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tv   White House Domestic Policy Council Director Joe Grogan Discusses Health...  CSPAN  December 2, 2019 5:40pm-6:58pm EST

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overthrowing people's in central america and replacing them with right wing dictators and then causing the migrant crisis. >> voices from the road on c-span. next white house domestic policy counsel director joe grogan speaks to reporters about domestic policy decision-making at the white house. specifically he addressed health care policy including vaping, the affordable care act and drug price prices. >> good morning, everyone. i'm the director of policy and programs at the alliance for health policy and i have the pleasure of welcoming you all on behalf of the alliance to our breakfast series for reporters. for those of you that are not
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familiar with the alliance, we are a nonpartisan organization that is dedicated to convening and educating the health policy community through a balanced exchange of evidence. we are so thankful to bill pierce for supporting the alliance and putting on this series and with that support we have had the privilege of hosting many esteemed guests and panel discussions over the past couple of years including joseph grogan who i'm honored to welcome back today. i believe you have the distinction of being our first repeat guest. he joined us about a year ago when he was an associate director at omb and so we look forward to hearing about your new role and health care priorities as the director of the domestic policy council. thank you for being here again, mr. grogan. thank you to all of you for being here and with that i will turn it over to bill to get us started. >> thank you, kathryn. welcome everybody, welcome on behalf of apco where with along with the alliance we think these are important events to hold.
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the breakfast is an important thing to hold since we believe strongly a well-informed press is extremely important to the washington, d.c. world and that a dialogue like this is extremely important. so we really appreciate, joe, you being willing to come in here and subject yourself to the questioning of this group of folks. so i'm senior director here at apco worldwide. joe and i have known each other for quite some time, worked in the bush administration together and as kathryn noteds this is his second go round, the first time must have been okay, then, i guess. with he appreciate you coming here today. joe has had a distinguished career in the private sector and public service and so we are welcomed -- welcoming you back again. the only admonition i would make is when we turn it over to question and answers that you state your name and what outlet you are for. we're live on c-span 2 so welcome c-span 2 viewers. so it's mostly for their benefit, too, so they know who
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is asking the questions and where you're from, that would be greatly appreciated. so with that i would like to turn it over to he joe. take it away. >> thanks for having me back and it's good to see some of you reporters again and for those of you who i don't know i like forward to the opportunity to be asked a few questions and share with you our views on health care in the trump administration, some of the function -- some of the way the domestic policy council functions and tell you a little bit maybe about some of the other issues that we are confronting as well. so just to start with how the domestic policy functions and what it is that we do on a daily basis, other administrations perhaps have had a more linear or defined area of responsibility for senior white house officials. this administration, this president, has a very entrepreneurial style, consistent with the way he's lived his life and he expects
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his senior leaders to pursue issues in an entrepreneurial manner. it requires us all to work in a very horizontal collaborative fashion. a lot of times there are stories in the d.c. media about how there's tension in this white house or tension among senior leaders. first of all, tension is not a bad thing, but to the extent that there are overblown factions or any of these things being reported on, it is wildly overblown. the senior leadership in this administration gets along extremely well. i spend a lot of time walking the halls visiting senior leaders' offices, getting alignment on issues before we go into the oval office. we have robust and open discussions in front of the president. i can tell you this week we had a meeting with the president and we had, i think, 14 people in there to brief him on an issue for which he had to make a
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decision. we couldn't find a senior leader of the team who disagreed so we went and found somebody else who could take the counter side so that the president would get the benefit of understanding a different side of the view. ultimately he made a decision. he works well when he watches people debate both sides of an issue and then he is able to make a decision. i love working in this white house, i think it's a lot of fun. i like the senior leadership team. that doesn't mean we agree on everything, but that's fine. what i found is a team of people that respect each other and work well together and has the best interests of the president and the american people first and foremo foremost. beyond that i'd say my philosophy at the domestic policy council is there are certainly some issues of which we are lead. health care is one and i think that's what we're going to talk about for the most today. we are lead on other issues as
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well, labor issues, for instance, but where we aren't lead we want to support. so we want to be as helpful as possible to advance a policy agenda, for instance, larry kudlow at the national economic council would be lead for tax policy. if there is something that crosses over into the domestic policy lane, say, health care, for instance, big achievement of this administration in tax policy and health care policy is the repeal of the individual mandate, we would help on that. we would help make the argument to the president, look, this is something that should be repealed, it makes no sense, it's onerous, it's at odds with our values. there are a whole host of other issues for which i may not be lead on the issue but i will go into the oval office with another principal and say, look, this is in my opinion what we should do, it comports with what the other principal wants to do or here is another take on it. so we lead when we -- when we
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have the baton and we support when somebody else does and it's all to move the ball forward for the president and the american people. now, one thing i think that people sometimes in this town struggle with because mr. trump is so different than the traditional politician is to say, well, what type of approach is he taking on this? he's very nonideological. he did not come in with 50 years of campaign donations from particular vested interests and a defined philosophy except for this, he likes to solve problems and he will ask a gazillion questions to figure out the right answer to something and he's not necessarily interested in somebody's opinion just because of their title or status, he wants to know from experts. i have watched him look over cabinet officials and ask a question of a 20-year-old or a
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30-year-old staffer sitting on the couch in the oval office and ask their opinion about an issue because he wants to know a variety of opinions and he really wants to know the opinion of people who are expert on any given subject. he has told the story about being on the u.s.s. jerry ford and asking the maintenance crew whether their preference was for the magnetic launches for the aircraft on the aircraft carrier or the old steam launches and they said steam and he said why, then said because when they break we can fix it. then they went into a description of how long it takes to load a plane into position and why the steam made more sense and i can submit to you i can't think of a president in my lifetime that would go over and ask the guys to go the actual work each and every day what their opinion is. now, that decision of the president to prefer steam i'm sure would anger a lot of defense contractors, it would
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anger a lot of procurement officers, it would anger a lot of project officers who were behind that, but this is a president who doesn't really care, doesn't really care about offending special interests or people based upon title. he wants to get to the right answer for the american people and he's willing to talk to anybody who has expertise in real world experience in it. so i know there is this other impression that people who haven't been able to hack it in the administration come out and they wilt under the president's questioning. well, tough, to be perfectly frank with you. the president asking tough questions of a lot of people and he puts people on the spot and a lot of people can't handle it. so that's the president's style, he wants to make sure that you understand what you're talking about and that you have the courage of your convictions and it's an environment that i enjoy and a lot of other people enjoy. some traditional d.c. dwellers can't really handle it, but
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that's not this president's problem, that's their problem and when they go out and they whine about it to the media or give anonymous quotes after the fact, it should be taken with a grain of salt because they've left for a reason. the president has
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administration said to tough. not interested let industry continue to suffer under regulations but they are outdated and they have prevented a lot of contracting in the healthcare space or arrangements that would benefit patients and that is why. we have a great relationship with the department it is a lot back and forth my staff is on the phone with any number of departments and the secretary will call me up or swing by and say i have an idea. do you want to help and then we move it forward. it's a great cabinet to do it. >> wheel open for
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questions please state your name and where you work. >> my question involves the white house moving forward although the senate republicans are not in favor of that provision. >> we have always wanted a bipartisan solution to drug pricing. that even goes before the house was taken by the democrats but is just a recognition of reality that the speaker of the house you will need democrats to get something on the president's desk that he can sign and you need 60 votes in the senate to get something the president can sign. you
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don't have 60 votes in the senate see you have to get them there so we are very supportive of the grassley wide and compromise it is a product very good bipartisan collaborative approach to solving drug pricing. and we continue to work with their staff each and every day republicans and democrats to improve to make sure premiums are kept low as we find the incentive to drive drug prices down to give seniors a true catastrophic cap where they pay zero right now it is at 8000 we would lower that to 3000 roughly that is a huge win for seniors. huge. as far as inflation caps are
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concerned it was not in the administration's proposal but it is the product of a bipartisan compromise. nancy pelosi's bill right now is unworkable and impractical and hyper-partisan it will not pass in its current form. the surest route to a bipartisan solution that is a real win for republicans and democrats and the president of the american people is grassley wide and and we are working very hard to get that done and moving. i have been talking to policies people since they took the house before she was speaker. i got calls from her staff when i was at omb at the time they called me and said do you want to work on drug pricing i said absolutely. we will work in a collaborative fashion. there's only one red line do not take savings and power into the
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affordable care act for additional subsidies that will get a veto and then a general direct approach we don't want to punish market success but address market failures there are clear instances where co-pays are way too high. drugs can command a premium price far beyond the original vision and spirit hatch waxman and that is what should be addressed not killing innovation or taking a product that somebody invented that is valuable to a lot of people and to dennis appropriate the value of it. we want to have new waves of innovation there is a huge push of new medicines coming on line
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and generic drugs that are on development right now to watch that be killed would be a tragedy. there's plenty of ways to save money for people and taxpayers and patients in companies to have a more rational system without killing innovation. >> so with the transparency with the bio similars but a lot say it would help them so why not go with the pilot program on that? >> first i will not get into what the president decided but the
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transparency pattern will not be solved in one step or one fell swoop we make a major push on a number of different fronts. frankly it it is impossible to believe more opacity or confusion or a lack of clarity will help patients to drive cost down. the problems of addressing drug pricing and why it is so hard because the programs are really complicated. every time you want to make a change congress or regulators make things worse. that is why the grassley wide in proposal is so important because it would dramatically simplify the program. transparency is
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revolutionary if we had true transparency in our healthcare system. i find it be will during whenever i get a health care bill i ignore the first 90 days because the first two are not true it says i owe $40000 that after three months now we only owe 280. that doesn't make sense the medical billing we are working on capitol hill is another element to get more transparency into the healthcare system and reforming part d. the grassley wide in proposal has a provision to have list prices that is transparency. it should be first and foremost in everything we do in healthcare and from a policy matter. taxpayers and citizens should understand these programs we
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should have more data out there generally speaking. not just healthcare but anything. it is a broad ranging philosophical direction we don't think the government knows better than the private market actually the government knows less if we have data at the let's get it out there. >> do you have any analysis of the transparency regulations quick. >> no. we won't have broadly speaking it could be huge if you look at the disparity of certain metropolitan areas some hospitals will pay ten times as much with no improvement of
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outcome for the same procedure and clinics versus hospitals, that type of differential or type of care. the key focus is it would be revolutionary with true transparency in healthcare pricing. and then to bring costs down. we don't have cost coming down as much as they should all the innovation we have gotten computing with the power that is in the system would cost how much ten or 20 or 30 years ago why don't we get the same reduction in prices of healthcare with improvements in quality cracks and then to be misaligned incentives. lasix surgery is
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the one constantly referred to and it is a great example. transparency is revolutionary it is not clear where it would end but it has to be better than the current system there is no way without level of confusion it is beneficial for taxpayers or patients or physicians. >> i am with politico. going to the national pricing index. >> the
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international pricing index i cannot get into detail these are difficult issues to be focused on to make sure that any policy that we rollout is solid to make sure the data is right and drug pricing is a difficult issue and we continue to make sure all healthcare policies that were not gonna do something we will regret. >> there was a lot of talk about
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that i am skeptical of the rebates and work on drug pricing reform with a great deal of skepticism with the rebates and with those specific proposals for legislative changes. we have spent more man hours on rebates and any other issue in healthcare to be honest the amount of resources the contractors and advisers and cms, hhs, trying to figure out what would happen under various scenarios. to be clear the way the rebates are
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structured and this should be confronted and what we have inherited so with that solution of the rebate problem i am all ears i would much rather focus on the part d benefit then go at the direct enumeration issue. and what we are supportive of and working with members and to have good feedback and that transparency would help. and the restructuring of the liability and to get a lot of these rebates to inject competition and aggressive negotiation in
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the private sector. just to restructure that benefit without calling it rebate before will be reform. >> how are you planning to address that barrier with canada cracks how do you plan to address that? >> with the proposal the president has been focused on this issue and with international prices. and then they find it bewildering and
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those that cross the border to buy drugs in canada because it's cheaper than it would be out-of-pocket in the united states. and governors have asked for the ability to import drugs. secretary a czar has made it clear his concerns can be alleviated with the modernization of supply chain tools to allow for importation through a mechanism like this to make sure there is no adulteration. we are not talking about importing drugs from thailand through canada but safe effective drugs to be imported if the state wants to do that so we are working very closely with states like colorado in florida and others exactly how they could be achieved but it is feasible and we could do it and we will see
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if it is disruptive to the market forcing companies to contract around it then so be it and the president wants us to address it so we will so it goes back the president says this is too hard or difficult that he is a disruptor makes those vested interest groups uncomfortable but that's the way it is and it is refreshing to be honest. >> it is on our
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radar screen but i don't want to get into deliberations and private discussions right now but it is an issue. i don't want to rule anything out. >> the administrator has said on multiple occasions the healthcare industry goes between a democratic direction for single-payer. so if they really wanted a push on that they would require with the commercial health plans. is that what you are looking for a quick. >> we are looking at
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more aggressive this is why we have kickback in a number of different context. is a delicate balance. we do want to force anybody into a value -based arrangement that the patient does not choose to be there. and that there are some patients that would do better in the comprehensive care value-based arrangement and others may choose not to. over the last eight or nine years is what happens where the patient is in all of this the obama administration promises 36
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billion are whatever that astronomical insane number that brings costs down yada yada yada. all of it was talk none of it happened it's not interoperable now we are finalizing that will before the end of the year to make sure the east is on - - systems can talk to one another i don't know if you have been in the emergency room but the doctor comes in and doesn't even make eye contact they are looking at the laptop asking questions typing away. it is an example of how a system is so screwed have been in the emergency room but the doctor comes in and doesn't even make eye contact they are looking at the laptop asking questions up we have allowed ourselves typing away. it is an example of how a system is so screwed not to think of the patient up we have allowed ourselves not to think of the patient first and foremost that if we first and foremost that if we give the government enough give the government enough power and data we will solve power and data we will solve all of our problems. not all of our problems. not trooper go these are human trooper go these are human beings that need to be taking beings that need to be taking care if we need to make sure patients and physicians have the flexibility and the
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choices they need to make the healthcare choice to make the patient healthier and we have been focused on that's when we issued our executive order asking about choice and competition we could do short term limited duration plans health reimbursement accounts which will be huge for employers and employees to get the plans that are more economically viable we are about the patient being in control it at the center. forcing arrangements that's it we would be skeptical about you want them to be more transparency and data out there. >> where do you stand with the van and are there any
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concerns about being hurt economically quick. >> the vaping issue specifically e-cigarettes is complicated pico i don't know if you saw the l.a. times story that was followed up with this is the industry that first came with regulators and policymakers during the obama administration the decision was made not to bring them into regulatory compliance. we have believed e-cigarettes are viable alternative everybody understands combustible cigarettes are a bad problem pulmonary and cardiac problems.
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that complication for adults but now we have 5 million kids using these as a major health challenge we really want to make sure we are data-driven and striking the right balance between choice and protecting kids and that is our focus as we look to finalize our policy. and then with the timing and then to give kids the choice they need to stay off of combustibles. >> and to have jurisdiction over nicotine i
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was too old when the vaping stuff started but if you go to the faith shop you can get flavored whatever and smoke that without nicotine but you can also get nicotine separately and mix it and that is fine too. and with these devices with the flavor mixed in that the adults have the options they need to stay off combustibles and kids are not addicted otherwise they would
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not be addicted to. nobody knows how would nicotine addiction plays out long-term there are some scary stories from parents and older brothers and sisters talking about members of their family. and to be very focused on it. >> is there any discussion about adult only vaping shots? work day we classify their flavor quick. >> at want to get into specific details. we would have to do extensive q&a. and fda regulation in the space is
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complicated. on a personal level fda should not be regulating this in the first place. when i was in the bush administration i was there this is a moronic idea it regulates drugs to help people to balance safety and effectiveness and devices that help people and you balance if they are safe and effective this is awful. tobacco has no redeeming qualities and it should not be regulated by a health agency like this. all of the unattended consequences is sucking up bandwidth over tobacco is a huge distraction. and whoever the next one would be that has spent all this time on tobacco issues they could be figuring out on these therapies to cure cancer or cystic fibrosis or get more drugs approved more quickly or to get more competition to bring
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prices down but they spend time on navigating all of this. i showed up at omb i told my team any industry can come in with a problem but nothing on tobacco. and i got hit all the time. tobacco. tobacco. tobacco. they want to come in and explain we are getting screwed by the fda. we do understand the standards. i'm getting burned up by members of congress and on and on and on. is a huge waste of time for regulatory agency the fda should come up with the next wave of cures to spend time on this all the time. the
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unintended consequences are mind-boggling if you think all the time spent on this issue it sucks. >> who should regulate tobacco quick. >> i don't know. this is not policy is my personal opinion. and those that should regulate tobacco but it has no redeeming qualities. what the hell are we doing with fda with this? it is just awful. >> there is a tendency however do you get around that cracks. >> with the drug prices and out-of-pocket and the frustration on the part of employers and health plans that is more front and center. the top healthcare issue and this is an issue that republicans and democrats
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should come together and unfortunately there are current complications on that front this is the right president to do it and a once in a generation opportunity to confront these issues in a non-ideological fashion. spending a ton of bandwidth. to rationalize the system and those set up to drive high prices. it is a win for democrats and republicans and i'm hopeful we can get there. and that's not in the but it best interest of pelosi to get a deal done. >> and then to have retail drugs with part d but the finance committee's
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trying to do something on it. and with that point of sale rebates. and with point of sale rebates. >> at want to get into any specific details. so somebody has a rebate idea that
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train left the station. this package needs to be wrapped up in the next few weeks. i have spent over two years working on the rebate issue nobody has come up with an easy solution. is not only negotiations are what they are proposing and why it is jettisoned. it has no chance of bipartisan support it is impracticable - -
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impractical with a whole new bureaucracy of hhs of what the drug value should be with consultants that all figure out how it should be valued it is dictating a price at the end of the day and why that kills innovation and then to read tool that is over. and great conversations wide open. we are done with ideas now. we have to get a solution and scored by cbo and on the president's desk. we have heard from the
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house side since january. and then to have that cbo score. and then to take this opportunity. >> there is some work being done so what areas could be tweaked? >> the wide in compromise the money saved from part d program. it was not redirected into the benefit. it is a bigger benefit for
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seniors. this is what we are working on. and just to make sure it is solid so you don't get the unintended consequences. but trying to dial in on the final specifics to incentivize bio similars to get that moving a little better. and energy and commerce and ways and means with the
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senate judiciary. senator collins has transparency efforts there with those submarine patents that pop up to have that market exclusivity of what is rational the effort would be well appreciated. there are things that could be tied together. >> what is the next step with the administration? and with any republican vote. and with the supreme court twice and with that coverage and allowing people to keep their doctor and that to spend $50 billion a year and 28 million people who are uninsured so much sure the one - - so much so democrats have moved beyond aca with a dominant debate of medicare for all everybody recognizes that aca is a failure. that could be a major constitutional issue
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administration on - - administration thought it was important and with any number that get decided. nothing will happen immediately. pending supreme court it may or may not be decided before the election but if it were the supreme court would stay its decision.
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but we need bipartisan approaches so with one party ramming something through bad things happen. with the aca all the healthcare issues that are percolating with opioids. and then it is beginning to manifest itself. f republicans and democrats come together we can solve pre-existing conditions problem much the way that and there is a market failure. and with those people with pre-existing conditions is
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not impossible to buy health care. and those that are 100 percent subsidize that is if that's what you want to accomplish. and you could do that far more effectively and far cheaper than the aca. and then to restore the market to health and move the other healthcare initiatives to address other problems in the system. but it is the protection of people with pre-existing conditions is the only lasting contribution. the president campaigned on it. of what should happen post aca. that is number one on the list. so if the democrats are in a
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position and then to wipe out health insurance but to totally eviscerate the medicare program and it won't work to show his ideas. they don't understand the free market. they go back to the mothership of central planning and say we will give government more control. would that work in any area cracks it
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is crazy. that we are even having this discussion around government control around health care. it takes away so many options that employers and employees alike and seniors like and it would be a real disaster if it was to get moving. >> to get surprise billing and then to have a lot of bipartisan support there is an opportunity for compromise.
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it is just down to a few issues. and it is easy for the american people to understand and people should be going to the emergency room expecting one price and then with that understanding that they have coverage for a reason and then sorry this does not apply in here is your surprise. they are not in a position to bargain were to fully comprehend what is going on. and unfortunately it hasn't already been addressed and its close but we could come together with a bunch of healthcare legislation. >> it could be
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standalone. >> yes it doesn't have to be attached there's a lot of movement with drug pricing that this could get attached to. there will be a lots of big bills at the end of the year. hopefully we won't just flush usmc day down the drain. that is ridiculous that would be a clear bipartisan win for the american people. and nda a bill that has been passed every year for 50 years the appropriations bill. >> we have
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ten minutes left. >> and so think of your questions. so one of the other big issues is and is that issue plan to address the issue. >> and with the hiv transmission all the technology is there to achieve this the pharmacological data and testing data i am a veteran of the hiv initiatives running the president's advisory council
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that is an exciting time if you are a veteran to see the opportunity. and to the presidents credit he said that's go for it. as an off hand comment how excited he is about this and somebody who lives in new york city during the height of the hiv epidemic and saw many people around him not live through the height of the aids crisis. we have deployed a lot of expertise. the team at hhs we have a lot of great people working on this. and then that is a huge win for public health. >> i
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appreciate it. so with the opening remarks that medicaid expansion could've hurt on - - healthy opioid epidemic quick. >> a lot of people were addicted to opioids were on nongovernment programs. this is something with two guidelines that were encouraged and frankly somebody wasn't minding
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the store. look at those lawsuits. and to get into specific litigation but in bad is it appropriate. it is an epidemic there are tens of thousands of americans being killed every year the president doesn't drink or smoke or doesn't do drugs into his credit he said that's confronted and kelly on conway has been up front and hhs. but to be frank she deserves a lot of credit focusing this on a laser beam. year-over-year we
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have declined on opioid death. it is an achievement of this president but we do have a larger addiction crisis we cannot just keep our eyes on one problem at one time we have to be open enough to confront problems that maybe we don't want to confront i don't know if anybody wakes up in the morning to dive into the details of the tragedy that is occurring with addiction in this country but you've got to because it's important to the american people and this is a
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president who has focused on fighting for people who have had them front and center or flyover country or families that are struggling with addiction. there is a long way to go but we have made a lot of progress and changing guidelines and incentives to drive opioid addiction. i have heard anecdotally from practitioners that said the opioid numbers will continue to trend down we are just seeing the beginning of the fruits of our efforts. >> that they see something different. >> doctor
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gottlieb said that the opioids would start to climb again because of all the mixtures of opioids with cocaine by those users who don't know. >> i would like to see that comment that yes we have a methamphetamine problem that is starting to take off. the fentanyl issue has been a big problem mixed in with many cases inappropriately with prescription opioid or sold on the street. it's not easy but i have to look at what he's talking about specifically looking at year-over-year decline that's it i am talking about right now. >> are there
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any plans talking about with your initiatives with it quick. >> i don't know. the president's agenda is often times thwarted by activist judges to have a celebration pointing over 150 federal judges and not make policy. we recognize the risk we run when
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we confront these challenges but the president respects religious institutions and people's conscience some will be skeptical. we spent a lot of time to make sure our rules and regulations are sound but at the end of the day you do roll the dice anytime you are disruptive to prosecute and appeal any case because we believe in it to spend time to make sure it is valid. >> in the final rule for the hospital outpatient for which was overturned previously by federal judges. why is the administration continuing to pursue that with financial payments with the discount program despite the court's saying they are not able cracks and also the thinking. >> we
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think the policy is solid and we think we can win and we will not apologize we cannot get something done at the very
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least it highlights a change that should be made and then we could say the courts are sticking it to us here and there and we need to clarify the law because we are on the right track. here's the policy we are pursuing it will not be as robust and strong as it could be without a legal change. if you are going to be aggressive and policymaking you will run a risk the court will hold you up but then you will expose an opportunity for
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legislation to fix the problem. again we could make our lives a lot easier i can leave at 4:00 o'clock every day but that's not the way we are approaching it. >> those that have that transparency requirement that they use that information to negotiate higher rates so there is there anything in the coming rule that can address that quick. >> i don't want to get in what specifics i'm happy to have more conversations later. >> we recognize any policy could have unintended consequences and we work hard to think them through but you also have a public comment. precisely for that reason the public has the opportunity to let us know you are on track or off-track to make this improvement and we have consistently pursued regulatory policy procedures to give the public the opportunity to contribute and find their rules. i cannot stress enough how important it is for members of the public to get involved in the regulatory process to make sure the government is doing the right thing. so it will go out as proposed and we will switch to comment and then maybe we will change. >> we are out of time. is there any subject you would like to throw
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out there that you did not cover or was not asked maybe just that we saw jobs numbers come out last week revised upward of 303,000 and with job creation at record low unemployment in the african-american community. three.5 percent nationally the most robust economic. but with healthcare specifically is an area that can contribute more to our gdp if we get more efficiencies out and a lot more incentives and the way to do that is not putting government in control but to inject more choice and competition and again stay focused on why we are in this business in the first place which is the american citizen that needs healthcare and needs to be healthy. >> thanks again. great job i hope you will come back again. we would love to have you back and we appreciate your willingness to stay here and answer these questions. surges. the supreme court has told you next year to issue a decision in this case.
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