tv HHS Secretary Confirmation Hearing CSPAN November 30, 2017 3:59am-7:01am EST
claim of any nature has come to my desk in the 11 months i have been chairman. >> [indiscernible question] >> had a senate confirmation hearing, president trump's nominee to head health and human services answered questions about the government's role in lowering prescription drug prices. he is the former ceo of the company eli lilly. this is three hours.
>> this in the committee will please come to order. cesars hearing is on alex -- alex azar. while the health committee holds a courtesy hearing on the nomination, the finance committee receives the paperwork and will vote on the nomination. senator murray and i will each of the opening statement and then former secretary and former governor of utah who we welcome today. good to have you back. senator young who is a member of this committee will introduce mr. azar after his testimony, signatures will each have five minutes of questions. we have a lot going on in the senate but we have a good
turnout so i anticipate a good, vigorous questioning. lead,ar confirmed to you'll the leading a $1.11 trillion organization that equals the total of the 12 appropriations bills that congress passes each year to fund everything from national parks to laboratories. you'll be overseeing medicare and medicaid. our nation's government run insurance programs for the poor and elderly, mental health and substance abuse, or you will have to address the opioid crisis among many other issues. the national institutes of health, where with francis leadership,llent the united states is leading efforts to develop a cure for alzheimer's. painkillerddictive to prevent opioid abuse and new treatments for cancer, the fda for scott gottlieb has gotten off to an excellent start for
speeding up approval of generic drugs and working to spur innovation and access to regenerative medicines. you will be faced with skyrocketing premiums and individual health insurance market that are currently a nightmare for the 9 million americans who don't receive a government subsidy to help pay for their health insurance. we also have an opportunity to implement what the majority leader of the senate called the most important piece of legislation last year. act whichentury cures senator murray and i and members of this committee agreed upon and gave broad new powers to the fda, the national institutes of health included the first major organization, senator murphy specially worked on that, mental aslth programs in a decade well as significant new funding for the opioid crisis, which virtually all of us support. i believe you are an excellent nominees this job. you have been confirmed by the united states senate twice.
you have offered to meet with every member of this committee and have met or spoken with 15 committee members. you have served in the judicial branch as law clerk for supreme court justice scalia. you know the executive branch, having been hhs general counsel for four years and deputy secretary for two years. and you know the private sector. you spent a decade in a leadership position at one of majoruntries pharmaceutical companies, so you know the system of how drugs get from the manufacturer to patients. with all these perspectives, you should need no on-the-job training to lead this department and should be able to take advantage of this exciting time in biomedical research to speed safe drugs through the system to patients more rapidly. i see your broad experience as one of the principal assets. experience in health care to me is an obvious asset for someone called upon to lead the nation's most important health care
agency. one reason dr. gottlieb, the fda commissioner has done so well so rapidly is he knows the agent the. and everyn commissioner, and he knows the private sector well, having worked in it. similarly, dr. collins knowledge of nih and his experience leading the human genome project has made him an especially effective leader at the national institutes of health. we plan to hold a third hearing on how the supply chain affects what patients pay for prescription drugs on december 12 two here from the national academies. given your experience, i would welcome your input as we continue to examine the price patients pay when picking up their prescriptions. health care is much broader than health insurance and only about
6% of the insured americans purchased their insurance in the individual market. but that is where we have had most of our debate and discussion. as i mentioned, 9 million individual markets don't qualify for subsidy. they are really getting hammered by skyrocketing prices. intimacy, premiums have increased 176% in four years and in addition -- in tennessee, premiums have increased 176%. senator murray and i and members this committee worked on an agreement cosponsored by 11 other republicans and 11 other democrats which the congressional budget office says will prevent a 25% price 2020 by in premiums by paying all sharing subsidies, decreasing dollars spent on a sea of premiums, and as result, lower the deficit. it will give the states
authority to use the waiver in the law to find other ways to lower premiums. for example, alaska created a reinsurance program and lower no newby 20% with federal spending. yesterday the president said he supported the alexander murray agreement becoming law but into the year. our agreement has so much in it that appeals to so many democrats and independents. it's hard to imagine our not passing something that prevents a 25% increase in premiums by 2020 and offers states electability to further lower rates. the democratic leader called it a good compromise and said it has the support of all 48 democrats. the chairman of the democratic national committee tweeted last , alexander murray has widespread bipartisan support. as secretary, there are many other steps you can take to lower premiums and stabilize the market.
the opioid crisis that is ravaging this country is a priority for the president and every member of this committee. we are having estate perspective on opioid crisis tomorrow. drug overdose deaths in tennessee went up by 12% from 2016.o it dramatically increase 74% in 2015 to -- pledged tos streamline programs and provide funding to states and communities on the frontline of this crisis, imprudent -- and putting preventing the comprehensive addiction and recovery act. we have included 860 million in the fiscal year 2018
appropriations bill. we stand ready to work where additional tools and authority is needed. some say that we need an opioid czar. in tellingll join me the president that this is a bad idea. once confirmed you need to be the one to take charge in leading the federal government response and letting us know how to help. exciting opportunity to implement the 21st century -- i hope you will work with us to includingtage president obama's precision initiative, the vice president's cancer moonshot. fda gave you and the authority to hire the scientists
it needs. i hope that you use these authorities to make sure we take full advantage of this exciting time. they will also provide oversight on the drug quality act. we will also try to figure out how to lower health care costs including the cost to patients who pay for prescription drugs. next to the committee will have to reauthorize the hand gimmick -- pandemic and all hazards preparedness act. making sure our nation is prepared for and able to respond to such emergencies such as hurricanes, diseases like zika, and bioterror attacks. there is a lot to do. i look forward to working with you on this and hearing more about your priorities today.
mr. a'zar, thank you and your family for being here and for your willingness to serve. because these were recent challenges are what this committee and the congress are discussing was supposed to be focused on, i will start my remarks with a few stories i have been told. my constituent julie is a four-time cancer survivor. she has said she would not be able to afford her medical expenses or even stay alive without affordable care act protections. kim from allensburg talked about her addiction to opioids and the
ability to overcome it. from marysville said before going to planned parenthood that she struggled to get birth control regularly. given her unpredictable schedule in the fast food industry. those are just some stories. there are many others and so many pressing health problems this administration could be solving. it seems it has been determined to create problems. the department has not attempted to help people get high-quality affordable coverage. they made it harder by stopping payments for out-of-pocket cost reductions. by letting insurers cover fewer benefits. by cutting the open enrollment period and slashing funding for consumer outreach and more. rather than allowing women to make their own health care choices, the department has tried to prevent them from
wentng care, even if they to a provider they trust. president trump went to states like new hampshire and ohio and said he would confront the opioid epidemic had on and called it a tremendous problem. this administration and its health department did the opposite. it proposed gutting medicaid which officers critical wrap around services and substance use disorder treatment to people who otherwise could not afford it. experts say it would cripple response efforts. all it took was a meeting with a few pharmaceutical executives for president trump to go dark, despite from us is of bringing down.ices the department has proposed using public health funds to close near term budget caps rather than to prevent costly illness and disease down the road.
they have utterly failed to see the urgency of the public health crisis is still going on in the wake of hurricane maria. the administration is rolling back protections that -- that prevent discrimination against people who have historically been denied access to health care. it shouldn't have to be said but the absolute last thing our nation's health department should be spending time on is encouraging more discrimination in our health care system. that is wrong. you and i do have stark disagreements, but your nomination could be an andrtunity for hhs to reset put aside the extreme politics and start focusing on the department as ignition instead of president trump's ideological agenda. people across the country would be far better off if you took this opportunity. , myazar, i have to say
review of your record leaves me with serious doubts that you will. eli lily is currently working to -- currently under investigation for working with other drug companies to needlessly raise the price of insula -- insulin. you made it clear on questions of women's health. ideology over science and right-wing politicians over women. although conservative experts, governors, and some members of congress have reject rejected -- have rejected president trump's attempts to sabotage health care, you said that this legislation would not spike premiums or undermine protections for people with pre-existing conditions, gutted medicaid, cost tens of millions of people their health care, defunded planned parenthood and more. you said it didn't go far enough. this leaves me very concerned about whether you would faithfully implement the
bipartisan agreement that the chairman just talked about with us. of president trump's profoundly underwhelming follow-through on his campaign promises about tackling the opioid epidemic, it is deeply --appointing that another hasn't supported committing the new resources we need for this effort. so i worry about your professional history and statements that point to a continuation of some of the extreme damaging and political driven approaches we have seen so far from this administration. let me return to the stories i mentioned at the beginning of my remarks to make my final point. right now, julie is traveling around the country raising awareness about open enrollment to help more people sign up. kim is pursuing a masters in social work and helping people
in central washington to get the necessary treatment and services so they can overcome their addiction. christina has become a vocal advocate for helping women in washington and nationwide to get care that works for their needs. christina ared doing more than their part to keep our communities healthy and well. my question is why isn't our nation's health department doing the same? people should have a secretary of health who will work for and with patients and families not against them. and who is committed to making policy based on science and not ideology. i'm looking forward to your thoughts on the many serious concerns i have raised and how you would be an appropriate choice for this position. i'm concerned that president trump has yet sent us an extreme ideologically-driven nominee to pick up where secretary price has left off and women and families deserve a lot better. so i'm interested in your responses today.
i hope i am pleasantly surprised and i do want to say if you are confirmed, i want to make it very clear i have not and will not let this administration's approach so far lower my expectations for any of the department this committee oversees, and i will continue doing everything i can to hold hhs to the highest of ethics andards service for people in my state and across the country. with that, thank you very much . >> welcome dr. azar. we also welcome your family and friends. we thank them all for being here. there's pretty good group of them and you may want to introduce them when you begin. mr. azar will first be introduced by governor mike leavitt. governor leavitt served as president george w. bush's
secretary of the department of health and human services from 2005 to 2009. he worked closely with mr. azar then while he served as deputy secretary. then the nominee will be introduced by his home state senator and member of this committee todd young. governor leavitt, please introduce mr. azar. leavitt: thank you, members of the committee. senator alexander and senator murray have very ably described the complexity and the importance of this role. and therefore, it's my privilege to introduce and to recommend he -- alex azar. he is up to the task and supremely well qualified to carry out this important work. as mentioned during my service as secretary of hhs, mr. azar was deputy secretary. chiefence, he was the
operating officer of this large and complex department. prior to his service, he served as the general counsel under sec i secretary thompson whom believe later will also introduce and robustly recommend him to the finance committee. that, plus his experience leads me to conclude that there may not have been a nominee to this office of secretary better prepared to hit the ground running than alex azar. it was mentioned that hhs is a large and complex place. while deputy secretary, alex azar was the manager of the day-to-day operations of 90,000 employees and $1.1 trillion budget. just a brief example of what i think would illustrate
his capability. president bush had a management agenda that laid out a criteria of several dozen different objectives, and then had a dashboard of green, yellow, red. alex had an objective to have every criteria green. he was the first equity secretary in the entire federal government to achieve that. he was also delegated oversight of much of the regulatory process. in a very skillful and lawyerly managed tohe processy adjudicate the which is robust. he's a world class policy thinker. you'll see that today. i can assure you, if he is confirmed as secretary, you can expect good communication on
both sides of the aisle. he is an experienced diplomat. experienced is a word that i think will be underscored here. i have seen him under fire. 911, he was part of the response. there was a point in time when , andna, pandemic influenza the rollout of medicare part b was happening at the same time. this is a personal with great experience in a complex department. say,important, can i just he is an extraordinarily good human being. he's got the kind of compassionate heart that i believe is required to serve to lead the mission of this important department. i commend him to urge the confirmation of the secretary of health and humanservices. >> thank you, governor. thank you for joining us again as you have before. senator young? sen. young: thank you, chairman and ranking member murray. and fellow members of this committee.
i am grateful to introduce a , to behoosier, alex azar secretary of the department of health and human services. president trump made an outstand -- outstanding choice to lead this critical agency which happens to be the largest civilian cabinet agency in the entire u.s. government. alex, as has been said, is an extreme the qualified nominee and a well known expert in the health care industry. his previous leadership experience, and as deputy secretary of hhs, and as president of india-based eli lilly incorporated, which is the largest affiliate of one of the largest health care companies in the world, will collectively be an effective combination as we work to solve our most significant health care challenges. former hhs secretary tommy thompson said that azar is one of the most competent people i
know. an experienced leader with deep , substantive health care knowledge. i agree. in addition to his impressive academic record, which includes degrees from dartmouth and yale, he clerked for the supreme court justice antonin scalia. he began his service in 2001, when the united states senate confirmed him to serve as the department's general counsel. since then, alex has been a leading voice in health care reform and health care innovation with a reputation as an effective leader. he has been particularly outspoken on the need to lower the price of prescription drugs saying patients are paying too much. if anyone can help solve this problem, it's alex azar. he's the right person to reform care systemealth
and can ensure the department succeeds in its mission to enhance and protect the well being of the american people. alex was confirmed to both of hhsprevious positions at with unanimous bipartisan support. confirmed twice by the united states senate for positions at hhs with unanimous bipartisan support. i'm hopeful this time will be no different. i note alex is a good man with a heart for service. i have gotten to know him personally over the years. i look forward to supporting his nomination and working together to ensure all americans have access to high quality and affordable care. thank you. >> mr. azar we invite you to , give your opening remarks. your full statement will be incorporated into the record. welcome. dr. azar: if i could take a second to introduce my family that i have here today, i'm pleased to be joined today by my wife jennifer and my daughter
claire, my son alex, my father dr. alex azar, as well as my sister stacey, and her team. -- her family. unfortunately, my mother could not be here today, and most tragically my stepmother wilma died of cancer just in july. i am very said she could not be here for this moment. having an opportunity such as this does not happen without a supportive family and their guidance. thank you, mr. chairman, members of the committee for the opportunity to appear before you today as the president's nominee to be thesecretary of health and human services. senator young and governor leavitt, thank you for those kind words, for your friendship, your mentoring over the years. i also thank president trump for the confidence that he has bestowed on me in nominating for this position. 97 years ago, my grandfather, and impoverished teenager who
spoke no english stepped out on -- stepped out of steerage on , completing his long journey from lebanon to america. as he entered the receiving hall at ellis island, he met an individual in a military uniform. that person possessed the power to admit him or to send him back to poverty and uncertainty. that person was a member of the united states public health service. it is a testament to all that i love about this country that just 97 years after my grandfather went through his six second physical on ellis island with no discernible prospects other than the political, economic and religious freedom that america offers, his grandson might be. in charge of that very public health service as well as the other renowned components of the department of health and human services. the mission of hhs is to enhance and protect the health and well being of all americans through
programs that touch every single american in some way, every single day. we are at an historic time in terms of delivering on that mission through innovation. through its outstanding leaders and career staff, hhs is prime to meet thatchallenge. that challenge. this task is humbling. it requires marshaling a leading the incredible resources of that department require innovating, never being satisfied with the status quo and preparing for the future. i think i gained these skills in the dark days after 9/11. as we faced a health and human consequences of those attacks. through the anthrax attacks and potential future biological, chemical, radiological, or nuclear attacks.
in the implementation of our completely novel prescription drug benefit, by helping to build state and local pandemic preparedness programs and our response to threats is such as sars and our effort to reform welfare programs to make them as responsive and empowering as possible for the individualsand individuals and families that we serve. through innovation and the private sector, to bring life improving therapies to ourpeople of the world and harnessing the power of big data and analytics to make us more capable of serving our fellow americans. with a department the size of hhs, it is often difficult to prioritize. nonetheless, should i be confirmed, i do envision focusing my personal efforts in four critical areas. first, drug prices are too high. the president has made this clear, so have i. through my experience helping to implement part d and with my extensive knowledge of how insurance manufactures, pharmacy and government programs work together, i believe i can bring the skills and experiences to the table that can help us
address these issues while still encouraging discovery so americans have access to high quality care. second, we must make health care more affordable, more available and more tailored to what individuals want and need in their care. under the status quo, premiums have been skyrocketing and choices dwindling. we must address these challenges for those who have insurance coverage and those who have been left out of the insurance market by the affordable care act. third, we must harness the power of medicare to shift the focus of our health care system from paying for procedures and sickness to paying for health and outcomes. we can better channel the power of health information technology and leverage what is best in our programs and in the private competitive marketplace to ensure the individual patient is the center of decision making and his or her needs are being met with greater transparency and accountability. finally, we must heed president trump's call to action and
tackle the scourge of the opioid epidemic destroying so many individuals, families and communities. we need aggressive prevention, education, regulatory and enforcement efforts to stop overuse of these legal and illegal drugs. we need compassionate treatment for those suffering from dependence and addiction. these are serious challenges that require a serious minded sense of purpose. if confirmed i will work with the superb team at hhs to deliver results. i thank president trump for this opportunity to serve the american people and thank you for your consideration of my nomination. >> i will just ask one question. i'd like to reserve two minutes askhe end so i can questions later. during the nomination process for the secretary ofagriculture,
of agriculture, there are concerns about his close ties to the agriculture industry. while moving treatments and cures through that agency. there was concern because he had worked with pharmaceutical companies. you have worked with a major pharmaceutical company in a major position for ten years. my own view is that that's a big help. having some familiarity with drug pricing as such a byzantine some a come inng who didn't know about it would be gone before they figured out 5% of how we might lower drug prices. what do you say to the skeptics who criticize you for that, especially those who criticize the increase in insulin prices while you were a leader at eli lilly over that ten-year period. mr. azar: mr. chairman, thank you for that question. as you and others have
mentioned, i had the honor of serving general secretary of hhs for almost six years in the senior leadership there. so for me, if i were confirmed, this is returning home. this is my place that i want to be. after hhs, i did spend ten years at eli lilly where i was a senior leader. eventually the president of the u.s. affiliate directly leading the sales and marketing of all oncology drugsot non-oncology drugs in the united states. as the geographic leader, i also supported operations for those other business units. i do believe, as the chairman mentioned, that these public and private sector experiences do prepare me very well for the role of secretary. this is especially true in the case of drug prices. the price of many drugs has risen substantially. in particular, insulin. the current system of other medicines may meet the needs of many stake holders but that system is not working for the patients who have to pay out of
pocket. we have to recognize that impact. that's why the president and so many members of this committee on a bipartisan basis and i have talked about the need to fix this system. i do think through my experiences in the public sector and at lily my expenses in the private sector, understanding how the channel works, how the channel sees these issues, how manufacturers, payers, pharmacy benefit managers, all distributors all work together. i believe i can hit the ground running to work with you and others and we can work to identify solutions here. >> i will reserve the plans of my time. thank you. sen. murray: let me just follow up. i think the cost of drugs is something i hear about more than anything else. it affects somany people in a negative way. and i'm assuming that you agree with the overwhelming majority that drug costs are too high. do you agree that congress and administrative actions are
needed? mr. azar: i absolutely do. sen. murray: as we know you are president of a major pharmaceutical company when it got worse. tell us how you would approach this as secretary? mr. azar: thank you to my senator murray. and i appreciate the chance we had to sit down together. i really enjoyed that discussion. also in terms of your opening, i hope if i'm confirmed, i hope i can earn your trust and show you this is the job of a lifetime for me. i would approach this not for any industry or past affiliation, but to serve all americans to improve their health and wellbeing. i think there are constructive things we can do but i'd also like to hear ideas from the committee, from people at hhs, and elsewhere, but let me throw a couple things out that are worth focusing on. we need to crease generic and
branded competition. the more drugs we get to the market, the more competition we have. that can bring down costs to the system. we have to fight gaming in the system of patents and exclusivity by drug companies. i have always been an opponent of abuse and gaming of the patent systems by drug companies. i led an effort to get rid of filing multiple patents to delay . the exclusivity saved $34 billion for consumers through the efforts that we pushed by reinterpreting. why are americans paying more than those in europe and japan and is that fair that we are baring the cost ofother nations. sen. murray: i am running out of time but i will say this. the skepticism comes from the world of pharmaceuticals and prices didn't drop. how will you do that as secretary? we can talk about it later.
there is this fox guarding the hen house, from what i hear. i know others will ask about that. i want to ask a question about women as ehealth because so far under president trump's leadership and former secretary price, a number of detrimental steps were taken that undermine women's health care, including appointing multiple antichoice ideologues, undermining title x, teen pregnancy prevention programs and critically rolling back protections for women to have full coverage for birth control from their insurance plan. ifi wanted to ask you, confirmed, will you commit to putting science and access to health care first rather than ideology and extremism? mr. azar: so senator murray, as we discussed in your office, if i'm secretary, i'm secretary for all americans.
i'm there to protect all americans, men and women. we have programs that this congress has created and that hhs is there to implement. i would faithfully implement those programs. we may differ in different elements of how those get implemented, but i firmly believe in following evidence and science where it will take us in running these programs. sen. murray: do you believe that all women should have access to health care that their doctor recommends for them? issue is thethe conscience exception, i believe we have to balance a woman's choice of insurance that she would want with the conscious of employers and others in a balance that's sort of an american values, trying to balance those and it's a very small group. sen. murray: the women's doctor recommended but you believe the employer has precedent over that?
mr. azar: not in terms of access, but in terms of insurance, to force those very few -- i believe it's less than 200 have come forward. very few employers that would be impacted by that conscious exception to respect their rights as well as respecting women's access through the insurance. i disagree. sen. murray: i think women's access to health care, their doctors require for them should take precedence. we disagree on that. i want to ask you about a question for senator and i have both raised. if confirmed, will you commit to implementing it as intended andworking with us to improve affordable coverage for patients. ? mr. azar: absolutely. sen. murray: i know that some people today are claiming that bill that we designed will fix other problems being proposed. do you think the cost sharing reduction payments will be sufficient to make up for chaos if other tax cut proposals are passed.
? mr. azar: i think the work of this committee on a bipartisan basis is awonderful model for addressing it. it recognizes problems with before the formal care act. there are problems with the implantation. there are going to be some new authorities in the package that you're talking about. those will be useful. i do want to caution, i don't believe it's a long-term solution to problems that are just inherent to the affordable care act that we need to work to address in terms of getting to affordable insurance. choice of insurance, that insurance delivering real access to health care for people. so not just a card but access to physicians and the insurance that lets the people get the insurance that they want not what we are telling them from the center. but it is an important stopgap to help along the way. sen. murray: i have other questions but i am way over time. i'll let the members ask at this point. senator paul.
sen. paul: i think most americans don't disparage or dislike people who accumulate wealth. we're fine if people accumulate wealth. if you ask americans, sam walton developed this great store and became wealthy. most americans don't think he's a terrible person or abused the system. i don't think americans have the same warm fuzzy feel inging for big pharma. i think most of us feel that they use their economic might to manipulate the system to maximize profits. it's not like they are selling a cheaper product to more people. they are using government to maximize their profits. do you acknowledge that the current system big far ma uses -- big pharma uses clout to manipulate the patent system to increase drug prices? mr. azar: there are clearly abuses in the system. that's why one of the steps that i mentioned to senator murray that we have to go after is the gaming of that. i have always believed we have a
waxman regime. it gives innovators a time period to sell the product. but there should be a moment with her should be full in the system and to the patients when they walk into the pharmacy. sen. paul: i will say this is a huge problem that's been going on for decades. we have had insulin since the 20s. everybody says they are going to fix it, but i tend to be a doubter because these problems go on and on and on. when you look at the drug problem, one of the things that people proposed was to allow us to buy drugs from europe, buy drugs from canada, from mexico or australia. in fact, this was the president's position when you -- when he said allowing consumers access to safe and dependable drugs from overseas will bring more options to
consumers. we have had legislation on this, i stated the position several times and it never happened. how do you feel about the president's position? mr. azar: i stated a position against unsafe importation of drugs into the united states. the president has said the same. reliable and safe. sen. paul: the drugs they use in the european union are unsafe? we have had a succession of democratic and republican commissioners who have been unable to certify under the law -- sen. paul: they have been wrong and beholden to the drug companies frankly. you'd have to sit there and say that the european union has unsafe drugs and it would be unsafe for americans to buy drugs from the european union or canada or australia. it is frankly not true. it's been going on year after year after year. we have this enormous problem and people say we're going to fix the drug problem and it never happens. what i think is important for america to know this isn't capitalism.
walmart is capitalism. bill gates was capitalism. big pharma -- it is not even their fault, they are try to maximize profit by using government but we are letting them do it. we have a terrible system. you get an epipen, you have it for 20 years, manipulate one little thing in the spring and they get another five years and another five years. so one of the things we could do that would dramatically change this is if you have a patent on the epipen for 20 years, you get it. if you change it and make it better, you get a patent on the new epipen. currently you can't have that. why don't we have generic insulin? it is going to take someone who really believes it. you have some convincing to make me believe that you're going to represent the american people and not big pharma. that is insulting and i don't mean it to be, i'm sure you are an upright person.
we also have our doubts. it is not capitalism. it's big government. we have to fix it. we can't tepidly go at it. we have to really fix it. you need to convince those of us who are skeptical that you'll be part of fixing it and won't be beholden to bigfharma. -- big pharma. mr. azar: as i said in your office yesterday, that issue of -- iplying the patents completely agree with you. i think that is one of the important avenues we ought to be pursuing. again, there should be a time certain when competition begins with generics and you shouldn't be able to simply make a change there and evergreen your patent. sen. paul: one thing in my last few seconds on the drug reimportation, we're going to give you a question that you can think about and write. so everybody says it's not safe.
my colleague's comments. another option is to figure out how to make prices the same. so people in america didn't have to go through the ridiculous contortion of having to import drugs from overseas but could afford drugs here. i want to congratulate you and your appointment and your willingness to serve during the difficult times. when president clinton left the white house, he left behind a projected $5.6 trillion surplus. and that's what he gave to president bush. then we fought two wars and didn't pay for those wars. we and acted medicare part d. which was not paid for. then we had the worst recession since the great depression. becameesident obama president we had a $1.5 trillion deficit. president trump ran for office. this is the one thing he was consistent on in his primary.
the republican party nominated him and the american people elected him. his promises were these. he would illuminate our debt over "a period of eight years." he would deliver a "massive tax cut." he would pass of the largest one increases in american history while saying, quote, i'm not going to touch social security and i'm not going to touch medicare and medicaid. those are the president's solemn promises to the united states. in the nine years i have been here, this congress has disgraced itself by not being able to pass a budget, having 30 continuing resolutions, by not being able to establish a set of priorities for the american people and we sit here today collecting 18% of our gdp and revenue and spending 21% of our gdp in expenditures. and on the floor this week, disgracefully, is a taxbill that would reduce that 18% to a lower
number, at least a $1.5 trillion additional deficit in our balance sheet. as much as $2.5 trillion. and the concern that a lot of people have in my state is that after this incredibley unpopular tax cut is jammed through with no hearing, that the administration is then going to break the president's promise to not touch medicare and medicaid and instead exploit the deficits that the republican majority has created in the time that george bush was president and now in the time that donald trump was president to go after medicare and medicaid. i'm wondering if you can assure this committee that the president through you is the head of hhs will honor the promises that he made on the campaign trail to make sure that he's not going to cut medicare and medicaid, which is what he said. i apologize for the long windup, but the history has been
forgotten by my colleagues and i think it's important. thank you, senator. it is a pleasure to see you and it was a great pleasure to meet with you yesterday. i hope we'll have the chance to work together. as i mentioned, one of the areas i want to focus on is about strengthening our medicare program. because there's so much mistake, fraud, waste, abuse in the program, and inefficiency in how we pay for health care procedures and sickness. if we can tackle that and if we can move to a value-driven system of health care, we can do two things that are important. we'll actually stretch out the resources and the medicare program to keep its solvency longer and along it to serve its beneficiary, especially as we reach the baby boom generation. it will serve as acatalyst for change throughout the health care system because so much of
the health care system free rides off of whatever medicare is doing on payments. so i think it's a really unique opportunity. the president is committed to both the strengthening, making medicare and medicaid as efficient as possible. sen. bennet: i hope we can do that in a way that isn't infected by the idiotic politics on health care we have had in this place. i completely agree that the incentives and disincentives are misaligned. we need to align them. it's also true that the reason why we are paying $1 in for every $3 we're consume inging in -- we are consuming and medicare is largely because of medicare part d, which was not paid for when it was enact eded by this -- and acted by this congress and under president bush. and because of the drug crisis. which is a double whammy that has caused us to blow this whole. so my concern, i have a fiscal concern, which i don't think is for some reason shared today by
my colleagues on the otherside -- other side of the aisle, but i have a concern that benefit. -- beneficiaries in my state are going to pay a price for the fecklessness of washington, d.c. i don't think that's fair. i hope we can proceed on a shared understanding of the facts. mr. chairman, thank you. >> thank you senator bennett. senator collins. sen. collins: thank you, mr. chairman. enjoyed, i very much our discussion in my office on drug pricing. i want to follow up on a couple issues. there was a recent investigation that found a wide variety of prescription drugs, uncertain -- drugs on certain insurance plans were actually less expensive when the consumer paid out-of-pocket than if the
consumer used his or her insurance plan. an example was a customer who had a co-pay of $43 for a common cholesterol drop where if she had not used or insurance, she would have paid less than half of that, $19. i met with a group of pharmacists in the state of maine. i was outraged to learn that they are under gag orders that prohibit them from informing their customers that there is this differential in price. that they would be better off and payingnsurance out-of-pocket. do you support prohibiting those prevent agreements that a pharmacist from giving true transparency on the drug pricing
to their customer? mr. azar: senator, thank you for the meeting. i enjoyed our discussion. how can you not hear about that and have your job -- jaw drop? how can you not find that frightening that that could go on? so i think those are the types of issues across the entire channel in drug distribution and payment that i want to bring the expertise i have to the table to work with you and others at hhs to try to resolve. that shouldn't be happening. there are many other things that shouldn't be happening in the channel. and how that system works. i think we can work together to come up with solutions here that are going to help haitians -- to pay as little as possible. that absolutely should be our goal. sen. collins: thank you. and i can't tell you how
frustrated these pharmacists were that they were una able to -- were unable to give that information to their customers who knew they were struggling to pay a high co-pay. a second issue that i wantto explore with you today has to do with the investigation that the senate ageing committee undertook into sudden price spikes in off patent drugs. we found that the risk evaluation and mitigation r.e.m.ies, or the system, which were intended to manage drugs with increased risk factors were being used by certain drug companies to block potential competitors from accessing a sufficient amount of the drug, once the patent has expired to do the bioequivalence equivalent --o
bioequivalency exams that the fda requires. and i have had extensive discussions with fda officials about this. dr. janet testified that the fda has referred 150 cases of potential anti-competitive behavior to the ftc. the ftc claims it doesn't really have enough authority. the new fda commissioner has suggested that there could be opportunities where the fda could partner strategically with medicare to prevent the deliberate blocking of generic competitors. from your perspective, how can we address this issue? mr. azar: i am aware of that also as one of the abuses that occur, generic-brand competition in the market. i would look forward to working with you to get to real solution the r.e.m. program
could be used to block entry. and once we get to the end of life, do the rems programs continue to make sense. are they legacies? are they still required for safety? be statutory changes, i don't know, but we need to solve that. that's one of the things that has to be solved. sen. collins: thank you very much. you referred to the end of life. mr. azar: the end of patent life! [laughter] thank you for clarifying that for me. >> senator warren. sen. warren: thank you, mr. chairman. i'll get right to the point. your resume reads like a how-to manual for profiting from government service. about a decade ago, you worked in government helping regulate the nation's most profitable drug companies. and when you left, you went through the revolving door and
became an executive at eli lilly. last year they paid you $3.5 million for doing that. not bad. and now you want to go back through the revolving door and regulate the same drug companies, at least do it until you decide to go through the revolving door again. i don't think private sector experience should disqualify serving, but the american people have is a right to know that the person running hhs is looking out for them and not for their own bank account or for the profitability of their former and maybe future employers. so i have some questions along that line. the first is, do you agree when a drug company lies about its products or defrauds taxpayers, it should be held accountable by the federal government? mr. azar: of course. sen. warren: good. because right before you went to work for eli lilly, you worked at hhs while they help the justice department with
an investigation of the drug zyprexa. it was approved to treat schizophrenia and bipolar disorder. but eli lilly decided to boost profits by pushing the drug ob -- on nursing homes for uses like dementia and alzheimer's. with no proof that it would work. the word for that is fraud. and it cost the government and taxpayers billions of dollars. eli lilly was still under investigation when you left government service and went straight to work for eli lilly. as the company's top spokesman, you helped manage the fallout in when the company was forced to 2009 pay the largest criminal fine ever imposed in a prosecution like this. $500 million. at that time, eli lilly's ceo
isd "doing the right thing nonnegotiable at eli lilly. " do you think that settlement represented adequate accountability for eli lilly's criminal behavior? mr. azar: so senator, i want to be really clear the conduct in that case occurred and ended long before i ever even left the government or thought about going to lilly. i was not involved in that case when i was in the government. i think i actually learned about even the investigation for the first time, although it had been in the media, i think i learned about it when i was interviewing and learned about it and wanted to do my own inquiring. sen. warren: then you became the spokesman for lilly. mr. azar: i became the global head of corporate affairs. i will tell you, the conduct that occurred there was unacceptable. and there's not a leader at lilly that would say differently. it was a massive learning and transformational experience for the company. sen. warren: was the settlement adequate accountability for eli lilly's unacceptable behavior?
mr. azar: it was the largest at the time for about a week and then another company had one. sen. warren: do you think it was adequate? that was my question. mr. azar: it was the largest ever. sen. warren: but was it adequate? what was senator, important about that is that it changed behaviors. sen. warren: i'm sorry. what is important is the and that is asking whether or not there was adequate accountability. mr. azar: i do believe so. i don't have any reason to believe not. sen. warren: lilly made billions of dollars off this scheme. and they paid a half a billion dollar fine. and they said that's a huge fine. the truth is it is a huge fine. but they made far more money than they actually paid out. and for me, that's just not adequate accountability. your ceo got to keep sleeping in his own bed at night. at the end of that year he was paid $1.5 million for his troubles and another $3.6
billion in so-called performance bonuses. i think the message was clear to other drug companies. within eight months, pfizer was caught doing the same kind of marketing. and slapped with a criminal fine. since then there have been four more drug company settlements in excess of these settlements have $1 billion. become a cost for doing business for the drug companies. and as we speak, eli lilly is the subject of multiple lawsuits and investigations accusing the company of conspiring to illegally raise its prices of its insulin products. but we're supposed to believe that this time around, you're going to be willing to hold them accountable in a way that's going to make a difference. shouldou think the ceos be held personally accountable when drug companies like eli
lilly break the law? mr. azar: so senator, there was a period of time where across the pharmaceutical industry, there were various practices that got resolved through litigation. what i'm quite proud of is the fact that i was not there as general counsel. i did not negotiate the settlement of that case. but the attitude that i saw top to bottom globally of the company around that was one of , how do we make sure this doesn't happen again? how do we ensure that the processes, the culture, the ethics, the oversight -- sen. warren: i'm out of time. i understand that i'm out of time. i just want to make it clear for the record i asked the question , about whether or not you think ceos ought to be held accountable when the companies they are running break the law? i'm just try to get a little accountability question answered. if you have a yes or no answer,
i'll take it. mr. azar: i'm satisfied with our discussion. sen. warren: i will take that as a no, you would not hold them accountable. thank you. >> senator cassidy? senator young? sen. young: thank you, chairman. you have been caricatured by predatory, avaritionary advisor. i want to say a few words here opposed to my giving an extended speech. can you talk about what you did in your previous tenure at the agency around the drugpricing issues? mr. azar: senator, thank you for asking about that. back in the bush administration when i was general counsel, there was a clear abuse occurring where pharmaceutical companies were taking advantage of a loophole in the drug laws to allow them to have longer, longer, longer patent periods. they would get to the end, they would file a new patent and get
another extension. and what i said to our legal team was this is unacceptable. nobody has ever thought of a way to deal with this without legislation. let us see, can we interpret the statute in a way that prevents that? drove that, drove that. we got to the point that we put out a rule that allowed only a single 30-month stay in litigations. you got one shot at the apple, instead of these things that could cause a drug to last for years and years longer. the economic impact of that rule was estimated to save consumers $34 billion over 10 years. that rule was later entliened through the leadership of senator mccain into statute. in the medicare modernization act. young: i would like you to
repeat that for those who may not have been paying attention and may want to fuel a false narrative that you are not sensitive to drug pricing. you created a process by recognizing an anomaly in the law that led to a regulatory change that saved how many billions for consumers in prescription drug prices? mr. azar: $34 billion over 10 years. sen. young: my constituents will be happy to know that. mr. azar, you participated in a symposium at the manhattan institute last year. do you recall that? mr. azar: i do. sen. young: at that symposium you stated we're on the cusp of a golden age of pharmaceutical breakthroughs, but the problem is our outdated process is threatening to squelch patient access to this recent and revolutionary burst of information by shifting a crushing burden directly onto individuals. a lot of americans paid for their drugs through health
savings accounts. is there something we can do with hsa's or other vehicles to help with drug costs? mr. azar: i do think that there is. so one of the things when you have a high deductible plan, that's one that has $6,000 that you have to pay out of pocket before the insurance starts paying. the law says that you -- that the plan can't cover during that period of deductible unless it but the government hasn't put out really good guidelines on what can be covered as preventive services so patients can have first dollar coverage, so their health savings account could cover those preventive services. also, changes that would allow more money to be put away, more flexibility, anything that lets the patient have access to more money or lower co-pays when they walk into the pharmacy has to be
part of what we drive towards. sen. young: i've asked that your past professional history. you were able to lower drug costs. i asked about any ideas you might have revolving around health savings accounts. you put forward an idea that could help reduce the cost burden on consumers. i'm encouraged by that. i hope others are as well. i have roughly 40 seconds left. president trump has indicated welfare reform will be a priority moving forward. it is a priority of mine. much of the policies that fall under the category of welfare are under the jurisdiction of hhs. i will submit a question for the record.
i want to see what sort of changes you anticipate hhs making through executive order to improve our welfare systems, and serve us. with that, thank you. >> thank you, senator young. senator hassan. hassan: thank you. good morning, mr. azar. congratulations on your nomination and congratulations to your family. as you know, new hampshire has been ravaged by the heroine and opioid crisis. we are in need of resources to help those on the front lines. flawed funding formula to allocate resources from the 21st century cures act, so the hardest hit states didn't get adequate resources. even though we've asked them to
change the formula am a hhs has declined to do that. that theig problem is trump administration has refused to request additional funding to fight the crisis, which has prompted many to question whether the president is serious about addressing it. we need this administration to send a request to congress for additional resources to combat the opioid epidemic. yes or no, if you are confirmed, will you commit to me that you will encourage the trump administration to ask congress for at least $45 billion to fight this crisis, a number that has bipartisan support? mr. azar: thank you. i'm glad we are able to have the discussion. i don't know the number, but what i will commit to you is, if i'm confirmed, i'm going to work
to assess if we have the resources we need. if i do not believe we have the resources we need, work with congress to do that. sen. hassan: i don't know a governor of either political party who believes we have the resources we need. will you also commit to examining all substances use funding sources and formulas and directing more funds to the states hardest hit by the crisis? sen. hassan: i don't know -- mr. azar: i don't know the precise issues, how much is statute and discretionary, but absolutely. i know your concern about the money going to new hampshire. i certainly will work with you to look at that and see what flexibilities there are. sen. hassan: the money has been distributed basically on population as opposed to the overdose death rate per capita in particular states. let's move onto another issue.
hasdrug company allergan engaged in unacceptable behavior to shield patents of its drug from review, in order to prevent generic products from entering the market, and denying consumers alternatives. allergan announced it paid a native american tribe to take ownership of the patents, and licensed the patents back from the tribe, continuing to sell the drug as usual, exploiting tribal sovereign immunity. allergan is renting the tribe's sovereign immunity to protect profits. the move ultimately is meant to stop generic versions from coming to the market. this outrageous deal was called a ploy by a federal district court judge. i would like to know what you think about this deal. should drug companies like allergan be allowed to rent out
tribal sovereign immunity to shield their patents? mr. azar: i do not know if i would have any actual enforcement. but i would say i would share your concern about any type of abuse around extensions of patent or protecting from whatever legitimate processes there are. sen. hassan: i appreciate that. if you are confirmed, i hope you will work with me and others on this issue, understanding there are multiple agencies that have some jurisdiction here. i want to touch on another issue. the country recently learned of the case of jane doe, a 17-year-old woman forced to continue her pregnancy against her will in the custody of a shelter that contracts with hhs. jane doe was eventually able to receive the abortion that she
decided was necessary for her and the court confirmed was necessary for her. that theme to light director of the hhs office used very disturbing tactics to block abortion access. seekingnted miners abortion care from meeting with attorneys. he suggested placing pregnant minors with sponsors who would override their choice about pregnancy. he personally visited pregnant minors to pressure them to continue their pregnancies. political appointees in washington at hhs should not be imposing their own ideology on these young women, nor should they be coercing or shaming them. if confirmed as secretary, do you agree you have an obligation to follow the constitution and the laws of the united states, even those you do not personally agree with? mr. azar: i take the obligation as a solemn obligation, absolutely. sen. hassan: i'm glad to hear
that. i will follow up in discussion with you. >> thank you. senator cassidy. : enjoyed our conversation yesterday. thank you. i'm a physician. i've worked in louisiana, taking care of the uninsured and the poorly insured, which is to say medicaid patients. there's a lot of data that patients covered through medicaid oftentimes have worse outcomes than those who are covered through other forms of insurance, even when correcting for disease burden and social economic factors. clearly we should have a bipartisan interest in having outcomes data that shows who is doing a good job and who is not. if someone is doing a good job, reward it. if not, find out why. fair statement?
mr. azar: i couldn't agree more. sen. cassidy: i'm told that for medicaid and chip, right now there is in theory a structure for this outcomes data to be accumulated and prepared. thoughts on that? mr. azar: i do not know the data sets, but if confirmed, i will gladly look into that. evaluating always be programs to see what works, what doesn't work. our goal is that people have affordable care, access to care. we ought to be using any data we have to find that. sen. cassidy: yesterday, you were meeting with senators from both sides to go over certain issues. our ranking member and chair have been very good about that. what can we do to have better data sets so that patient outcomes can be monitored? if you don't measure it, it doesn't improve. we need to measure that.
mr. azar: i appreciate your invitation in the event that i'm of processo any kind to work through these issues. if i am confirmed, i hope you will find that my style is, i don't believe i've got the answer to every problem. i want to have an open dialogue. i'm a problem solver. my brand is that if there's a program that is not working, i want to work on solving that problem and get the best input and best ideas. there's something you can do administratively, we don't have to mess with it. if there's something you need legislatively, that is the purpose of this. mr. azar: if there are ideas about what can be done, i would want those ideas also. sen. cassidy: public health, i as working with others regards how to have a public
health fund. we've got another zika, it doesn't take a special appropriation, just to give you my thoughts on that. under katrina, congress had to appropriate money to respond to katrina. out, let's putd the money up front. from my perspective, we should be doing that for public health as well. what thoughts do you have as regards how we can help you better respond to public health emergencies? mr. azar: i was one of the architects around project bio shield. i really see the benefit of having predictable funding and the ability for the government to be a reliable partner in the development process. i would be happy to work with you. sen. cassidy: how do you safeguard from the money being frittered away on things which are not public health emergencies? mr. azar: one would have to draw
the line. i would share that concern. you would need to make sure it is built into a program for public health emergencies like zika, ebola, or the countermeasures development programs. sen. cassidy: this may be something to encourage that you monitor. i, if i say white house, they think pennsylvania avenue, sheldon and i put forward something for health i.t. my physician colleagues are retiring at age 55 because they are sick of electronic medical records and the dampening on their ability to interact as well as their productivity. includedh i.t. act was , supposedly it is progressing well, any thoughts about that and how we can ensure that health i.t. becomes an enabler
of patient physician relationships? mr. azar: i need to be careful here because my father may jump to the table and start telling you about all the problems you are talking about. i think when secretary leavitt was secretary and we went down the journey on health i.t., he was adamant. electrification of health records without interoperability is not useful. that is just moving files to a different place. i'm afraid we've done a bit of that. we've electrified, but we haven't gotten interoperability. we have made it to complex. i would love to work with this committee. i will work within hhs to drive towards interoperability. it should be an enabler.
the doctors eyes should be on the patient, not on the computer screen. sen. cassidy: fantastic. i yield back. >> during our 21st century cures, we veered off to the side and held hearings on electronic medical records. all of us are interested in it. we made some progress with the last administration. tomay set up a roundtable try to continue that focus over the next couple of years. senator baldwin. sen. baldwin: thank you. thank you, mr. azar. there's been a lot of discussion about experience, insight, as well as potential for conflicts. obviously experience and insights can be extraordinarily helpful.
presidentd from the that he wanted to drain the swamp. we've heard phrases like, foxes guarding the henhouse. and the revolving door. that, the perspectives you would bring, having served in large pharmaceutical corporations in a leadership post, brings a very specific perspective, especially as we tackle one of the critical problems of our day, the high cost of prescription drugs. hearing recently in this committee on drug prices. i felt there was a lot of finger-pointing from the folks
dais, talkingr about whether they were from the perspective of big pharma, or pharmaceutical benefit managers, or all the other players in this system, citing complexity, citing their fault, not ours. but because of your background in the pharmaceutical industry, i would like to not hear finger-pointing, but what can be done. whove many constituents share personal stories about their challenges with the increasing and skyrocketing cost of life-saving medications. wisconsinstoddard, sons with type 1
diabetes. extending over $1000 a month just to maintain insulin and test strips. president at eli lilly, you were there during a time that there were radical increases in insulin prices. 1000%reased more than since 1996 and over 200% during your tenure. , moreu tell us specifically greg and his sons, why eli lilly and other companies are systematically increasing the list prices of drugs that are already on the market? mr. azar: thank you for that question and thank you, i really
enjoyed our discussion the other day on this and other issues. finger-pointing, i've been really clear, even when i was at lilly, finger-pointing is not a constructive enterprise. everybody owns a piece of this. the government owns a piece of this. that is why i want to serve. the experience i bring can help me with changes that one company can't impact. sen. baldwin: my question specifically is, what would you tell greg and other constituents about eli lilly's role? mr. azar: the insulin prices increases have been significant. the problem is that system. greg and his kids -- o i should tellho
them it is the system? what about the drug manufacturers are the starting point? what should i tell greg about increase during the time you were there in the price of insulin? mr. azar: what we need to do is work to fix so that greg and his kids have insurance that covers that insulin, so they have low out-of-pocket, so we have to get the list prices down. sen. baldwin: that starts with the drug manufacturers. this is reminiscent of the hearing we just had. it is a complicated system, this and that. it starts with manufacturers setting the list price. i see i'm already hitting my time and i had lots of questions. you talked about generic and branded competition. you talked about the gaming of the patent system. there's a bit of q&a about
reimportation. the things i want to talk about, the role of transparency and getting the pharmaceutical companies to justify their increases in price. i have a bill along with senator mccain to require that for companies planning on increasing their prices. and secondly, the role of negotiation. thank you, senator. senator isakson. sen. isakson: thank you. i'm glad we didn't have our meeting before this. i'm going to ask a question i might have been talked out of asking you. having heard ms. warren, having been part of the debate, being a senior that buys a lot of pharmaceuticals myself, the cost
of pharmaceuticals, the gaming of the system, is a huge issue. at the risk of being presumptuous, i would give you a homework assignment that i hope the chairman and senator will back me up on. will you come back to us with your recommendations on what to do to help end the gaming of the system? mr. azar: absolutely. sen. isakson: you are uniquely qualified, having been a ceo, knowing what you know, taking on the responsibility you are about to take on, to say these are the things that are being abused by the pharmaceutical companies or whoever it is. i'm not interested in blame. i'm interested in solutions. oftentimes these debates and responses end at obfuscating solutions that otherwise might be talked about. mr. azar: i would look forward to the opportunity. sen. isakson: secondly, i live
in atlanta, georgia. i've been a representative for 20 years. cdc, the home of world's health center, which got very little notoriety, but solved the ebola problem when it contained an outbreak. same thing with ceca. -- zika. we were able to get people under care, isolate them, treat them, and all for who went to emory survived ebola infection. commitment that you will continue to advocate for cdc and its funding and its ability to meet the challenges of the 21st century. we don't yet know what they are. the cdc and its leadership and career staff are
the envy of the world. i share that view. sen. isakson: they've saved a lot of lives and prevented so many tragedies from happening. this may seem to be a silly question. i was a salesman all my life. the medical loss ratio in the affordable care act includes the cost of a sales commission as part of the medical loss ratio formula, which put most people who sold health insurance to individuals out of business. the commission they would be paid, though very modest, would throw it over the cost ratio. today would try to find a way to get insurance. there's no financial insurance, security, for anybody to offer them, because they are priced out. senator kunz and i have
introduced legislation to end that by taking it out of the calculation. i think that will expand access and exposure. would you help us with that? mr. azar: i would be happy to work with you looking at that. it is an issue i haven't focused on. i had not known of that concern before. sen. isakson: thank you very much. >> thank you, senator. senator franken. sen. franken: thank you, mr. chairman. congratulations on your nomination. i would like to ask a few short questions, yes or no. are you aware that the aca required health plans to cover evidence-based preventive health services free of charge? mr. azar: there's a provision -- those are part
of the essential health benefits, if i understand the framework correctly. sen. franken: are you aware that hhs commissioned the institute of medicine and the independent nonpartisan organization of experts on health and medicine to review what preventive services are necessary for women's health and well-being? the institute of medicine recommended coverage for all fda approved birth control methods free of charge. mr. azar: i believe that is the case. sen. franken: do you agree with the conclusion that access to free birth control is vital to women's health and well-being? mr. azar: separate from the issue of any birth control or which ones should be covered, one of the principles we have around thinking about access to insurance, is it ought to be assurance the individual wants to acquire. if i have concerns, my concerns
are at a much more precedent level, not about this drug, that product, but rather, should there be flexible for the individual to choose the insurance package they want? animus toward any preventive service. our system off to enable flexibility that does not exist with the current framework. but you agree thatou the institute of medicine's conclusion that free birth control is vital to women's health and well-being? mr. azar: i haven't studied the report. programs has important to provide family planning assistance and services. sen. franken: do you agree with the institute of medicine's conclusion that access to contraception free of charge reduces unintended pregnancy, which reduces frequency of abortions? mr. azar: i haven't studied it.
it seems to make some sense as you state it. sen. franken: do you agree with the institute of medicine's conclusion that reducing unintended pregnancy also reduces the health risks associated with such pregnancies, and that contraception helps women to increase the length of time between birth, which reduces maternal mortality and pregnancy related convocations? mr. azar: i think we all share the goal that unintended pregnancies, especially by teens, is something we want to work to prevent, and educate, and use our programs to support that. sen. franken: do you agree with the trump administration's actions to undermine the access to birth control? mr. azar: on that issue, that is a balance between the essential health benefit and the conscience of the organizations involved. i think it was close to only 200
organizations, whereas the actual affordable care act implementation around the contraception mandate actually excluded tens of millions of people who were in grandfathered plans. this conscience exemption has a much smaller impact, i believe. sen. franken: the law requires that preventive services be evidence-based. this is evidence-based. hhs you take steps as secretary to make sure that women have free access to contraception? mr. azar: i will follow the law. if the law requires the coverage and the evidence and science and facts support that, i will follow the law there. i will also, as the president has done, try to balance the conscience objections of organizations and individuals. sen. franken: a number of my colleagues have expressed concerns regarding your track
record and eli lilly's track record on drug pricing, and i share their concerns, especially in regard to eli lilly's actions to spike insulin prices. i'm running out of time, so i'm not going to be able to, but i wanted to get into medicare drug price negotiation. the president has said he is for medicare being able to negotiate in part d with the pharmaceutical companies on the price of drugs. do you agree with the president that medicare should negotiate for lower drug prices? sen. franken: the president -- mr. azar: the president has spoken to the fact that medicare is negotiating and getting the best prices. part d has negotiation through the biggest pharmacy benefit managers that secure the
best net prices of any players in the commercialsystem. -- the commercial system. i sat on the other side of that. what i'd like to do is think about how can we take the learnings from part d maybe into part b? part b is the program when a physician administers a drug, the government simply pays the sales price plus 6%. how could we think about ways to take the learnings from part d and actually bring lower costs to the system but also lower costs to the patient, because they pay a share of whatever medicare reimburses in part b. that's a double win. it could lower for the system and lower for the patient on their out-of-pocket. that's the kind of thing i would have energy to see where we could actually really save money and improve things for our patients.
>> i'm out of time but i would just note that the v.a. is able to negotiate for prices for their drugs and i think in medicare part d we should be able to do the same thing they do in the v.a. >> thank you, senator franken. senator roberts. >> thank you, mr. chairman. mr. azar, alex, thank you for coming. congratulations on your nomination and thank you for being here today. it's already been stressed about your prior work at the department of health and human services, as well as the confidence in you shown by the senate. sometimes we have to do a multitask here. i apologize for that.
but at any rate, the confidence shown by the senate to unanimously confirm you to positions at that agency twice already and highlight the strength of your qualifications. i appreciate the chance we had to chat. i think it was monday. some particular areas of interest for me, improving our care system. you are a hoosier but you did find a kansas girl to marry. as the folks in kansas know, there's nothing better than a south raider. i wanted to make sure that you understood that. thank you for bringing your family. as both a member of the health committee and chairman of the agriculture committee, particularly interested in hhs and more importantly the fda's
work on food and nutrition policy. we talked about that. a common message i hear is the need for regulatory certainty. just a moment. i beg your pardon. will you turn that off? thank you. more importantly, fda's work on food and nutrition policy. a common message i hear is the need for regulatory certainty, in particular on the biotech front which is a critical tool for agriculture today. back in january, both fda and the usda proposed rules and guidance on biotechnology. recently, as a recent stake holder comments, the usda's animal plant and health inspection service has decided to withdraw the proposed rule, reengage stake holders and solicit comments to create a new rule. if confirmed, what steps would you take to engage and coordinate with other agencies involved with the regulatory review of biotech products to harmonize future rule making efforts? >> i'm not familiar on that particular rule making with the pullback, but i can assure you
that i would share both goals that i think you have articulated. the first is it is the job of the government when regulating to give clarity. they want to comply, they want to know the rules of the road. the second is especially in the area of food safety the level of coordination between hhs and the agriculture department is absolutely essential. i appreciate that very much. -- absolutely essential. >> i appreciate that very much. i just want to make one other observation, mr. chairman. i've been watching your children and these youngsters are here and i've been watching your dad. your dad is very proud of you and your wife is obviously very proud of you. i want to tell you young folks welcome to politics 101.
-- polly site on a one. we're asking questions that many members have on their mind and they're very important questions. i want you to be proud of you dad. he's done a good job in the past. he will do a good job in the future. he will be confirmed in my view and not only by this committee and not only by the finance committee but also on the floor of the united states senate and then also by the president. that's a long process. sometimes it gets a little tough. we ought to be handing out selective earmuffs for young people. be proud of your father. he's a good man. thank you. >> senator roberts. senator whitehouse? >> welcome, cesar -- mr. a's are.
i don't think there is much that you and i are going to accomplish today on the question of drug pricing, but i hopevery -- hope very much in office you will take the side of the american people and not just the pharmaceutical industry or worse yet the investors who have raided the pharmaceutical industry with the solo mission to jack up prices on necessary pharmaceuticals and extract money with monopoly authority. we know how to deal with that ordinarily. i want to talk about a different situation, which i think is an opportunity for considerable bipartisan progress. i want to start with tworhode -- two rhode island stories. you know what a medicare aco is. i do. -- >> i do. >> we have two in rhode island. one is a very early one, coastal medical, which over four years has saved medicare $28 million relative to its benchmark while maintaining a 99% quality score.
that makes it one of the best in the country. its average per member per year expenditure is going down, while the satisfaction and health of its members are going up. similarly, integra community care network has saved medicare $12 million while achieving a 95% quality score. i say this not just to bragon -- brag on rhode island providers but because i think , it is the answer to a much larger question that we face which is -- here's the graph of health expenditures more or less in my lifetime for the country. 27 billion to 3.2 trillion. it's a curve that is breaking the bank. we have got to figure out how to
fix it. one of the ways that we can look at fixing it is to look at this oecd chart which shows a lot of our competitor nations right here. there's the usa as a big outlier. this map's life expectancy puts us at the highest cost per capita for health care in the world and gives us life expectancy comparable to the czech republic and chile. we're actually beginning to see a little progress here. let me explain what this is. this top line, the red line, is what cbo predicted for federal health care expenditure back here when it made the prediction in 2010. then events moved forward post the affordable care act. sure enough, we were coming in below. here in 2017, the baseline was rewritten by cbo. the difference in this ten-year budget period between what cbo
predicted in 2010 and 2017 amounts to $3.3 trillion in savings. so the case that i would make to you is that if we want to take on the health care cost problem, we've got to take it on through entities like these aco's, because there is a sweet spot that we can bring that cost back from our outlier position in the united states while improving the quality of care. i've seen it happen in rhode island. the reason the cost is going down for coastal medical's patients is because they get home visits when they're sick because there's telemedicine that gets their testing results in because a nurse will call them when they don't hear with them. over and over again, it is better humane engagement that reaches the patient where they are that has this wonderful benefit of improving health and
patient experience while also bringing costs down. we're not seeing less increase in the cost-curve from integra and coastal medical. we are seeing cost per medical going down. promise me you will not get idealogical when it comes to solving this problem and you will work to solve it in a sensible, bipartisan, thoughtful way. >> i would just say amen. just hearing those stories is exciting to me. it is i think one of the great legacies of secretary burrwell's tenure was launching so many of the alternative payment models that we have out there. that was that third leg of my priorities if i am confirmed as secretary. i think for those of us who care so deeply about improving quality, reducing cost in our health care system, improving coordination.
there's just so much opportunity for bipartisanship here because we share so much of the same goals on this. medicare can play such a role. it's the only payer that sits there with enough concentration of lives to change the system. >> correct. >> i think united health care -- i don't think there's a market that has more than a couple percent of patients and has to follow what medicare does. >> i'm going to invite you to come to rhode island and see these guys. >> i would love to. >> i look forward to that visit. >> thank you, chairman. senator casey? excuse me, i made a mistake. senator murkowski is here. >> thank you, mr. chairman. i know i'm at the end of the dais and came in later but there
is added benefit to being one of the later ones and having the full opportunity to not only hear most of your opening comments, sir, but to hear the questions and inquiries in your responses back. again, congratulations on your nomination. i will also be curious to hear your response to senator paul's inquiry regarding importation of drugs. certainly for those of us in alaska where our neighboring country is canada. many in my state wonder why we are not able to do more when it comes to safely importing. i too am curious to know what you might propose in that area. senator baldwin mentioned the hearing we had some weeks ago about drug pricing.
and i think a general level of just confusion and bemusement that many of us had, we're engaged in a fair amount of finger pointing. when you try to drill down to how we can do more from a transparency perspective, i think this is something that we all recognize that we can do a better job with. again, i look forward to more detailed response from you. we're going to have an opportunity to meet tomorrow. so i will probably hold more of my alaska specific questions for that time. one of the other discussions that we have had in this committee recently as we have been discussing the aca and some of the requirements within it.
we had recommendations from some who have suggested that the navigator program currently in place no longer needs to be funded. the president really axed it not too many months ago and it was pointed out that not all parts of america are equally situated. we don't have a drug store on every corner in alaska. in most of my communities we don't even have a drugstore. so the role that the navigators have played in helping walk many alaskans through the intricacies of insurance and what is available has been important to us. nobody's really asked that question here today so i would ask for your views, your plans. what do you see the role of navigators moving forward? how can you provide assurances in areas where we simply don't
have the professionals that could assist individuals, that they know what their options are? >> thank you. it's good to see you again. i look forward to discussing alaska issues with you when we meet. i doubt there will be a secretarial nominee who has spent as much time in alaska as i have. >> i think you recognize there are some unique aspects and your focus on behavioral health with native peoples. >> absolutely. in terms of the navigator program and outreach, myfew, as -- outreach, my view, as it is with so much of the programs, is do what works. i am not at the department, so i don't have the data. i haven't seen everything. my understanding about the changes in the navigator program
were focused on navigator program elements that weren't working in renewing and funding navigators that were age to demonstrate results in doing the work. i don't know the specifics about the alaska situation. i can only tell you i do genuinely get it in understanding the uniqueness of the very frontier nature of so much of alaska. i'd be happy to work with you so see what are the ways we deal with that. it's really just what works. >> i think i said pharmacies. it's not only pharmacies. it's also those who help us navigate through the insurance side. very quickly, there's been a lot of focus also on women's health care, preventive care, eliminating the risk of unwanted pregnancies. i happen to believe the more we can make contraception available and affordable to women, the better off we are.
i have long wondered why we are still these many, many, many decades after prescription birth control was made readily available, why we have been so reluctant to move to over the counter products for birth control. you also have the requirement for a medical appointment in in order to get that prescription. do you see a way or an opportunity for us to reduce the barriers for more affordable birth control, pills, contraception and in a way that can really help women in gaining greater access to contraception?
>> so the over the counter regulatory regime, as you know, is this otc monograph procedure that commissioner gottlieb, i am very glad, has -- was out of date in the 1970's and need a lot of updating and work to really speed to approval of products over the counter for the course availability, cost to the system. of course there are scientific and legal standards that have to be met by the sponsors of a product in terms of theability -- in terms of the ability to self-diagnosis, self-treat. and there are user studies that basically need to be conducted. it would be driven by that, would be my view on any product that the fda would have to decide on. i think the regulatory system really needs a close look at on
how we just generally think about over the counter and improving availability of otc products for people. >> i would encourage you. >> mr. azar, good to be with you. we had some opportunity to talk in my office yesterday. i'm grateful for that. grateful for your willingness to put yourself forward again for this work. i want to thank you family and extended family for their commitment. as much as public officials work hard, their families often sacrifice more. you and i have a home state in common in terms of where we were born, not where we were raised. i know you're a johnstown native. i'm a scranton native.
but i wanted to start with something fundamental. i wish we didn't have to start here but because of the interaction between dr. price and this committee i have to ask this question. when dr. price came before this committee prior to his confirmations, members of this committee submitted a number of questions to him to answer on the record in writing. he didn't provide a lot of responses. i'm going to be very precise in these questions. do you commit to finding answers to all the questions you received following appearances before this committee? >> i'll certainly be happy to comply with the senate's nomination procedures and the nomination setting. and then of course, ongoing appearances before the committee with the protocols of the committees in the senate. >> do you agree that answers questions for the record posed by committee members during the
nomination process is part of that compliance? >> what i do not know is just what the protocols are between the health committee and the finance committees. i am not familiar with the customs. i'd be happy the get back to you on that i'll take that as a -- happy to get back to you on that. >> i'll take that as a tentative yes for now. i hope you familiarize yourself with those rules and respond accordingly. we should not have to engage in a back and forth on basic questions for the record. i wanted to ask you in light of the debate on health care, the substantial debate that undertaken over the last couple of months on the affordable care act and especially medicaid.
in addition to that debate, some of the statements you've made that have been critical in one way or the other of the affordable care act and commenting on the process. now but're seeing appointment, a confirmation vote on hhs secretary. that, of course would confer on you responsibilities you don't currently have. in light of that and in light of that and in light of the debate, just to be very clear, do you commit to faithfully implementing the affordable care act? >> if i am confirmed as secretary, my job is to
faithfully implement whatever the congress has decided. my hope would be to implement it in ways -- if it remains, i obviously belief, the administration believes that statutory changes would be good. if it remains the law my goal is to have a way that leads to affordable insurance, choice of insurance, real access, not a meaning -- a meaningful insurance card. and insurance that has the benefits that people want. >> let me ask you about an issue that frankly doesn't get enough attention. it's the efforts that have been made by the administration to undermine the affordable care act. that is my view of it. i used the word sabotage. i think that's an appropriate description. let me define more specifically what i mean. when i say sabotage of the forgot, i mean the following. drastically cutting funding for
advertising and out reach activities. number three, spending funds meant to promote enrollment on a pr campaign to instead undermine the law and support repeal of the aca. number four, spreading false health about the health of the marketplaces. number five, working to roll back health insurance protections in undermined coverage. that's the predicate for the question. would you oppose those efforts knowing you have a responsibility to faithfully implement the wall? -- implement the law? >> i would disagree that there's any effort to sabotage the program. people want to make the program work. people want to make the program work. the csr's was a legal decision that congress had not appropriated the money. other elements -- i can speak for myself -- how about cutting funding on out reach and advertising, appropriate or inappropriate? the stizing cut ingadvertising cuts put the level of this program to the level of medicare
part d. are you asserting that the advertiseing dollars are not cut? they were cut. they were cut to the annual that is close to -- we'll have more time to engage in these. thank you very much. senator kaine? good visiting with you yesterday. i have one question about each of your four goals, but before i do i'll tell you what i said to you yes. what i'm looking for from you is a commitment to the health care safety. i voted against your predecessor because he had commented negatively about planned parenthood, chip, medicare, medical care and the affordable care act. i don't thinkwe can have an hhs secretary who doesn't support the safety net. that's what i'm looking for you. you say drug prices aretoo high.
's what i'm looking for you. you say dr as a member of the aging committee, i kind of became convinced that there's a new model out there that's patients as hostages, patient who is need drugs who can't afford to go without them without risk to their life or health are treated - ashostages. -- as hostages. it convinced me that -- as i said in my remarks earlier today, the insulin prices are
high and they're too high. the system that we've got, it may fit for the stake holders behind the scenes, but for the patient that you're talking about we've got to recognize it's not working. do individual actors in the system have no culpability? they're making the decisions, the choices are happening. i think everyone shares blame here. what we've got to do is i want to be a productive engine if i can be secretary to work with you on solutions to fix that for the patient. let me ask you about your second one. we must make health care for affordable and more tailored to what individuals want in need of their care. then you've got a system that's interesting. we must address those challenges for those who have been pushed
out of the affordable care act. it's interesting that you talk about people pushed out of the market by the aca. of course you know that the uninsurance rate has dramatically reduced in the country. i'm not arguing that it's perfect. but ifyou just read your -- if you just read your statement it suggests there are fewer people insured because of the aca. we had dr. adams in here recently from indiana. he said the uninsured rate in indiana has gone dramatically down because of the affordable care act, and the availability of premiums to help folks afford. in looking at this question, are you going to be part of the wrecking crew, i don't think that's an accurate or fair summary. i'm happy to explain. i believe we can do better. i do too. i believe both for the folks that are in the mid markets
right now that too many of them are paying too much for insurance. was that your opinion before the affordable care act passed? i thought that was how it would happen, unfortunately. but the numbers of people uninsured in this country were dramatically higher than they are now. our goals are the same in the sense that we want to improve access to affordable insurances better. the president wants this. i want this. i think we may only differ about tactics and approaches. i worry about the forgotten who aren't in that individual market because it isn't affordable for them. third, we must harness the power of medical care. why didn't you mention medicaid? medicaid is a very important part of your portfolio. i found it interesting in read
that sentence you didn'tsay a word about medical. the only reason i don't mention medicaid in that context, it's really that medicate does not have the same kind of payment rules at the national level. that was my focus. say i'm a governor and i ran a program. it's interesting. wouldn't you also agree that we can focus to paying for procedures and sickness, shift that focus to paying for health and outcomes. the medicaid program can be part of that as well. it certainly could. if governors are willing partners to try to drive that, medically the secretary has more leaves in his or her control to do would you try to do the same thing in medicaid?
public school. if we can make medicaid better, it will let us solve that. i enjoyed our conversation. i was very open to your namtion. i'm very concerned about your answer to senator casey's series of questions. i just want to state it to you one more time and give a second chance here. this administration has shortened the open enrollment period by half. it has cut outreach funding by9d 0 90%. it is pulled out of state enrollment partnerships. isyour testimony here today that this is all in service of an effort to make the aca better? do you really believe the goal of this administration is to help people sign up for the affordablecare act? so obviously i'm not in the
government. i don't have access to all the data. my understanding -- and i can't validate this from the outside was that choices were made about what's working and what's not working. there also a policy decision around advertising that it's time for it to be regularized in its amountof tunding in advertising. so you think president trump is taking these actions in the goal of making the affordable care act work better. i don't know that president trump was involved. those are probably decisions made at the hhs level or made as a matter of budgeting. i think the goal with the program you've got is do as best you can. this one has a lot of problems. if the alexandermurray bipartisan package here helps -- what does cutting the enrollment period in half do to help? i wasn't involved, nor did i study the comments on the role
period change. the enrollment period went from 95 days to five days. let the plans know kwho's in their plans so they can plan predictably for the following year. you run right up to the end of the year there, it's harder for the plans to set their actuarial basis for the open enrollment period in the pricing. if you roll up that to the end there, the close you are you run up to january 1 on that one, it is very hard to implement effectually in the coming here. you put that next to an i vis ration of all the programs thatwould help people understand the fact that the enrollment period has been cut in half. i'm happy to look at that.
i was not involved in that. so you said that there are things that the hhs secretary couldbe doing to make the open open enrollment work better to make sure that people have the ability to choose wisely within theexchange? if you say these are changes that are made in the service of making the open enrollment period belter, what else do you think can be done? just to clarify, i don't believe i said these are changes to make it better but rather to eliminate what i think -- again, i'm on the outside. i'm not looking at data or running the programs. so i don't know the status of thinking on each individual element there. my point is if manage's not
something is not working, we ought to look at it. if certain of these vendors are not delivering, why keep funding that. that would be my perspective in looking at it. and then using your resources to put it on whatever the most effect live outreach programs. i haven'tbeen involved. i haven't been at hhs for the affordable care actinitiation or implementation. let me follow up on some questions that senator warren was asking. i agree with her. experience in the private sector shouldn't be disqualifying. we want to make sure you are not bringing the history of who you used to work for into thegovernment.
legalization of director consumer advertising. iknow you've been critical of specific practices of individual drug companies. is there any major issue on pharma's legislative advocacy list that you disagree with? senator, if i get this job, my enchance is to advance and protectthe well-being of americans. i don't have pharma's policy agent. agenda. i've been gone for a year that's not my area of focus. my area of focus is the president's agenda and how can i work with this congress to make the programs of hhs better in the interest of all americans. this is the most important job i will ever have in my lifetime
and my commitment is to the americanpeople, not to anywhere that i have worked in the past or any industry i've. connected with in the past. i think we have some senators who want to ask additional questions, so we'll have a second round. mr. say zarazar, let mebegin. senator cassidy asked, senator bhiet white house would have. we can do something about this in the congress. most of what needs to be done, you'll have to do. it's a matter of administration. i had urged the previous administration to delay meeting because it was implementing it at a time when it was changing the way doctors and providers are paid. i think it would be wise to slow that down and get it right and build confidence among the
physicians and other providers want what we are trying to do. i said that based on visits with hospitals like vanderbilt university where they said meaningful use was helpful. number two was ok and number three wasterrifying. -- was terrifying. and i think -- so we ended up with six differenthearings and a and a lovet hearings of bipartisan interest in this. one thing that seemed to me to make some difference would be pretty simple. there was an ama study that showed that doctors believe they are spending 50 or 60% of their time on documentation. it seemed to me that a good approach for this would be -- if that'strue or not, at least that's the perception. might be for the secretary to work for the doctors in medicare. and there are a half million of them say, ok, if you think you
are spending that much time on documentation, either you're not doing your job right or we're not doing our job right. why don't we worktogether and -- work together and set a goal to bring that from 50-60% down to some other goal over the next three or four years and change the reality and the perception over time. would seem to me thatsome is essential because the inoperability is one problem,excessive documentation is another. it's a big mess still. even ata sophisticated hospital, and you want to take your ownmedical records to some other place, the best thing you can do is xerox them yourself, put them in your briefcase, carry them over and hand them to the next doctor. even in a sophisticatedplace, after we spent $30 billion or $35 billion. can you make it a priority, and you use some of this skillful managerial and executive experience background you have, to help us improve, a,
interoperability, and b, reduce excessive physician documentation both in reality and in perception. what are your thoughts on that? i think in both of those areas, that's a very sensible approach, mr. chairman. interoperability, again, it is ridiculous if we have a system now where you have to collect your paper records to go to a different facility. that is a betrayal of division secretary levittt laid out originally when we started down that journey and working towards, he would talk about the railway system and if you don't get a single gauge, it doesn't work. and how in australia, they never decided on a gauge. you have three different railway gauges to get around australia now. my brother-in-law can tell you about that. that's where he's from.we need to work on that and get that fixed. on the regulatoryburden or just the burden on the electronic health records with physicians,
that would be my style of how to work, the affected individuals, they know what's wrong, what's happening, and get the input from them to see if there are appropriate changes that can be made. might get your father to help you with that. he's probably got some ideas. secretary burr will actually change something in heradministration with she believed the reality was different than the perception. it was the patient satisfaction survey that many of us were convinced was causing doctors and hospitals to prescribe more opioids in order to get a higher score on patientsatisfaction. -- patient satisfaction. she was convinced that wasn't true. but it was true that people believed that. so she persuaded president obama to change the policy. i don't know exactly the amount of time thatphysicians are spending on documentation, but they're really fed up with it. and for a whole variety of reasons which you understand well, we need to change that. so i would think some simple initiative, working with physicians especially, and hospitals, to say let's, if it's
60% and the perception is 60%, let's agree on a goal. let's take it a step at a time, let's take it to 50%.if it's 40%, let's take it to 30%, and let's see what's being doneabout that. we can't do that well here. we can monitor it, encourage you, make some changes in the law, but basically, it'san administrative challenge, one you will hopefully take up andwe'll let the senators here who are interested in that work withyou in a way that would encourage that. senator murray, do you have additional questions? i do. thank you again. i am very concerned about some of theresponses, particularly to senator casey and senator murphy, who talked to you about what many perceive as this president directly and his direction to the administration, hhs, has been to make sure that aca does not work. the reason that we veryadamantly support that is because many
people are now getting access to care through insurance that did not get it before. those are the harder to reach people, lower income, tougherpopulations. and they end up, we all pay for them at the end of the day if they're not covered by insurance. the goal is to have as many people as possible insured, have access, get their preventive care, and don't show up in emergency rooms, costing everybody else, taxpayers and other folks who own insurance. part of making sure, a critical part of making sure that they get access is through the outreach and through the longer enrollment. you answered a question about the open enrollment to make it in half, had to do with actuarials. the exact opposite is true. insurance companies put their prices out. they have already figured that out. the open enrollment doesn't change their prices or their actuarial costs. what it does is make sure we have time for the harder to reach people to get enrolled and
that they know what they're doing, they often haven't bought insurance before or have different kinds of access problems that take time to reach them and to makesure they understand what they're buying. that is the intent ofthe longer enrollment, which this administration has cut in half and made it more difficult. the second thing is theoutreach. and i was surprised to hear you answer senator caseyby saying that insurance companies should pay for thatoutreach. they have a very different goal here. they're notlooking for the tougher, sicker, harder to reach, more rural folks to sign up. they have a very different goal. as a country,as other people who pay for insurance see our premiums go up, we have that goal, and that's why it's so imperative, and in fact, in the murray/alexander bill, which you have been asked about, we reinstate that outreach money for that exact purpose. you will be hhs secretary if you're confirmed. you will be responsible for making sure that outreach money is used, used effectively, and
the enrollment period works so that we reachthat. do i hear you that that's not what you're going to do? senator, i share your commitment. any program hhs has, i want it to run as efficiently and effectively as possible and serve thebeneficiaries of the program. that's my style, my commitment to you and how i would work. any particulars here, i'm not there, ihave not studied the particulars of why the changes were made.i offered a hypothesis of what might have been the reason ofthe cutting in half of that to the 45 days, pricing before, andthen implementation afterwards. i did see that with part d, when you bump up against january 1, just the insurance companieshave time to get them insured, getting them cards and up and running. i have not seen that problem. i don't know, but senator, i want to be really clear. i want the programs to work for our people. i want to work with you if there are ideas to make them work, i want to make that happen. do you share the goal of making
sure as many people as possible who may be sick or harder to reach in rural orcommunities that haven't been reached before should be part of what we're working for? of course i do. i want to make sure as many people have affordable insurance as possible. absolutely. who do you think is best equipped to do that? reach them? the question you had asked there around advertising,advertising budgets, that money, my understand is that thelevel of part d in medicare advantage, that's my understanding, is television. i don't think that's your rural outreach or hard toreach. that was just your television, is my understanding. i may be wrong. that was my understanding there. so not about trying to reach potential beneficiaries get people enrolled into the program. it may just be talking past each other on that issue or my misunderstanding the nature of that part of the program. ok. well, i'm confused by your answer. i will say that. i want to ask one more quick question. i know my colleagues do as
well.and that is, will you advocate for women to be able to make their own health care decisions by supporting a broad safety net and insuring all women are able to see the willing, able, and qualified provider of their choice? so senator, the administration has, i believe you're asking aquestion about a particular provider that would be at issue. the administration has a perspective about whether that should be funded or not. that is a legislative choice. if i am secretary, i willimplement what congress has passed and whatever congresshas passed and the laws that we have there faithfully. i'm out of time, but that does concern me. i will turn it over to my colleagues. thank you, senator murray. senator franken. thank you. mr. azar, on monday, the "l.a. times" published ananalysis of the senate republican tax plan. which repeals the individual mandate or the federal requirement that americans have
health insurance coverage. the analysis shows thatrepealing this provision, quote, threatens to derail insurance markets and conservative rural swaths of the country. and could leave consumers in these regions including most of all --sorry, most or all of alaska, iowa, missouri, nebraska, nevada,and wyoming, as well as parts of many other states, with either no options for coverage or health plans that are prohibitivelyexpensive. mr. azar, in your opening statement, you said that you want to make health care more affordable and available toindividuals. given this new data, do you support repealing theindividual mandate as part of the republican tax plan? knowing that it puts rural americans' coverage in jeopardy? so senator franken, what i do not support is forcing 6.7
million americans to pay $3 billion of penalties to not buy something they don't want to buy through a mandate upon them. and 90% of whom make $75,000 a year or less. that i do not support. well, i think you understand the structure of the aca, which isthat you guarantee that you aren't discriminated against for having pre-existing conditions. and then if you're not discriminated against because you have pre-existing conditions, then the motive for someone to get care, to get insurance, buyinsurance, we have to mandate it. this is my understanding of the logic behind this. that to mandate it, people don't wait until they get sick to get
insurance. and that just is the way -- and thenyou give subsidies to people who don't have the means to buy it.that's sort of the three-legged stool of this. if the individualmandate is repealed, the congressional budget office estimates that 13 million more people will be uninsured, and that premiums will go up by 10%. the alexander/murray deal, which i worked onthose negotiations and thank the chairman and the ranking member for that, those are helpful. it's helpful, but it's a temporary measure that cannot offset these estimated price increases or coverage losses. and given this and given thatpeople living in rural areas tend to be older and have greaterhealth care needs than the average populations,
whatspecifically will you do to make sure that people living in ruralareas are not hurt by all these current efforts by the trumpadministration to undermine the affordable care act? so as you articulated, i think you articulated well the theory of the mandate was a mechanism to pool insurance risk tocreate an insurable risk pool for the insurance companies to do their actuarial business. that was the theory. the challenge was human behavior decided otherwise. 28 million people are not inthat pool. and it eroded the risk pool there. what i would loveto work with you and congress on is coming up with systems that create effective -- the fact of the matter is -- so your rural citizens can actually have affordable care thatgives them access, gives them choice, real choice. half of our counties have one plan available to them.
right, and the fact -- i worry about that. fact of the matter is under the aca, over 20 million people whoweren't insured have insurance. and it feels to me thateverything that this administration has been doing is basicallyaimed at undermining the markets and undermining the way theaca and undermining so that we can throw away these gains,but everything that is getting rid of the individual mandate, putting out plans, temporary plans, short-term plansthat will not cover the basic, you know, the ten basic health guarantees, it just seems
that this is a conscious effort toundermine the health of americans. and it just -- i think that aswe go forward, we have to find ways to make sure that peoplearen't discriminated against because they have pre-existing conditions and that we have large -- the largest pools possibleand we spread the risk, and we make sure that people have, as many people have health care, and if you repeal this, 13 million more people will be uninsured, and premiums will rise. senator, i think we share so many of the same goals and justdisagree about the approaches and tactics to get there. my heart and my goal is to share so much of what you're talking about in terms of affordable care for people. thank you. >> thank you. thank you.
>> thank you, senator franken. we'll continue with our second round of questioning. we'll conclude the hearing after the second round. i think there may be at least one other senator who wants to come back, so we'll go next to senator warren. thank you, mr. chairman. i share the concerns that have been raised by a number of my colleagues that this administrationhas spent the first 11 months of this year trying every trick in the book to destroy health insurance system in this country. and mr. azar, you're being considered now for the top job to oversee key parts of the affordable care act and medicaid. so i want to start by asking about a basic principle. mr. azar, would you agree that it's important that we have a system that allowsfor every single american to have access to the kind ofcoverage they need? i think we all share the goal that we want all americans to have access to affordable insurance that they desire. so is that a yes? as i framed it, yes. ok. good. here's the problem. those are the exact words that dr. price used during his
confirmation hearing before thiscommittee. he sat exactly where you're sitting right now and said exactly that. he pretended that he cared about people being able to get their health care coverage. and then he gotconfirmed, and spent eight months doing everything he couldto take away people's health care coverage and crash the health care system. so i think that's the reason we're trying to be very specific about what it is you will and won't do. so i want to follow up on senator murphy and senator murray'squestions. they asked about shortening the time period for theenrollment, and you said you wanted to be very data driven about that. and you thought maybe there was a data reason for doing that. that is that it was ineffective and somehow it hadn't worked. so let me ask the question this way.
mr. azar, if you'reconfirmed as hhs secretary, and there are no data showing that cutting the enrollment period improves enrollment, will youcommit to going back to a three-month-long period for healthinsurance enrollment? my view would be that if the enrollment period does not make sense and work for the efficacy of the program, for the insurers who have to work in it and for beneficiaries, i would be open to changing it back if confirmed as secretary. i'm not in thegovernment, i can't commit to government action not having seen anything there. that's the question i'm asking. you have used data as an excuse. you said i care about the facts, i want to be data driven. you had a good exchange with senator alexander about the importance of data. i agree with that, so i'm just asking. if there are no data to support your hypothesis that cutting the time periodsomehow might improve enrollment, will you commit to going back to the three-month enrollment period? i would need to look at the data. if the data drives in that direction, then i'm going to push to insure that the program is effective and if a longer period is needed -- i don't know what kaurnt balancing factors
there might be. i'm not in the inside to know. so it's not all about data for you. there's data, but i don't know the other elements. i'll take that as a no. let me ask another question. when secretary price was in office, he supported republican bills torepeal major portions of the affordable care act. if confirmed as secretary, will you oppose such bills? senator, i and this administration support legislation, various forms of legislation that would have a system that leads to more affordable insurance, more choice, and more access.there's not support of getting rid of -- i asked a very specific question. because i'm trying to get this. this is what price said when he was in here. so i'm trying to get avery specific question. would you publicly oppose republican bills to repeal the aca like the ones we have seen so far this year?
are you saying we should just wait and see what you'lldo? i would work with this congress and within the administrationto build a system that helps people get affordable insurance.you and i will differ fundamentally, senator, i guarantee you, on what the contours of the system to do that will lead to. you will not oppose the bills we have heard so far? all right, let me ask another one. what about turning medicaid into a blockgrant? secretary price pushed that idea while he was in office.would you do the same? i have actually said before that i think looking at block granting and empowering states to be fiscal stewards there can be effective, can be an effective approach. the contours ofthat, the amount of funding, the size, what the baseline -- >> you support block granting? >> i support it as a concept to look at. one needs to look at block granting as an abstract. the question is instead, what is the precise program, but the notionof a state being empowered to run a program and having all of the sentives to run an effective program. you could own up to the fact that you want to cut medicaid and gut the affordable care act,
like every other member of the trump administration, but you want to smile and pretend otherwise until you get the job, and yet you say exactly thesame things that would let you pick up right where tom price left off in trying to gut the affordable care act. tom price lied through his confirmation hearing. and now you come in here and say the same things he said. no one should be fooled. thank you, senator warren. senator hassan. thank you, mr.chair. i wanted to pick up where we left off onthe question about the case of jane doe, the young woman i asked you about. at the end of that question, you said that, yes, you agree that you have an obligation to follow the constitution and all of the laws of the united states, even ifyou don't personally agree with that. is that correct? that is correct, yes. and i'm glad to hear that. as you know, under the supreme
courtdecisions in roe v. wade, women have a constitutional right to make their own reproductive health care decisions. so yes or no, will you commit to upholding those constitutional rightsas well? i would -- i would always work to insure implementation of the constitution and laws as currently interpreted by the courts, yes. thank you. i'm glad to hear that. now, i want to return to the issue of essential benefits for a second. you have said you would make the opioid addiction crisis a priority if you'reconfirmed. i appreciate that, but we need a lot more than lip service to make a dent in this epidemic. one of the key tools tocombat this crisis is the set of ten essential health benefits ined the aca, requiring that insurance cover -- insurance cover substance use disorders. in october, cms proposed their benefitand payment parameters which if finalized could let states erode the benefits, including the substance use
disorder benefits. if states develop their own benchmark, the rule would set the ceiling on the generosity of benefits states could include in their plan. before the aca was passed, more than a third of plans on the provide coverage for substance use disorders. i am concerned under the rule proposed now, states would decide to limit this critically important benefit. given your stated commitment to to rejecting the harmful changes to the essential health benefits in the proposed rules? i believe that states are most effective in determining, they are most effective in determining the benefit packages their citizens and the circumstances you described earlier, even with new hampshire, the unique circumstances of each state. the problem, of course, is when they do that, the insurance companies come in and charge
much more for that benefit. and that's one of the advantages that the central health benefits. nobody in my state plans to get an ilthesis that their insurance doesn't cover. to prescription drugs after surgery, let's say. and then, you know, says oh, too bad i didn't buy insurance coverage for that treatment. and the advantage of the essential health benefits is millions and millions of people not only got coverage through the aca, but they got coverage that actually addressed their needs. as governor, and before when i was in the state senate, it was often the case that insurance companies kept dropping coverage for things they couldn't make money on. and eventually, the public picks up that cost. so i would ask you to look at that issue very, very closely because the essential health benefits under the aca have been critical to fighting the epidemic in our state. last topic i wanted to touch on with you, and you have heard a lot about it. it's about drug pricing. and some of it is about your past employment as president of
the u.s.part of eli lilly. i want to read a quote of yours in "the new york times" article because there's a reason that people are skeptical about your commitment to lowering drug prices. what you're quoted as saying in the niemgz. all players, wholesalers like mckesson and cardinal, farmallies like cvs and walgreens, and drug companies make more money when list prices increase. the unfortunate victims of these trends are patients. so basically, in that quote, you're admitting that high list prices are hurting consumers and creating profits for drugcompanies. but yet you continue and you did this just lastspring, to push the blame, here you have said it's everybody, everybody's got a part to play. but last may at a conference,you pushed the blame on everyone but pharmaceutical companies for high list prices, even saying setting list prices issomething that even though setting list
prices is somethingthat manufacturers directly control. you have also blamed insurance plan designs for high drug prices, but it's really thelist price set by manufacturers that is driving the increases in what consumers are paying because requiring lower cost sharing for drugs will lead to increased premiums. again, all at the expense of consumers. so i want to ask now that you will be taking off your pharmaceutical company hat and will be responsible for advocating for consumers, do you think it's time that the federal government take action to limit the profit drug companies can make off of setting high list prices? much the way we limit insurers right now with loss ratio. so in my earlier remarks, i certainly did not mean to besuggesting that list price was irrelevant or that pharma isn't have a piece of this also. the challenge is as we think about theburden on the patient when they walk into that pharmacy, if the list price is $500 and they have to bear that
$500, or if the listprice is $250 and they have to bear that $250 under a high deductible plan, both of those can be unaffordable for thatpatient. so my point is, and where i want to work -- i'm way over. we're running out of time. my point is, without some action by us, it will just be passed on inthe insurance premium, which will also become unaffordable. thank you, and thank you, mr. chair wherein. thank you, senator hassan. senator baldwin. thank you. i too want to continue along the same lines thatsenator hassan was asking you about, and also what we weretalking about in round one of questioning. and you mentioned your example at $500 a month. i told you a story earlier about greg from stoddard, wisconsin, mentioned diane who lives
in western wisconsin, has ms, has taken a medication for over 23 years. to slow the progression of her ms. became medicare eligible and therefore the way in which the family was insured and paying for medication, she and her a heartbreaking discussion at the beginning of this year whereby she and he decided that she would stop taking the medication. it had reached $90,000 a year. no change as far as i know in the ingredients, the manufacturing process, or anything else. it just had crept up, crept up, crept up over all of that time. so i want to return to this issue of transparency. we talked a little bit about this when we met yesterday. i have offered along with my colleague senator john mccain
the fair drug pricing act which would require basic transparency drug corporations. again, understanding that it's a complex system, but that the list price setting starts with the drug corporations. it would require disclosure to of hhs on elements like executive pay, investment in research anddevelopment, and development, investment in -- marketing, stock buybacks. etcetera. as a way to inform policymakers so we can take better and stronger approaches to this crisis in many respects. whatare your views on requiring drug companies to make basic information public when they are intending to increase the list price of existing drugs?
even as i referred to in my opening remarks, i generally am in favor of increased transparency within our health care system. i think it generally is a good thing. we always need to look to see if there might be any to transparency, as you and i discussed in your office. we always have to be careful there, but as a general matter, i think transparency can be good and where would be happy to study that more and work with you as part of all the options that need to be on the table to think about this, to see does it help with reducing what a patient pays out of pocket, does it help with reducing list prices, does it help with reducing what the system ends up paying. i'm very open to looking at allof these kinds of options with you. one note that i want to make. oftentimes the difference between pharmaceutical product prices in the u.s. and overseas haspointed back to the investment in research and
development. but in recent years, the investment, if you can call it that, in stock buybacks and dividend payouts has surpassed that of r &d. is that a troubling trend in your opinion? i don't know. i don't study the financials of the companies on buybacks, for instance, but i certainly believe that one of thebedrocks of the r & d based pharmaceutical industry is that kind of heavy investment. i think where i was employed, it was upwards of 20% to 25% of revenue was invested in r & d. a largepercentage of that here in the united states. as we talked a bitearlier at the hearing, in reference to some of those entitiesthat simply buy a product and increase the price, i am very supportive of that type of intensive r & d work. if i'm in that role, i'll have nih, which plays such a role in the basic foundational science
there and is a partner in all of that work. i don't know the particulars of that issue. i haven't connected those twothings. it's quite striking in an academic report earlier this year, in aggregate, i think, over half a trillion dollars invested in stock buybacks and less than that now in r & d. it's certainly not specific to the pharmaceutical industry, but very pronounced inthe pharmaceutical industry. the last point i would make is just to note for the record that i actually agree with president trump regarding his emphasis on authorizing the secretary ofhhs to negotiate directly with pharmaceutical companies forlower drug prices and medicare. and hope that is something
youwill embrace if confirmed. >> thank you. thank you. >> thank you, senator baldwin. senator whitehouse. thank you, chairman. mr. azar, we talked in our lastconversation about care organizations and the ways we candeliver better care at less expense. there's another much more particular area where i think there's another bipartisanopportunity to improve care. in this case, it probably wouldlower expense, but that wouldn't be the point. that area is endof life care. advanced care. there's a very good group that you may be familiar with called the coalition of transformed care which has very, very broad corporate institutional support that is focusing in these areas. rhode island has been very active in this space. we have enormous support from --
we're the most catholic state in the country, the catholic diocese has been very helpful. the state council of church has been helpful,our major hospital groups and medical society have all beenextremely helpful. and what we see is that from time to time, we bump up against problems within the medicare and medicaidbilling system, which in a general arbitrary world might make some sense, but once a state or a community has decided that it's going to undertake a path to deal more humanely with people near the end of their lives, suddenly, those prescriptionsbecome obstacles. and i think do more harm than good to the patient and probably to the public as well. here's my -- here's some examples we're trying to fix. and medicaid patients aren't supposed to receive both hospice
care and curative care at the same time. if you're seriously focusing on the care of an end of life patient, that's a completely stupid distinction, to force into that situation. nurse practitionershave way too small a role, and their role could be increased. the whole two-night three-day inpatient stay rule before somebody can be moved into a nursing home is nonsensical in the context of somebody who is operating under a good end of life care based or hospice plan. home health services ought to be provided without having to meet the full regulatory definition of being homebound. very often, a dying patient can still move around for a while and is not fully homebound, but it would be cheaper for the system, better for the family, easier for the loved ones who are providing care, to get home health services. so that rule, again, backfires. finally, caregivers oftenneed respite. respite care is a very valuable
because without that, you wear out the caregiver and now the system has to come in at a vast expense and pick up with potentially inpatient treatment. home-based respite care, where you don't have to put your family member into an inpatient place while you get your couple of days of respite, would seem of sense. none of those things are being done. and the result is that this very precious time of life towards the end, states that want to make it better, that want to make sure that the wishes of the patient are honored and that it's clear around the family what those wishes are so there aren't horrible fights at the end of life, all of those things can be made so much better, and here is the government with all of these rules that may make again, in isolation, but once you start to deal with end of life care in any kind of a comprehensive and humane fashion, they begin backfiring
in your face. will you work with us, particularly with rhode island, to try to support models. we don't need to get rid of them entirely, but what we really want to do issupport waivers so when a state or community steps forward with a really good, humane, i'm saying this sitting next to senator baldwin, whose state is legendary for end of life care planning, by the way, so i should give wisconsin some props here as well. would you help us with that? >> so senator, i just want to thank you for those very thoughtful comments and reflections. you know, as i mentioned in my opening remarks, mystepmother wilma died just in july. it was a blessing that she was able to be in her house, in her bed, throughout the whole time. yeah. and i want to make sure people have that chance. and so, you know, happy to work with you. i think what we will find is that it actually helps the public fisk as well. but to be perfectly blunt, i
don't actually care if we have to spend a little bit more money so the people at that veryfend tender time of their life and the people who are surrounding them at that time in their life aren't treated disrespectfully and aren't pushed to make dumb decisions ss based on bureaucratic rules that don't make sense at that time, so god bless you and thank you. thank you, senator whitehouse. senator murray, do you have any closing remarks or questions? again, mr. azar, thank you so much for you and your family patiently sitting through this. i do have some additional questions and i would just ask that we do get timely and sufficient answers to our questions. we have had that problembefore under secretary price, and on full confirmation andafter your confirmation, i respectfully ask we get timely answers so we can do our jobs as well. i did want to put one issue on the table that we didn't have time to address. that ishhs plans for implementing the preschool development grantsprogram. we authorized that in our every
student succeeds act. it's something i'm very concerned about and i'm going to be watching very closely to make sure that really vital program isimplemented the way congress intended so it helps us access to high quality early learning and care for our most vulnerable children. i will follow up with you, but know that i will be following that very closely. so again, thank you for being here. i know you've got another hearing to go through, numerous questions. we'll be looking at all of those. if you're confirmed, i want you to know that we will talk to you, work with you, and hope that you will be as responsive as we need youto be. thank you, senator murray. mr. azar, thank you for your -- for being here, for your willingness to serve. for answering the questions. i do hope you will respond to
the senators' questions and we don't have any limit on the number of thosequestions, but i hope there will be a reasonable number of questions. about a third of the members of this committee are also members of the finance committee, which is the committee which will vote on your confirmation and report it to the floorof the senate. i think you have seen today the diverse points of view on this committee, and some people wonder how we could ever get anything done, but the fact of the matter is we get quite a bit done. a couple years ago, we fixed no child left behind in a way that president obama called it a christmas miracle. last year was the 21st century cures legislation that the majority of the leaders said was the most important legislation of the year. you'll have a chance to implement that legislation as well as the mental health reorganization that was a part of it. this year, we worked, senator murray and i worked to try to see if we could find some area of agreement, even though it's for short-term on the affordable care act, which still, which we
were able to do. it's not law yet, but we were at least able to take a step. so there are a number of areas,and you have heard many of them today. senator whitehousesuggested two major areas of bipartisan cooperation. we talked about electronic health care records. i think you'll find most of us would like to create an environment in which you'reable to succeed and we'll not be shy about giving you our points of view, as you are able to tell today. i hope also that we can talk about more and work with you on more than the individual insurance issue. for the last seems like forever, we have focused on health insurance and only 6% of the americans who buy health insurance on the individual market, they're every single one important, but we year after year give ourselves, like going to college and taking only one course and earning a c or d or f
on it every semester. we don't seem to be making very much progress. and the important thing about it isthere's so much other important that we should be working onwhen we talk about health and health care and the agencies you work on. drug pricing is one this committee has a greatinterest in. i, for one, am excited about the fact that you know something about this. health insurance is complex. i think drug pricing is byzantine. and i think if we had a secretary who was new to the subject, that he or she would leave after two or four or eight years without having accomplished much of anything because it would take that long to understand what'sgoing on. you arrive knowing the subject and helping us answer to question of where does the money go, do we really need rebates? can there be more negotiations? on drug pricing.should we really
think seriously about finding a way to let americans buy drugs in the united states that are not approvedby the food and drug administration? we haven't ever done that before. and several senators think we should. and we'll need to talk about that. we should be talking about wellness. we have had two or three hearings on that, that offers great promisefor reducing health care costs. electronic health care recordswe talked about. biomedical research. we hear a lot about the president's budget proposals. we hear less about the fact that senator murray and senator blunt for two years, hopefully for three, have increased funding for national institutes of health at $2 billion a year, and we added another $4.8 billion in the 21st century cures. we're putting big new dollars into the national institutes of health as well as big new authority into nih and the fda, all of which you will have a chance to take advantageof and
to make something of. i think it's a very exciting time forsomeone with your experience and background and energy to come to this position. i think you could help families all over america, and i hope if you're confirmed, which i'm confident youwill be, that you will look to this committee, both the democrats as well as the republicans, as a resource to create an opportunity in which you can succeed. i ask consent to introduce four letters of support for alex azar into therecord, which will be done. if senators wish to ask additional questions of nominee, questions for the record are due by 5:00p.m. this friday. december 1. for all other matters the hearing record will remain open for ten days. members may submit additional information for the record within that time. the nextmeeting of the health committee will be a hearing tomorrow. november 30, 10:00 a.m., hear from experts on the opioid crisis. thank you for being here. the committee will stand
forest and cleanup of national waste sites. in today's "washington journal" we talk of tax legislation and sexual harassment in the workplace. call in with your comments. ♪ host: today the senate continues debate on the republican proposal looking to make significant proposals to the tax code. 50 votes are needed to pass it. however, several republican senators are looking to make changes to the tax plan. changes such as bumping up the corporate tax rate from the proposed 20% and imposing, quote, triggers to keep the national debt from increasing. with so much activity in mind, we're dedicating the entire program today to give you the latest information on the senate debate and hear your opinion of the republican proposal for tax reform. here's how you can let us know your thoughts this morning. if you want to call us, 202-748-8000 for democrats,