Transcripts For CSPAN3 HHS Secretary Confirmation Hearing 20

today's hearing to serve on secretary of health and human services. it will vote on the nomination. we will each have an opening statement and then former secretary and former governor who we welcome today good to see you and senator young will introduce him after his testimony each will have five minutes of questions. we already have a good turnout. i anticipate a good vigorous questioning period. you'll be overseeing medicare and medicaid national institutes of health and excellent leadership. the united states is leading efforts to develop a cart for efforts. a nonaddictive painkiller and new treatment for dancer. you also have an opportunity to implement what the majority leader of the senate called the most important piece of legislation last year. the 21st century cures act which members of our committee agreed on and gave broad new powers that included the first major organization they worked on mental health programs as well as significant new funding for the opioid crisis you have been confirmed fwi united states senate twice. you have offered to meet with every member and have met or spoken with 15 committee members. you served in the judicial branch as law clerk for scalia. you know the private sector. you know the system of how drugs get from the manufacturer to patients. will all of these perspectives you should need no on the job training and should be able to take advantage of this exciting time to speed safe drugs to patients more rapidly. i see it as one of your principal assets. it is an obvious asset called upon to lead the most important health care agency. he knows the agency and he knows the private sector well. similarly dr. collins knowledge of nih and experience has made him an effect ef leader at the national institutes of health. i'm glad to know people like you have issues on issues you'll be dealing with every day. we plan to hold a third hearing on how the supply chain effects for what patients pay for prescription drugs. given your experience i would welcome your input as we continue to examine the price patients pay when picking up their prescriptions. only about 6% of the insured american but that is where we have had most of our debate and discussion. many don't qualify for a subsidy and getting haermed by sky rocking prices. premiums increased in four years and additional 58% for this coming year. senator mur ri and i cosponsored by 11 other republicans and 11 other democrats which the congressional budget office says will prevent a 25% price inkres by 2020 by paying cost sharing subsidies, decreasing the federal subsidies and as a result lower the deficit. it would also give the able to use the waiver already in the law to find other ways to lower premiums. for example alaska created a reinsurance program and lowered with no new federal spending. yesterday the president said he supported the agreement by the end of the year. the senate and the chairman of the democratic national tweeted last month alexander has widespread support tlchlt are many other steps you can do to stabilize the markets such as increasing access to lower cost plans and incentivize younger and healthier individuals to purchase insurance. the opiod crisis is a priority for every member of this committee. we are having more tomorrow. you'll be coordinating to combat the opiod drug abuse. it went up from 2015 to 2016. they have dramatically increased from 169 and to 294 in 2016. it is to provide funding on the front lines of this crisis including the protecting our infant sack, recovery act and durs act. we included 816 million in the first year to help address this growing crisis. we stand willing to work with you. some are saying that. i hope you join me in advising the president it is a bad idea. you need to be the one to take charge in leading the federal government respon and letting us know how to help. as i mentioned, we have an exciting opportunity to represent the cures act. i hope you'll work with us to take advantage of all this law offers including the vice president's cancer moon shot and brain initiative. cures also gave you the opportunity to hire scientists it needs to make sure it is for americans. we all thought that was a big priority. i hope you take full advantage of this exsight time in science. the law we pass to help ensure the safety. and also the patients pay to prescription drugs. next year they will have to repair which provides the authority to ensure it is able to respond to public health emergencies such as hur danrica and bio terror attacks. and another bill to fund the fda the one on the animal drug user fee act. so there's a lot do. i look forward to working with you on this and hearing more about your priorities today. >> thank you very much. thank you for being here and your willingness to serve. in november of 2016 people started coming up to me in the grocery store with tears in their eyes wondering what the future health. it hasn't stopped. because these challenges are what this congress and the department were discussing today is supposed to be focused on i'll start my remarks with a few examples of the stories i have been told. she is a four time cancer survivor. she would not be able to even stay alive without affordable care act protections. kim from allensburg talked about the ability to overcome it. chris tin that said before going to planned parent had she struggled to get wirt control regularly. there are so many pressing health problems this administration could be self-ing. it seems it has been determined to create problems. it the department has not helped her get high quality dove raj, by letting insurers cover fewer benefits. rather than allowing women to make share own health care choices the department has tried to and revent them from getting care if he twoent states like new hampshire and ohio and he called it a prethis administration and its health department did the opposite. it proposed gutting medicaid which officers critical wrap around treatment to people who could not afford it. experts say it would cripple response ft. worths. all it took was for it to go dark despoit the kmomss. it is no, ma'am -- the department has proposed using public health funds to close near term budget caps rather than to prevent costly illness and disease down the road. the public health crisis is still going on in the quake of hurricane. shouldn't have to be said but the absolute last thing our nation's health department should be spending time on is encouraging more discrimination in our health care system. that is wrong. you and i do have stark disagreements but it could be an opportunity to put aside the extreme politics and start focusing on the mission. people across the country would be far better off if you took this opportunity. i have to say that my review of your record leaves me with. lily is currently working to need les needlessly and made it clear on questions with womens health. you side with right wing politics over women. although experts and some members of congress have reject rejected you say it would be for people with preexisting conditions, cost tens of millions of people their health care, defunded planned parenthood and more. you said it didn't go far enough. this leaves me very concerned about whether you would faithfully implement the agreement he just talked about with us. we reached earlier this year should it become law? in light of the follow through on his campaign promises it is deeply hasn't supported committ resources we need for this effort. so i worry about your professional history and statements that point to a continuation of some of the extreme damaging and political driven approaches we have seen so far from this administration. to make my final point. right now, julie is traveling around raising wareness. helping people in central washington to get the necessary treatment and services so they can overcome their addiction. christina has become a vocal advocate for helping women in washington and nationwide to give care that works for their needs. julian, kim and christina are doing more than their part to keep our communities healthy and well. my question is why isn't our nation's health department doing the same. people should have a secretary of health who will work for and with patients and families not against them. and who is committed to making policy based on science and ideology. i'm looking forward to your thoughts on the many serious concerns i have raised and how you would be appropriate choice for this position. i'm concerned that president trump has yet sent us an extreme nominee to pick up where secretary price has left off and women and families deserve a lot better. so i'm interested in your responses today. i hope i am pleasantly surprised and i do want to say if you are confirmed, i want to make it very clear i have not and will not let this administration's approach so far lower my expectations for any of the department this committee overseas and i will continue doing everything i can to hold hhs to the highest possible standards of ethics ask service for people in my state and across the country. with that, thank you very much br figure here. >> we also welcome your family and friends. we thank them all for being here. there's pretty good group of them and you may want to introduce them when you begin. mr. a sar will first be introduced by governor left. he served as president george w. bush's secretary of the department of health and human services from 2005 to 2009. he worked closely with mr. azar then while he served as deputy secretary. then the nominee will be introduced by his home state senator and member of this committee todd young. governor lev it please introduce mr. a sar. >> thank you, members of the committee. senator alexander and senator murray have very ably described the complexity and the importance of this role. and therefore, it's my privilege to introduce and to recommend he is up to the task and supremely well qualified to carry out this important work. as mentioned during my service as secretary of hhs, mr. azar was deputy secretary. he was chief operating officer of this complex department. prior to his service, he served as the general counsel under c secretary thompson, who i believe later will also introduce and robustly recommend him to the finance committee. that plus his experience leads me to conclude that there may not have been a nominee to this office of secretary better prepared to hit the ground running than alex azar. it was mentioned that hhs is a large and complex place. while deputy secretary, alex asdzar was the manager of the day-to-day operations of 90,000 employees and $1.1 trillion budget. just a brief example of what i think talk would illustrate his capability. president bush had a management agenda that laid out a criteria of several dozen different object i haves and had a dash board. he set an object i-. the entire federal government to achieve that. he was also delegated oversight much of the regulatory process in a very skillful and lawyerly like way. he managed to carefully and ek quit bli adjudicate the process, which is robust. he's a world class policy thinker. you'll see that today. i think it's a word that will be underscored here. 911, he was part of the response. there was a point in time when katrina pandemic flu flu and the the rollout of medicare part b was happening at the same time. this is a person with great experience in a complex department. most b important, and i just say he's an extraordinary good human being. he's got the kind of compassionate heart that i believe it requires to serve to lead the mission of this important department. i commend him to urge the confirmation of the secretary of health and human services. >> thank you, governor. thank you for joining us. >> thank you, chairman and ranking member murray. and fellow members of this committee. to introduce a fellow hoosier to be secretary of the department of health and human services. president trump made an outst d outstanding choice to lead this critical agency which happens to be the largest civilian cabinet agency in the entire u.s. government. alex is now an extremely qualified nominee and a well known expert in the health care industry. his previous leadership of hhs and as president of indiana-based lilly incorporated, which is the largest affiliate of one of the largest health care companies in the world will collectively be an effective combination as we work to solve our most significant health care challenges. former hhs secretary tommy thompson said that azar is one of the most competent people i know. an experienced leader with deep health care knowledge. i agree. in addition to his impressive academic record, which includes degrees from dartmouth and yale, he clerked for the supreme court justice antonin scalia. he began his service in 2001, when the united states senate confirmed him to serve as the department's general counsel. >> the reputation is an effective leader. he's been particularly outspoke b on the need to lower the price of prescription drugs saying patients are paying too much. if anyone can solve this problem, it's alex azar. he's the right person to reform our broken health care system and ensure the department succeeds in its mission to enhance and protect the well being of the american people. alex was confirmed to both of his previous positions at hs with unanimous bipartisan support. confirmed twice by the united states senate for positions at hhs with unanimous bipartisan support. i'm hopeful this time will be no different. i know he's a good man with a heart for service. i have gotten to know him personally over the years. i look forward to supporting his nomination and working together to ensure all americans have access to high quality and affordable care. >> thank you. we invite you to give you opening remarks. the full statement will be incorporated into the record. welcome. >> if i could take a second to introduce my family that i have here today, i'm pleased to be joined today by my wife jennifer and my daughter claire, my son alex, my father dr. alex azar as well as my sister stacey and her team. unfortunately, my mother could not be here today. most tragically my stepmother died of cancer just in july. i'm very sad she could not be. here for this moment. having an opportunity such as this does not happen without a supportive family and their guidance. thank you, mr. chairman, members of the kmecommittee for the opportunity to appear before you today as the president's nominee to be the secretary of health and human services. senator young and governor, thank you so much for those extremely kind words for your friendship, your mentoring over the years. i also thank president trump for the confidence that he has bestowed on me in nominating tr this position. 97 years ago, my grandfather, an impoverished teen who spoke no english stepped out on the ss argentina. completing his journey from lebanon to america. as he entered the receiving hall at ellis island, he met an individual in a military uniform. that person possessed the power to admit him or to send him back to povty and uncertainty. that person was a member of the united states public health service. it is a testament to all that i love about this country that just 97 years after my grandfather went through his physical on ellis island with no discernible prospects other than the political, economic and religious freedom that america offers, his grandson might be. in charge of that very public health service as well as the other renowned components of the department of health and human services. the mission of hhs is to enhance and protect the health and well being of all americans. through programs that touch every single american in some way, every single day. we are at an historic time in terms of delivering on that mission through innovation. through its outstanding leaders and career staff, hhs is prime to meet that challenge. this task is humbling. marshaling and leading the incredible resources of that department require innovating, never being satisfied with the status quo and preparing for the future. i think i gained these skills in the dark days after 9/11. as we faced a health and human consequences of those attacks. through the anthrax attacks and potential future further biological, chemical, raid logical or nuclear attacks. in the implementation of our completely novel prescription drug benefit, by helping to build state and local pandemic preparedness programs and our response to threats is such as sars and our effort to reform welfare programs to make them as responsive and empowering as possible for the individuals and families that we serve. through innovation and the private sector, to bring life improvi improving therapies to our people of the world and harnessing the power of big data and analytics to make us more capable of serving our fellow americans. with a a department the size of hhs, it is often difficult to prioritize. nonetheless, should i be confirmed, i do envision focusing my personal efforts in four critical areas. first, drug prices are too high. the president has made this clear, so have i. through my experience helping to implement part d and with my extensive knowledge of how insurance manufactures, pharmacy and government programs work together, i believe i can bring the skills and experiences to the table that can help us address these issues while stillen couraging discovery so americans have access to high quality care. second, we must make health care more affordable, more available and more tailored to what individuals want and need in their care. under the status quo, premiums have been skyrocketing and choices dwindling. we must address these challenges for those who have insurance coverage and those who have been left out of the insurance market by the affordable care act. third, we must harness the power of medicare to shift the focus of our health care system from paying for procedures and sickness to paying for health and outcomes. we can better channel the power of health information technology and leverage what is best in our programs and in the private competitive marketplace to ensure the individual patient is the center of decision making and his or her needs are being met with greater transparency and accountability. finally, we must heed president trump's call to action and tackle the opioid epidemic destroying so many individuals, families and communities. we need aggressive prevention, education, regulatory and enforcement efforts to stop overuse of these legal and illegal drugs. these are serious challenges that require a serious minded sense of purpose. i thank president trump for this opportunity to serve the american people and thank you for your consideration of my nomination. >> i'd like to reserve two minutes at the end so i can ask questions later. during the nomination process for the secretary of agriculture, there are concerns about his close ties to the agriculture industry. treatments and cures through that agency. there was concern because he had worked with pharmaceutical companies. you have worked with a major pharmaceutical company in a major position for ten years. my own view is that that's a big help. having some familiarity with drug pricing is a businessen teen situation. much about it by the time they came in, they would be gone before they figured out 5% of how we might lower drug prices. i think that's a plus. they increase insulin prices while you were a leader at eli lilly over that ten-year period. >> mr. chairman, thank you for that e question. as you and others have mentioned, i had the honor of serving general secretary of hhs for almost six years in the senior leadership there. so for me, if i were cob firmed, this is returning home. this is my place that i want to be. after hhs, i did spend ten years at eli lilly where i was a a senior leader. the president of the u.s. affiliate directly leading the sales and marketing of all nondiebs diabetes, non-oncology drugs in the united states. as the geographic leader, i also supported operations for those other business units. i do believe. as the chairman mentioned that these public and private sector experiences do prepare me very well for the role of secretary. this is especially true in the case of drug prices. the current system of other medicines may meet the needs of many stake holders but that system is not working for the patients who have to pay out of pocket. we have to recognize that impact. that's why the president and so many members of this committee on a bharp basis and i have talked about the need to fix this system. i do think through my experiences at lilly and the private sector, understanding how the channel works, how the channel sees these issues, how manufacturer, payers, pharmacy benefit managers, all distributors all work together. we can work to identify solutions here. >> i will reserve the plans of my time. >> thank you. let me just follow up. i think the cost of drugs is something i hear about more than anything else. it affects so many people in a negative way. and i'm assuming that you agree with the overwhelming majority that drug costs are too high. do you agree that congress and administrative actions are needed? >> i absolutely do. tell us how you would approach this as secretary? >> so thank you, senator, and i appreciate the chance we had to sit down together. i really enjoyed that discussion. also in terms of your opening, i hope if i'm confirmed, i hope i can earn your trust and show you this is the job of a lifetime for me. i would approach this not for any industry or past affiliation, but to serve all americans to improve their health and beiwell being. i think there are constructive things we can do but i'd also like to hear ideas from the committee, from people at hhs, but let me throw a couple things out that are worth focusing on. the more drugs we asked to get to the market, that can bring down costs to the system. we have to fight gaming in the system of patents and exclusivity by drug companies. i have always been an oen point of patent systems by drug companies. the exclusivity saved $34 billion for the efforts that we pushed by reinterpreting. why are americans paying more than those in europe and japan and is that fair that we are baring the cost of other nations. >> the skepticism comes from the world of pharmaceuticals and prices didn't drop. i wanted to ask a question about women's health because so far under president trump's leadership and former secretary price, a a numb of detrimental steps were taken that undermine the health care. and critically rolling back protections for women to have full coverage for birth control from their insurance plan. so i wanted to ask you if confirmed, will you commit to putting science and access to health care first rather than ideology and extremism? >> so senator murray, as we discussed in your office, if i'm secretary, i'm secretary for all americans. i'm there to protect all americans, men and women. we have programs that this congress has created and that hhs is is there to implement. i would faithfully implement those programs. we may differ in different elements of how those get implemented, but i firmly believe in evidence in science where it will take us. running these programs. >> do you believe that all women should have access to the health care, their doctor recommends for them. >> if the issue is the conscious intention. a women's choice of insurance that she would want with the conscious of employers and others in a balance that's sort of an american values, trying to balance those and it's a very small group. >> the women's doctor recommends it but you believe the employer has the presence dense over that? >> not in terms of access, but in terms of insurance, to force those very few -- i believe it's less than 200 have come forward. very few employers that would be impacted by that conscious exception to respect their rights as well as respecting women's access through the insurance. >> i disagree. i think women's access to health care, their doctors require for them should take precedence. we disagree on that. both raised, know about the legislation we put forward. if confirmed, will you commit to implementing it as intended and working with us to improve affordable coverage for patients. >> absolutely. >> i know that some people today are claiming that bill that we designed will fix other problems being proposed. do you think the cost sharing reduction payments will be sufficient to make up for chaos if other tax cut proposals are passed. >> i think the work of this committee on a bipartisan basis is a wonderful model for addressing it, it recognizes problems with the affordable care act. there are problems with the implementation. there are going to be some new authorities in the package that you're talking about. those will be useful. but i do want to caution i don't believe it's a long-term solution to problems that are just inherit. we need to work to address in terms of getting to affordable insurance. choice of insurance, that insurance delivering real access to health care for people. so not just a card but access to physicians and the insurance that lets the people get the insurance that they want not what we're telling them from the center. but it's an important stopgap to help along that way. >> i'm way over time. i'll let the members ask at this point. >> senator paul. >> i think most americans don't disparage or dislike people who accumulate well. we're fine if people accumulate well. if you ask americans, sam walton developed this great store and became wealthy. most people don't think he's a terrible person or abused the system. i don't think americans have the same warm fuzzy feel iing for b pharma. they use their economic mind to manipulate the system to maximize profits. it's not like they are selling a cheaper product to more people. they are using government to maximize their profits. do you acknowledge that the current system big far ma uses clout to manipulate the patent system to increase drug prices? >> there are clearly abuses in the system. that's why one of the steps that i mentioned to senator murray that we have to go after is is the gaming of that. i have always believed we have a regime that gives inno varieties a time period to sell is the product. but there should be a moment certain when there should be full competition and that's a gift to this country to the system and to patient when is they walk in the pharmacy. >> i will say this is a huge problem that's been going on for decades. we have had insulin since the 20s. everybody says they are going to fix it, but i tend to be a a doubter because these problems go on and on and on. to allow us to buy drugs from europe, buy drugs from khan darks buy drugs from mexico or australia. in fact, this was the president's position when you said allowing consumers access to safe and dependable drugs from overseas will bring more options to consume eers. >> i stated a position against unsafe importation of drugs into the united states. the president has said the same. reliable and safe. >> the drugs they use in the european union are unsafe? >> we have had a success session of democratic and republican commissioners who have been unable to certify under the law -- >> they have been wrong and beholden to the drug companies frankly. you'd have to sit there and say that the european union has unsafe drugs and unsafe for americans to buy drugs from the european union or canada or usa trail ya. it's just frankly not true. it's been going on year after year after year. we have this enormous problem and people say we're going to fix the drug problem and it never happens. what i think is important for america to know this isn't capitalism. walmart is capitalism. bill gates was. capitalism. big farm ma is trying to use the government. you get an epipen, you have it for 20 years, manipulate one little thing in the spring and they get another five years and another five years. so one of the things we could do that would dramatically change this is if you have a patent on the epipen for 20 years, you get it. if you change it and make it better, you get a patent on the new pen. currently you can't have that. why don't we have generic insulin? it's going to take someone who really believes it. you have some convincing to make me believe that you're going to represent the american people and not big farm ma. we also have our doubts. it's big government. we have to fix it. we can't tepidly go at it. we have to really fix it. you need to convince those of us who are skeptical that you'll be part of fixing it and won't be beholden to big fharma. >> i completely agree with you. that's one of the important avenues we ought to be pursuing because, again, there should be a time certain when competition begins with generics and you shouldn't be able to simply make a change there and evergreen your patent. >> one thing in my last few seconds on the drug reimportation, we're going to give you a question that you can think about and write. so everybody says it's not safe. what i want you to tell me is why the drugs are not safe and the european union and how you'd make it safe. if there's restriction to go through one e committee, i'm fine with ta. vote on a committee for the drugs as they come through. it needs to be expedite d and happening. that's bs and the american people think it's bs you can't buy drugs from europe or from canada or mexico or other places. we just say it's unsafe. so you're going to have to convince me you're at least open to the idea that the president is that was his position in the campaign. if you're open to it and not just say it's unsafe, we'll say this is how i would do it and reimport drugs and make it safe. that's an honest reform. if you can't do that, i can't support you. i. hope you'll come back with an answer that says this is how i'd make reimportation safe. thank you. thank you, senator paul. senator bennett. >> thank you, mr. chairman. i tell you just following on my colleaguesen comments. another option is to figure out how to make prices the same. so people in america didn't have to go through the ridiculous contortion of having to import drugs from overseas but could afford drugs here. i want to congratulate you and your appointment and your willingness to serve during the difficult times. when president clinton left the white house, he left behind projected $5.6 trillion surplus. and that's what he gave to president bush. then we fought two wars and didn't pay for those wars. we enacted e medicare part d. this is the one thing he was consistent on in the primary is the republican party nominated him and the american people elected him. he would pass win of the largest increases in american history while saying, quote, i'm not going to touch social security and i'm not going to touch medicare and medicaid. those are the president's solemn promises to the united states. by having 30 continuing resolutions. by not being able to establish a set of priorities for the american people and we sit here today collecting revenue and spending 21% of our gdp and expenditures. and on the floor this week, disgracefully, is a tax bill that would reduce that 18% to a lower number at least a 1.8 trillion additional deficit. and the concern that a lot of people have in my state is that after this incredibly unpopular tax cut is jammed through with no hearing, that the administration is then going to break the president's promise to not touch medicare and medicaid and instead exploit the deficits that the republican majority has created in the time that george bush was president and now in the time that donald trump was president to go after medicare and medicaid. i'm wondering if you can assure this committee that the president through you is the head of hhs will honor the promises that he made on the campaign trail to make sure that he's not going to cut medicare and medicaid, which is what he said. i apologize for the long wind up, but the history has been forgotten by my colleagues and i think it's important. >> thank you, senator. it's a pleasure to e see you and a pleasure to meet with you yesterday. i hope we'll have the chance to work together. as i mention ed one of the area i want to focus on is about strengthening our medicare program. because there's so much mistake, fraud, waste, abuse in the program, inefficiency in how we pay for health care procedures and sickness. if we can tack thal and if we can move to a value-driven system of health care, we can do two things that are important. we'll actually stretch out the resources and the medicare program to keep its sol ren si longer and along it to serve its beneficiary, especially as we tas the baby boom generation. it will serve as a catalyst for change throughout the health care system because so much of the health care sl just really free rides off of whatever medicare is doing on payments. so i think it's a really unique opportunity. both the strengthening, making medicare and medicaid as efficient as possible. >> i hope we can do that in a way that isn't infected by the idiotic politics on health care we have had in this place. i completely agree that the program were missed. we need to align them. it's also true that the reason why we are paying $1 in for every $3 we're consume iing in medicare is largely because of medicare part d, which was not paid for when it was enact ed b this congress and under president bush. and because of the drug crisis. which is a double whammy that has caused us to blow this. so my concern, i have a fiscal concern, which i don't think is for some reason shared today by my colleagues on the other side of the aisle, but i have a concern that benefit. ris in my state are going to pay a price for the fecklessness of washington, d.c. i don't think that's fair. it's a shared understanding of the facts. >> senator kcollins. >> thank you, mr. chairman. a wide variety of insurance plans were actually less expensive when the consumer paid out of pocket. where she not used her insurance she would have paid less than half of that. $19. i was outraged to learn that they were under gag orders that prohibit them from informing their customers that there is this differential in price. but paying out of pocket. from giving true transparency on the drug pricing to their customers. >> how can you not hear that and not have your draw. drop. how can you not find that frightening that that could go on. so i think those are the types of issues across the entire channel in drug distribution and payment that i want to bring the expertise i have to the table to work with you and others at hhs to try to resolve. because that shouldn't be happening. there are many other things that shouldn't be happening in the channel. and how that system works. i think we can work together to come up with solutions here that are going to help patient when is they pay as little as possible. >> that absolutely should be our goal. and i can't tell you how frustrated these pharmacists were that they were una able to give that information to their customers who they knew were struggle iing to pay a high co-. a second issue that i want to explore with you today has to do with the investigation that the senate ageing committee undertook into sudden price spikes in off patten ent drugs. we found that the risk evaluation and mitigation strategies are the rem system which were intended to manage drugs with increase d risk factors were being used by certain drug companies to block potential competitors from accessing a sufficient amount of the doctoring once the patent has expired to do the exams that the fda requires. and i have had extensive discussions with fda officials about this. dr. janet testified that the fda has referred 150 cases of potential anti-competitive behavior to the ftc. the ftc claims it b doesn't have enough authority. the new commissioner has suggested that there could be opportunities where the fda could partner strategically with medicare to prevent the deliberate blocking of generic competitors from your perspective, how can we address this wsh. >> i am aware of that issue also as one of the abuses. a full competition in the mar t market. i would look forward to working with you to get to real solution there is on just how the programs could be abused to block entry and once we get to the end of life, do the rems programs continue to make sense. are they still required for safety once we have the potential for generic status. there may be statutory changes needed. i do not know, but i think we need to solve that. that's one of the things that has to be solved. >> thank you very much. someone you referred to the end of life. >> the patent life. >> thank you. >> thank you, senator. senator warren? >> thank you, mr. chairman. i'll get right to the point. rr resume reads like a how-to manual for profiting from government service. about a decade ago, you worked in government helping regulate the nation's most profitable drug companies. and when you left, you went through the door and became an executive at eli lilly. they paid you $3.5 million for doing that. not bad. and now you want to go back through the revolving door and regulate the same drug companies, at least do it until you decide to go through the door again. i. don't think private sector experience should disqualify anyone from serving, but the american people have is a right to know that the person running hhs is looking out for them and not for their own bank account or for the profitability of their former and maybe future employers. so i have some questions along that line. the first is do you agree when a drug company lies about its products or defrauds taxpayers, it should be held accountable by the federal government? >> of course. >> good. because right before you went to work for eli lilly, you worked at hhs while they help the justice department with an investigation of the drug zypreya. . it was for biporl disorder. but eli lilly decided to boost profits by pushing the drug ob nursing homes for uses like dementia and alzheimer's. with no proof that it would work. the word for that is fraud. and it cost the government and taxpayers billions of dollars. eli lilly was still under investigation and went straight to work. then as the company top spo spokesman you helped manage the fallout in 2009 when the company was forced to pay the largest criminal fine ever imposed in a prosecution. more than half a billion dollars. at that time, eli lilly's ceo said, quote, doing the right thing is nonnegotiable. do you think that settlement represented adequate accountability for eli lilly's criminal behavior? >> so senator, i want to be really clear the conduct in that case occurred and ended long before i ever even left the government or thought about going to lilly. i was not involved in that case when i was in the government. i think i actually learned about even the investigation for the first time, although it had been in the media, i think i learned about it when i was interviewing and learned about it and wanted to do my own inquiring. >> then you became the spokesman for lilly. >> i became the global head of corporate affairs. i will tell you, the conduct that occurred there was unacceptable. and there's not a leader at lilly that would say differently. it was a massive learning and transformational experience for the company. >> was the settlement adequate accountability for lilly's unacceptable behavior? >> it was the largest -- >> it was the largest. >> for about a week and then another company had one. >> do you think it was aud adequate, that's my question? >> it was certainly the largest ever. what i will tell you -- what was important about that was that it changed behaviors. >> i'm sorry. what is important is the question and that is whether or not there was adequate accountability? >> i do believe so. i don't have any reason to believe not. >> lilly made billions of dollars off this scheme. and they paid a half a billion dollar fine. and they said that's a huge fine. the truth is it is a huge fine. but they made far more money than they actually paid out. and for me, that's just not adequate accountability. your ceo got to keep sleeping in if his own bed at night and at the end of that year he was paid $1.5 million for his troubles and another $3.6 billion in so-called performance bonuses. i think the message was clear to other drug companies. within eight months, pfizer was kaulgt doing the same kind of marketing. and slapped with a criminal fine. these settlements have become a cost for doing business for the drug companies. and as we speak, eli lilly is the subject of multiple lawsuits and investigations accusing the company of conspireing to illegally raise its prices of its insulin products. but we're supposed to believe that this time around, you're going to be willing to hold them accountable in that way that's dpoing to make a difference. so do you think the ceo's like john lek lighter should be held personally accountable when drug companies like eli lilly break the law. >> so senator, there was a period of time where across the pharmaceutical industry, there were various practices that got resolved through litigation. what i'm quite proud of is is the fact that i was not there as general counsel. i did not negotiate the settlement of that case. but the attitude that i saw top to bottom globally of the company around that was one of how do we make sure this doesn't happen. how do we ensure that the processes, the culture, the ethics the oversight. >> i'm out of time. i understand that i'm out of time. i just want to make it clear for the record. i asked the question about whether or not you think ceos ought to be held accountable when the companies they are running break the law. i'm just trying to get a little accountability answered. if you have a yes or no answer, i'll take it. >> i'm satisfied with our discussion. >> i'll take that as a, no, you would not hold them accountable. >> senator cassidy? >> senator young? >> thank you, chairman. you have been caricatured by some as a predatory avendviser. i want to say a few words here opposed to my giving an extended speech. can you talk about what you did in your previous tenure at the agency around the drug pricing issues. >> senator, thank you for asking about that. back in the bush administration when i was general counsel, there was a clear abuse occurring where pharmaceutical companies were taking advantage of a loophole in the drug laws to allow them to have longer, longer, longer patent periods. they would get to the end, they would file a new patent and get another extension. and what i said to our legal team was this is unacceptable. nobody has ever thought of a way to deal with this without legislation. let us see can we interpret. the statute in a way that prevents that. and drove that and drove that. and we actually got to the point where we put out a rule that allowed only a single 30-month stay in litigations. you basically got one shot at the apple instead of these things that could cause a drug to last for years and years longer. it was to save $34 billion over ten years and that rule was later entliened through the leadership of senator mccain into statute. >> you may want to fuel a false narrative that it you're not sensitive to drug pricing. you have a process by recognizing an anomaly in the law that led to a regulatory change that saved how many billions for consumers in prescription drug prices? >> $34 billion over ten years. >> okay. you participated in a symposium at the manhattan institute. do you recall that? >> i do. >> at that symposium you stated we're on the cusp of a golden age of pharmaceutical breakthroughs, but the problem is our outdated sl is threatening to patient access to this recent and revolutionary burst of innovation by shifting a crushing burden on individuals. a lot of americans paid for their drugs through health savings accounts. is there something we can do with hsas or other vehicles to help with drug costs? >> i do think there is, actually. so one of the things when you have a high deductible plan, that's one that has $6,000 that you have to pay out of pocket before the insurance starts paying. the law says that you can't -- that the plan can't cover during that period of deductible unless it's something as a preventic service. but the government hasn't put out good guidelines about what can be covered as preventive services so patients so you have first dollar coverage in that deductible period. changes would allow more money to be put into health savings account, more flexibility for use, anything that lets the patient have access to more money or lower co-pays when they walk in the pharmacy has to be part of what we drive towards. >> i asked about your past professional his wi with respect to drug costs. you were able to cite an example where you catalyzed a fros lower drug costs. i ask you about any ideas you might have about health savings accounts. you put forward an idea to reduce the cost burden on consumers. i'm encouraged by that. i hope others are as well. i have roughly 40 seconds left. television indicated welfare reform will be a major priority for his moving forward. it's a priority of mine. are under the jurisdiction of hhs. i will look forward to see what sort of changes you anticipate hhs making through executive order as the administration is pursuing in other areas to improve our welfare systems and serve. >> senator hassett? >> thank you very much, mr. chairman and ranking member murray. good morning, mr. azar. congratulations on your nomination and congratulations to your family too. this is a family affair. we're grateful for their willingness to support you in this work. as you know, new hampshire has been ravaged by the fentanyl crisis. we're in need of real resources to help those on the front lines combat it. hhs used a flawed funding formula to allocate resources from the 21st century act. the hardest hit states like new hampshire didn't get adequate resources and now even though we have asked them to change the formula hhs has declined to do that. but another big problem is the trump administration has refused to request additional funding to fight the crisis, which has prompted many to question whether the president is truly serious about addressing it. we need this administration to send a supplemental funding request for addition resources to combat the addiction epidemic. so mr. azar, if you are confirmed, will you commit to me today you will encourage congress to ask for at least $45 billion in new supplemental funding to fight this crisis. a number that has had bipartisan support? >> so senator, thank you and i'm glad we were able to have the discussion about this terrible opioid crisis and the impact in new hampshire. i don't know the number, but what i will commit to you if i'm confirm the, i'm going to work across the government to assess, do we have the resources we need. if i do not believe we have the resources we need to address the problem and work with the president and congress to do that. >> i will tell you i don't know a governor of either political party who believes we have the resources we need. i dent know anybody on the front lines of this crisis who thinks we have the resources we need. will you also commit to examining all substance misfunding sources and directing wherever possible under your authority more funds to the states hardest hit by the crisis. >> i. don't know the precise issues around that formula, how much is in statute and how much is discretionary, but absolutely, i know your concern about the money going to new hampshire. if i'm confirmed, to work with you. do we think it's the right approach. >> it's been distributed ba basically on population opposed to the overdose death rate per capita in particular states. let's move on to another issue. the drug company has recently engaged in unacceptable behavior to shield the patents of its dry eye drug tr review. they announced it had paid a native american tribe to take ownership and license the patents back to sell the drug e exploiting the doctrine of immunity to protect its profits. they are renting the tribal immunity to protect its profits. this outrageous first of its kind of a deal was called a ploy reel rooet ly ly by a court jud. so i would like to know what you think about this deal, yes or no, should drug companies be. allowed to rent out tribal sovereign immunity to shield their patents from review. >> i do not know as secretary if i would have any actual enforcement issues. i want to be careful about any particular situation. but i would say i would share your concern about any type of abuse around extensions of protecting from whatever processes there are for evaluating validity of patents. >> i appreciate that. if you are confirmed, i hope understanding that there are multiple agencies to have some the country recently learned of the case of jane doe who was forced to continue her pregnancy while in the custody of a shelter that contracts with hhs overe seeing unaccompanied minors. they were able to receive the abortion that was necessary for her and that a court confirmed was necessary for her. but because of this case, it has come to light with the director of the hhs office it would override the pregnancy rather than placing her with family members and he personally visited pregnant minors to pressure them to continue their pregnancies. political appointees in washington, d.c. at hhs should not be imposing their own ideology on these young women, nor should they be coercing them for their choices. if confirmed as secretary, do you agree you have an obligation to follow the constitution and all the laws of the united states even those you may not personally agree with. >> i am a lawyer, and i take the obligation to follow the laws and constitution as interpreted by the courts as a solemnabsolu. >> i know i'm running over and i'll follow up on the discussion with you, thank you. >> thank you, senator. senator cassidy? >> enjoyed our conversation yesterday, thank you. i've worked in the public hospital system taking care of the the uninsured. now there's a lot of data out there that patients. >> clearly, we should have a bipartisan interest in having outcomes data that shows who is is doing a good job and who is not. and if someone is doing a good job, reward. if not figure out try to improve it. >> i couldn't agree more. >> any thoughts about the data sets that are currently available? i'm told that for medicaid and chip right now there's in theory a structure for this outcomes data to be accumulated and compared. but in practice, it is not. thoughts on that? >> i do not know the data sets, but if confirmed, i will gladly look at that. we ought to always be evaluating our programs to e see what eval program to see what works, what doesn't work. are there certain programs that work better than others. our goal is people have affordable care, access to care. if one approach is better than the other for delivering quality for, that we ought to be using any data we have to find that. >> yesterday you were opening the meeting informally with senators for both sides. our ranking member and chairman very good about convening that. what can we do as a federal government to have better data sets so patient outcome can be monitored. if you don't measure, it doesn't improve. we need to measure that. >> i appreciate your invitation. if i'm confirmed to convene any kind of bipartisan process to work through these difficult issues. if i'm confirmed, i hope you find, my style is one i don't believe i have the answer to every problem. these are complex and vexing issues. i want an open dialogue back and forth. i'm a problem solver. my brand is if there's a program not working, can be made better, i want to work on solving that problem and i want the best input and ideas from the board of directors. >> if there's something can you do administratively we don't have to mess wit. if there's something you need legislatively we devote our attention. that would be the purpose of this. >> if there are ideas what could be done administratively, i would want those ideas also if confirmed. >> let me get some ideas. public health, there's been a problem i've been working with senator schiotz. if we get another zika it doesn't take a special appropriation. i compare it to under katrina congress had to come in and appropriate money for fema to respond to katrina. now we figured out no. before we came in, figured out, no, let's put the money up front to immediately draw it out. from my perspective, do it for public health as well. what thoughts do you have regards how we can help you better respond to public health emergencies? >> well, i was actually back in the bush administration, one of the architects around project bioshield. i really see preparing for public health emergency and response, the benefit of predictable funding and the ability for the government to be a reliable partner in that development process. i'd be very happy to work with you. i can't speak for the administration but my personally. >> how do you safeguard the money being frittered away on things not public emergencies or used as a slush fund to cover shortages elsewhere. >> one would have to draw the line clear. i would share that concern. you would need to make sure it's built into development or response program for public health emergencies like zika, ebola, or counter-measurement development programs. >> let me also say. this might be something to encourage and monitor. sheldon whitehouse and i -- i'll say sheldon, if i say whitehouse they think 1300 pennsylvania avenue. we put something forward for health id. my physician colleagues just are retiring at age 55 because they are just sick of electronic medical records and the dampening it has been on their ability to interact as well as their productivity. so in the 21st century act, directives supposedly progressing well but nonetheless, trust and verify. any thoughts about that and how we can ensure health i.t. becomes an enabler of patient physician relationships as opposed to an impediment. >> i need to be careful because my father, dr. alex azar may jump to the table and tell you about the problems oes exactly the approximate you're talking about. i think when secretary levitt was secretary and we went down the start of the journey on health i.t. he was adamant. electroification of health records without operability isn't useful. that's just moving files to a different place. i'm afraid we've done a bit of that where we've electrofied our records systems, we haven't gotten interoperability, too complicated point of entry with the doctor. i would love to work with this committee and i certainly if i'm confirmed will work with nhs. continue that focus over the next couple of years. senator baldwin. >> thank you. thank you, mr. azar. there's been a lot of discussion about experience, insights, as well as potential for conflicts already in this hearing today. obviously experience and insights can be extraordinarily helpful, but we've heard from the president that he wanted to drain the swamp. we've heard phrases like foxes guarding the hen house and the revolving door. so noting that, the perspective that you would bring having served in large pharmaceutical corporation in a leadership post brings a very specific perspective, especially as we tackle one of the critical problems of our day, the high cost of prescription drugs, often times life saving and life extending medicines for our constituents. we had a hearing recently in this committee on drug prices. i felt that there was a lot of finger pointing from the folks who were at our -- talking about whether they were from the perspective of big pharma or pharmaceutical benefit managers or all of the other players in this system. and citing complexity, citing it's their fault, not ours. but because of your background in the pharmaceutical industry, i'd like to not hear finger pointing but what can be done. i have many constituents who share their very personal stories about their challenges with the increasing and skyrocketing costs of, again, life saving or life extending medications. greg from stoddard, wisconsin, has two adult sons, both with type i diabetes. they are now expending over a thousand dollars a month just to maintain insulin and test strips. when you were president at eli lily you were there during a time that there were really radical increases in insulin prices. it increased more than 1,000% since 1996 and over 200% during your tenure. can you tell us -- and more specifically, greg and his two sons with type i diabetes, why eli lily and other companies are systemically increasing the list prices of drugs that are already on the market? >> so senator baldwin, thank you for that question. i really enjoyed our discussion the other day on this and other issues. so first on the finger pointing, i've actually been really clear, even when i was at lily on this issue of drug pricing. finger pointing is not a constructive enterprise. everybody owns a piece of this, everybody in the system owns a piece of this. i think the government owns a piece of this. that's why i want to serve because i think the experiences i bring can help me with the government. one company can't actually necessarily impact -- >> i appreciate that, but my question specifically is what would you tell greg and other constituents about eli lily's role. >> yep. and the insulin price increases have been significant for all drug prices pretty much. the problem is the system makes it so -- greg and his kids -- >> i should tell them it's the system. >> the system has to get fixed. that's the problem. >> what about the drug manufacturers are the starting point? they set the list price. what should i tell greg about the 200% increase during the time you were there in the price of insulin? >> what we need to do is work to fix so that greg and his kids have insurance that covers that insulin so they have low out-of-pockets so that we've got to get the list prices down also. >> that starts with the drug manufacturers. >> it does. >> this feels reminiscent of the hearing we just had. it's a complicated system and it's this and that. it starts with the manufacturers setting the list price. now, i see i'm already hitting my time and i had lots of questions. maybe we'll have a second round. you talked about generic and branded competition, fighting the game of the patent system and exclusivity. the two things i want to talk about should we get a second round is the role of transparency and getting the pharmaceutical companies to justify their increases in price. i have a bill along with senator mccain to require that for companies planning on increasing their prices. and secondly, the role of negotiation, somebody in your role directly with the pharmaceutical manufacturers. >> thank you, senator baldwin. senator isaacson. >> thank you. i look forward to our meeting tomorrow. i'm glad we didn't have our meeting before this. i want to ask a question i might have been talked out of asking you had i met with you before. in listening to your testimony, having heard ms. warren over the years, being a senior that advise ad a lot of farm suits mysel -- pharmaceuticals. it's a huge issue. i'd like to give you a homework assignment i hope chairman alexander and murray will back me up on. will you come back to us in six months on your recommendation of what you are going to do to help end the games of the system in terms of pharmaceuticals? >> absolutely. >> these are the things that are being abused by either the pharmaceutical companies or whoever it is. i'm not interested in blame. i'm interested in solutions. let's try and end the gaming of the system. often times these debates end up ob -- i live in atlanta, the home of the cdc. it solved the ebola problem when it contained an outbreak and ended its spread. same thing with zika. we were able to get the people under care, isolate them, treat them. all four who went to emery survived an ebola infection. that type of partnership is what we're going to have to do for the -- >> senator, the cdc and its leadership and career staff are the envy of the world and i share that view. >> and they have saved a lot of lives. >> amen. >> and prevents so many tragedies from happening it's just unbelievable. >> have indeed. >> last, this may seem to be a silly question, i was a salesman all my life, was on a commission income all my life. the medical loss ratio in the affordable care act includes the cost of a sales commission as part of the loss ratio formula, which in effect put most people who sold health insurance to individuals who bought in the market out of business. because the commission they would be paid, although very mode modest, would throw it over the 85% cost ratio. most americans today would look to try and find a way to get insurance. there's no financial security for anybody to offer it to them because they're priced out. senator coons of delaware and i have introduced legislation to end that by taking it out of the calculation for medical loss ratio. would you help us with that? >> i'd be very happy to look at that. i had not known of that concern before. >> we'll use some of our time tomorrow to do that. >> thank you. >> senator franken. >> thank you, mr. chairman. congratulations on your nomination. i'd like to ask you a few short yes or no questions, if that's okay. mr. azar, are you aware that the aca required health plans to cover evidence based preventive health services free of charge, right? >> yes. there's a provision in there -- i think it determines preventive services and those are part of the essential health benefits in the aca. >> are you aware that hhs commissioned the institute of medicine, an independent, nonpartisan organization of highly respected experts on health and medicine, to review what preventive services are necessary for women's health and well-being. on that basis, the institute of medical recommended coverage for all fda approved birth control methods free of charge. >> i believe that's the case, yes. >> do you agree with the institute of medicine's conclusion that access to free birth control is vital to women's health and well-being? >> senator, separate from the issue of any birth control or which ones should be covered, one of the principals we have around thinking about the access to insurance is that it ought to be insurance that the individual wants to acquire and the level of coverage they want. my concerns are actually at a much more precedent level, not about this coverage, this drug, that product, this one or the other, but rather should there be flexibility for the individual to choose the type of insurance package they want. no animus towards any particular type of preventive service. it's more that our system ought to enable flexibility in there that does not exist with the current framework. >> but you agree that the institute of medicine's conclusion to that free birth control is vital to women's health and well-being? >> i couldn't speak. i haven't studied the report. obviously we had hhs have important programs to provide family planning assistance and services? >> do you agree with the institute of medicine's conclusion that access to contraception free of charge reduces unintended pregnancy, which in turn reduces frequency of abortions? >> i haven't studied it. it seems to make some sense, as you state it. >> do you agree with the institute of medicine's conclusion -- this is their conclusion -- that reducing unintended pregnancy also reduces the health risks associated with such pregnancies and that contraception helps women to increase the length of time between births, which reduce -- >> in light of this, do you agree with the trump administration's action actions to undermine the access to birth control? >> so on that issue, that is a balance between the essential health benefit and the conscience of the organizations involved. as i mentioned earlier, i think it was close to only 200 organizations whereas the affordable care act actually excluded tens of millions of people in grandfathered plans. >> i just want to focus here on the science. the law requires that preventive services be evidence based. and this is evidence based. will you take steps as hhs secretary to make sure that women have free access to chron t -- contraception? >> i will follow the law there. but i also will, as the president has done, try to balance the conscience objections of organizations and individuals there. >> a number of my colleagues have expressed concerns regarding your track record and eli lily's track record on drug pricing. i just want to tell you i share their concerns, especially in regard to el li lily's actions spike insulin prices. i'm running out of time so i'm not going to be able to, but i wanted to get into medicare drug price negotiation. the president has said he is for medicare being able to negotiate in part d with the pharmaceutical companies on the price of drugs. do you agree with the president that medicare should negotiate for lower drug prices? >> the president has generally spoken about the desire to ensure that medicare is negotiating and getting the best deal possible for drugs. part d actually has a negotiation through the three or four biggest pharmacy benefit managers that negotiate and secure the best net prices of any players in the commercial system. i sat on the other side of that. what i'd like to do is think about how can we take the learnings from part d maybe into part b? part b is the program when a physician administers a drug, the government simply pays the sales price plus 6%. how could we think about ways to take the learnings from part d and actually bring lower costs to the system but also lower costs to the patient, because they pay a share of whatever medicare reimburses in part b. that's a double win. it could lower for the system and lower for the patient on their out-of-pocket. that's the kind of thing i would have energy to see where we could actually really save money and improve things for our patients. >> i'm out of time but i would just note that the va is able to negotiate for prices for their drugs and i think in medicare part d we should be able to do the same thing they do in the va. >> thank you, senator franken. senator roberts. >> thank you, mr. chairman. mr. azar, alex, thank you for coming. congratulations on your nomination and thank you for being here today. it's already been stress ed abot your prior work at the department of health and human services as well as the confidence in you shown by the senate. sometimes we have to do a multitask here. i apologize for that. but at any rate, the confidence shown by the senate to unanimously confirm you to positions at that agency twice already and highlight the strength of your qualifications. i appreciate the chance we had to chat. i think it was monday. some particular areas of interest for me, improving our care system. you are a hoosier but you did find a kansas girl to marry. as the folks in kansas know, there's nothing better than a south raider. i wanted to make sure that you understood that. thank you for bringing your family. as both a member of the health committee and chairman of the agriculture committee, particularly interested in hhs and more importantly the fda's work on food and nutrition policy. we talked about that. a common message i hear is the need for regulatory certainty. just a moment. i beg your pardon. will you turn that off? thank you. more importantly, fda's work on food and nutrition policy. a common message i hear is the need for regulatory certainty, in particular on the biotech front which is a critical tool for agriculture today. back in january, both fda and the usda proposed rules and guidance on biotechnology. recently, as a recent stake holder comments, the usda's animal plant and health inspection service has decided to withdraw the proposed rule, reengage stake holders and solicit comments to create a new rule. if confirmed, what steps would you take to engage and coordinate with other agencies involved with the regulatory review of biotech products to harmonize future rule making efforts? >> i'm not familiar on that particular rule making with the pull back, but i can assure you that i would share both goals that i think you've articulated. the first is it is the job of the government when regulating to give clarity. they want to comply, they want to know the rules of the road. the second is especially in the area of food safety the level of coordination between hha and the agriculture department is absolutely essential. >> i appreciate that very much. i just want to make one other observation, mr. chairman. i've been watching your children and these youngsters over here and i've been watching your dad. your dad is very proud of you and your wife is obviously very proud of you. i want to tell you young folks welcome to politics 101. we're asking questions that many members here have on their mind and they're very important questions. i want you to be proud of you dad. he's done a good job in the past. he will do a good job in the future. he will be confirmed in my view and not only by this committee and not only by the finance committee but also on the floor of the united states senate and then also by the president. that's a long process. sometimes it gets a little tough. we ought to be handing out selective earmuffs for young people. be proud of your father. he's a good man. >> thank you. senator roberts. senator whitehouse? >> i don't think there is much that you and i are going to accomplish today on the question of drug pricing, but i hope very much in office you will take the side of the american people and not just the pharmaceutical industry or worse yet the investors who have raided the pharmaceutical industry with the solo mission to jack up prices on necessary pharmaceuticals and extract money with monopoly authority. we know how to deal with that ordinarily. i want to talk about a different situation, which i think is an opportunity for considerable bipartisan progress. i want to start with two rhode island stories. you know what a medicare aco is. >> i do. >> we have two in rhode island. one is a very early one, coastal medical, which over four years has saved medicare $28 million relative to its benchmark while maintaining a 99% quality score. that makes it one of the best in the country. its average per member per year expenditure is going down, while the satisfaction and health of its members are going up. similarly, integra community care network has saved medicare $12 million while achieving a 95% quality score. i say this not just to brag on rhode island providers, but because i think it's the answer to a much larger question that we face which is -- here's the graph of health expenditures more or less in my lifetime for the country. 27 billion to 3.2 trillion. it's a curve that is breaking the bank. we have got to figure out how to fix it. one of the ways that we can look at fixing it is to look at this oecd chart which shows a lot of our competitor nations right here. there's the usa as a big outlier. this map's life expectancy puts us at the highest cost per capita for health care in the world and gives us life expectancy comparable to the czech republic and chile. we're actually beginning to see a little progress here. let me explain what this is. this top line, the red line, is what cbo predicted for federal health care expenditure back here when it made the prediction in 2010. then events moved forward post the affordable care act. sure enough, we were coming in below. here in 2017, the pace libaseli rewritten by cbo. the difference in this ten-year budget period between what cbo predicted in 2010 and 2017 amounts to $3.3 trillion in savings. so the case that i would make to you is that if we want to take on the health care cost problem, we've got to take it on through entities like these acos, because there is a sweet spot that we can bring that cost back from our outlier position in the united states while improving the quality of care. i've seen it happen in rhode island. the reason the cost is going down for coastal medical's patients is because they get home visits when they're sick because there's telemedicine that gets their testing results in because a nurse will call them when they don't hear with them. over and over again, it is better humane engagement that reaches the patient where they are that has this wonderful benefit of improving health and patient experience while also bringing costs down. we're not seeing less increase in the cost curve from integra and coastal medical. we are seeing cost per medical going down. promise me you will not get idealogical when it comes to solving this problem and you will work to solve it in a sensible, bipartisan, thoughtful way. >> i would just say amen. just hearing those stories is exciting to me. it is i think one of the great legacies of secretary burrwell's tenure was launching so many of the alternative payment models that we have out there. that was that third leg of my priorities if i am confirmed as secretary. i think for those of us who care so deeply about improving quality, reducing cost in our health care system, improving coordinati coordination. there's just so much opportunity for bipartisanship here because we share so much of the same goals on this. medicare can play such a role. it's the only payer that sits there with enough concentration of lives to change the system. >> correct. >> i think united health care -- i don't think there's a market that has more than a couple percent of patients and has to follow what medicare does. >> i'm going to invite you to come to rhode island and see these guys. >> i would love to. >> i look forward to that visit. thank you, chairman. >> senator casey? >> excuse me i made a mistake. senator murkowski is here. >> thank you, mr. chairman. >> i know i'm at the end of the dais and came in later but there is added benefit to being one of the later ones and having the full opportunity to not only hear most of your opening comments, sir, but to hear the questions and inquiries in your responses back. again, congratulations on your nominati nomination. i will also be curious to hear your response to senator paul's inquiry regarding importation of drugs. certainly for those of us in alaska where our neighboring country is canada. many in my state wonder why we are not able to do more when it comes to safely importing. i too am curious to know what you might propose in that area. senator baldwin mentioned the hearing we had some weeks ago about drug pricing. and i think a general level of just confusion and bemusement that many of us had, we're engaged in a fair amount of finger pointing. when you try to drill down to how we can do more from a transparency perspective, i think this is something that we all recognize that we can do a better job with. again, i look forward to more detailed response from you. we're going to have an opportunity to meet tomorrow. so i will probably hold more of my alaska specific questions for that time. one of the other discussions that we have had in this committee recently as we have been discussing the aca and some of the requirements within it. we had recommendations from some who have suggested that the navigator program currently in place no longer needs to be funded. the president really axed it not too many months ago and it was pointed out that not all parts of america are equally situated. we don't have a drugstore on every corner in alaska. in most of my communities we don't even have a drugstore. so the role that the navigators have played in helping walk many alaskans through the intricacies of insurance and what is available has been important to us. nobody's really asked that question here today so i would ask for your views, your plans. what do you see the role of navigators moving forward? how can you provide assurances in areas where we simply don't have the professionals that could assist individuals, that they know what their options are? >> thank you. it's good to see you again. i doubt there will be a secretarial nominee who has spent as much time in alaska as i have. >> i think you recognize there are some unique aspects and your focus on behavioral health with native peoples. >> absolutely. in terms of the navigator program and outreach, my few, as it is with so much of the programs, is do what works. i am not at the department, so i don't have the data. i haven't seen everything. my understanding about the changes in the navigator program were focused on navigator program elements that weren't working in renewing and funding navigators that were age to demonstrate results in doing the work. i don't know the specifics about the alaska situation. i can only tell you i do genuinely get it in understanding the uniqueness of the very frontier nature of so much of alaska. i'd be happy to work with you so see what are the ways we deal with that. it's really just what works. >> i think i said pharmacies. it's not only pharmacies. it's also those who help us navigate through the insurance side. very quickly, there's been a lot of focus also on women's health care, preventive care, eliminating the risk of unwanted pregnancies. i happen to believe the more we can make contraception fordable and available to women, the better off we are. i have long wondered why we are still these many, many, many decades after prescription birth control was made readily available, why we have been so reluck tant-- reluck about thct over the counter products for birth control. you also have the requirement for a medical appointment in order to get that prescription. do you see a way or an opportunity for us to reduce the barriers for more affordable birth control, pills, contraception and in a way that can really help women in gaining greater access to contraception? >> so the over the counter regulatory regime, as you know, is this otc monograph procedure that commissioner gottlieb, i achl very glad, h-- was out of '70s and need a lot of updating and work to really speed to approval of products over the counter for the course availability, cost to the system. of course there are scientific and legal standards that have to be met by the sponsors of a product in terms of the ability to self-diagnosis, self-treat. and there are user studies that basically need to be conducted. it would be driven by that, would be my view on any product that the fda would have to decide on. i think the regulatory system really needs a close look at on how we just generally think about over the counter and improving availability of otc products for people. >> i would encourage you. >> mr. azar, good to be with you. we had some opportunity to talk in my office yesterday. i'm grateful for that. gratd full for your willingness to put yourself forward again for this work. i want to thank you family and extended family for their commitment. as much as public officials work hard, their families often sacrifice more. yound i have a home state in common in terms of where we were born, not where we were raised. i know you're a johnstown native. i'm a scranton native. but i wanted to start with something fundamental. i wish we didn't have to start here but because of the interaction between dr. price and this committee i have to ask this question. when dr. price came before this committee prior to his confirmations, members of this committee submitted a number of questions to him to answer on the record in writing. he didn't provide a lot of responses. i'm going to be very precise in these questions. do you commit to finding answers to all the questions you received following appearances before this committee? >> i'll certainly be happy to comply with the senate's nomination procedures and the nomination setting. and then of course, ongoing appearance -- >> do you agree that answers questions for the record posed by committee members during the nomination process is part of that compliance? >> what i do not know is just what the protocols are between the health committee and the finance committees. i'd be happy the get back to you on that question. >> i'll take that as a tentative yes for now. i hope you familiarize yourself with those rules and respond accordingly. we should not have to engage in a back and forth on basic questions for the record. i wanted to ask you in light of the debate on health care, the substantial debate that undertaken over the last couple of months on the affordable care act and especially medicaid. in addition to that debate, some of the statements you've made that have been critical in one way or the other of the affordable care act and commenting on the process. now but're seeing appointment, a confirmation vote on hhs secretary. that, of course would confer on you responsibilities you don't currently have np in light of that and in light of the debate, just to be very cloer, do you commit to faithfully implementing the affordable care act. >> if i am confirmed as secretary, my job is to faithfully implicate whatever the congress has decided. my hope would be to implement it in ways -- if it remains, i obviously belief, the administration believes that statutory changes would be good. if it remains the law my goal is to have a way that leads to fordable insurance, choice of insurance, real access, not a meaning full insurance card. and insurance that has the benefits that people want. >> let me ask you about an issue that frankly doesn't get enough attention. it's the efforts that have been made by the administration to undermine the affordable care act. that's my view of it. i used the word sabotage. i think that's an appropriate description. let me define more specifically what i mean. when i say sabotage of the forgot, i mean the following. drastically cutting funding for advertising and out reach activities. number three, spending funds meant to promote enrollment on a pr campaign to instead undermine the law and support repeal of the aca. number four, spreading false health about the health of the marketplaces. number five, working to roll back health insurance protections in undermined coverage. that's the predicate for the question. would you oppose those efforts knowing you have a responsibility to faithfully implement the wall? >> i would disagree that there's any effort to sabotage the program. people want to make the program work. the csrs was a legal decision that congress had not appropriated the money. other elements -- i can speak for myself -- >> how about cutting funding on out reach and advertising, appropriate or inappropriate? >> the stizing c iadvertising c level of this program to the level of medicare part d. >> are you asserting that the advertising dollars are not cut? >> they were cut. they were cut to the annual that is close to -- >> we'll have more time to engage in these. thank you very much. >> senator kaine? >> good visiting with you yesterday. i have one question about each of your four goals, but before i do i'll tell you what i said to you yes. what i'm looking for from you is a commitment to the health care safety. i voted against your predecessor because he had commented negatively about planned parenthood, chip, medicare, medicalcare and the affordable care act. i don't think we can have an hhs secretary who doesn't support the safety net. that's what i'm looking for for you. you say drug prices are too high. as a member of the aging committee, i kind of became convinced that there's a new model out there that's patients as hostages, patient who is need drugs who can't afford to go without them without risk to their life or health are treated as hostages. according to the "washington post" analysis over the past two decades eli lily and nova raised prices on their insulins 450% above inflation. it convinced me that eli lily -- >> as i said in my remarks earlier today, the insulin prices are high and they're too high. the system that we've got, it may fit for the stake holders behind the scenes, but for the patient that you're talking about we've got to recognize it's not working. >> do individual actors in the system have no culpability? >> they're making the decisions, the choices are happening. i think everyone shares blame here. what we've got to do is i want to be a productive engine if i can be secretary to work with you on solutions to fix that for the patient. >> let me ask you about your second one. we must make health care for affordable and more tailored to what individuals want in need of their care. then you've got a system that's interesting. we must address those challenges for those who have been pushed out of the affordable care act. it's interesting that you talk about people pushed out of the market by the aca. of course you know that the uninsurance rate has dramatically reduced in the country. i'm not arguing that it's perfect. but if you just read your statement it suggests there are fewer people insured because of the aca. we had dr. adams in here recently from indiana. he said the uninsured rate in indiana has gone dramatically down because of the affordable care act, and the availability of premiums to help folks afford. in looking at this question, are you going to be part of the wrecking crew, i don't think that's an accurate or fair summary. >> i'm happy to explain. i believe we can do better. >> i do too. >> i believe both for the folks that are in the mid markets right now that too many of them are paying too much for insurance. >> was that your opinion before the affordable care act passed? >> i thought that was how it would happen, unfortunately. >> but the numbers of people uninsured in this country were dramatically higher than they are now. >> our goals are the same in the sense that we want to improve access to affordable insurances better. the president wants this. i want this. i think we may only differ about tactics and approaches. i worry about the forgotten who aren't in that individual market because it isn't affordable for them. >> third, we must harness the power of medical care. why didn't you mention medicaid? medicaid is a very important part of your portfolio. i found it interesting in read that sentence you didn't say a word about medical. >> the only reason i don't mention medicaid in that context, it's really that medicate does not have the same kind of payment rules at the national level. that was my focus. >> say i'm a governor and i ran a program. it's interesting. wouldn't you also agree that we can focus to paying for procedures and sickness, shift that focus to paying for health and outcomes. the medicaid program can be part of that as well. >> it certainly could. if governors are willing partners to try to drive that, medically the secretary has more leaves in his or her control to do that. >> would you try to do the same thing in medicaid? >> public school. if we can make medicaid better, it will let us solve that. >> i enjoyed our conversation. i was very open to your nation. i'm very concerned about your answer to senator casey's series of questions. i just want to state it to you one more time and give a second chance here. this administration has shortened the open enrollment period by half. it has cut outreach funding by 9d 90%. it is pulled out of state enrollment partnerships. is your testimony here today that this is all in service of an effort to make the aca better? do you really believe the goal of this administration is to help people sign up for the affordable care act? >> so obviously i'm not in the government. i don't have access to all the data. my understanding -- and i can't validate this from the outside was that choices were made about what's working and what's not working. the also a policy decision around advertising that it's time for it to be regularized in its amount of tunding in advertising. >> so you think president trump is taking these actions in the goal of making the affordable care act work better. >> i don't know that president trump was involved. those are probably decisions made at the hhs level or made as a matter of budgeting. i think the goal with the program you've got is is do as west you can. this one has a lot of problems. if the alexander murray bipartisan package here helps -- >> what does cutting the enrollment period in half do to help? >> i wasn't involved, nor did i study the comments on the role period change. the enrollment period went from 95 days to five days. let the plans know kwho's in their plans so they can plan predictably for the following year. you run right up to the end of the year there, it's harder for the plans to set their actuarial basis for the open enrollment period in the pricing. if you roll up that to the end there, the close you are you run up to january 1 on that one, it is very hard to implement effectually in the coming here. >> you put that next to an i vis ration of all the programs that would help people understand the fact that the enrollment period has been cut in half. >> i'm happy to look at that. i was not involved in that. >> so you said that there are things that the hhs secretary could be doing to make the open enrollment period work petter or to -- what do you think that you could do in the face of these changes to make open enrollment work better to make sure that people have the ability to choose wisely within the exchange? if you say these are changes that are made in the service of making the open enrollment period belter, what else do you think can be done? >> just to clarify, i don't believe i said these are changes to make it better but rather to eliminate what i think -- again, i'm on the outside. i'm not looking at data or running the programs. so i don't know the status of thinking on each individual element there. my point is if manage's nsometh working, we ought to look at it. if certain of these vendors are not delivering, why keep funding that. that would be my perspective in looking at it. and then using your resources to put it on whatever the most effect live outreach programs. i haven't been involved. i haven't been at hhs for the affordable care act initiation or implementation. >> let me follow up on some questions that senator warren was asking. i agree with her. experience in the private sector shouldn't be disqualifying. we want to make sure you are not bringing the history of who you used to work for into the government. legalization of director consumer advertising. i know you've been critical of specific practices of individual drug companies. is there any major issue on pharma's legislative advocacy list that you disagree with. >> senator, if i get this job, my enchance is to advance and protect the well-being of americans. i don't have pharma's policy agen agenda. i've been gone for a year that's not my area of focus. my area of focus is the president's agenda and how can i work with this congress to make the programs of hhs better in the interest of all americans. this is the most important job i will ever have in my lifetime and my commitment is to the american people, not to anywhere that i have worked in the past or any industry i've. connected with in the past. >> i think we have some senators who want to ask additional questions, so we'll have a second round. mr. say zazar, let me begin. senator cassidy asked, senator bhi white house would have. we can do something about this in the congress. most of what needs to be done, you'll have to do. it's a matter of administration. i had urged the previous administration to delay meeting because it was implementing it at a time when it was changing the way doctors and providers are paid. i think it would be wise to slow that down and get it right and build confidence among the physicians and other providers want what we are trying to do. i said that based on visits with hospitals like vanderbilt university where they said meaning full use was helpful. number two was okay and number three was terrifying. and i think -- so we ended up with six different hearings and a love of bipartisan interest in this. one thing that seemed to me to make some difference would be pretty simple. there was an ama study that showed that doctors believer they're spending 50 or 60% of their time on documentation. it seemed to me that a good approach for this would be -- if that's true or not, at least that's the perception. might be for the secretary to work for the doctors in medicare. and there are a half million of them say, okay, if you think you are spending that much time on documentation, either you're not doing your job right or we're not doing our job right. why don't we work together and set a goal to bring that from 50-60% down to some other goal over the next three or four years and change the reality and the perception over time. i would seem to me that some is essential because the inoperability is one problem, excessive documentation is another. it's a big mess still. even at a sophisticated hospital, and you want to take your own medical records to some other place, the best thing you can do is xerox them yourself, put them in your briefcase, carry them over and hand them to the next doctor. even in a sophisticated place, after we spent $30 billion or $35 billion. can you make it a priority, and you use some of this skillful managerial and executive experience background you have, to help us improve, a, interoperability, and b, reduce excessive physician documentation, both in reality and in perception. what are your thoughts on that? >> i think in both of those areas, that's a very sensible approach, mr. chairman. interoperability, again, it is ridiculous if we have a system now where you have to collect your paper records to go to a different facility. that is a betrayal of division secretary levittt laid out originally when we started down that journey and working towards, he would talk about the railway system and if you don't get a single gauge, it doesn't work. and how in australia, they never decided on a gauge. you have three different railway gauges to get around australia now. my brother-in-law can tell you about that. that's where he's from. we need to work on that and get that fixed. on the regulatory burden or just the burden on the electronic health records with physicians, that would be my style of how to work, the affected individuals, they know what's wrong, what's happening, and get the input from them to see if there are appropriate changes that can be made. >> might get your father to help you with that. >> he's probably got some ideas. >> secretary burr will actually change something in her administration with she believed the reality was different than the perception. it was the patient satisfaction survey that many of us were convinced was causing doctors and hospitals to prescribe more opioids in order to get a higher score on patient satisfaction. she was convinced that wasn't true. but it was true that people believed that. so she persuaded president obama to change the policy. i don't know exactly the amount of time that physicians are spending on documentation, but they're really fed up with it. and for a whole variety of reasons which you understand well, we need to change that. so i would think some simple initiative, working with physicians especially, and hospitals, to say let's, if it's 60% and the perception is 60%, let's agree on a goal. let's take it a step at a time, let's take it to 50%. if it's 40%, let's take it to 30%, and let's see what's being done about that. we can't do that well here. we can monitor it, encourage you, make some changes in the law, but basically, it's an administrative challenge, one you will hopefully take up and we'll let the senators here who are interested in that work with you in a way that would encourage that. senator murray, do you have additional questions? >> i do. thank you again. i am very concerned about some of the responses, particularly to senator casey and senator murphy, who talked to you about what many perceive as this president directly and his direction to the administration, hhs, has been to make sure that aca does not work. the reason that we very adamantly support that is because many people are now getting access to care through insurance that did not get it before. those are the harder to reach people, lower income, tougher populations. and they end up, we all pay for them at the end of the day if they're not covered by insurance. the goal is to have as many people as possible insured, have access, get their preventive care, and don't show up in emergency rooms, costing everybody else, taxpayers and other folks who own insurance. part of making sure, a critical part of making sure that they get access is through the outreach and through the longer enrollment. you answered a question about the open enrollment to make it in half, had to do with actuarials. the exact opposite is true. insurance companies put their prices out. they have already figured that out. the open enrollment doesn't change their prices or their actuarial costs. what it does is make sure we have time for the harder to reach people to get enrolled and that they know what they're doing, they often haven't bought insurance before or have different kinds of access problems that take time to reach them and to make sure they understand what they're buying. that is the intent of the longer enrollment, which this administration has cut in half and made it more difficult. the second thing is the outreach. and i was surprised to hear you answer senator casey by saying that insurance companies should pay for that outreach. they have a very different goal here. they're not looking for the tougher, sicker, harder to reach, more rural folks to sign up. they have a very different goal. as a country, as other people who pay for insurance see our premiums go up, we have that goal, and that's why it's so imperative, and in fact, in the murray/alexander bill, which you have been asked about, we reinstate that outreach money for that exact purpose. you will be hhs secretary if you're confirmed. you will be responsible for making sure that outreach money is used, used effectively, and the enrollment period works so that we reach that. do i hear you that that's not what you're going to do? >> senator, i share your commitment. any program hhs has, i want it to run as efficiently and effectively as possible and serve the beneficiaries of the program. that's my style, my commitment to you and how i would work. any particulars here, i'm not there, i have not studied the particulars of why the changes were made. i offered a hypothesis of what might have been the reason of the cutting in half of that to the 45 days, pricing before, and then implementation afterwards. i did see that with part d, when you bump up against january 1, just the insurance companies have time to get them insured, getting them cards and up and running. >> i have not seen that problem. >> i don't know, but senator, i want to be really clear. i want the programs to work for our people. i want to work with you if there are ideas to make them work, i want to make that happen. >> do you share the goal of making sure as many people as possible who may be sick or harder to reach in rural or communities that haven't been reached before should be part of what we're working for? >> of course i do. i want to make sure as many people have affordable insurance as possible. absolutely. >> who do you think is best equipped to do that? reach them? >> the question you had asked there around advertising, advertising budgets, that money, my understand is that the level of part d in medicare advantage, that's my understanding, is television. i don't think that's your rural outreach or hard to reach. that was just your television, is my understanding. i may be wrong. that was my understanding there. so not about trying to reach potential beneficiaries get people enrolled into the program. it may just be talking past each other on that issue or my misunderstanding the nature of that part of the program. >> okay. well, i'm confused by your answer. i will say that. i want to ask one more quick question. i know my colleagues do as well. and that is, will you advocate for women to be able to make their own health care decisions by supporting a broad safety net and insuring all women are able to see the willing, able, and qualified provider of their choice? >> so senator, the administration has, i believe you're asking a question about a particular provider that would be at issue. the administration has a perspective about whether that should be funded or not. that is a legislative choice. if i am secretary, i will implement what congress has passed and whatever congress has passed and the laws that we have there faithfully. >> i'm out of time, but that does concern me. i will turn it over to my colleagues. >> thank you, senator murray. senator franken. >> thank you. mr. azar, on monday, the "l.a. times" published an analysis of the senate republican tax plan. which repeals the individual mandate or the federal requirement that americans have health insurance coverage. the analysis shows that repealing this provision, quote, threatens to derail insurance markets and conservative rural swaths of the country. and could leave consumers in these regions including most of all -- sorry, most or all of alaska, iowa, missouri, nebraska, nevada, and wyoming, as well as parts of many other states, with either no options for coverage or health plans that are prohibitively expensive. mr. azar, in your opening statement, you said that you want to make health care more affordable and available to individuals. given this new data, do you support repealing the individual mandate as part of the republican tax plan? knowing that it puts rural americans' coverage in jeopardy? >> so senator franken, what i do not support is forcing 6.7 million americans to pay $3 billion of penalties to not buy something they don't want to buy through a mandate upon them. and 90% of whom make $75,000 a year or less. that i do not support. >> well, i think you understand the structure of the aca, which is that you guarantee that you aren't discriminated against for having pre-existing conditions. and then if you're not discriminated against because you have pre-existing conditions, then the motive for someone to get care, to get insurance, buy insurance, we have to mandate it. this is my understanding of the logic behind this. that to mandate it, people don't wait until they get sick to get insurance. and that just is the way -- and then you give subsidies to people who don't have the means to buy it. that's sort of the three-legged stool of this. if the individual mandate is repealed, the congressional budget office estimates that 13 million more people will be uninsured, and that premiums will go up by 10%. the alexander/murray deal, which i worked on those negotiations and thank the chairman and the ranking member for that, those are helpful. it's helpful, but it's a temporary measure that cannot offset these estimated price increases or coverage losses. and given this and given that people living in rural areas tend to be older and have greater health care needs than the average populations, what specifically will you do to make sure that people living in rural areas are not hurt by all these current efforts by the trump administration to undermine the affordable care act? >> so as you articulated, i think you articulated well the theory of the mandate was a mechanism to pool insurance risk to create an insurable risk pool for the insurance companies to do their actuarial business. that was the theory. the challenge was human behavior decided otherwise. 28 million people are not in that pool. and it eroded the risk pool there. what i would love to work with you and congress on is coming up with systems that create effective -- >> the fact of the matter is -- >> so your rural citizens can actually have affordable care that gives them access, gives them choice, real choice. half of our counties have one plan available to them. >> right, and the fact -- >> i worry about that. >> fact of the matter is under the aca, over 20 million people who weren't insured have insurance. and it feels to me that everything that this administration has been doing is basically aimed at undermining the markets and undermining the way the aca and undermining so that we can throw away these gains, but everything that is getting rid of the individual manda mandate, putting out plans, temporary plans, short-term plans that will not cover the basic, you know, the ten basic health guarantees, it just seems that this is a conscious effort to undermine the health of americans. and it just -- i think that as we go forward, we have to find ways to make sure that people aren't discriminated against because they have pre-existing conditions and that we have large -- the largest pools possible and we spread the risk, and we make sure that people have, as many people have health care, and if you repeal this, 13 million more people will be uninsured, and premiums will rise. >> senator, i think we share so many of the same goals and just disagree about the approaches and tactics to get there. my heart and my goal is to share so much of what you're talking about in terms of affordable care for people. >> thank you. >> thank you. >> thank you, senator franken. we'll continue with our second round of questioning. we'll conclude the hearing after the second round. i think there may be at least one other senator who wants to come back, so we'll go next to senator warren. >> thank you, mr. chairman. i share the concerns that have been raised by a number of my colleagues that this administration has spent the first 11 months of this year trying every trick in the book to destroy health insurance system in this country. and mr. azar, you're being considered now for the top job to oversee key parts of the affordable care act and medicaid. so i want to start by asking about a basic principle. mr. azar, would you agree that it's important that we have a system that allows for every single american to have access to the kind of coverage they need? >> i think we all share the goal that we want all americans to have access to affordable insurance that they desire. >> so is that a yes? >> as i framed it, yes. >> okay. good. here's the problem. those are the exact words that dr. price used during his confirmation hearing before this committee. he sat exactly where you're sitting right now and said exactly that. he pretended that he cared about people being able to get their health care coverage. and then he got confirmed, and spent eight months doing everything he could to take away people's health care coverage and crash the health care system. so i think that's the reason we're trying to be very specific about what it is you will and won't do. so i want to follow up on senator murphy and senator murray's questions. they asked about shortening the time period for the enrollment, and you said you wanted to be very data driven about that. and you thought maybe there was a data reason for doing that. that is that it was ineffective and somehow it hadn't worked. so let me ask the question this way. mr. azar, if you're confirmed as hhs secretary, and there are no data showing that cutting the enrollment period improves enrollment, will you commit to going back to a three-month-long period for health insurance enrollment? >> my view would be that if the enrollment period does not make sense and work for the efficacy of the program, for the insurers who have to work in it and for beneficiaries, i would be open to changing it back if confirmed as secretary. i'm not in the government, i can't commit to government action not having seen anything there. >> that's the question i'm asking. you have used data as an excuse. you said i care about the facts, i want to be data driven. you had a good exchange with senator alexander about the importance of data. i agree with that, so i'm just asking. if there are no data to support your hypothesis that cutting the time period somehow might improve enrollment, will you commit to going back to the three-month enrollment period? >> i would need to look at the data. if the data drives in that direction, then i'm going to push to insure that the program is effective and if a longer period is needed -- i don't know what kaurnt balancing factors there might be. i'm not in the inside to know. >> so it's not all about data for you. >> there's data, but i don't know the other elements. >> i'll take that as a no. let me ask another question. when secretary price was in office, he supported republican bills to repeal major portions of the affordable care act. if confirmed as secretary, will you oppose such bills? >> senator, i and this administration support legislation, various forms of legislation that would have a system that leads to more affordable insurance, more choice, and more access. there's not support of getting rid of -- >> i asked a very specific question. because i'm trying to get this. this is what price said when he was in here. so i'm trying to get a very specific question. would you publicly oppose republican bills to repeal the aca like the ones we have seen so far this year? are you saying we should just wait and see what you'll do? >> i would work with this congress and within the administration to build a system that helps people get affordable insurance. you and i will differ fundamentally, senator, i guarantee you, on what the contours of the system to do that will lead to. >> you will not oppose the bills we have heard so far? all right, let me ask another one. what about turning medicaid into a block grant? secretary price pushed that idea while he was in office. would you do the same? >> i have actually said before that i think looking at block granting and empowering states to be fiscal stewards there can be effective, can be an effective approach. the contours of that, the amount of funding, the size, what the baseline -- >> you support block granting? >> i support it as a concept to look at. one needs to look at block granting as an abstract. the question is instead, what is the precise program, but the notion of a state being empowered to run a program and having all of the the sentives to run an effective program. >> you could own up to the fact that you want to cut medicaid and gut the affordable care act, like every other member of the trump administration, but you want to smile and pretend otherwise until you get the job, and yet you say exactly the same things that would let you pick up right where tom price left off in trying to gut the affordable care act. tom price lied through his confirmation hearing. and now you come in here and say the same things he said. no one should be fooled. >> thank you, senator warren. senator hassan. >> thank you, mr. chair. i wanted to pick up where we left off on the question about the case of jane doe, the young woman i asked you about. at the end of that question, you said that, yes, you agree that you have an obligation to follow the constitution and all of the laws of the united states, even if you don't personally agree with that. is that correct? >> that is correct, yes. >> and i'm glad to hear that. as you know, under the supreme court decisions in roe v. wade, women have a constitutional right to make their own reproductive health care decisions. so yes or no, will you commit to upholding those constitutional rights as well? >> i would -- i would always work to insure implementation of the constitution and laws as currently interpreted by the courts, yes. >> thank you. i'm glad to hear that. now, i want to return to the issue of essential benefits for a second. you have said you would make the opioid addiction crisis a priority if you're confirmed. i appreciate that, but we need a lot more than lip service to make a dent in this epidemic. one of the key tools to combat this crisis is the set of ten essential health benefits ined the aca, requiring that insurance cover -- insurance cover substance use disorders. in october, cms proposed their benefit and payment parameters which if finalized could let states erode the benefits, including the substance use disorder benefits. if states develop their own benchmark, the rule would set the ceiling on the generosity of benefits states could include in their plan. before the aca was passed, more than a third of plans on the individual market did not provide coverage for substance use disorders. i am concerned under the rule proposed now, states would decide to limit this critically important benefit. given your stated commitment to addressing the opioid epidemic, yes or no, will you commit to rejecting the harmful changes to the essential health benefits in the proposed rules? >> i believe that states are most effective in determining, they are most effective in determining the benefit packages for their citizens and the circumstances you described earlier, even with new hampshire, the unique circumstances of each state. >> the problem, of course, is when they do that, the insurance companies come in and charge much more for that benefit. and that's one of the advantages that the central health benefits. nobody in my state plans to get an ilthesis that their insurance doesn't cover. nobody plans to become addicted to prescription drugs after surgery, let's say. and then, you know, says oh, too bad i didn't buy insurance coverage for that treatment. and the advantage of the essential health benefits is millions and millions of people not only got coverage through the aca, but they got coverage that actually addressed their needs. as governor, and before when i was in the state senate, it was often the case that insurance companies kept dropping coverage for things they couldn't make money on. and eventually, the public picks up that cost. so i would ask you to look at that issue very, very closely because the essential health benefits under the aca have been critical to fighting the epidemic in our state. last topic i wanted to touch on with you, and you have heard a lot about it. it's about drug pricing. and some of it is about your past employment as president of the u.s. part of eli lilly. i want to read a quote of yours in "the new york times" article because there's a reason that people are skeptical about your commitment to lowering drug prices. this is what you're quoted as saying in the niemgz. all players, wholesalers like mckesson and cardinal, farmallies like cvs and walgreens, and drug companies make more money when list prices increase. the unfortunate victims of these trends are patients. so basically, in that quote, you're admitting that high list prices are hurting consumers and creating profits for drug companies. but yet you continue and you did this just last spring, to push the blame, here you have said it's everybody, everybody's got a part to play. but last may at a conference, you pushed the blame on everyone but pharmaceutical companies for high list prices, even saying setting list prices is something that even though setting list prices is something that manufacturers directly control. you have also blamed insurance plan designs for high drug prices, but it's really the list price set by manufacturers that is driving the increases in what consumers are paying because requiring lower cost sharing for drugs will lead to increased premiums. again, all at the expense of consumers. so i want to ask now that you will be taking off your pharmaceutical company hat and will be responsible for advocating for consumers, do you think it's time that the federal government take action to limit the profit drug companies can make off of setting high list prices? much the way we limit insurers right now with loss ratio. >> so in my earlier remarks, i certainly did not mean to be suggesting that list price was irrelevant or that pharma isn't have a piece of this also. the challenge is as we think about the burden on the patient when they walk into that pharmacy, if the list price is $500 and they have to bear that $500, or if the list price is $250 and they have to bear that $250 under a high deductible plan, both of those can be unaffordable for that patient. so my point is, and where i want to work -- >> i'm way over. >> we're running out of time. >> my point is, without some action by us, it will just be passed on in the insurance premium, which will also become unaffordable. thank you, and thank you, mr. chair wherein. >> thank you, senator hassan. senator baldwin. >> thank you. i too want to continue along the same lines that senator hassan was asking you about, and also what we were talking about in round one of questioning. and you mentioned your example at $500 a month. i told you a story earlier about greg from stoddard, wisconsin, mentioned diane who lives in western wisconsin, has ms, has taken a medication for over 23 years. to slow the progression of her ms. and when she became medicare eligible and therefore the way in which the family was insured and paying for medication, she and her husband had a heartbreaking discussion at the beginning of this year whereby she and he decided that she would stop taking the medication. it had reached $90,000 a year. no change as far as i know in the ingredients, the manufacturing process, or anything else. it just had crept up, crept up, crept up over all of that time. so i want to return to this issue of transparency. we talked a little bit about this when we met yesterday. i have offered along with my colleague senator john mccain the fair drug pricing act which would require basic transparency from drug corporations. again, understanding that it's a complex system, but that the list price setting starts with the drug corporations. it would require disclosure to the department of hhs on elements like executive pay, investment in research and development, investment in marketing, stock buybacks. et cetera. as a way to inform policymakers so we can take better and stronger approaches to this crisis in many respects. what are your views on requiring drug companies to make basic information public when they are intending to increase the list price of existing drugs? >> even as i referred to in my opening remarks, i generally am in favor of increased transparency within our health care system. i think it generally is a good thing. we always need to look to see if there might be any counterproductive aspects to transparency, as you and i discussed in your office. we always have to be careful there, but as a general matter, i think transparency can be good and useful, and where would be happy to study that more and work with you as part of all the options that need to be on the table to think about this, to see does it help with reducing what a patient pays out of pocket, does it help with reducing list prices, does it help with reducing what the system ends up paying. i'm very open to looking at all of these kinds of options with you. >> one note that i want to make. oftentimes the difference between pharmaceutical product prices in the u.s. and overseas has pointed back to the investment in research and development. but in recent years, the investment, if you can call it that, in stock buybacks and dividend payouts has surpassed that of r & d. is that a troubling trend in your opinion? >> i don't know. i don't study the financials of the companies on buybacks, for instance, but i certainly believe that one of the bedrocks of the r & d based pharmaceutical industry is that kind of heavy investment. i think where i was employed, it was upwards of 20% to 25% of revenue was invested in r & d. a large percentage of that here in the united states. as we talked a bit earlier at the hearing, in reference to some of those entities that simply buy a product and increase the price, i am very supportive of that type of intensive r & d work. if i'm in that role, i'll have nih, which plays such a role in the basic foundational science there and is a partner in all of that work. i don't know the particulars of that issue. i haven't connected those two things. >> it's quite striking in an academic report earlier this year, in aggregate, i think, over half a trillion dollars invested in stock buybacks and less than that now in r & d. it's certainly not specific to the pharmaceutical industry, but very pronounced in the pharmaceutical industry. the last point i would make is just to note for the record that i actually agree with president trump regarding his emphasis on authorizing the secretary of hhs to negotiate directly with pharmaceutical companies for lower drug prices and medicare. and hope that is something you will embrace if confirmed. >> thank you. >> thank you, senator baldwin. senator whitehouse. >> thank you, chairman. mr. azar, we talked in our last conversation about care organizations and the ways we can deliver better care at less expense. there's another much more particular area where i think there's another bipartisan opportunity to improve care. in this case, it probably would lower expense, but that wouldn't be the point. that area is end of life care. advanced care. there's a very good group that you may be familiar with called the coalition of transformed care which has very, very broad corporate institutional support that is focusing in these areas. rhode island has been very active in this space. we have enormous support from -- we're the most catholic state in the country, the catholic diocese has been very helpful. the state council of church has been helpful, our major hospital groups and medical society have all been extremely helpful. and what we see is that from time to time, we bump up against problems within the medicare and medicaid billing system, which in a general arbitrary world might make some sense, but once a state or a community has decided that it's going to undertake a path to deal more humanely with people near the end of their lives, suddenly, those prescriptions become obstacles. and i think do more harm than good to the patient and probably to the public as well. here's my -- here's some examples we're trying to fix. medicare and medicaid patients aren't supposed to receive both hospice care and curative care at the same time. if you're seriously focusing on the care of an end of life patient, that's a completely stupid distinction, to force into that situation. nurse practitioners have way too small a role, and their role could be increased. the whole two-night three-day inpatient stay rule before somebody can be moved into a nursing home is nonsensical in the context of somebody who is operating under a good end of life care based or hospice plan. home health services ought to be provided without having to meet the full regulatory definition of being homebound. very often, a dying patient can still move around for a while and is not fully homebound, but it would be cheaper for the system, better for the family, easier for the loved ones who are providing care, to get home health services. so that rule, again, backfires. finally, caregivers often need respite. respite care is a very valuable thing because without that, you wear out the caregiver and now the system has to come in at a vast expense and pick up with potentially inpatient treatment. home-based respite care, where you don't have to put your family member into an inpatient place while you get your couple of days of respite, would seem to make a ton of sense. none of those things are being done. and the result is that this very precious time of life towards the end, states that want to make it better, that want to make sure that the wishes of the patient are honored and that it's clear around the family what those wishes are so there aren't horrible fights at the end of life, all of those things can be made so much better, and here is the government with all of these rules that may make sense, again, in isolation, but once you start to deal with end of life care in any kind of a comprehensive and humane fashion, they begin backfiring in your face. will you work with us, particularly with rhode island, to try to support models. we don't need to get rid of them entirely, but what we really want to do is support waivers so when a state or community steps forward with a really good, humane, i'm saying this sitting next to senator baldwin, whose state is legendary for end of life care planning, by the way, so i should give wisconsin some props here as well. would you help us with that? >> so senator, i just want to thank you for those very thoughtful comments and reflections. you know, as i mentioned in my opening remarks, my stepmother wilma died just in july. it was a blessing that she was able to be in her house, in her bed, throughout the whole time. >> yeah. >> and i want to make sure people have that chance. and so, you know, happy to work with you. >> i think what we will find is that it actually helps the public fisk as well. but to be perfectly blunt, i don't actually care if we have to spend a little bit more money so the people at that very fe tender time of their life and the people who are surrounding them at that time in their life aren't treated disrespectfully and aren't pushed to make dumb decision s based on bureaucrati rules that don't make sense at that time, so god bless you and thank you. >> thank you, senator whitehouse. senator murray, do you have any closing remarks or questions? >> again, mr. azar, thank you so much for you and your family patiently sitting through this. i do have some additional questions and i would just ask that we do get timely and sufficient answers to our questions. we have had that problem before under secretary price, and on full confirmation and after your confirmation, i respectfully ask we get timely answers so we can do our jobs as well. i did want to put one issue on the table that we didn't have time to address. that is hhs plans for implementing the preschool development grants program. we authorized that in our every student succeeds act. it's something i'm very concerned about and i'm going to be watching very closely to make sure that really vital program is implemented the way congress intended so it helps us expand access to high quality early learning and care for our most vulnerable children. i will follow up with you, but know that i will be following that very closely. so again, thank you for being here. i know you've got another hearing to go through, numerous questions. we'll be looking at all of those. if you're confirmed, i want you to know that we will talk to you, work with you, and hope that you will be as responsive as we need you to be. >> thank you, senator murray. mr. azar, thank you for your -- for being here, for your willingness to serve. for answering the questions. i do hope you will respond to the senators' questions and we don't have any limit on the number of those questions, but i hope there will be a reasonable number of questions. about a third of the members of this committee are also members of the finance committee, which is the committee which will vote on your confirmation and report it to the floor of the senate. i think you have seen today the diverse points of view on this committee, and some people wonder how we could ever get anything done, but the fact of the matter is we get quite a bit done. a couple years ago, we fixed no child left behind in a way that president obama called it a christmas miracle. last year was the 21st century cures legislation that the majority of the leaders said was the most important legislation of the year. you'll have a chance to implement that legislation as well as the mental health reorganization that was a part of it. this year, we worked, senator murray and i worked to try to see if we could find some area of agreement, even though it's for short-term on the affordable care act, which still, which we were able to do. it's not law yet, but we were at least able to take a step. so there are a number of areas, and you have heard many of them today. senator whitehouse suggested two major areas of bipartisan cooperation. we talked about electronic health care records. i think you'll find most of us would like to create an environment in which you're able to succeed and we'll not be shy about giving you our points of view, as you are able to tell today. i hope also that we can talk about more and work with you on more than the individual insurance issue. for the last seems like forever, we have focused on health insurance and only 6% of the americans who buy health insurance on the individual market, they're every single one important, but we year after year give ourselves, like going to college and taking only one course and earning a c or d or f on it every semester. we don't seem to be making very much progress. and the important thing about it is there's so much other important that we should be working on when we talk about health and health care and the agencies you work on. drug pricing is one this committee has a great interest in. i, for one, am excited about the fact that you know something about this. health insurance is complex. i think drug pricing is byzantine. and i think if we had a secretary who was new to the subject, that he or she would leave after two or four or eight years without having accomplished much of anything because it would take that long to understand what's going on. you arrive knowing the subject and helping us answer to question of where does the money go, do we really need rebates? can there be more negotiations? on drug pricing. should we really think seriously about finding a way to let americans buy drugs in the united states that are not approved by the food and drug administration? we haven't ever done that before. and several senators think we should. and we'll need to talk about that. we should be talking about wellness. we have had two or three hearings on that, that offers great promise for reducing health care costs. electronic health care records we talked about. biomedical research. we hear a lot about the president's budget proposals. we hear less about the fact that senator murray and senator blunt for two years, hopefully for three, have increased funding for national institutes of health at $2 billion a year, and we added another $4.8 billion in the 21st century cures. we're putting big new dollars into the national institutes of health as well as big new authority into nih and the fda, all of which you will have a chance to take advantage of and to make something of. i think it's a very exciting time for someone with your experience and background and energy to come to this position. i think you could help families all over america, and i hope if you're confirmed, which i'm confident you will be, that you will look to this committee, both the democrats as well as the republicans, as a resource to create an opportunity in which you can succeed. i ask consent to introduce four letters of support for alex azar into the record, which will be done. if senators wish to ask additional questions of nominee, questions for the record are due by 5:00 p.m. this friday. december 1. for all other matters the hearing record will remain open for ten days. members may submit additional information for the record within that time. the next meeting of the health committee will be a hearing tomorrow. november 30, 10:00 a.m., hear from experts on the opioid crisis. thank you for being here. the committee will stand adjourned. later today, officials from the national institutes of health and other medical professionals will testify before a house subcommittee about what the u.s. government has done about global alzheimer's research and treatment. that will be live at 2:00 p.m. eastern. also, you can watch it online at c-span.org or listen with the free c-span radio app. >> the hill is writing today, texas senator john cornyn dismissed reports today that democrats are being shut out of the republicans' discussions on tax reform, telling chris cuomo in an interview that democrats are welcome at the table if their amendments can find bipartisan support. quote, that's just not true. sherrod brown is on the senate finance committee with me, and last thursday night, we had an amendment process. he didn't win a lot of his amendments, but when you're in the minority, that happens. senator cornyn said. that's not when you take your ball and go home, which is essentially what they did. you can read more at the hill.com. join us on c-span3 this weekend for american history tv. here are a few highlights. saturday at 3:00 p.m. eastern in honor of the 50th anniversary of the 1967 public broadcasting act, the library of congress discusses news programming with jim lehrer and dick cavett. and at 8:00 p.m. eastern on lectures in history, university of kansas professor randall gel on the role of african-american ministers in politics and how churches help members gain experience with organizing and running for political office. sunday at 8:00 a.m. eastern, recollections of the battle of midway from four world war ii navy veterans who took part in the battle, and sunday at 4:00 p.m. eastern on reel america, the film dreams of equality featuring recreation of the 1948 women's rights convention. american history tv, all weekend, every weekend. only on c-span3. >> in the washington examiner has this. the house will pass a resolution later today that will require lawmakers to undergo sexual harassment training, making the first move in congress to deal with a wave of sexual misconduct allegations that started in hollywood but quickly found its way to washington. the resolution from virginiaroomen barbara comstock would require all house lawmakers, officers, and staff to under go an antiharassment and antidiscrimination training program inn each session of congress. it's expected to pass easily. here's more. >> explain why they're taking this vote today and what would happen in congressional offices if it does pass.h, >> well, this follows a move by the senate earlier this month, john, to require training for all members and staff about how to prevent and avoid harassment and discrimination in the workplace. the reason they're taking this step t is, i'm sure viewers and listeners know the constant stream of high-profile harassment and some cases assault allegations against media figures. today, matt lauer. previously, charlie rose, and f course, senator al franken and congressman john conyers. thisg is what some lawmakers insist will be a first step in trying to change the culture on capitol hill. >> remind us what happens in the senate when it comes to this issue and why the house and senate are on two different tracks here.s >> right, wellom the house and senate oftentimes, it's tough to tell from the outside, but they own rules.enheir they have two separate committees that determinena this like payments and employment policies and the senate has calleded the rules committee an it's called the administration committee. the senate acted fast because pretty much inentire rules committee got together and said let's just pass a resolution saying we're going to institute mandatory training. the house, it's a bigger chamber. they decided to have a hearing which happened a couple weeks ago. and at this hearing, there were some arexplosive details shared. congresswoman jackie speiers said she knew of two sitting members of the house who had engaged in , sexual harassing conduct. so it caused quite the furor, and that really is what teed up today's vote. >> and is there any chance this vote will fail today with that two different members on today, congressman tom cole, earl blummenwe hower said they both expect it to pass, they'll be voting for coit? >> they expect it to pass very easily. the real question is whether congress can and will go furthe and do more. >> what would more constitute? what else are members like jackie speier and others who have pushed the effort looking for? >> they're looking for a wholesale remodeling of the way capitol hill's quote/unquote office of compliance, the official name of the work misconduct cops, a wholesale reform of the way they handle complaints. right now,o any aide or member who undergoes harassment is required to sign on for counseling and remediation and required to sign confidentiality pacts in a lot of cases deterthem from speaking about their experience. that.want to changen >> how close is that legislation to getting a vote or any sort of movement? >> well, we hear there will be another hearingng in the house administration committee in the coming weeks. this time, on the secret settlement fund that is used to pay claims related to not just sexual harassment, but workplace safety, pay disputes, discrimination, and this is all a part of the case that the bill sponsors are making to pass it. however, as we all know in washington, the news cycle moves fast. it's really tough to say whether this momentum can be sustained. >> lastly, before you go, if this bill does pass today as we expect it will, when does this new training kick in for congressional offices? and what would that training look like? what do you know about it. >> well, there will be options to get training. the popular option is an online video provided by the office of complianc compliance, butli that office ds in-person training and it's also possible to get trained by the employment counsel's office, the lawyers who work on behalf of members' interests. as far as requirements, it would give them time to comply. in some cases we might not see 100% training until early next year, but the turnaround time is pretty fast. >> appreciate your time. talk to you again down the road. >> thank you. labor secretary alexander acosta testified before a house committee. members are asked about overtime rules, training, and apprenticeship programs, collective bargaining rights, retirement savings programs and other employment benefits. the committeen

Related Keywords

New York , United States , Australia , Nevada , New Hampshire , Missouri , Texas , Alaska , Washington , Delaware , Rhode Island , Indiana , Ellis Island , Nunavut , Canada , Manhattan , Wisconsin , Mexico , Nebraska , Wyoming , Iowa , Chile , Kansas , Ohio , Hampshire , Americans , America , American , Matt Lauer , Antonin Scalia , Alex Azar , Alexander Murray , Dick Cavett , Jane Doe , Roe V Wade , Sherrod Brown , Eli Lilly , Al Franken , El Li , Sheldon Whitehouse , John Conyers , Tom Cole ,