. good morning, everybody. i think before i give my

statement, we have several votes at 10:30 and i think we've worked it out with senator wyden and other people that we'll keep this meeting going so i'm going to leave at the 10:30 and vote and come back and i think the first vote always takes a long time and then when senator wyden gets back -- or no, you know, in other words, i'm going to -- for the second and third vote i'm going to stay over there and do them together. you know how it works out. i may not explain it very good. i want to welcome our witness, our secretary of health and human services, honorable alex azar. i appreciate, secretary azar, your appearing before the committee to discuss the budget, the new budget.

secretary azar oversees a very sprawling department, with programs that are crucial to the health and well-being of many americans and maybe you would say all americans. the budget represents the administration's recommended funding for those programs as well as key policy proposals, while congress decides funding levels and program changes, we have a duty, of course, to review the administration's budget proposal and secretary azar is here to help us do that. as with any budget submission, i disagree with some of the proposals, but i do want to speak to a few issues where it reflects priorities that i have and a lot of these priorities are shared by a lot of democrats and particularly working with senator wyden. i mentioned representative widen

and my working to lower prescription drug prices as our top priority. president trump's focus on this issue has been a real game changer, particularly because in the state of the union message he has brought attention to that. secretary azar has been a point person in this effort as well. the secretary has also helped greatly with our legislative effort. again referring to prescription drugs because your team, as well as you, have provided guidance and technical assistance as we develop and refine the bipartisan bill the committee reported out 19 to 9 last july last year. i'm pleased that the budget calls on congress to quickly pass a bipartisan bill and includes a prescription drug placeholder for $135 billion in reduced taxpayer subsidy to drug

companies. i will ask the secretary to expand on this when we have questions. for now i will say i look forward to continuing to work with the secretary, the ranking member and other senators to provide relief on these prescription drugs to consumers. the budget also contains a number of proposals to improve health care in rural communities, ensuring access to health care in iowa and other rural areas, has long been a priority for me, but also for most of the members of this committee. it's not really been a controversial issue in most cases. ranking member and i continue to discuss how to help rural and other underserved areas. the administration's budget further bolsters those efforts. i would like to also take a moment to highlight efforts to help hhs be more effective in

executing its mission. i understand that hhs office of national security is forging new ground with the intelligence community to leverage technology in innovative ways to better streamline intelligence operation procedures and threats. i encourage the intelligence community to provide even broader access to the office of national security as it relates to its products and database, to allow then hhs to access vital information that it needs to mitigate threats to the department, its funded partners and interagency colleagues. as you're aware, via my oversight efforts, i've worked to make sure that the office of national security receives access to certain intelligence

community-related material and that you have gained access to some, but not all that you want. however, more work needs to be done then. recently i sent two classified letters to the intelligence community components to help bridge the gap between the office of national security and the i.c. counterparts. as i've said before, the left hand and right hand work together for the taxpayers, as we found out 9/11 may not have happened if we had more cooperation between the intelligence people and the fbi as one example. now, of course, hopefully that's better, but i'll bet it's not as good as it should be. i will conclude by noting that hhs has many important challenges, some are long-standing like the high cost of prescription drugs, other appeal -- appear with little notice such as now coronovirus.

while there is sure to be disagreements on many items in the budget, the issues i have highlighted are a reminder we can work together in a bipartisan way to get things done for the american people. >> thank you very much, mr. chairman. i appreciate your scheduling this so quickly and appreciate your working with me on a host of issues. mr. secretary, we appreciate your being here and that you're willing to come right after the budget comes out while these issues are ones we'll all face while on our way home tonight and over the next week. president trump's health care agenda, in my view, rips scores of new holes in the safety net that vulnerable americans are sure to fall through and the textbook example is medicaid. right now, the administration is trying to do on its own what it

failed to get through congress, block grant medicaid. it's a policy, colleagues, we debated in this very room back in september 2017. it didn't make it out of the committee, it didn't get a vote on the floor, it didn't go anywhere, because it's really horrible policy. horrible policy that would hurt our people. that said, the trump administration doesn't seem to mind. now it's trying to pull an administrative run around the congress to push the dirty work of medicaid block grants on the states. you hear washington lingo about flexibility. they even gave it a name that goes into the george orwell hall of infamy. it's called healthy adult opportunity. let's make no mistake, the trump administration proposal to block grant medicaid led by cms

administrators verma would be the beginning of the end for the health care safety net. it's not about flexibility. it's certainly not about opportunity for healthy adults. it's about harsh draconian cuts and it comes in addition to the other cuts the trump administration has proposed for medicaid. i'm going to take just a minute and i see my good friend bob casey who is so el low kwepts on this subject and talk about what medicaid really means forth american people. medicaid pays for two out of three nursing home beds in this country. that's because growing older in america costs a lot of money. before i was elected to congress, i was the co-director of the great panthers organization for the elderly and spent a lot of time and the majority of them were folks who had to stretch every last penny to get by. this is an issue i take very

personally. and even when our people do everything right, when they scrimp and save over decades, when they give up vacations and didn't buy a boat and lived modestly, they do everything they can to prepare for retirement, people run out of money when they get older. all it takes is one surprise illness or injury for the bills to start stacking up or a family emergency or damage to a home, your savings dry up. that's the way real life is. that's on top of those who don't have savings. the millions who couldn't save just because they had to walk an economic tightrope and half of our people struggle to keep up with $400 if they had an emergency. that doesn't mean that they have no right to see a doctor or get long-term care. protecting those people is what medicaid and the nursing home

guarantee. that's what it is, it's a guarantee. and it's what medicaid is all about. without it, where do seniors turn when their savings dry up? how are nursing homes supposed to stay open without cutting the services down to frighteningly poor levels? how are low-income seniors who want to stay in their homes, afford their health care? when you hear all this talk, colleagues, about flexibility, innovative solutions, holding the states accountable, in my view, it's code for big medicaid cuts. the consequences are dangerous and they are personal. a couple other points, the trump administration has gone to court to have the entire affordable care act thrown out. protections for preexisting conditions gone. tax credits for health care gone. rules banning the worst insurance company abuses, gone. millions of people kicked off their health care. it would just be devastating for

young people like jasper, pictured on this card in front of me, a little guy, but he has a really big heart and he was born with serious medical issues. one of my constituents, cystic fibrosis, cardiac and pancreatic problems, hearing loss, gets a lot of costly treatment, and for them, his family, he and his family, the affordable care act is a lifeline to the peace of mind they absolutely consider vital. donald trump has no backup plan for jasper and his family to if repeals the affordable care act. that didn't stop the president from saying during his state of the union address he had made an iron clad pledge to protect seniors with preexisting conditions. donald trump protects preexisting conditions like sea lions protect salmon on our mighty columbia river. it's the kind of protection that

comes with an uptick in the mortality rate. i'm going to close with some comments about prescription drug prices. the president's had a lot of curtain raising events on this. he was going to force big pharma to list drug prices on tv. that policy was blocked. he's talked about requiring repates to go to patients, no follow through. going to tie drug prices in the u.s. to drug prices abroad. nothing there. he had a policy to speed approval of generics, no apparent effect. the reality is, patients are still getting mugged at the pharmacy counter. drug prices are up again in 2020. now the senate finance committee has worked hard and long on the prescription drug issue as has the house of representatives. as i've said on a number of occasions, chairman grassley has been good partner on this and i hope that we can find a way to

move all this good work forward. bottom line, the president's been making promises about bringing down drug prices for three years. it hasn't gotten done. again, mr. secretary, we appreciate your being here, particularly coming quickly. a lot for us to talk about. i look forward to hearing from the members. >> before i call on the secretary, repeat for some people just coming in, we're going to keep things going while we have votes and -- and secretary, so come back if you want to ask questions because the secretary has to leave at 12:30. mr. azar is secretary of the department, as i've said. prior to his current position he served as general counsel at hhs for four years, '01 to '05 and deputy secretary from '05 to '07. secretary azar earned his

bachelor's degree from dartmouth college and a law degree from yale university. proceed. welcome. >> chairman grassley and ranking member widen, thank you for inviting me to discuss the president's budget for fiscal year 2021. i'm honored to appear before this question for now the third time. especially after the remarkable year of results that the men and women at hhs have produced. with support from this committee in many respects this past year we have seen the number of drug overdose deaths begin to decline for the first time in two decades. another record year of generic drug approvals from fda and historic drops in medicare advantage, medicare part d, and insurance exchange premiums. the president's budget aims to continue delivering these kinds of results and move towards a future where hhs' programs work better for the people we serve, where our human services programs put people at the center and where america's health care system is affordable, personalized, puts

patients in control, and treats you like a human being and not like a number. that is the vision behind this budget. i want to note that hhs has the largest discretionary budget of any non-defense department, which means that there are again this year difficult decisions made in order to put discretionary spending on a sustainable path. the president's budget proposes to protect what works in our health care system and make it better and i'll mention two ways we do that. first, by facilitating patient center markets and health care and second, by tackling key impactble health challenges. the health care reforms in the president's budget aim to put the patient at the center. it would, for instance, eliminate cost sharing for colonoscopies after discovery of a polyp, a life-save, preventative service. we would reduce patient coinsurance and promote competition by paying the same for certain services in hospitals and outpatient

settings. the budget endorses bipartisan drug pricing legislation like the plans formulated by chairman grassley and ranking member wyden and supported by members of this committee as well as price transparency efforts that many of you have championed. these reforms will improve medicaid and extend the life of the hospital insurance trust fund for at least 25 years. we propose investing $116 million in hhs' initiative to reduce maternal mortality and morbidity and we propose reforms to tackle the rural health crisis in america, including expansions of telehealth and new flexibility for rural hospitals. the budget increases investments to combat the opioid epidemic including the state opioid response program which we have focused on providing medication assisted treatment, while working with congress to give states flexibility to address stimulants like methamphetamine.

we request $716 million to expand implementation of the president's initiative to end the hiv epidemic in america by using the effective evidence-based tools we have at our disposal, as we've already begun doing with congress' help in four jurisdictions. finally, the budget reflects how seriously we take the threat of other infectious diseases, such as the china coronovirus, which has been a top priority for me as i've led the federal government's coordinated response as chairman of the president's coronovirus task force. the budget prioritizes funding for cdc's infectious disease programs and maintains ineffective investments in hospital preparedness. last night we announced the 14th confirmed case of the china coronovirus in the u.s. and this morning cdc will be announcing the 15th. both of whom came from wuhan and are in quarantine. as of today, i can announce that cdc has begun working with health departments in five cities to use its flu surveillance network to begin

testing individuals with flu-like symptoms for the china coronovirus. many questions about the virus remain and this effort will help see whether there is broader spread than we have been able to detect so far. on the human services side, the goals detect so far. we cut back on programs that lack proven results while reforming program to drive state investments in supporting work and all the benefits it brings for well being. this year's budget aims to protect and enhance american's well being and give them a more affordable health care system that works better rather than spend more. i look forward to, working with this committee as always to making that common sense goal a reality. thank you, mr. chairman. >> questioning. we'll start out with what you probably would expect me to start out with. i referred to it in my opening statement.

and in that statement i commended you for help -- your leadership in the effort to lower prescription drug prices, and particularly helping us with our legislation. can you speak to the proposal in the budget to reduce prescription drug cost and the notation of 135 billion to reduce spending and also include in your answer your general thoughts on how this could be helpful to me and senator wyden and all the people on this committee that support our bill. >> thank you, mr. chairman. i've been delighted to work with you and ranking member wyden on this legislation. this package is reasonable, it's bipartisan. and it can help in terms of helping to control list price increases to decrease out of pocket spending by our seniors

and fixing the incentive in the part d program to give the plan to negotiate hard against big pharma. i don't understand why big pharma isn't supporting it. these are important reforms. packages like this and other bipartisan efforts are important at saving senior's money, stopping list price increases and getting negotiations and i think these are some of the best reforms we can work on together. >> thank you. i'm interested in rural health care and this committee has been in the middle of that for at least three decades. it's difficult to keep high quality medical care in those environments. over the past decades i've championed landmark rural health care legislation. we've had some successes, but things change rapidly and -- well, maybe not rapidly, but they slowly change in rural

america so we have problems still developing. i'm pleased to see in the president's budget it containing a new -- renewed focus on rural health care while the hh budget material provides a broad outline of past accomplishments and future goals they do not contain specific details about the policy. that is why today i wanted to give you, secretary azar, an opportunity to explain in some detail how the administration plans to build rural delivery models, leverage technology and create appropriate rural provider payments. >> thank you, mr. chairman. thank you for your decades long advocacy supporting rural health care. it's a passion of mine also. i'm the product of rural health care in america and rural health care suffering. we have developed a comprehensive agenda i'm delighted to see how prominent it is in this year's budget.

some of the changes we propose in our budget one is to help stop rural hospital closures. what we would do is ask congress to allow critical access hospitals in rural areas to voluntarily convert to emergency hospitals so they don't have to comply with the regulatory requirements of also offering inpatient beds. they get the same medicare payment rates as others paid under the outpatient system plus an additional payment. we are also working to advance tele health and medicine, expanding for providers who participate in medicare advanced payment models by lifting telehealth models. they deserve more money, we want to increase flexibility for critical hospitals to convert to the outpatient only facilities and continue serving their communities.

>> ranking member wydewyden and sent a letter to the network of organ sharing questioning the advocacy of their oversight. i know you appreciate this as a problem. there are more than 600 people in iowa waiting for organ transplant and 113,000 nationwide. about 20 die a day without getting the help. what is hhs doing to take a more active role in providing oversight over this system to hold its government contractor and procurement organizations accountable because we think, except in a few, there's not really a very good effort made to harvest organs. >> so mr. chairman, in regard to the particular issue of liver allocation policy, i wanted you

to know as i said before, that i share your concerns and other members' concerns and frustrations with unos and the decision-making process there. i have been rebuffed also in my efforts. the oversight there we have as hhs is limited by statute to protect independents of the organ allocation policies, but happy to work with congress if ever it saw fit to address that question. more broadly, though, around the super vision of the organ procurement organizations we have proposed a comprehensive rule bringing first time ever real accountability and metrics to these opos to get more organs procured and more successfully transplanted. that's a major focus of our efforts through the regulation we have now proposed. >> thank you, mr. chairman. i'm going to walk through a few facts that i think are on the record and then i have a

particular question for you. the president talks about health care in terms of his vision. and yet, when i look at the specifics, it really looks like a nightmare to me. first, i touched on the graham cassidy bill in addition to the punitive approach to medicaid that would have gutted pre-existing conditions, we have witnesses that actually said that at that witness table. the 1332 waivers basically are green lighting junk insurance, paperwork led to thousands losing coverage in one state alone. what do we have to show for it? the uninsured rate has gone up since 2017 and the rate of uninsured kids is up for the first time in a decade. so to me this vision looks more like a nightmare. and that's because we're going to have worse health care for fewer people.

now i want to ask a specific question with my time about women's health under trump care. since day one the administration has taken aim at women's health by making it harder and harder for women to access the health care they need. last month the administration approved federal medicaid funding for a texas program that excludes qualified family providers like planned parenthood. so they have an agenda making it harder for patients to see the providers they trust and the administration is now proposing a budget that would cut even more women's health protections. medicaid is a lifeline for so many women. it's the nation's primary payer of essential family planning services and it would be slashed to the bone, putting coverage for millions of women and girls in jeopardy. president trump's apa repeal lawsuit would end the ironclad

protections for pre-existing conditions. again, vital for women, taking america back to the day when a woman could be charged more for health care just for being a woman. so my question, secretary azar, is why should the department of health & human services be in the business of telling women which doctors they can go and see? >> so, senator wyden, we don't have any role in telling women, men, where they should go in terms of which doctors they would see in our programs. we grant flexibilities to states in running the medicaid program. we made major investments and we continue to make major investments and direct health care for women's health. it's a priority to ensure access for health care for women and girls, including community health snen centers were where 58% of our clients are female.

we're going to spend in this budget approximately $137.5 billion on women's health. i look forward to working with you on ways we can keep advancing women's health care. >> i'll say, mr. secretary, because i think i outlined the medicaid cuts. i just would respectfully disagree with you on that particular point. you all are telling the states that they can tell women which doctors they're going to see. and that's what i think is particularly unfortunate. it seems to me that women in this country, particularly women of modest means, shouldn't, in effect, be excluded from the kind of health care choices that millions of other americans have, and you're basically green lighting that kind of opportunity for the states. now one last question. talking about how medicaid and health care is, in my view, paying for tax cuts. now, confirm some of the numbers

in the president's budget for me. let's just stick to the numbers. sit right that the president's budget redeuces medicaid spending by $920 billion? >> the president's budget has changes to medicaid that would result every year in an increase in medicaid. right now medicaid increase is 5.4% per year, twice what the average worker makes in a pay increase. we would change it to 3.1% increase. >> doesn't the budget say it would be $920 billion less than it would be without the budget? that's a yes or no. >> that is less than the rate of growth, but again grows every year. >> that is a yes. is it also correct that the president's budget reduces the net medicare spending by $450 billion? >> again, medicare spending is growing at 7. -- i believe it's 7.3% per year, we would reduce the rate of growth by 6.3% by

making common sense changes that have been recommended by moving graduate medical compensation to tax revenue, site neutral payments, bringing control to post payment -- >> my time is up because i have two or three other kinds of examples. what i'm concerned about is paying for unpaid breaks to professionals and big pharma on the backs of low income americans and i think that's what this budget adds up to. thanks, mr. chairman. >> senator portman. >> thank you, first of all, i want to thank you for everything you're doing secretary azar. first on prescription drugs we voted on a bipartisan package, 19 of us voted for it, i was one of them. you put a place holder in the budget i noticed that is roughly equivalent to the amount of savings we would have to the prescription drug cost reductions we passed in this committee. i thank you for that, and i urge

you to continue working with us on a bipartisan basis. it's important to all the of the constituents we have back home and i think we have the potential to find some common ground. i noticed in the opioid area you increased funding for the opioid program and the recovery act. i appreciate that. we need it badly. i would love to say we've been victorious in this battle. we do have fewer overdose deaths but crystal meth and cocaine have come back with a vengeancv. i appreciate what you're providing. i just finished around round of visits in ohio talking to folks about this. unfortunately we had overdose deaths in the last couple weeks with fentanyl, cocaine and meth. i have a question for you on money follows the person. this is a great program.

ohio is a leader in it. it's demonstration program we want to make it permanent. you have put in the budget that it should be permanent. it's a great program because it's's win-win. it provides better care to get people out of institutional care into home care and also saves the government money. what's wrong with that? so i would hope for our seniors in ohio and people with disabilities in ohio that your budget actually is successful in making it permanent. it's already transitioned 90,000 americans to home and community care. you have a report from hhs saying this lowers hospital readmission rates among those coming out of nursing care, which is a great objective. it says that the average per person monthly cost decreased from $13,500 to $9,500 per month. it's providing better care and it's also less expensive. a challenge has been that cbo is

skeptical of the cost savings. can you talk about that for a second and also commit to working with cbo to come up with a more realistic cost based on the data you have given us. >> yes. i struggle with acchairries and how they do their calculations in terms of savings because we have seen the program, it's popular, the results of the demonstration have been positive. thank you for your leadership on that. it's time to convert this from a grant program with the lack of predictability that comes with a grant program to a state option they can build into their program. happy to keep working with you on that. >> hospice, i'm a big supporter, we were one of the states that pushed hard for medicare coverage for hospice back in the day. i'm told based on a study, 2017 marked the first time ever that a majority of medicare beneficiaries selected hospice for their end of life services.

i think that's a good thing. within my own family we've chosen osmi chosen hospice. it's important for people to have the end of life dignity they deserve. yet there are those not meeting the standards. we've been working on this issue, we've introduced legislation. it's something i have seen in your budget, you said you would like to see similar penalties to bad actors in the space. my question, would you be able to work with us to provide more input into our legislation, specifically technical assistance we've had a hard time getting? i know hhs is busy. but we want to move this forward, it can be a good bipartisan accomplishment to this committee and help so many constituents back home that are looking for the dignity at the end of life but also high quality care. >> we'd be happy to help you on that. in our budget we propose we have

greater ability to make transparent via accreditation surveys so people can make informed choices. we also make a major investment with $442 million in the survey and certification work to ensure we're doing our job with the expanding number of providers. finally with regard to hospice in particular we're proposing the oig's recommendation there how we can bring modified payments to hospice providers so they reduce the inscentives for hospice to seek out beneficia beneficiaries in nursing facilities. >> we look forward to working with you on that. and hopefully legislation will give you statutory authority to do that. thank you. thank you, ranking member and mr. chairman. welcome secretary azar. i want to express concerns about the medicare, medicaid cuts and other cuts and i want to transition to something you and i have talked about a number of

times where we can work together and improve people's quality of life and access to care. and we have an opportunity to do that this year. but first, i just want you to see henry. this is henry, he's 9 years old. he lives in gross pointe, michigan, he loves people, greets everybody with a hug. he loves performing, he's in dance class and sings karaoke at home. he's also living with a number of pre-existing conditions, including down syndrome, autism. he's been in and out of the hospital, a lot of challenges and his mom said, if we didn't have access to affordable health care coverage we would be bankrupt before henry was a year old. so the cuts on medicare and medicaid, i'm concerned about that that are in the budget. there's nothing that stops the lawsuit on the aca going through the courts that would take away

coverage on pre-existing conditions and everything else under the aca. i'm very concerned that when the court initially agreed with the fact that the aca should be repealed, including pre-existing conditions, the president tweeted great news for america. not great news for henry. so i'm very, very concerned about that. the area we have the opportunity to work together and make a difference is in the area of mental health. when you said grants are not enough, you are right. we have champions around this committee for addiction and opioid treatment. it's a grant, and when the grant runs out, so sorry. the folks asked to do that in health care are the mentally ill and people with addiction. as you know, senator blunt and i, and now we have 12 members,

democrats and republicans, we're expecting to add more people, we have a house bipartisan effort to expand an eight-state demonstration project that was set up that shows people saved money, they aren't in jails, emergency rooms. when you do quality community mental health, outpatient care and addiction services you not only save lives you save money. we want to expand that. the chairman is supportive, the ranking member, there are 19 states that actually have -- meet the quality standards now, are ready to take the next step and we are also doing grants to help other -- every state be able to get ready. but i wonder, there's been study that has shown, in the last two years, some of the results -- the positive impacts that have happened as a result of what has been done in the excellence in mental health and addiction

treatment act. i wonder if you might share some of those, if you're aware of the results we've seen in two years? >> yes. thank you for your leadership. this program has already served over 24,000 individuals as of august of 2019. these are clinics, as you said, that provide comprehensive coordinated range of evidence based treatment and behavioral health services to individuals. the results show that we see that they are making services more convenient, they're introducing more frequent appointments, tailoring services offered to diverse populations, such as school age youth and veterans, and expanding care in our communities. in our budget we plan to extend the program through fy-2021 because we are believers in this program and happy to continue working with you as we think about expansion to other states. >> thank you, mr. secretary.

and i want to thank chairman grassley and ranking member wu d wyden to putting the full program into your health care bill that's come guard on health care extenders. we have a chance in may to do this right. i will also say if you want to talk to folks excited about this, talk to a sheriff in one of the communities where folks are no longer going to the jail. they are now getting community outpatient treatment. talk to the hospital folks who are running emergency rooms who no longer have folks sitting in their emergency room but they're getting care through the 24 hour psychiatric emergency centers that have been set up. and the final thing i would say, mr. chairman, is that this is actually a good news story in that cbo, who we all struggle with around health care savings has actually dropped more than in half their original estimate on what it would take for us to

pass excellence act this year. so i hope you will lean in heavily with us. it's my intent to make sure the mentally ill and people with addiction are not left behind this year. thank you. >> i'll pass over senator menendez and go to senator carper. >> welcome. thank you for taking on a tough job, mr. secretary. we appreciate that and the work you're doing. don't always agree but we appreciate nonetheless. i think senator grassley has raised the issue of bipartisan legislation he and senator wyden and others on the committee crafted to reduce prescription drug prices for medicare beneficiaries. it's not every day we have the consensus we have in this committee on this issue. we're encouraged by that. as you know the administration would lower drug prices for seniors, for medicare and medicaid and require drug

companies to publically justify prices for their products in a day and age we're trying to save money in respect to costs in ways that are humane to people. i think this is a good effort and we're proud of it. do you support the committee's bipartisan bill to reduce drug prices? >> we've been active working with the bipartisan leadership of this committee to try to advance this legislation if we want to get this or some other bipartisan package through, we need to do this. this is certainly one that fits the bill. if there are other approaches that we need to take to try to get this to the floor and get it passed, we're open to that. but we've been engaged with democrats and republicans on this committee to advance the grassley wyden legislation. >> some on of republican colleagues believe the finance bills would result in price controls in the pharmaceutical

industry and jeopardize new therapies. as a former ceo of a major drug company, do you agree with these concerns? and the second half of that question would be do you think drug companies can continue to innovate under the finance committee's bill? >> with all respect i disagree with the notion that the inflation penalty provisions in the grassley/wyden bills cause price caps and bills, these create a financial disincentive year after year to the price increases we see. as long as those are in the system we'll continue to see year after year price increases and the package would contain that. it's important to remember, these drug companies already signed contracts with the middlemen with long-term price predictability guarantee. so this is not an alien concept to the drug companies. it exists as a commercial

practice already. we would get the benefit for our seniors and tax players through this program. i'm sorry, the second part to your question? i want to make sure i get that. >> senator carper, before you repeat the second question without taking time away from you, wouldn't another way of saying it, is since we pay $138 billion of taxpayer money for medicare drugs that we would be just capping the subsidy that we give to pharmaceutical companies? >> it does. and that's one of the really important innovations of the grassley/wyden package, it changes the dynamic. right now interestingly the middle men who run the drug plans have every incentive for the drug companies jack up their prizes because it raises the senior to the catastrophic phase where the government pays most of the cost through the reinsurance. this would be fixed through

grassley/wyden. >> the second half of my questi question, do you think drug companies can continue to innovate under the bill? >> yes. the changes here leave plenty of room for innovation and investment. there would be no material impact to the r&d enterprise in the united states. which we're all committed to. >> my colleagues, quote, matthew 25 from time to time, when i was hunga hungry did you feed me, when i was cold did you clothe me. it doesn't say anything about prescription drugs. sadly with respect to the president's budget, the answer to these questions is not entirely but too often, no. over 100 million americans, as you heard, as you know, 100 million of our fellow americans have pre-existing conditions. folks depend on the affordable care act's protections for the

affordable health insurance regardless of their health conditions. the president has doubled down on the texas lawsuit against the aca and this budget contains no plans, as far as i can tell to replace the aca to replace the law, if the court strikes down the aca. my question, mr. secretary, how will the president protect americans with pre-existing conditions if the aca is struck down in the courts? >> so the president has been very clear that he will never sign legislation that doesn't replace the affordable care act if it does not have adequate protections for those with pre-existing conditions. it's important to remember, though, even under the aca, there is a statement of protecting against pre-existing conditions, but let's say you're a two-person family making 70,000 a year in missouri. you're going to pay over 30 nourks a year for premium and

have $10,000 in out of pockets. so i think we have to not overglamourize the current situation in terms of the protection of those with pre-existing conditions. for those people, that insurance card is sometimes a meaningless protection. we want to work with congress if there's a something to really protect people. >> my understanding if the aca is struck down in the courts the president won't have to sign anything, that'll be it. and i want us to keep our eyes on that. thank you. >> senator menendez. >> thank you, mr. chairman. mr. secretary you're a named defendant in texas versus u.s., correct? >> reporter: yes, i'm one of them. yes. >> is it true that this administration has taken the position that it will not defend the affordable care act in court and support striking down the entire law. >> the individual mandate is

unconstitutional, as a result the other provisions in it are not receive rabble. >> so in essence it would strike down the law and the justice department is part of the administration. >> yes. >> therefore, it is the administration's view that the entire law of the affordable care act should be struck down. so if it's struck down, what's your immediate plan to replace it? if tomorrow the court decides that, in fact, the entire law is struck down, millions have health insurance who didn't have it before, many under medicaid expansion have health insurance that didn't have it before, millions have protections against preexisting conditions that didn't have those protections before, millions have no more lifetime cap, a ceiling on the expenditures they have, especially if they have a serious illness, so what's the administration's plan? i haven't seen it yet and i think this committee has

jurisdiction. >> the litigation has a long way to proceed. the fifth circuit remanded the case to the district court for a searching detailed analysis -- >> why are we going to wait? why would you wait with the health care of millions of americans and their fate to see what the court decides? it seems to me, we've been hearing about killing obamacare since it was created. there have been years to have your own version of what it is. why would you wait until there's a disaster to then deal with the millions of americans with health care insurance? you see this young man? he's alive today because of the affordable care act. like him, millions in my state and across this country are alive because of it. i don't know what you're waiting for. if you have a better idea, show us. i have yet to see one plan that the administration has put forward over the health care of millions of americans. what are you waiting for?

>> we would wait until there's a final judgment by the final court of authority in this case it would obviously be the supreme court. there is a very long process to go to see whether the statute is struck down or even in part is struck down by the supreme court. these are hypotheticals at this point. we are faithfully administering the aca now. >> let me say, mr. secretary, these are hypotheticals that we don't play with. this is not some abstract consequence if it happens. not some abstract consequence if it happens. let me ask you this. the president's 2021 budget calls for zeroing out cdc funding for gun violence research. did the nra tell the administration to do this? did you have influence from the nra to zero out funding? >> i have no idea about any interactions there. i can tell you why we can't put that in the budget. we have a tight budget, a 9% cut

at hhs because the discretionary caps go to a plus 1.5% or 1% increase. in 2021 we are the largest nondefense part we absorb a share of that. i had to prioritize, i prioritized to infectious disease -- >> if we didn't have a trillion and a half dollar tax cut unpaid for driving you huge debt and further plussing up the military beyond everything that's been done. it seems to me understanding the consequences of gun violence, how we get around it, would save lives here in the united states. one of the priorities of a government is to save its people. let me ask you one final question in the less than minute i have. the remain in mexico policy called the migrant protection protocol has forced 60,000 asylum seekers to wait in

dangerous conditions in mexico for a court hearing. over 800 cases of murder, rape, torture, kidnapping and other violent assaults returned to mexico have been reported. what mechanism or process is there in the office of refugee resettlement used to identify and protect children affected by the mpp. what does orr notify when an mpp affected child is identified. >> hhs has no role in determining eligibility for the mpp, which al aliens are enrolled in that or whether an alien is allowed in the united states. if a child returns with their family to mexico as part of the mpp, that's not subject to the statue and orr's jurisdiction. >> to the part the child is unaccompanied and ultimately is returned to family in mexico,

are you doing any tracking through the -- >> so if children are determined to be enrolled in the mpp and o.r.r. and dhs determine the child's parents are in dhs custody or if they return to mexico and stay here, dhs determines if there's a criminal history to preclude reuniting. we inform intake teams that the child's refederal rral is with family in the mpp so we try to keep track if the child comes to us, if the family decides to return to mexico and keep the child here, we work to keep them in contact as we do with any child in our care, to make sure they're in telephonic contract we track them whenever we receive a referral like that. >> senator cardman. >> thank you, mr. chairman.

i want to follow up on prescription drugs first if i might. you talk about the middle person who's supposed to be there to protect the patients and in really they're not doing that. and we have a chance of really passing prescription drug bill in this congress. so i hope we can follow the leadership of our chairman, ranking member and get a bill to the finish line. i'm going to tell you one of my pet peeves we're the wealthiest nation in the world, spend the most on prescription drugs and we have 200 plus common drugs that are in shortage in america. these are relatively inexpensive drugs and they are critically important for care. we're talking about newborn babies, the drops they need. we're talking about bladder cancer patients who need the therapy drug that's not available for treatment. that's outrageous. no one is speaking out in

regards to these necessary drugs being available to consumers in this country. we need your help to make sure that we include this so that we do look after the people in this country and we recognize the day that the pharmaceutical managers and the pharmaceutical benefit managers are not protecting the patients of this country. >> thank you, senator. first happy to talk about shortages. i did want to give you a little bit of good news. you have been an advocate for many years to see that cms has a chief dental officer. i'm pleased to announce that cms is working through an agreement to bring on board a chief dental officer. >> thank you. >> thank you for your continued leadership there. >> you can dodge my questions any time with that good news. >> thank you for your leadership. i completely share your passion around dental health and its central importance. in terms of drug shortages,

there are several legislative proposals in the budget that would help us better prevent or mitigate shortages, one would enhance fda's ability to assess manufacturing infrastructure so we can collect better and accurate information about supply chain management. the fda task force has three key recommendations, though. one on is to create shared understanding of the impact of the shortages and contracting practices, particularly around generics, that may be contributing to them, low pricing, et cetera, that may be driving that. we want to create a rating system around manufacturing quality so we can perhaps have a race to the top on drug quality. and the third is to promote sustainable private contracting practices. we've had a race to the bottom in terms of generic prokufrm

procurements. >> i think every one of those is what you need to do but you can get congressional back up to what you're doing in legislation that's moving through here. help us create the legislative mandate so we don't have drug shortages in america, particularly drugs that are not being produced because it's not as profitable as other drugs. no one would argue that the pharmaceutical community are not making enough money. why should we not have these drugs available? let's look for a legislative back up. your budget is good on tele-health. appreciate that. we have bipartisan support to expand that. we need technical assistance to your agency to se with back up tele-health in this country. that's where we can work together and provide a permanent basis to make sure we don't have drug shortages and expand

tele-health. i want to cover one other issue. we've heard your explanation on a medicaid cut you call medicaid growth. in poorer neighborhoods it's difficult to get providers to provide the access of care that we need. and the block grant type of proposal you're making could very well lead to lower reimbursement rates for medicaid patients. fewer services provided and less eligibility, which means there'll be additional effort for providers not locating in underserved communities. i just urge you, as you look at this, to develop the accountability system to make sure that we are providing top care to all communities in this country. because today we're not meeting

that goal and i'm afraid that if you turn medicaid into a block grant program, you're going to find a much more difficult circumstance for underserved communities to have adequate health care. >> mr. chairman, can you tell us what the plan is for the vote series in terms of questions. are we going to keep rolling? >> we're going to keep rolling. senator haskin. >> thank you, senator roberts and i want to thank the chairman and ranking member wyden for having the hearing. as others have noted this committee has passed bipartisan legislation addressing the high cost of prescription drugs and senator cassidy and i have been working with our colleagues on the health committee to end the practice of surprise medical bills. the administration's focus should be on working with us to

get those bills across the finish line and bring relief to patients and families not on cutting medicare and medicaid. secretary azar, according to the kaiser family foundation, nearly four in ten adults with opioid use disorder received their care through medicaid. state medicaid programs cover costs of medication assisted treatment, residential rehabilitation and outpatient therapy. simply put, medicaid saves lives moreover, according to your department the evidence is strong that managing substance use disorders provides substantial cost savings. this is a woman named ashley raymond who lives in new hampshire, this is a picture of her with her husband and two children. she started using opioids at age 14 and was unable to access treatment until getting coverage through medicaid. i met ashley last year when i

visited dartmouth hitchcock medical center rehabilitation from, where ashley is a client. without medicaid she would be unable to afford her treatment or prescription medication. mr. secretary your department recognizes the savings in lives and federal spending. how does that square with a budget that would cut almost $1 trillion from medicaid? >> so thank you. i hope that we will have your support for a new state option in the budget that would actually extend medicaid coverage for women pregnant suffering -- >> how does an almost $1 trillion cut square with our understanding that medicaid saves dollars and lives? according to the cbo, your proposed cuts would cause states to start the process of ending

their medicaid expansion programs, which would put 17 million americans at risk of losing coverage, including 57% people in new hampshire. it doesn't address the rising cost of health care, it does so by cutting funding and eliminating access. >> this one is a broader allowance in the budget to work with congress to address how to fix some incentives in congress that for instance have an incentive towards able bodied adults over pregnant women -- >> let me say this, i will follow-up with you but those proposals, too, are essentially cutting eligibility and keeping people away from health care as opposed to looking at the rate of growth in health care cost. so let's move on to a second question. as others have mentioned, your administration continues to

support efforts to repeal the affordable care act, including the backing the lawsuit that would strike down the law in its entirety. the president claims he wants to protect patients with pre-existing conditions, yet if the affordable care act is appealed, health plans will be able to deny coverage to individuals struggling with substance abuse disorders. in response to earlier questions you said those protections were somehow meaningless. to the people in my state who have preexisting conditions and can get health care and don't face bankruptcy if they get sick, this is not meaningless and abstract. can you point to specific policies in your budget that would protect not just patients struggling with substance abuse disorder but also pregnant women or people with diabetes or heart disease from receiving a denial based on what their plan could deem a pre-existing conditions?

are there specific elements in your budget that provide those protections? >> there would be no change to the affordable care act that doesn't protect president xi. so even if at some remote date and the remote possibility of the supreme court decision around the frakt affordable care act. the president will not veto anything with pre-existing conditions -- >> we would be farther along strengthening the bill if you weren't in court trying to cut it. i am out of time i'll follow up with you and your office about some of the recent settlements we've seen and some of the things we can do to prevent misuse of electronic health records.

thank you. >> mr. secretary, there's been a coup here. three senators aren't here, so senator cornyn, please. >> thank you, mr. chairman, thank you mr. secretary. please send our thanks to the folks at hhs doing the work day in and day out. i appreciate it. i guess i'm going to take the bait. many of our colleagues have talked about the lawsuit involving the constitutionality of the individual mandate in affordable care act. as you point out, it could be years before that litigation is finally concluded by the supreme court. in the meantime, the leading candidate for the democratic nomination for president of the united states is proprosing to do away with all private health insurance including the affordable care act and replace it with medicare for all.

if you're a member of a labor union and negotiated a good health care coverage, you would be prohibited from keeping that coverage and everybody would be forced into medicare. without having even paid the premiums over your lifetime to be able to help contribute to the cost of it. what would be the consequence to our public health system in america if medicare for all became the law of the land? >> medicare for all would be devastating to american seniors and the american people. right now american seniors get a real benefit through medicare, that's what we call cross sub designation. basically medicare underpays, and as a result commercial result has to overpay providers to keep them in business. if we move to medicare for all or medicare options that rely on medicare rates that gig is up for american seniors, the

benefit is gone. like we see in other socialist and european systems, a two tier system of health care is what we'll see. the better doctors flee the system and go off the books. so we reduce access for american seniors. it will take away with what people like. 180 million americans have private insurance through their employer or labor union. people want improvement in health care but they like their expectations there. that's why the president's philosophy is protect what works and make it better. don't take away what works for people. >> secretary azar, talking about prescription drug reform and bringing down the cost to consumers and to the government, i supported the finance committee bill, the bipartisan finance committee bill and look forward to continuing to work on that as well as other proposals. but we have a couple of bills

that have made their way out of the judiciary committee with regard to patent gamesmanship, one that addresses the patent problem where drug companies, for example, who make the drug humira have 120-something patents to block competitors from making it. meanwhile, in europe there are five different competitors available. we have this bill i introduced with senator blumenthal that was voted out of the senate judiciary committee, we tried to bring it on the floor several times but the democratic leader objected to it and blocked it, even though he admits it's a good bill, he says it doesn't do as much as he wants it to do. i'm willing to do more but let's

bank what we have in the hand right now. if the senate were to pass it and it would come to the president's desk, would you recommend to the president he sign that into law? >> i don't know if the we have a formal statement of administration position on that piece of legislation, i'll have to check and get back to you on that. but your leadership on ending these patent thickets is vital. we need to address them. so the particulars on that i want to get back to you on. you're correct, one drug alone the savings from bio similar market entry would be billions of dollars of savings but they layer patent on patent on patent. just added, added, extending beyond anything one would have thought of as the original deal of property. it's what's stopping us from having bio similar products in the states. they have to get to market, be reimbursed, there has to be

financial incentive to use them. >> the fiscal accountability rule is a concern to my governor, and in the state we're worried -- their stake holders are worried about the rule as proposed could lead to hospital closures, problems to access to care. i would ask for your commitment here to continue to work with us and stake holders in my state and around the country to make sure these concerns are addressed. would you make that commitment? >> absolutely. with the rule we will work with states to help them recreate their practices in ways that are in conformity with the statute and try to be fair and equitable in dealings with all the states. >> i'm holding a picture, as a lot of our colleagues have, of folks that we represent. these are the children of erin gabriel, she's from beaver county. you were born in cambria county.

the three children are abby, in the wheelchair, bridgett and collin. each of these children, all three of them have autism. they all receive the benefit of medicaid. thank god for that. erin's children depicted in the picture represent i think why we have a medicaid program. here's what erin said to me, quote, my children's health and lives are so much better because of the medicaid services they receive and they need to see their doctors and specialists much less because they receive these services early. so their lives are much better, but because they got services early through medicaid, they need to see their doctors and specialists much less. when we debate either the new regulation that senator cornyn just referred to, which is the subject of a lot of debate and

real concern, or whether we debate the budget cuts to medicaid, i and i know so many colleagues on both sides of the aisle will be thinking about families like erin's. i'm also thinking about a part of my state you're familiar with, and i think a lot of people are. i represent a state that has 67 counties but 48 of them are rural. i'll show you a map of the state but you look at most of the state and it's a state of rural counties. we have, i think, last count the largest rural population in the nation of any state, about 3.5 million people that live in rural pennsylvania. some states have a huge rural population, they just don't have as many people. when i think of rural pennsylvania and rural america we're thinking of rural hospitals, you spoke to some of the concerns you have about rural communities. i think about the jobs at those hospitals.

in my state, 25 to 30 counties, the first or second largest employer in the county is the hospital. and they're already operating under very tight margins. we know rural children use medicaid and chip at a higher rain than urban kids. that's a fact. rural children were 29% more likely than urban kids to live in poverty. so if you're a child in a rural community, the medicaid program takes on even greater significance than it does for other children. we know in 2018 the uninsured rate for children actually went up for the first time, as senator wyden said, in a decade. then we read the details of this year's budget, the medicaid cut is $920 billion, and then you have the regulation that the --

not only senator cornyn's governor but a lot of other governors have a concern in a bipartisan way. the letter dated january 29th says, quote, we're concerned that the proposed rule as drafted would significantly curtail the long-standing flexibility states have to fund services in their medicaid programs, unquote. so i ask you, on behalf of erin gabriel and lots of other families and the worries they have that the medicaid cut will hurt their family and the changes to medicaid expansion, the 17 million covered by medicaid expansion, many with an opioid or addiction problem. how do you, number one question is how do you justify those cuts? and number two, can you guarantee erin gabriel's children -- or guarantee erin that her children will never

lose coverage under medicaid as long as you're the secretary of health & human services. >> obviously any changes to medica medicaid are going to have to be done on a bipartisan basis given the makeup of both houses of congress. so these are proposals that we think fix some of the poor incentives for our children. the medicaid expansion created financial inscentives for state to focus on able-bodied adults over children, blind, disabled, and pregnant women. so part of the budget is how to restore the focus there and make sure medicaid is there for them. >> answer the question about the children. will they lose coverage? those three children with aut m autism, will they lose coverage? >> there's nothing that proposes to change the eligibility categories of traditional medicaid. >> i hope you can guarantee that three kids with autism will

never lose coverage as long as you have power. thank you, mr. chairman. >> senator roberts. >> thank you, mr. chairman. thanks for coming back. mr. secretary, thanks for coming. i think you're doing a good job. it's an even numbered year so you get adjectives and adverbs that are a little tough from the other side of the aisle, maybe here too. i have 105 counties, by the way, and there's about six that are not rural. 82 critical access hospitals that we have in kansas. and we are facing difficult situations way out there. and you are proposing a new model to allow these hospitals to convert to what we call an emergency facility that does not maintain inpatient beds. we've seen this proposal by med-pac and other groups in the

past but it's new to the budget this year. and the budget proposes these hospitals be reimbursed at medicare outpatient rates plus a patient to assist with capital costs. last year alongs with the rest of the kansas delegate we sent a letter to cms, requesting that the agency work with kansas hospitals in developing a pilot program for this model. they were in to see me yesterday i told them i was going to see you. i'm going to ask you on their behalf, my behalf, on when we can expect to see a new model from the agency? >> i'm afraid i do not know the details on that kansas model. i'd be happy to ask -- >> there's several models and you're working on yours. can you give me a time frame of those 86 -- yeah. i would imagine there's 10 to 12 on the edge?

if we can get some certainty and predictability, that's what i'm asking for. >> so the big change, the one that i'm very supportive of and i know you've been supportive of, the one you mentioned around critical access hospitals, boosting payments and allowing them to focus as emergency hospitals and not have to support the inpaisht beds if they're not viable to them, that would require legislation, not models. >> i have a bill on it, and i think a bunch of people are on it, just as well. let me move real quickly. the 96-hour rule, if there's anything that i think our rural care delivery system folks out there do not care for, it's that. and that requires our critical access hospitals as well to have a fizz certify in writing for each admission that the patient is expected to discharge or transfer within 96 hours. on top of the requirement to keep patients an average length

of 96 hours or less, this is a very burdensome and redundant thank. it could force hospitals to turn away patients. they could have provided with high quality care. i know of several situations that have happened when a person came in with a diagnosis that was not correct, not the fault of the folks there, just the way that it happened. obviously couldn't come back in until three days even though the situation was very dramatic. can you explain the decision process to include this policy in the last two bullets considering the proposal was not included in budget requests prior to last year? last year's budget incated that repealing the division certification requirement would have zero budget impact? this year is it it states that the impact is just not available. so if you could -- what happened in the last year that accounts for this change? >> i don't know the difference in model there, but thanks to your leadership, our budget does

propose to get rid of that 96-hour rule. it has all the absurdities that you have talked about. >> thank the lord. >> we want to make sure the providers can take time with their patients. one of them includes removing this physician requirement. that's an excess burden, even as you describe it there, it causes people to tilt their head and say, you have to be able to predict before somebody can come in exactly how it's going to work? we want to keep working with you to get rid of that. >> i really appreciate it. thank you again for doing good work. i yield back 30 seconds. >> before senator white house asks his question, for the staff of people that aren't here, i need to know if there's people coming back, because we got to let him go by 12:30 anyway. between now and then there's no sense of keeping him here if

people don't have a question. >> thank you stretch. i want to raise with you a rhode island situation that continues to bedevil me. for awhile, rhode island has been in kind of a reimbursement hole with lower reimbursement rates than nearby connecticut and massachusetts. we were not a high-cost reimbursement area. we were already under compensated. then came october of 2018. in october of 2018, your cms administrator, miss verma, unilaterally undid a rule, something called the imputed rule floor. which made our payment discrepancy to neighboring connecticut and massachusetts worse by 20 to 25 basis points.

she created this situation, where here in rhode island, we have westerly hospital at a 1.05 roughly reimbursement rate. and half an hour down the road, if, at lawrence and memorial hospital in connecticut, 1.35, 25. do the math. it's a 30-damned percent discrepancy. st. ann's in massachusetts which is literally five minutes from the border, they're at 1.28 compared. do the math. that's a 25% discrepancy. and what we got told at the time is, don't worry, there's going to be this big reform that's

going to smooth it all out. i feel i was lied to. i don't think there's been any sign of this reform. and then comes in budget. in this budget not only is there no reform, there's a demonstration project, which is the kind of thing that gets put together in fine minutes overnight when you don't have a real plan. and guess what the demonstration project has the nerve to say. that it's going to be the purpose -- here is the language from your budget. the demonstration aims to reduce sharp differences in the way jen deks and medicare payments between nearby hospitals. does that not mean that your organization knows that miss verma knows that sharp differences in the way jen deks and medicare payments between

nearby hospitals are a bad thing? >> so, senator, i share your anger and frustration about these disparities that are impossible to explain. >> this one you created. >> simply by geography. in fact i keep -- i keep with me this chart. >> thank you. >> because i do -- i do share that concern with you. the way jen deks is a perverse -- >> to be specific to my question, you do agree that sharp differences in the way gin deks and medicare payments between nearby hospitals, your language, are a bad thing, and that is why you want to reduce them? >> i do agree. >> great. >> i would like to -- >> could you please get miss verma to undo what she did over a year ago? she unilaterally made these sharp differences in the wage index and medicare payments between nearby hoptsz worse by a factor of 25 to 25%.

and we were already under reimbursed. lifespan hospital reports that $25 million las in the last fiscal year because of the decision that she made. you can go to other hospitals with similar patient mixes around the country, and they would be making money because of the way in which they're reimbursed. we had our reimbursement hole you kn unilaterally dug deeper by 20 to 25% by your administrator. we were not told the truth about what was going on. we now have this bogus demstration project coming out of no place as best we can tell, that admits that its wrong to be doing just what she did. this is a real consequence for our hospitals. they are in real pain as a result of this. and it is tiresome to no end that your bureaucracy just sits

around doing nothing about this, making it worse, actually making a problem that you identify as a purpose to solve, deliberately and unilaterally worse. >> can i -- senator, thank you. i do want to say, neither of us, the add mid- to upper straytor or myself have the you knowluni control over these policies. >> you did this one, she did. >> none of us have the unilateral control. and the challenge with the wage index, and it's you and i, and we've had a good partnership. >> i don't blame you. i blame her. i want you to fix it. >> senator cassidy. >> hi, mr. secretary, how are you? >> how are you? >> the antibiotic market, your wheelhouse has a person very familiar with the challenges in the pharmaceutic industry. we have these very resistant

organisms, and you want to have an antibooikt that covers them. but you're going to use it on very few people. and most of the people that you use it upon are either on medicare or medicaid, if you throw in v.a. it's going to be probably at least two-thirds, maybe four-fifths public pairs. one idea has been to carve out these extraordinarily important but rarely-used antibooikts from the drg, and to put them into medicare part b, but making sure you have the accountability associated with the stewardship program. knowing that we may end up saving known you have a shorter hospital stay, and of course lives if you have a more effective anti-bitic. any thoughts about that? >> you put your finger on exactly the problem with iechbt

microbial resistance in the next generation. it's something i'm wrestling with our team right now. we have a market failure, as you describe it so rightly. we want drug companies to invent an antiboikt that won't get used. >> yes. >> that is an economic problem. i am looking at different approaches. >> more properly it will be used rarely? >> exactly. one approach could be around our payment policies, as you mentioned direct pass-through payments. i will look at that. the other is it is increasingly rezblembling our bio terrorism counter measures, where the government oopz ois the only purchaser, almost a stockpiling government purchase issue. we have tools and we need to look at how those tools could be used for amr. >> i will say that there's at

least one antibiotic that the united states developed and was sold to india because the business model didn't work. as you say very expensive to develop but rarely used? >> we have got to ensure there's a commercial marketplace that's viable to sustain them or a government market. >> you said something which of course my ear perks up, that you're working perhaps on a solution regarding this. now, would this solution be in the offing? at what stage does this work? >> so it is still foundational, so i'd love to hear your ideas, we could work together offline about that. i've got my teams working on this, identified some of the reason, you can see in the "wall street journal," some of the recent challenges of these products and them even not surviving necessarily. and it's an economic problem. >> we'll bring in ideas to you. >> thank you. >> next another issue i'm interested it, the mentally ill,

currently they lose medicaid when they go into a jail setting. and so even before they're aj e adjudicated, they lose medicaid. if they're on a mood stabilizer, for example, that works for them, but it's not on the jail form lairy, then we get either not placed on something or placed on something innadcat and then decompensate and their behavior worsens or when they're released they are wandering on the streets as opposed to holding a job and paying taxes. i think the administration's budget allows them to continue coverage for six months while in jail. but i would ask that the definition of a jail is you stay there until you're adjudicated, why not extent it for an entire year? and then at least for the mental health issue, i think that would go a long way to addressing the

revolving door of the mentally illl going in and out of jail with disruption of care. any thoughts on that? >> it's an important question. we were able to get in the budget this year this prohibition of states terminating med acade coverage for the first six months and requiring that process to fa sill state the enrollment on release. we got that far. but you raised important issue about whether one should go further. happy to work with you on that, share the issue around that transition that handoff from incarceration and out to community integration. >> there's at least some suggestive data out of los angeles that the mentally ill are cycling out of jails. we need to begin to fundamentally address the issue of homelessness. i yield back. >> senator warner, you better be ready to.

>> of course. i'm going to start on a question that's already been asked, but i want to give a slightly different frame on that, and that's medicaid fiscal accountability regulation. and let me acknowledge on the front end, i get the goals of transparency, and i get the goals also that there's perhaps not everybody comes with fully clean hands. and this has been a challenge that's been going on for some time. in virginia where we finally expanded medicaid a year ago, we've got 375,000 people who have gained access to health care, critly, critically important. i absolutely agree with the bipartisan letter, that the national governors and the former governor, myself, i really want to make sure you've said you'll work with the states. but we really -- state, as you probably are aware, all states are going through their

budgeting process right now. and the way i read this regulation is, it could potentially come out sometime later this year and dramatically affect medicaid eligibility. and the payments plans that are in place. and that will wreak havoc in budgets, red states and blue states all across the country. so i hope that you will also commit to working to make sure that we work with the states, but we do so to make sure that we limit the impact, because this regulation will not be i don't think finished by the time most states have actually put forward their budget which they're actually a little bit better than we are in terms of meeting their deadlines. they will mostly be done by mid- to late spring. >> we understand the budget cycles of states and commit to working with the states to be reasonable in our approaches. you know, not every state has improper, these improper

transfers. some of this is transparency to even sidefy what's going on to make sure real money is being spent in the program. we'll work with states also to help them design ones that are compliant in the future. we're going to try to be very reasonable. we're in this together. we're not trying to cut medicaid through the m-far regulation, just make sure it's the right kind of spending. >> they are having with visiting with the some of the governors, there is grave concerns, candidly, that that is part of the goal of the administration, and i hear this from both democratic and republican grofrpz. i think it's reflected a little bit in the president's budget. i hope you will -- i'm going to be following this very, very closely. if there is a new systemic approach to this, that allows everybody to bring a little cleaner hands, i get it. let me move -- two minutes left. your inner opera bilt rule.

i think we talked about this at one point. i think one of the grave mistakes when, again there was large bipartisan agreement, the one piece around obamacare was we need to move to ehr, have better use of data. one of the major mistakes we didn't make is we spent all that money without any interoperability. my background was in cell phones. we would have never had a wireless industry in america if we hadn't required interoperability between systems. i support the efforts. but we've also seen in the years since it's been put in place the privacy, cybersecurity concerns, the vul nesh iblts of this approach is -- we've really got to be thoughtful about it. and i frankly do not believe, you know -- i took great exception to your cms administrator that said that technology companies are doing a

good job of protecting this information. i don't think they are. it's not just the equifaxs of the world that are grossly screwing up. and i think some of that -- we've seen lots of and lots of history amongst the health care providers. i want to make sure you move forward with this ruling, but i also want to make sure that consumers have rights for example to delete their information, have privacy protections. how do we make sure in this last 30 seconds, much longer question, i have much more, that we get this right? i agree with you on getting to the goal with you i'm i'm concerned we're not taking everything into consideration? >> first, thank you for creating the cybersecurity caucus. if ooud you'd ever like to come see i'd be happy to host you. >> we've contacted almost all the health care systems and you would be amazed at how they will

acknowledge and will share how unprepares they are. >> for hoptsz and others, i think cybersecurity is number one risk management issue for them. the interoperability rules, we want to hear you. the transfer of their informations, that is actually core to everything we're doing is patient ownership of their information and that transfer and consenting to that. as we work on final rulds on inner operability and information blocking, that is centerpiece. >> time is up. we want to work with you. i think there are mixed signals coming from the administration. >> senator brown. >> thank you, mr. shareman. mr. secretary, welcome. cholo rektal cancer is the saekd leading cause of cancer death among men and women in the u.s. the american cancer society estimates there will be many more this year.

we can prevent it or treat it successfully if we catch it early enough. thanks to the aca, the screenings are considered a preventive service and as a result they're avamu available at no cost, no co-pay, no deductible, another thing in the affordable care act. unfortunately due to a glitch, you get that cancer screening, a polyp is removed to prevent the potential for cancer, you wake up with a hefty co-pay. it discourages folks from getting the he screenings. i'm thankful the president's budget includes this to eliminate the out-of-pocket costs. my bill the removing barriers to screening act ensures that preventive cholo rektal cancer screenings are covered by waving the costs. even if a polyp or tissue is removed. my legislation has 61 cospoer

sores. 339 supporters on the house side. i would like to ask publicly mr. secretary for your commitment to working with me and the chairman and ranking member wyden in getting this done? >> absolutely. you were the one who brought this real anomaly in the statute to my attention. it's absurd that a senior goes in for a colon oskpy expecting to have no co-pay, and if they have a polyp which is what we're screening for, they come out of anesthesia and they get a bill. so you raised this to my attention, and i have worked to sho champion that and i'm delighted it's in the budget. we'll work with you. >> i thank chairman grassley and wyden. last year's budget hearing i asked you to commit to a number of things related fda efforts to curb e-cigarette use. when reducing nicotine to nan

addictive levels. you said absolutely. you went on to say you'd be driving for the effort to restrict flavors in e-cigarettes with full vigor, your words, you wouldn't hesitate to take more aggressive action. despite these strong commitments, hhs dropped its nick teeb redux proposal from the agent. it also back tracked on its promise to remove all flavored e-cigarettes from the market. the final last month exempted some vaping e-cigarettes and liquids. huge progress we made for 50 years bipartisanly is in jeopardy because of that. if you'd please tell me why has the department decided to cave to the industry and step back? >> actually, where we ended up was an even more aggressive posture than when we spoke last

year about this issue. actually requiring that those child-friendly ab and child-used flavors come off the market. we actually advanced to a more aggressive posture than before because at the time commissioner gottleib had been speaking about site of sale restriction there's. i want to be very aggressive on this one. february 6th has hit us, the enforcement date. the disposable cigarettes, if we see utilization there and disposable, we had seen the pod-based, replaceable items, were driving this. if we see movement we'll take enforcement action. nothing has to be set in stone. we want to keep these away from kids even as we want to make the aprorkds awabl to adults to move off combustible. >> i believe there's a white house where the white house on

thursdays and fridays looks like a retreat for tobacco executives. you need to do better. we need to do better. last point, mr. chairman, the president's budget recommends a cut of more than 9% hh snks. the primary payer of direct services is medicaid, the budget cut is a lot contrary to a promise in the president's campaign. whether it's the flu, addiction, coronavirus, medicaid is the most important tool states have to prepare for the inevitable and ensure people get care. the budget has not proposed cuts to medicaid but will slow the growth rate. that does not mean much to the hundreds of thousands of iowans who get left out. cutting medicaid will cause hundreds of thousands, maybe millions of people to lose health care.

i remember chapter and verse with governor kasich working with him to expander medicaid. the president claims to support pre-existing condition. his proposal to slash medicaid all to pay for huge tax cuts for the wealthy doesn't work for public health in our country. >> again, i just want to as we close, just wanted to thank you for your support and work on the coalo rektal cancer issue. i think that's going to be a huchlk event if we can get this passed. >> i guess that means you don't want to say much about the -- >> talk about medicaid, you know, on the medicaid program, you -- as you -- we are reducing the rate of growth from 5.3% to 3.1% in every single year of the budget outlook medicaid will increase expenditures. we set an allowance to work with congress together on how we can

grant flexibility to states related to expansion populations of able-bodied adults, how we can control the rates of growth and how we can fix the perverse incentive where we favor able-bodied adult coverage over kids and pregnant woman, the traditional medicaid beneficiaries we now prejudice against. >> would you in the last -- would you at the next time you see the president or at a cabinet meeting, i don't know if he knows he's lying about this or is just used to doing it, but would you correct him when he says he's supporting this? he's trying to take them away in texas lawsuit and here. i assume it won't change him. he'll still talk about how he supports it. but if somebody of your stature tells him he's lying maybe that would be helpful. >> senator hassan you have one question? >> yes, sir. >> and then we've got to have other staff speak up here, because we're going to adjourn

this meeting. i've got to go vote, too. >> yeah. and so do i. and secretary, thank you for again for being here. one note, we are already hearing from pediatricians in new hampshire that one week after the ban on flavored pods, teenagers are already migrating to the disposalls. it's taken one week for teenager behavior to begin to change, and they're still using these divises and the harm is still happening. i'd love to follow up with you on that. but the question i had was about transparency and recent antikick back settlements because i think we could work together. the department of justice republican announced a settlement with an lec tronkds record that was paid by perdue pharma so that providers would unknowingly pror overprescribe oxycontin. we have to be able to rely on

records. what steps are you taking to keep this kind of misbehavior to put it lightly illegal behavior from happening again? >> i just want to make sure i'm understanding this. i'm not familiar with that. is this an issue where a drug company got in the electronic medical record essentially an edit in there that coached towards a certain product? >> no, it prompted physicians to prescribe an opioid when the patient might not have needed it and it was paid for by pure due to the electronic records? >> i'd like to get back to this one, but i believe we've had efforts working with the major emr vendors at beck, to try to get them to actually put the nonopioids at the top of the list as they in terms of pain medication, so it's not right there. but happy to -- >> and this is really about the

integrity of electronic health records. we have to be able to depend on them, doctors too. was there a second settlement about making sure we're policing the drug companies correctly. second announced in january, a nonprofit co-pay assistance program found to have taken money from the drug company for the sole purpose of paying medicare co-pays for their fentanyl-based medication. this knowingly facilitated access to this drug for off laibl use. we've seen an increasing number of these in recent years. the drug companies have become more sophisticated. one way to protect fen fisheries and saver taxpayer dollars is to leverage transparency inored to identify these illegal relationships before they can take hold in the medicare program. does your department collect data on payments from drug companies to nonprofit co-pay assistance programs or payments to electronic health record

surrenders that could help identify this hostr costly and dangerous behavior? >> can you give a short answer? >> i appreciate that. >> i do not know about for sure what level of disclosure is. let me check and get back to you on when they submit that to medicare and medicaid. >> i'd love to work more with you. thank you for your indulgence, mr. chair. >> secretary, our thank you for being here today. like many of my colleagues i here from seniors across my home state of montana who are struggling with high out-of-pocket costs. tharz why i'm working across the aisle with this committee to lower the cost of prescription drugs and establish an out-of-pocket maximum in medicare part d in order to provide montana seniors with

badly needed relief. i'm zblad the administration voiced its support. can you explain how an out-of-pocket cap would affect the average senior in this montana? >> thank you, senator. and thank you for being willing to be part of this bipartisan effort on drug prices. let me give you a made-up example but i don't have betty's actual name. let's say there's a betty in helena who uses revlined. under the counter part d, she would have to pay $6350 before she would hit the catastrophic cap. once she hits that, she's going to pay 5% on all drug costs ar that point, to infinity. that can add up to a lot when you're talking about these kind of expensive therapies. now, those would also be frontloed in the benefit yes,

sir -- year. she would move through that deductible period and get to the catastrophic. in the plan the grassley/wyden plan that you have supported, that will provide two benefits. because of the savings we get, we create a new cat troughic cap at $3,100. she will never pay again for drug expense during that year. in addition, we allow her the option of spreading that cap over a 12-month period. she could elect to never pay more than $258 a month for her drugs no matter what her drug expense is. it's an incredible out-of-pocket change for the american senior if we can do this. >> thank you. that's a great example app and it's an important policy that i'm going to continue advocating

for this committee and getting a vote here. i want to shift gears and talk about meth for a moment. many states have been hit hard by the opioid epidemic, but in montana, we're facing a meth crisis. that's why it's been one of my top priorities in congress to ensure that our communities, our kpleemz, indian reservations, law enforcement, have the resources they need to help combat meth use. in fact i had the vice president, the vice president and concern pence came out to montana in june and got to see it firsthand, what's going on when we visited billings. the efforts include states like montana because we need to make sure we target the available resources where they're needed to prevent drug overdoses. i'm pleased the president's budget increases funding for state opioid response programs. and allows states to use these funds to address the abuse of meth in addition to the scourge

of opioids. my question is can you speak to the importance of allowing states and tribes to address thb unique community needs when it comes to combating substance abuse and drug overdoses? >> absolutely, senator. as you said, each state is going to be different. some are facing more of an opioid problem and some facing a meth problem. in 15 of the 36 states that report overdose deaths by drug type, meth use is responsible for more deaths than synthetic opioids even. between 2018 and 2017, we've seen a 30% rise in deaths from methamphetamine. as you say, it's a very big issue. these gangs out of mexico that brought us so much of the opioid crisis, as we have pressured them down on the opioids, they've expanded into commercial grade and commercial scale importation of methamphetamine. i was delighted from congress in

the 2020 appropriation allowed money to be used for stimulant and metham fet mooenz. we've continued that recommendation this year, that flexibility for states to address meth from it being the fourth wave of the addiction crisis. >> and on the time remaining, i want to thank you also for calling out the mexican cartels. this is the shift we're seeing in montana. we are a northern border state with a southern border crisis. and that is once upon a time the homegrown meth had purities in the 20%, 30% range. this mexican has purities north of 95%, far more potent, price gone down, distribution increased. this is why this is the battle. we've got to fight back home as it relates to meth. thank you for your help in that. i'm out of time, and i believe senator langford, you're up next. >> okay. thank you. secretary, thank you for being

here, for all the work, you've done a lot to be able to help folks have opportunities to get greater health care and options. i want to bring up something that's new that you proposed that my state actually was first in line to be able in engage in, the health adult opportunity initiative, greater flexibility on medicaid so they can taylor it. oklahoma is not alaska, illinois, new york, allowing greater flex iblts. where does that stand at this point for the healthy adult opportunity initiative? >> so we have put the guidance out to the states and are now really open to working with states. i think it's very important to robe, because a lot has been said about this opportunity for states to apply for this flexibility. this would preserve and the insurance would have to cover essential health benefits. no individual would be deemed ineligible. the requirements for the medicaid expansion would remain. there would not be other partial

expansion or partial deexpansion. this really would be for states to come up with ways to create a better approach for the expansion population, not traditional medicaid. only if the state wishes to be doing this. >> something my state is currently exploring. you've also out out proposals on part d generic tiering to allow a secondary to dry to get better benefits out there. if we could continue to lean in on that and make sure it's not just a benefit across the board but really a benefit to those folks that are the consumers and purchasers. where does that stand at this point and what are your thoughts on that? >> we have proposed that as part of part d, to create this second, allow the second drug plans to have the second tier. those are the more expensive.

i think they may be around $660 a month that triggers that. right now the regulation is actually somewhat disable the insurance companies from negotiating bigger discounts from pharma because it has just the one tier. this would allow there to be a more favorable tier. not more retrektive where but more favorable to entice drug companies to give more discounts in order to secure access to that tier of lower cost sharing. >> it's one thing we're working through to block some of the companies that are preventing drugs from going on the generic tier and pushing it on to the higher priced one. we're trying to work it out. several of us have mentioned things about the rural hospital relief. my state has seen seven rural hospitals closed of late. this is a big issue. senator durbin and i are working on legislation dealing with critical access hospitals and getting greater flexible.

i know you're trying to deal with that, to allow them to be out paisht emergency hospital. where does that stand at this point? >> i'm actually happy that it's in the president's budget this year to have congress to authorize us to allow that kind of flexibility to a critical hospital could have emergency function, out patient, but not be required to all the inpatient things. in addition, critical hospitals would elect for emergency so they could be reimbursed at the emergency rate as well as a supplemental amount of payment for them. >> we look forward to that. that will be important for all of us. we'll continue on with legislation trying to solve this. the university of vermont medical center made a decision to have a nurse during an eelective abortion be forced against her conscience to be able to participate in the abortion even though there were other nurses available and willing to do it.

she was compelled to be able to do that against her conscience. your team has reached out to the university vermont medical center has made requests to find out where they are, what their standards are. it's been months. has there been a response in that process? >> with any of these cases in our office for civil rights, we try to work towards resolution that brings into compliance. >> right. >> the university of vermont medical center refused to work with us on that. we had to issue a notice of violation to get their attention. where things stands now because that is a lauchlt matter, i couldn't go into detail. but the critical issue, we try to work with providers so they get commitment to bring themselves into compliance. >> we'll continue to be able to watch for that and see what we can do. one last quick question, dealing with nicotine levels in vaping. there's not a standard. several of the vaping devices have very, very high levels that

they know is the most addictive portion. this is an area we've raised to the fda to say, is there a way to get a standard for nicotine so these devices don't intentionally load them up to increase addiction. where does that stand? >> there's not a regulation under the pmta, the process we have for novel tobacco products, regulations setting a level. but in the course the may 2020 deadline the court has said for these e-cigarettes to come in and apply for approval or authorization, under the pmta looking at appropriate nicotine levels will be one of the factors we can examine in determining if an e-cigarette into the marketplace is furtherance of the public health. we can look at that. >> thank you. >> senator cortez masto. >> thank you, secretary azar, thank you for being here. so appreciate it. like my colleagues many of us

are concerned about the cuts to medicaid. similar to what i've heard earlier in nevada, we are one of the states that thinks the affordable care act we are able to expand medicaid, and many like this young gentleman here, alex come bares, he's alive because of medicaid. why are we making these cuts to medicaid? why are we putting vulnerable groups against each other? and how can you make those decisions to decide what life to save and not to save? those are our concerns. let me take this further. i am also concerned about what i have seen happening in indian country, and let me put this on your radar. because i know there's some good work that is being done. but i don't think people appreciate the impact that the aca has had on indian country. the law designates ihs as the

payer of last resort, helping stretch those dollars further. medicaid expansion, premium tax credits have boosted coverage and enabled ihs to collect reimbursements to allow them to hire more. it's helped ensure their facility met all required standards including those for ongoing accreditation or to undertake any needed maintenance, such as by repairing roofs and heating systems. the reality is that we know right now in a court of law, this administration is trying to repeal and take away the affordable care act including coverage for pre-existing continues. that's the law, realty. it's not con soeptual. if that happens, i guess my question to you is, what happens to indian country? how do we address their needs if we take away the affordable care act, coverage? what are we going to do to help them move forward and continue to have access to care? >> so again, in terms of the

litigation position, this has now been sent back to the district court for a searching analysis provision by provision. this is going to take time. go back to the fifth circuit and mash the supreme court. this is a remote item. >> let me stop you there. i'm an attorney. i was attorney general for eight years. i know what litigation is about. and when you go into litigation, you are setting forth your values and your principles as part of that litigation. so this administration has clearly said they think it's unconstitutional and want to take away the affordable care act and pre-existing conditions. no matter how long it takes through that course of litigation, you cannot sit here and tell me today that the administration position is that they support the affordable care act and they want to keep that coverage and pre-existing conditions. so don't try to walk around it somehow by saying this is going to be prolonged so we don't care, it doesn't matter right now. it does matter. that's what this administration

values, and it sets it out, and the american public needs to know that. please don't start with that. my concern is, if it's taken away right now, let's assume there's a ruling and it's taken away, what are we doing for indian country? >> it's not going to be taken away right now. that can't happen. unless you decide to work with us on reform or change -- >> i get that. listen, let's speculate. hypothetical, if it's taken away what do we do for indian country? what's the plan b? >> this administration has had historic funding so we've increased the budget by 10%. we've got an additional 3% in 2021. we're making critical investments in the indian health service. we put $85 million in this budget into quality improvement programs. we have created the first ever quality office within ihs trying to bring better outcomes. i'm trying to drive and i hope

we'll get the admiral confirmed as our director, i want to bring a quality safe transformation within the service. we owe this in indian country to deliver the finest quality service to our beneficiaries there. and it's not just about getting various facilities to meet their cmf certification, a baseline, but it's actually quality ingrained into the culture of every aspect of what we do in the organization. that's part of what we're doing but also what the admiral will bring if confirmed. >> good. a agree with you. i've had conversations with the nominee. i think he's the perfect person for the job. and i think we have to work together to really address the needs of indian country. so i'm glad to hear you say that and look forward to working with you on those issues. another area i want to talk about is alzheimer's research. in 2018 the president signed into law a law for the alls mooichlers act. it was a bill i cosponsored.

it tasks the cdc with overseeing preparedness and surveillance associated with the decease. in december congress funded the bold act grants. and the cdc is now getting ready to send that money out to states and local centers of excellence. those funds are going to support alzheimer's intervention focused on increasing early detection. this budget proposes to discontinue cdc's work on chronic disease management and instead task states with that work, using the new america's health block grant. it doesn't appear to include alzheimer's activities. so i guess my question to you is, does it? >> so the america's health block grant on that would actually grant flexibility to states to fund the areas of highest concern. right now cdc's chronic disease programs are very siloed, micro

machlkd by this area, this area, this area. the america's health block grant would grant flexibility for states to go where they need, alzheimer's surveillance, perhaps, as you're talking about. i believe that's correct. >> we've been fighting for this funding and i want to make sure pursuant to the act that the money is still going in and being targeted by the cdc. that would be very, very helpful. i appreciate that. thank you for being here. >> senator wyden. >> we have a vote on so you can count on my being brief. i'm going to cover two things. as you know i have been strongly opposed to the department allowing taxpayer funding faith-based foster care places to refoousz to work with patients. eight months later your department expanded this taxpayer funded discrimination announcing it would allow all of your funded grantees to deny

services to people on the basis of six or religion. now not only could vulnerable kids in foster care be denied, early childhood center could turn away a child because that child's parents are jewish or lgbtq people could refused demestic services. how can you claim this is protecting the religious litter of americans? >> we believe all individuals should be treated with dignity and respect, whether health care or other areas. we also enforce discrimlation laws that are paused by congress and want to enforce those. the regulation that you mentioned was promulgated singling out one particular supreme court case and posing

that as an obligation, and also risking the violation of the regulatory flexibility act in its implementation. we did not feel we could enforce that. we have a proposed regulation out that would require grantees to not single one rule out. at our core, we believe everybody should be treated with respect in our health and human service programs. >> all i can tell you mr. secretary is as i read the law, you went from essentially a pilot project to saying that all hhf funded grantees could deny services to people on the basis of sex or religion. i think that is horrendous. we're not going to get parents that we need for those foster care programs. let me ask you about one other thing, and that is, as you know, i have felt very strongly that

we're in the middle of an enormous transformation in the medicare program. back when i was director of the great panthers it was about acute care. now it's about chronic disease, cancer and diabetes and heart disease and strokes. and here in this committee, senator danes will remember this, we passed on a bipartisan basis the chronic care act. it helped the medicare advantage programs. it helped technology with, telehealth programs. and you could have programs for example medicare advantage programs, be able to pay for safety bars in a bathroom for those at risk of a fall. my question to you, because time is so short, what can you tell us is being done to make sure that this program gets extended to traditional medicare? because as you know, that has been an area where we said, look, there's a lot more to do, but the future of medicare is

not what i was dealing with when i was director of the gray panthers, broken ankles. the future is cancer, diabetes, heart disease, strokes, and people who have two or more of these. what's being done to address traditional medicare? >> absolutely. with the chronic care act that you led, it's really important advance in thinking about medicare for chronic care and telehealth as part of that. i'd say longer-term and traditional medicare, this is where i'd encourage you to look at what we're doing at the center for medicare and medicaid around direct contracting for total cost of care. if we can get providers, intgraded systems or primary care, and the applications are due very soon, if we can get them to actually assume total cost of care, we can get out of micromanaging them on the procedures, the individual procedures, instead paying for that longer-term outcome, and then having the financial upside

of effective long-term management, i believe long term that is what is causes the investments in real chronic care management like what you're talking about. they may decide because they have the skin in the game too put the bar in the bathroom or the rammelp at the house or a air conditioner because they'll have skin in the game. >> what you're talking about sounds constructive. if you could for the record give us a brief report about what the department has done since you all took office there, and what are the pronlz projects that you plan to do in the next year, i think this would give us something to point out. and you've always taken my calls. and i look forward to looking with you. >> uplifting to the hearing. >> thank you for your participation today. i ask a member who wishes to

submit questions to do so by close of business thursday, february 27th. with that the hearing is adjourned.

saturday nevada's clark county democratic party hosts a kickoff to caucus gala in las vegas. the event includes speeches by 2020 presidential candidates a week before the state's democratic caucuses are held. live coverage begins at 11:00 p.m. eastern on c-span. they say this is the pan halgded handel of texas is the only place you can watch your dog run away for two weeks. >> the majority in the pan handle wouldn't exist if it wasn't for the coming of the railroad.

♪ the c-span cities tour is on the road exploring the american story. this weekend we travel to am rillo texas. >> am rillo is in the center of the texas panhandle. we ateksatly call ourselves the capital city of the texas panhandlel. i think our super power here in the city is that we think regionally. >> with the help of our sudden link cable partners we'll learn about the history and life around here. as we talk with local authors. >> the state park today is a lot like it has been for thousands of years. all of a sudden you come across this huge drop into the earth. it's the second largest in the united states after the grand.

>> she was here twice, between 1912 and '14, she was in am rillo teaching for the public school system of am rillo. and in 1916 to 1918 she got a faculty position here. sometimes they don't write. o'keefe wrote prolifically. thk teach us so much more about this artist. she's struggling with just the kind of things you can imagine yourself struggling with. she's relatable. she's not this grumpy antiwar figure. >> join us this saturday at 5:30 p.m. on c-span book tv. and then on sunday. as the c-span cities tour takes you to am rillo texas. next a look at how the customs and border protection agency uses facial recognition in bio metrics technologies to identify people coming