zero-tolerance was announced at that point. then subsequently as we have been going through this, i believe in the summer or late summer -- actually it might have even been through the inspector general's work that you asked for -- learned of some of the previous piloting or demonstration work that may have been occurring. a lot of it prior to my even arriving at hhs. >> how many children were affected by this piloting or demonstration effort? >> well, as the inspector general said, there was a surmise there only of numbers. the inspector generals just said that there could be a couple of thousand but didn't know how many in that case. >> did you play any role in crafting this policy of zero tolerance? >> no. how could i if i learned about it in april when it was announced? >> so let me ask you about unaccompanied children now. you say there's an inflow of 300 to 350 unaccompanied children a day coming into the system. your website says that you have facilities for placement of up to 14,000 children and currently some 12,000 are placed in your facilities. is that correct? >> so as of this morning, we have 12,340 children in our care. we have got 428 available beds with another 1,314 beds subject to -- that could be available but are usually it's an issue of getting adequate staffing to be able to bring them online. we are very tight right now, senator. >> understood. and what is the outflow of children who are actually sent to families or placed outside your facilities? >> so our discharge rate has been quite high lately actually. we've really been prioritizing on that. our discharge rate on a 30-day reference has been 2.0 children per 100 children on discharge. and on the seven-day, we're actually 2.4 children per 100. i think as i've looked in the last couple of weeks, we are essentially adding almost 70 to 80 children per day just because of the inflow and outflow rates. >> the net -- >> exactly. >> so is it true, as we've been reading, that these children are primarily coming from three countries? >> that's absolutely correct. we get a -- it's guatemala, el salvador, and honduras. one of the particular challenges lately has been we've been getting -- it's a lot easier for us to place children out where they have one parent here in the united states or a close relative because with the tvpra we can make that a faster process to check on them. some of the children, we've been getting an increasing mix of guatemalan male teenagers who have no family connections here. those become extremely difficult for us to try to place out. >> i understand that part of it. it is interesting to note that these children are coming from three countries, not nicaragua, not costa rica, not mexico, but these three countries that the president now says he wants to cut off all foreign aid to these countries, believing in his mind that that is somehow going to solve the problem. i think it will make it much worse. i think it is also important to note that this administration eliminated the program where children could go through the screening in home country, at the local embassy, the u.s. embassy and consulate. and now many of these families in their desperation have no other recourse to test their status than to come to the border of the united states and present themselves. so wouldn't you believe that it would be helpful if we had a system restored as it was under the obama administration for screening that begins in-country? >> senator, i'm not an immigration law expert. hi not known about that project in country. it seems consistent with the discussions i've heard from secretary nielsen about the desire to have asylum claims adjudicated while people are in country. i'd be happy to raise that with her. >> please do because she was part of the group that eliminated it. i have a lot of really good questions on prescription drug pricing. >> i hope we can keep working together, you and i, and i really appreciate your support on direct to consumer advertising. >> listing the price is favored by 88% of the american people. thank you for on a regulatory basis for moving on this. we did include it in the appropriation bill in the last round. >> we got close. >> we got close. it was killed in the conference in the house, but i'm hoping and praying that senator blunt and others will stand behind restoring that. >> i'd encourage you to take a look in the office of management budget rocas system, which is where regulations are filed when sent over to omb for review. there is a rule with a title. >> thank you. >> thank you. senator moran. >> chairman blunt, thank you very much. secretary, thank you for being here. let me raise just a topic, and then i want to continue where senator blunt left off in regard to transplant program. i want to highlight for you that we have three hospitals in kansas, horton, hillsboro, and oswego, small, rural hospitals, all of them -- they're owned by a company called empower hms. empower hms has been vict investigated for billing fraud. as a result of that and business factors, management factors, those three hospitals are in various conditions either shut down or have a trustee in bankruptcy attempting to operate those hospitals. and i would first of all encourage you to take -- not to change your enforcement procedures or not to any way pursue fraudulent behavior any less. but recognize there's a consequence to a community hospital that regardless of who the owner of the hospital is who can be gone that night, the community is left in a circumstance in which their hospital is no longer functioning. and so i would hope that cms and others at health and human services, perhaps in conjunction with our state and others, can have a plan in place that when you are creating a circumstance that forces a business out of business because of fraud, the end result is that the person who committed the fraud, the company who committed the fraud is who pays the price, not the community, who no longer has a hospital. and i would welcome any thoughts that you or your folks at cms could provide in this particular case, but just generally there's a consequence for this bad behavior. and i hope that whatever bad behavior is determined, if you determine that, that if appropriate, it's referred to the department of justice because the consequences for this behavior is long-term generational consequences to communities and the people who live there, just of significant challenges now as a result of, in addition to the challenges we just have at keeping hospital doors open generally in communities across kansas. in regard to the liver allocation issue, mr. secretary, let me ask just a couple of questions and then express my concern and dissatisfaction. let me first ask if you believe that enough is being done to help individuals with end-stage liver disease who are not yet on the wait list? >> so there's another population. those who are on a wait list waiting for a liver transplant. there are those who are not on the waste list yet. is enough being done to advance their well being? >> i think the number one thing that we can all be doing is working, as the chairman referred to it early, increase the supply of livers that we have for transplantation. that's the most important thing we can do. i hope we're doing everything that we can with regard to care for individuals suffering from liver disease awaiting transplant. if there are things we could be doing differently, please do let me know. i'd want to make sure we're doing that. >> would you commit the department to a full public disclosure, a transparent public debate on this allocation, organ allocation transplant process? >> i'm happy to work with you on what that might look like. as i mentioned to the chairman, the challenge with this optn and organ allocation issue is congress deliberately took that out of my hands to make it a non-political issue. so when we don't like a conclusion, i'm fairly restricted in what i can do. but we certainly -- i believe the optn process was a public process with a public record. but happy to work with you and your staff on any vehicle to ensure that. >> mr. secretary, you're movingmy to my complaining aspect by your comments because it was only after a lawsuit was filed, as i understand it, that this allocation process was then considered for change. and when you tell me that we constructed the ground rules for you to be removed from the process, you do appoint the hersa director. the hersa director is the one who has written a letter to optn, encouraging them to quickly implement the decision that they made and encouraging them. i would also tell you that while from time to time in this job people tell me something that doesn't always turn out to be true, but in our meeting, senator blunt and i had with the hersa director, the request was that we make certain that our constituencies, transplant programs in our states, submit not just comments, but please bring us a proposal because we're so interested in listening to the proposal. don't just complain about the proposal that's out there. tell us how to do it better. and i can tell you that the end result of our programs doing that, they were not considered. and, in fact, the decision was made before those comments were submitted, before that proposal was submitted by our constituents. and your -- i quoted you in -- i wrote down what you said in a last minute or late. the computer program shut down because there were so many comments, the only lateness of our programs supplying their comments and proposals was because the computer was shut down because of commentary, and the decision was made before these were ever read. and then they were approved with no changes thereafter. the original decision was made by the liver intestine committee without ever seeing the comments of our constituents. and then secondly, it was approved immediately with no change even though you can claim, perhaps correctly, you can claim that the comments were then read after the initial decision was made. my point is that while i'm often -- perhaps i misunderstand what has been requested of me or what my instructions are of how i can be a help to my constituents. what i think we did was exactly what we were told to do with no beneficial thing happening as a result of following those instructions. so this process has been flawed, and it is a flaw that arises out of the fear of a lawsuit. and after a long period of time -- i know what you're saying chairman blunt. after a long period of time, the policy in place was changed almost overnight in response to a lawsuit. and you're right. the issue is more organ donation, and the policy that is being developed is contradictory to what you said is the goal. i'll be back for the second round. >> senator merkley. thank you, senator moran. >> thank you very much. you mentioned that there's a big influx of unaccompanied minors crossing the border, and are you referring to people crossing between ports of entry? >> we will receive the 300 to 350 children from wherever they show up. if they show up at a border crossing alone, if they show up at a non-border crossing alone, their uacs, how they came across, or even if they were already resident and come into federal authorities and they're unaccompanied alien children, they're be referred to us no matter what. so i don't know where they crossed the border. >> so they're in tijuana where you're saying that youth can walk up to the port of entry and present themselves? >> if a child comes up to the border, presents them self and is a minor and an unaccompanied alien child, i believe at that point subject to the rules of what dhs . i believe that. >> this is not the way it works and i would encourage you to learn a lot more about this. right now, if an unaccompanied minor comes to the border in san diego they are allowed to present themselves at the border. everyone 18 and up is in instructed to return to mexico to get into the book. this is the metering process. if under 18 you're not allowed in the book and not allowed to cross the border. we are leaving these children permanently ex i'lled in tijuana with no choice how to proceed that's a good choice. if they present themselves to mexico authority they are returned back to horrific circumstances. if they stay in tijuana they are subject to gangs and crime circles. the president of the united states telling the world don't cross at ports of en entry we're blocking minors from crossing at ports of entry, do you think that's acceptable. >> i do not know the process. >> i encourage you to find out. it's why so much are crossing at ports of between ports of entry instead of ports of entry because it's being blocked. second, you said you sent a letter to congress to fund an expansion of the child prison system under this administration. what expansion level are you planning to go to? >> so we went a funding and reprogramming request, not a request but basically a transfer message we were transferring 286 million dollars utesing the secretary transfer authority and reprogramming 99 million dollars of money that is in -- notneeded for the refugee program within orr as part of the transfer and reprogramming. >> so 385 million dollars on top of the 266 million. >> at this current rate as a mentioned to the chairman, that will not prove adequate for this year. >> what is the capacity of the child prison system you're seeking with the money. >> that is supportive of the current rate of 14 thousand beds i believe as well as expected added -- we're trying to add asmany fixed beds to care for them. you keep saying prison system if you have an alternative approach on how to care for the children, please tell us. >> let me tell you. >> if there's a better way we want to be compassionate. >> yes, we'll that dialogue it's called sponsors the reason it's hard to get sponsors is the administration is telling potential response source all their information will be shared with ice. therefore people are not coming forward to be response source because they don't want to be stuck into the criminal examination system. >> i believe the congress actually passed an appropriations rider limiting the use of information going to dhs as part of the background checking we have to do -- that we do as part of the sponsorship check. i think that's probably dated information. >> the families are still being told the information could be used in this capacity. so as long as you're telling families that, then their discretionary. >> i would be happy to look at that to see. i wasn't being aware they were being told that. >> these children belong in homes and schools and parks and not locked up. i call them prisoners because they are locked up. i don't know if you visited the facilities but i have. >> i do frequently. >> then you understand what i am talking about. >> i completely agree with you. i do not want any child in our custody. i want every child out with an appropriately safely bedded sponsor in the community. >> please and the reasons why it's hard to recruit response source. that will facilitate and it costs a huge expense. a temporary influx for an operator to run a former air base facility when a permanent facility cost less and with with response source can costs a fraction to have a case worker working with the familiesment not only much better for the children as a they a wait an asylum process, it's much better for the american tax payer and maybe it means less profit for the for profit companies you're hiring to run homestead shouldn't you watch out for the tax payers and children instead. >> senator, i completely share your goal and my goal and the government's goal these children should be with response source and not in our care. >> good let's -- >> we can work together to make that happen, i would be delighted to work with anyone to make that happen. >> let's know they are in homestead in florida, they are not undertaken to address the child abuse and neglect checks for the staff members so they can make sure the individuals they hire working with the kids do not have a record as a sexual predator and that's unacceptable. thank you, senator. senator kennedy. >> thank you mr. chairman and thank you mr. secretary. mr. secretary, do you believe in the rule of law? ? >> yes, i do, especially as a trained lawyer, i do indeed. >> is it illegal to come into our country illegally? >> it is indeed illegal to come into our country illegally. >> okay. do you dislike children? >> i love children and i want to care compassionately for any child i'm ever entrusted with. >> are you trying to hurt children coming into the country at the border. >> not only that, but i am proud to lead an organization of people and have grant yees that are some of the most compassionate child caring people that i ever interact who love the children and care deeply. >> i read in march we had about 100 thousand folks, mostly from central america and mostly family units and children come into america illegally across the southern borders does that sound about right. >> that's my information it's about 100 thousand coming across now in family units per month and it is created an absolute crisis for my colleagues. >> ten times more or double than it was like 10 years ago or something like that, yeah, yeah. let me ask you about the affordable care act. i remember when congress passed it. we were promised, we meaning i'm an american like you are. we were promised two things: we were promised, number 1, it would make health insurance cheaper. more affordable. has it done that? >> no, it has not, it actually we were promised health insurance would cost half what it cost at the time. in fact during president obama tenure it doubled in cost. >> i remember vividly because i watched it on vspan congress also promised it would make health insurance more accessible has it done that. >> no, it's not it's restricted choices for individuals now with a large percentage of stages having only one carrier in the individual market. >> now, let me ask you this. the president has expressed his disappointment with the affordable care act. does he support getting rid of it before we have a replacement? >> the president has always supported replacing the affordable care act with someone else that is better, never there should be nothing. >> i want to make sure you understand. does he support getting rid of the affordable care act without a better plan in place? >> absolutely not. >> okay. >> he insistses there be a better plan in place for people. >> do you know on capitol hill republican or democratic who supports healthcare insurance program or healthcare delivery system that would not cover preexisting conditions. >> i haven't met them. >> okay. does the president support a replacement plan for obamacare that would cover preexisting conditions? >> he does indeed and will never sign any other plan that doesn't take care of people with preexisting conditions. >> okay. i want to look at the healthcare system from 30 thousand people. here's what i don't'd. i keep reading that 10% of the american people spend about 67% of the healthcare dollars, which makes sense because we all know that the chronic kale ill spend more money than others. and when you run the numbers and consider that we've got 320 million people, really 330 million people, so 10% of that is 33 million people and we've got a 21 industrial yob dollar, 12 zeroes gdp and we spend 18% of that on gdp and you take 2/3 of the 18% and then you divide it by 33 million, what you come out with is 80 thousand dollars a person. so for these 33 million people, out of 330 million, we're spending about 80 thousand dollars a person. why can't we identify those 33 million, i didn't say 8,000, i said 80 thousand. i'm only in this plan on time. why can't we identify the people and with 80 now dollars a person manage their care better? you know what senator, you're absolutely right. in fact we can and we can do that through vehicles like either visible or invisible insurance pools. even under the eca i approved 7 insurance state plans that brought premiums down by anywhere 9% to 30% by clearing off the risk for those higher risk people and separately reinsuring so the burden isn't born by all the other healthier people in the pool. absolutely. >> thank you. thank you, senator, senator schotts. >> thank you chairman thank you for being here. i'm worried about tobacco use among the oning people and the young people and that's about i'm about to introduce the tobacco 21 act. it would raise the age from 18 to 21 for the purchase ace of tobacco products including the combustible products and e- cigarettes. it is raising the age of sales to 21 which would reduce the tobacco initiation especially kids among 15 to 17 and also lead to 12 % smoking decrease in prevalence. 9 states including hawaii and hundreds of loelts have low kalts. do you agree it is a severe public health program and commit to me we can work together on the legislation. >> senator, thank you very much for your question and thank you for your work in this area. like you, i am extremely concerned about tobacco use and the he cigarette epidemic among the youth. i'm committed to working with you and other members of congress on other legislation to address tobacco use among youth as well as taking any necessary regulatory action. commissioner golly his last day today and i have been very clear why he cigarettes may offer a lower risk alternative to adult smokers who still want access to nicotine we can not allow he cigarettes to be an on- ramp for an entire new generation. fda is proposing to prioritize for flavored nicotine products. they will consider when the products are sold under circumstances without height and age verification. while we pursue to regulatory policy we call on the industry, manufacturers and retailers to step up with meaningful measures to reduce the access and appeal to young people. the epidemic rise in youth he cigarette use also prompted an escalating actions by the fda in enforce thement and public education. thank you very much sir for your help and i look forward to working with you. >> thank you. let's move to tele health. ernst you are a big supporter of telehealth and you noted that the regulatory and payment barriers can limit telehealth services. one service would give you authority to waive barriers under two circumstances: if the telehealth services would reduce spending while maintaining quality or if they would improve healthcare quality without impressing spending. can you talk about what the waiver authority means in terms of public health and expenditures regarding public health. >> as you mentioned, i've been passionate in my advocacy of telehealth. i think it's vitalally important for hawaii and states rural for expanding access to care and expanding thely quality of care even where we have care delivery and to make sure all america shares in centers of excellence through telehealth. the act was written in the 1960s where telehealth existed and there are many barriers and i look forward to working with you on any greater flexible in especially ways that don't open the door to fraud abuse and don't waist resources. >> this remains we got a lot done with senator hatchis leadership and telehealth, and there are a few more things today. the waiver authority is kind of the holy gale and for the members we have to get it done. >> i hope this can be included in the work senator murray and senator alexander are leading on cost work. >> a final comment and question i was struck by the exchange between senator and america lee and you in one particular way. obviously it got contentious this is frankly the kind of thing that should cause people to be emotional. but to the extent that there's a statute that provides for confidentiality for potential response source but in the -- in the moment where a decision is being made, response source are not aware of the statute. that seems to me to be a light bulb going off for all of us. we need to do a better job to communicating with sons source their confidentiality is protected and family situation is protected and that they -- we in fact as a matter of government policy whatever we think about the border wall or who's fault is what and what we ought to do with counselor offices and all the other arching umths. at a minimum, these kids need response source and the extent that potential response source are afraid to do so because they're afraid they'll end up in some data base we need to do a better job of telling them there is a law that protects confidentiality i'm hoping we can work together to follow up on that. >> thank you. of course. >> thank you very much. thank you senator schotts. senator hyde-smith. >> thank you chairman and certainly appreciate secretary alex azar being here and answering the questions the way that you're doing this. i obviously, i am the senator from mississippi and we have so many rural hospitals in mississippi that are really struggling. a recent report found that half of all rural hospitals in mississippi are at the high financial risk of closing. i just read an article that mississippi has more rural hospitals at risk of closing than any other state in this country. when a hospital closes, obviously, that effects the whole community in so many ways. not only the employment there but mainly and what's most important, it means no more access to emergency care for the communities' residents. in an emergency, timely care is of essence. and having close by access to them can truly mean life or death. we just recent hl a young lady in mississippi just a few weeks ago that died of an asthma attack. so i guess my question is, what is hhs doing to respond to the rural hospital close users that is very critical in my state? >> thank you, you have repeatedly raised with me the concerns about rural hospital access in mississippi and in part because of your efforts, i have created a task force across hhs to help come up with all ideas we can around how we can address the hospital crisis. let me give you some ideas. one of them we were just discussing this is telehealth how can we help we're expanding access into rural america because we'll end up consolidating everyone in rural areas if we can't provide healthcare in rural america. telehealth is important and providers are able to practice to the max of the licensure so we're not having artificial restraints on trade and commission that are blocking access in rural america. and we have to measure that our regulations are not creating artificial barriers to economic economically viable models of hospitals in rural america. are we trying to force a 1960s model of hospitals through payment systems and other regulations on to rural america so we're looking at how do we reconceive the needs of rural america from a hospital perspective. you said er r for instance. i was talking with a leader of critical access hospital, i learned about a protocol to be on call you have to to have a surgeon on staff. one has to ask does that requirement still hold in the modern era and part of that making that facility he canally viable long term to be able to provide access in that community. this is a deep passion of mine. we're working on this. any ideas you have we can do to be helpful. certainly, we want to be there. >> thank you very much. thank you, senator. senator baldwin. . >> thank you mr. chairman, secretary alex azar. i want to tell you about zoey from seymore, wisconsin. zeoy was born with a congenital heart defect and had open-heart surgery rerat 5 days old. she will be able to continue to get coverage and the care she needs thanks to the affordable care act and its protections for people with preexisting health conditions. when the republicans were working to repeal the affordable care act legislatively, i got a letter from zeoj's mom and she wrote to me and said to me it's like taking the american dream from her referring to her daughter. she writes, she wrote i'm pleading with you as a mother to fight for those with preexisting conditions. kids in wisconsin with preexisting conditions are counting on you to protect that right. in your administration recently decided to support a lawsuit aimed at striking down the affordable care act in its entirety. and all of its protections. so, how do i explain a decision like that to zoey and her mom, she by the way just celebrated her 6th birthday and this is more or less a rhetorical question because i have specifics but how do you tell a little girl like that what's going to happen to her? and so i wanted to just confirm my understanding that if the a forkedable care act is struck down in it's entirety in court, a position your administration is supporting, what protections preventing insurance companies from discriminating against those with preexisting conditions will still remain in law, if it is struck down. >> of course there are the existing aresa conditions and hipa protections that wouldn't be impacted. employer sponsored insurance and i was mentioning with ranking member murray, we will be working then with congress. we will to ensure. >> okay. >> any new better care as protections. >> in other words if it's struck down for a time, there will be nothing in place to protect zoey and kids like her? the truth is there isn't a plan right now to protect her or people like her with preexisting conditions and not only would this lawsuit take away these protections but president trump has broken his promise by expanding the use of junk health plans. that's what i call them because they don't have to cover preexisting conditions. and i want to share a couple of examples in wisconsin. one of the plans currently available in wisconsin from companion life, the very first sentence of their policy states, quote, preexisting conditions diagnosed within 60 months -- the 60-month period immediately preceding such covered persons effective day are excluded for the first 12 month of coverage. another plan sold in wisconsin now says, quote, no benefits are payable for expenses for a preexisting condition. described as a condition that, quote, would have caused an ordinarily prudent person to seek medical advice, diagnoses, care or treatment within 12 months immediately preceding the date of coverage. so explain to me how this digsz not only to join this lawsuit to try to totally repeal the -- overturn the affordable care act but this decision to pro actively expand the use and availability of junk plans is not a broken promise to protect people with preexisting conditions. >> i assume you're referring to short term limited duration plans that we restored to use that the obama administration had. these plans are not for everyone and a plan like that and quite glad that the enhanced consumer disclose users we had are making it parent if you had a preexisting condition those are plans you should not choose you want a short term duration plan that does cover it. >> you are arguing in court to overturn the affordable care act. so there won't be a marketplace. now i want to move on to something you and i discussed at length which is drug prices. if the administration is successful in the lawsuit and the affordable care act is struck down the law's prescription drug price reforms would also be gone. secretary alex azar your own medicare drug price proposal would be wiped out because your own pilot program is being tested through the center of medicare and medicaid medications cmmi which was created undered affordable care act. yes or no mr. secretary if the lawsuit succeeds and the affordable care act is struck down this court. cmmi will crease to exist sp and so is the pilot is that true or false? >> there are a great deal of ifs but cmmi is part of the affordable care act and it is my hope that any better program we set up would give me authority to set up pilots which we are firmly committed to you would have to find additional authority. >> it is crease to exist. thank you. >> thank you chairman and being here. from the state we have been travis i should by the opioid epidemic and we are looking at ripple effects and you in your statement addressed the issue of help a and b and also hiv. could you tell us briefly how you're meeting with the challenges working with the public officials in the state some forward leaning in trying to master this. >> absolutely first off the hiv epidemic will be very pep full with the additional funding and focused efforts there. we see 10% of new cases are coming out of inject i believe drug use. >> right. >> so the efforts there where we hope hopefully stop the spread of hiv in the country would tackle that. in addition, we have special funding as part of the budget and the opioid initiative that we've requested to help with hiv and infectious disease spread connected to the opioid problem that we have in the country. >> well, in my conversations with the head of the cdc just recently he did tell me that with the new availability of different met tricks you're able to identify clusters quicker. >> yes. >> and be more effective with that. so that's -- that's very important to us. i'm shifting to another issue i'm very passionate about and that is senator read and i, he's a member of the subcommittee as well, work together to pass the star act which is the childhood cancer survivorship treatment access and research. we got 30 million dollars in the budget for that. i would like to know what your department is doing on that and where you think it will lead to. >> yeah, first thank you for your support of the star act and getting that passed. we've already begun implementation at the national cancer institute of the nci specific sections there. one of the most important parts here is enhancing the bio specimen collection and buy so he repositives to hers aid us in the research programs needed to focus on pediatric cancer that's vital to building the evidence and information we need. and also to conduct and support childhood cancer survivorship research efforts. at cdc we're working the registries there and we look forward to the continued successful early case capture program that let's us identify children right away so that also helps us with the research programs by getting that type of information to make that available. >> does the budget reflect a -- next year, a continuation of that funding? >> so as you know our budget proposes an additional 50 million dollars to nih for the pediatric cancer research program as part of 500 million program 10 year program with a focus on pediatricic cancer research. >> good. >> it has been neglected for a good amount of time. >> i knew that. >> thanks to the star act and to the president's help i hope we get a greater focus there. >> i hope so too. and some of the leading hospitals, research hospitals in our state are putting a great focus on this. lastly i would like to ask you another thing that a statistic i found surprising because i don't think we think of ourselves like this as a country. but the rising statistics of maternal mortality and i think you're quoted in statement as saying over 700 women died in and around associated with childbirth. we did pass with a bipartisan effort to maternal -- maternal mortality accountability act for us to get good statistics on what's actually going -- goingon here because you state that these deaths are actually many of them very preventable. what steps is your department taking to take charge of the issue. >> as you mentioned maternal mortality rates in the u.s. have more than doubled over the past decades. >> do you have any idea why so much of it is about prenatal care and labor and delivery care and access in rural america. we have a real labor and delivery crisis. >> yeah. >> and associated with that is is appropriate prenatal care and of course the immigration crisis is bringing in so many individuals in terms of getting adequate prenatal and labor and delivery care also. i don't know the full demographic break down but i appreciate obviously senator murray's leadership in this space also and our budget proposes the 58 million dollars for the maternal mortality prevention and surveillance, which you just mentioned. >> right. >> and that includes 12 million dollars to support data collection and research to understand even better the causes of these deaths because -- so we really canreally aim at the problem and get solutions towards that. >> i think you will both find senator murray's leadership and others you have a very supportive senate and probably congress in this effort obviously the president supporting this as well. thank you so much. >> thank you. shoe, senator murphy. >> thank you very much mr. chairman thank you and mr. secretary being for being here today. i want to thank the chairman and ranking member for acknowledging at the outset what is the reality here this budget is not going to be reflected in the one that congress ultimately passes. we would never support the kind of dry conian cuts that are in it to people in need to very sick people to very vulnerable population and so i understand we are working together republicans and democrats to make sure that this budget never ever seize see is the light of day. for the good of the order it makes sense to repeat why the budget is so offensive to many of us. it's not just the cuts its that they stand in contrast to a giant gift wrapped present that this congress gave to the very, very wealthy in this country about a year ago, a 2 million dollar unpaid tax cut that was promised to cut wages per person. when fully implemented will deliver 80% of the benefits to the top 1% and now we're seeing who's asked to pay for it. frail senators? connecticut who will have heating shut off in the winter because the trump budget doesn't fund the low income heating assistance program. so i think that's -- at the heart of our frustration. it's not just that this budget doesn't reflect values is that it stands in contrast with a tax cut that is not going to deliver results for the majority of americans. mr. secretary i wanted to talk to you about the effect of the budget on the opioid epidemic n. your testimony, you point to about 5 billion dollars in funding that is directly dedicated to the opioid epidemic that is largely money already in the budget. but it stands in contrast to 1.5 trillion dollars in medicaid cuts in this budget including the whole sale elimination of the medicaid expansion. 4 out of 10 nonelderly adults that are dealing with opioid addiction today are on medicaid. and so when you put 5 billion dollars in essentially flat funding for specific opioid treatment, next to 1.5 trillion dollars in cuts to the insurance program that actually allows states to pay for treatment, the result is a devastating net negative, a dramatic contraction of federal dollars out of the opioid treatment system and i guess i just want to be honest what we're doing here. i know you may say, well we're still spending more money in real dollars but this is a -- 1.5 trillion dollar cut compared to what we expected states to spend and -- i feel like weshould be honest what this budget asks is for states to pick up a much bigger share of the burden for caring for people with addiction. and that this national emergency we declared comes with an expectation the federal government will do less and states do more. connecticut will try to scramble to come up with the money when we lose 100 thousand people off the roles of the medicaid program. other states may not come up with those dollars. i just want to ask you that: isn't this what we're doing, aren't we asking states to essentially pick up the burden of the opioid epidemic given the comparison of the medicaid cuts in the bill to the 5 billion dollars in specific opioid funding. >> i don't think so. well, you're right we have a 1.5 trillion dollar reduction that's in the budget for the medicaid expansion and the affordable care act exchange subsidies. we add back a 1.2 trillion dollar program that would be state based flexible. my hope is that it would actually correct -- one of the things i worry about with the opioid crisis and many other public health issues we deal with is that the medication expansion with focus on abled body adults has taken away us from -- actually in sent viced coverage away from the aged and disabled children, pregnant mothers. versus opioid addicted part of the core medicaid. my hope with the 1.2 trillion dollar program and complete flexible for the states on the money that they actually would focus that in areas like you just talked about where the needs are greatest. and really prioritize in those areas and it might actually enhance coverage and access for those individuals that we all care so much about. >> yeah, we've heard this for a long time that flexibility will allow states to enhance and greater focus their coverage. in the end, it's a whole lot less money than they were getting today and state's are begging for additional dollars to care for people with opioid he democrat mix, asking them to just focus better with less money. i just think i go norris the feedback that all of us are getting republicans and democrats about the realities on the ground, thank you mr. chairman. >> thank you, senator. senator mansion followed by senator that mean. . >> thank you that i remember i appreciate it and thank you secretary first of all for being here and also for your service. and you i talked briefly and i just i'm asking for the help that we need in our little state of west virginia. we face the largest per cap that economic burden in the consistent my deer friend sandra that mean is right behind us on this. the epidemic is costing or economy and forcing us to share the largest gdp of any state of cost related to the crisis which is 12%. i appreciate what you all done and everyone is concerned about the cutting i think we'll work through this, okay. but the 15% set aside for hard hit states, i'm asking through rules and regulations if you can do this, you have to take into consideration the deaths per cap that not just the total deaths. i have counties where it's enormous. if you look at the total deaths in off setting 159% we can't help them that much. does that make sense? >> there's a lot of sense to that. and i appreciate your raising that issue. one thing would be wear and you all helped us with the support with not just the support act but with proegsz funding on opioids with helping us with the form las to allow a focus of money on the highest burden states f. that issue of deaths versus incidents per cap that is in there obviously i need you to fix that. >> if not -- >> yeah and there maybe some allocation issues within the state, for instance, rural versus urban within the state, happy to work with you and the government in west virginia to educate and focus on that area. >> okay. i would too. one more final comments. jessie's law we talked about that and you might want to expand what can be done and how quickly you can make this happen. all of us agreed jessie's law is something extremely needed and can save lives and it's so simple but yet we are running into complications as far as privacy and hip pa and can you previously state that. >> thank you for priority idesing the work in the area and i will speaking with the office of the national coordinator to make sure it's a top priority. we have to and issues like 42cfr part 2 to make sure there aren't unintended consequences for instance where providers don't put information about somebody's addictions status in the lon tron in this case medical record for father of additional regulatory complications there. we need to work on that and make sure that's not standing in the way of care and treatment. what happened to jessie shouldn't happen. >> i appreciate you understand it and diligence towards it. it means so much to all us of us. funding for this horrible, horrible disease of addiction. i've introduced life boat year after year after year. life boat basically says that all pharmaceuticals producing opiates should pay 1 penny per milligram per production fees that would give us permanent funding. i know it's a tough one. it's a heavy lift for some of my friends. i'm looking at a tax. if you want to make the products, then you all pay production fee. make sure we have a constant stream of money that goes to the areas hit the hardest. >> you know the genesis of this crisis for the legal opioids and that's why i am so glad we've gotten legal opioid prescribing down by 20% and the mme, the morphine. >> if you could talk to then 1 penny per milligram would be a tremendous help. finally on affordable care act. the president says no we're not going to do anything until after 2020 so we'll have depending what courts do. let's say the court advocate for this and we still have it. you have a lot of expertise and bring an awful lot to the table how would you fix what's in front of you if that's all you had? nothing new and not reinventing the wheel. i wasn't here in earlier. i would work like heck to change a few things. what we have integrated into the system how would you recommend fixing it. >> i believe there are deep programs in the aca and just how the insurance benefit is structured there. issues around for -- i'll give you one example which is the 3 to 1 rating. essentially you've made insurance for individuals who are healthy and young you say unaffordable and they walk from the market and that created this downward spiral. >> got you. >> you're saying because we're preventing higher than the 3 to 1 rate on the people that are very sick. >> right. >> but that's where we get into where our difference with our republican friends, they cannot come up with how do you protect preexisting conditions, you can say, oh, yeah we'll make it illegal for anyone, any insurance not to sell and that by definition you said they can't deny you preexisting condition. you can charge us out of the market that i can't afford it and my aunt can't afford and it will break the family and they go without because back home in west virginia they say i don't want to be a burden to the family. that means they can't afford what's out there. you're preventing them from being denied. you're not preventing from being able to afford it. >> right and there are ways that one can actually make sure that insurance for people with preexisting conditions is affordable. senator kennedy and i had a bit of a discussion. >> i heard that. >> about reinsurance vehicles that are very, very quite well- established and work very well. >> here's what we have a bill called it was a collins nelson and i'll be introducing that with suzanne since bill is not here and we would love to have your support on that because we think that would be a big fix in reducing from the private pay from anywhere from 20 to 40% overnight we would be heap to work with you with you special until conjunction with what we had before which was going to be alex anned deer murray kol deer collins bill. >> they were laying on the desk for close to 2 years. >> where we have a stumbling block senator murray was around the funding on the csrs would have an appropriate high dak protections that ended up being the stumbling block. >> i'm sure she would like that. >> if you want to stay for a minute there will be a time for more questions. senator she mean. >> thank you mr. secretary for being here. i would say there was actually an agreement between both sides on the alexander murray legislation and a strong list of bipartisan response source and it's unfortunate that because there was opposite position from the white house and because there was opposite position from the leadership and the senate that bill wasn't able to come to the floor and i would encourage you, i think everybody who has been in the senate since we passed the affordable care act recognizes that we need to improve some things and some things are not working. the response is not to refuse to come to the table. it's not to overturn the law so people have no alternatives. the answer is to work together to get it done and i'm very disappointed that we have not seen that kind of leadership either from the senate leadership or from the white house. so i hope you will share your views that you think there are things we can do together because so far that's been miss ing from the conversation. i want to just agree with senator mansion of the importance of the set aside on the opioid funding. it has been critical in a state like new hampshire in a state as you know you're familiar with it. we have a huge problem and we are behind west virginia in terms of the overdose death rate but way too high for our state. we have way too many families who are affected and the pain is -- you can't talk to anybody in new hampshire who doesn't know someone or hasn't been affected personally by this epidemic and those set aside dollars that have been used for the state opioid response grants made a huge difference in new hampshire allowed us to set up one hundred and spokes system that keeps people within an hour from within a place where they can get treatment which is important and we're waiting to see exactly how it this will work but it's an improvement in something that would not have been done without those dollars. we had a hearing here a couple of weeks ago and i was talking to you about at the start of this hearing where there were people from states across this country who were directors of programs to respond to the opioid epidemic. and i asked them all a question. one was from new hampshire she has a recovery center. i said what happens if these federal dollars go away? and she said well, i'll go back to bake sales. the other some of the other folks were a lot more direct. they said people will die. and in new hampshire, the expansion of medicaid has been one of the things that has been most critical to ensuring that people can get treatment and that we can prevent some of those deaths. and yet, i share the concerns that senator murphy was raising about what this budget does to repeal the medicaid expansion and replace it with block grants because not only does it cut the amount available to states but it assumes every state will come up with the funding to replace that. and i think that's a huge question in a lot of the country. so, can you talk about what we -- what we should say to those people who are running the programs to address the opioid epidemic about why they -- what they should do if these federal dollars go away? >> well, i appreciate your concern. the president is adamant or budget reflects this about the funding and support for the opioid epidemic and the work we have together and want to keep working with you to ensure the state's with the highest burden are getting the share of resources they need to deal with it. in addition, our budget proposes with medicaid that we would actually expand access for women postpartum for one year to have eligibility postpartum suffering from addictions that's one of the changes we have in the budget. we continue to process the imd exclusion waivers to ensure we have inpatient capacity and expanded capacity for inpatient in communities. so we're continuing to drive forward and fully engage and had fully focused around the opioid epidemic. we're seeing results and targeted the state opioid response grants to ensure treatment the gold standard and i think we're helping to really to just expand capacity by making it quite quite clear this is the most evidence based approach to people for treatment and life long recovery. >> well, i appreciate those changes, i think they're very important but if the fundamental funding source and coverage source for people to get treatment goes away, then those are -- those will make a small difference but they won't address the underlying problem. i would like -- can i ask one more question mr. chairman? yesterday a study from the kaiser family foundation found that medicare part br spending on insulin grew by 840% between 2007 and 2017. as you know, diabetes is one of the most expensive chronic illnesses we have in the country and figuring out how to help patients with the cost of insulin at the favrm see counter is very critical but also a question about how can we be most effective with our public dollars to address illness? so i know that your department is proposed new rules to limit the impact of pharmacy benefit manager rebates that helped to drive up the cost of part d drugs. occur tell us when you think removing that link is going to help address things like those insulin costs or do we need to be doing something else? >> well, i would defer on the something else. i can tell you that the rule that we have proposed to get thesis rebates out of the system and instead have those go as discounts to the patient at the farnl see pharmacy level would be revolutionary to the patients in the classes you're talking about. especially with insulin or arthritis medicine or high cholesterol medicine that are highly rebaited. you may have 70% rebaits. imagine january 1 of 2020, when that patient walks in the pharmacy if this rule goes forward, they will get a 70% discount every time they fill that prescription. it's a revolutionary change for patient access and affordability if we can get this through and i pray we'll have your support to help do that. it's 29 billion dollars of rebates going to pb -- the pharmacy benefit managers now that would go to patients starting january 1, 2020. if we can make this happen. >> well, i look forward to hearing more about it. thank you. senator murray. >> thank you very much mr. chairman and thank you for allowing us to ask one more question. mr. secretary, i did want to express my serious concerns about what's going on in the uncompanied children program. most shelters that you know are work to go provide excellent care to the very vulnerable population. hhs as you know is charged with the welfare of every child in its care and i am deeply troubled by some of the reports of forced drugging, sexual abuse, substandard conditions at some of the temporary facilities and i was especially appalled by the great lirngsz that former or director scott lloyd went to prevent minors in orr custody from accessing reproductive care including cases where pregnancies were the result of sexual assault. and despite the thakt that a federal judge issued an in junction of march of 2019. buying orr obstructing access to abortion and recently released spreadsheet shows orr continued to track minors private reproductive health information through june 2018. there's no indication that the information collected in the spreadsheet is being used to ensure access to reproductive care. i wanted to ask you, does orr still keep a spreadsheet containing the reproductive health insurance of pregnant minors. >> i am not aware of any centralized spreadsheet. i believe -- i could not answer for him but i believe the intention -- this was the last menstrual period date which of course for any of us have children know is vital to prenatal care to know guess takingsnal age feel child, not on going cycle information or otherwise that is my understanding. i'm not aware when there would be and i doubt when there's any central type of reposistory we've ensured the delegation from the orr director of all decisions on significant medical procedures for unaccompanied alien charn to the orr career staff and i believe we're fully compliant with the court's order and in junction and faithfully execute onning that. >> well, what do you doing to make sure that orr complies with court order? >> i have have and always will make clear when there's a court order in place we will to faithfully apply that. the cord order you're referring to i believe we're in full compliance if not i would like to know but i certainly would give instruction always we should be in compliance with court orders. >> okay when were you first aware director lloyd was being regularly briefed on pregnant minors health information and actually personally pregnant minors to scourge seeking abortions do you believe that's an appropriate role for the director and when did you know. >> you and i spoke about this actually during the confirmation process if i remember correctly back in my first hearing in early december before i was in office. so i think probably this was an issue of some controversy even then, public controversy so i think probably around then, goodness, i can't quite remember. listen, the issue of a 12-year- old girl pregnant in our care, we're the custodian of the child and we are delegated to make serious medical decisions as the parent of the child but in consultation, if we can with the parents. >> okay well -- >> of that child. >> this is really important information and senator feinstein and i sent you last week a letter asking you to have your staff full ol what you are doing and where the information is and how it's being used and would like you to commit to having that. >> i would certainly work with you on that absolutely. >> thank you. thank you senator. i have two quick things: there will be more for the record i'm sure but one is we're nearing the end of the 2-year pilot period of excellence in mental health. not my goal or senator stabbine stabbiner's goal for the federal government to be the permanent sponsor of that effort of treating behavioral health like all other health but it is our goal to come up with all the information we can about the impact of treating behavioral health like all other health and what's the impact on other health costs. so my request to you as we talked about maybe two year extension to get more information for states to look at in the future, be very helpful if you could commit to provide us any early cms data before that program expires. >> i'll work with the administrator to duet you any information we have data to help support the analysis of the legislative -- to support thatlegislative sgleefrt do you understand what i'm saying if you have early data. >> any data, yeah. >> to show one thing or another it would be helpful for us to say we believe this is where this is headed and we would like to exile a little more information. >> mm-hmm. >> and the goal here again is not for the federal government to make behavioral health their health responsibility but to put the information out there that shows not only is this the right thing to do, which everybody already knows but its the physician kale smart thing to do as well. and my other question on the sponsor criteria on the unaccompanied children you talked about who sets the sponsor criteria in terms of what the sponsor has to provide and how that is shared or not shared? is that you or is that -- homeland security. >> so it would be statute as well as us. so the sponsorship criteria are staffed in the trafficking victims protection act largely the categories of category 1, 2, 3 and 4 response source are preference is always a category 1 sponsor which would be a parent or guardian here in the united states already that we can place them with. and then category 2 would be our other relatives, aunt's, uncles, brothers, sisters, that we would place them with and then 3 would be more distant relatives that we could place. we -- what we do is try traded -- there are certain mandates to the statute where there are various red flags we have to do home visits and home inspections. we always have the right to do fingerprints and other biometric check to go confirm identity or assist with background checking of any individuals that to my knowledge has long been the case. we have had heightened requirements in part driven by if you remember your colleague on the permanent subcommittee on investigations did some work, senator port man and senator car per on children who got placed with traffickers or ended up with traffickers in ohio at the eggplant. and so we -- it's always a balance. we want to make sure we're balancing keeping children in congregate care as short of time as possible but also making sure when placed out, we're placing them into a safe environment and so we're always assessing any discretionary aspects of that balance to strike that. so we have required fingerprints at various times of all, say, household members for a level 2 sponsor. we decided in december that that wasn't -- that we weren't seeing enough hits there in terms of information added information that that was mare mare ritd the delay from people coming in as these household members and so we pulled back on that. we're just -- we're always assessing what the needs are. >> i believe in your earlier responses so senator measure america lee you said you believe the direction from congress was that that information is not to be shared with the immigration service. >>, no, no if i could clarify. that information is shared with immigration, with immigration so we can confirm identity, do background checking or and also get immigration status. we have long previous administrations included gotten immigration status as part of the placement decisions. want they're precluded by being illegally in the country. we don't do that rather if somebody for instance is just to be deported they wouldn't be an adequate long-term sponsor for someone we want to make sure of that information. my understanding -- >> if you find out someone is illegally in the country and not about to be deported, what do you do with that. >> we still place -- if the person is within the category sglags of response source and an appropriate sponsor from a child welfare perspective. most of the children are probably placed with individuals illegally in the country. the information at dhs my understanding there is an appropriations rider that was passed as part of the large budget deal to end the -- the closure of the government that actually restricts the use of the information over at dhs but i would have to defer to dhs and its lawyers on that question. >> thank you, secretary. senator mora n? >> i'll attempt to come brief. thank you for the second round. mr. secretary i want to highlight, i mean i would -- you and i would agree this is ray significant issue affecting liver transplants this policy has consequences and significance that's true am i correct. >> yes, the issue of liver transplants are very important to all of us absolutely. >> i got involved or interested after a conversation a conversation of a liver transplant program in our state. but as a result of that activity i've been amazed at the number of people individuals in kansas and elsewhere who come to me to talk about the importance of the liver transplant policy. people who have had a liver transplant and peopling waiting for a liver transplant and people who want to be a list for liver transplant and you and i again would use the opportunity to highlight the importance of people being organ donors. we need more organs to meet the demands. this is not a -- just about the consequences to a particular transplant program. this issue has significant consequences, in fact, life and death consequences for people across the country. and finally, i would remind you that senator grassley along with almost half of the senate, sent a letter to you which i don't believe at least i've not seen a response and i would encourage you to respond. >> yep, thank you and i do want you to know that i take that letter very seriously. it was -- it has my personal attention and that was what prompted me that we went to otpm to think again and and go to the providers and that was in spite of the computer glitch and i understand the process was bad in terms of the interactions with you and on behalf of the department i apologize to you for any lablg of courtesy and also any problems in the process. my understanding is those comments in spite of the computer glitch were summarized to the optm board in decision- making and at least it was part of the sum reese as part of the original decision-making and presented in full to the liver committee later. i understand that is not necessarily everything you want to hear in terms it would have been nice if they were presented in full before any initial prufrptive decision was made. that's why i went back and said please think again. please, you know, look at -- look at these comments and concerns. obviously i've got tremendous respect for every signatory on the letter. i can only -- i hope if you don't have it, we'll get it to you the letter of response that i got and if there are further avenues that are appropriate legally justifiable to ensure appropriate process and consideration, i'm most happy to consider them. >> i ever not been discourteously treated. >> oh, well. >> but i've not -- i failed to get the results i'm looking for even when courteously treated and it's the -- it is results i'm looking for on behalf of folks who desperately need a liver transplant and other organs. >> thank you. thank you secretary alex azar the record will stay open for one week for additional confess. the subcommittee stands in recess.

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