tv HHS Secretary Azar Testifies on 2020 Budget Request CSPAN April 4, 2019 8:01pm-10:01pm EDT
cay da center's daniel griswold. then trump administration security clearances, and we'll discuss new york city's congestion fee on vehicles entering its most congested streets with transportation consultant bruce shaller. be sure to watch c-span's "washington journal" live at seven eastern friday morning. join the discussion. ♪ ♪ >> and to capitol hill for testimony from health and human services secretary alex iowa czar. members -- iowa czar. members -- azar. a court case challenging the legality of the affordable care act. this is about two hours.
>> the appropriations subcommittee on labor, health, human services, education and related agencies will come to order. secretary azar, thank you for being here again this morning and for our efforts to work together that i, although they could always be better, i think we're about to get you staffed up to a point where that will no longer be the excuse. so we'll think of finish. [laughter] what comes as the next reason this is not working the way it should. i want to encourage you to continue to do that. obviously, this is a difficult budget for us to talk about and, frankly, i think it's a difficult budget for you to defend, and we'll see what we have to do here. the budget control act has
impact on this. in the case of the budget that you have been asked to submit, it's -- there's a reduction of 14%. the budget control act would require an overall reduction in the non-defense discretionary spending of 9%, so this budget exceeds even that. i would say for the 9%, as i mentioned last week with the education secretary, you know, president trump didn't sign the budget control act, president obama did. and you didn't vote for it, and any of us, most of us who were here when we did the budget control act did. so there's some shared responsibility in where that decision has led us. but there'll be a number of concerns that i imagine you have to share about what this budget asks for. we've made a top priority in the years i've been chairman of this committee insuring that medical
research has the resources it needs at this particular time of real breakthrough potential to do what it does in a way that saves lives, improves lives and, frankly, benefits taxpayers as we find more solutions. as an example, if we could find a way to identify alzheimer's and delay onset by five years, we'd cut the projected cost for alzheimer's by a third between now and 2050. the cuts that you're proposing for nih would be an overall cut of 12.6% in research or almost $5 billion. i'm sure that's not going to happen. but for that not to happen, we have to have a number to work with that you don't have to work with yet, and i believe we'll have that number.
you know, we're not going to eliminate funding that provides six million households with heating and cooling assistance. this cuts resources that train hot of people -- lots of people for medical professions and behavioral health and pediatric dentistry, and we're not likely to do any of those things. finish i understand you had to make difficult decisions here. i do appreciate the two new initiatives that you've proposed, and i'll be supportive. i'm sure, i believe the committee will be supportive of those. one, to eliminate the transmission of hiv in the united states by 2030. phase one of the ten-year plan would infuse the hardest hit states and communities -- missouri is one of those -- with additional resources, additional expertise, additional diagnostic and treatment options. and i'm pleased to see that
that's a new proposal, as is the new pediatric cancer program to provide $5 million over the next decade to launch of a major data project on childhood cancer. now, that runs pretty dramatically in the face of cutting overall nih funding, but i do think it gives us the opportunity to look even closer at pediatric cancer and factor that in as we continue to, hopefully, improve nih funding. in addition to these new programs, i believe that mental health treatment needs to be treated as any other health issue, and the budget request includes level funding for the certified community behavioral health clinics. missouri's one of the eight pilot states in those clinics
and 200 locations in our state treating behavioral health like all other health. and we need to do more to encourage that. the head of barnes jewish hospital told me just last week, quote: i can't treat a person's tie beets -- diabetes until their schizophrenia is under control. and i believe we're going to find that if you treat behavioral health like all other health, you actually save money on the other health care costs than you spend doing the right thing in behavioral health. finally, the administration's commitment to ending the opioid epidemic is well reflected in this request. according to the council of economic advisers, the total economic cost of the opioid epidemic in 2017 was $684.6 billion. the cost to our economy, the cost to families of the opioid epidemic was that.
according to the missouri hospital association, this estimate suggests the epidemic cost the u.s. nearly $1.6 billion every day, $21,700 every second of every day through 2017. the past four years this subcommittee has increased funding to combat the epidemic by with more than $3.5 billion, and we have had great bipartisan leadership on this with people who really, on both sides of where i'm sitting, understand how this has impacted their states and have forcefully made that case. i appreciate what you had to do to try to prioritize limited resources. we will try to do things that make those resources more realistic, and i'm glad you're here today and glad you bring all the expertise and ability you bring personally to this
job, and i'd like to turn to my partner here in this effort, senator murray. >> welk thank you very much, chairman blunt. welcome, secretary azar. people across the country made pretty clear last november that they want us to fight for their health care and make sure families get the care they need. that means fighting for protections that allow people with pre-existing conditions to get quality, affordable health coverage. it means fighting to bring down the skyrocketing health care costs. it means fighting for public health investments that keep our communities safe and address crisis like the hiv and opioid epidemics. and it means fighting for investments in research that can help discover new treatments, save lives. but instead of fighting to defend people's health care, president trump is fighting in court to take health care away for millions of people who are covered through the exchanges, covered through medicaid and are covered by their parents' plan. instead of fighting to bring
those costs down and help people get the care they need, he is fighting in court against protections for over 130 million people with pre-existing conditions. even for people who get their insurance policy through their own job. and for letting insurance companies offer plans that don't cover essential services like maternity care for prescription drugs. and president trump's budget before us is cut from that same cloth. it bulldozes right over the concerns of families with proposals that would make it harder for people to get care and cuts that would undermine the well-being of families across the nation. overall, this budget proposes a deep $12.7 billion cut to the department of health and human services, slashing it 14%. i always say a budget is a reflection of your values. well, like many of his actions, this budget tells a very different story about president trump's health care priorities
than his empty promises. despite claiming time and time again he would fight for people's health care and despite his recent claim republicans would be the party of health care, president trump is continuing to push for harmful policies that would weaken patient protections, take coverage away from people and put needed health care further out of reach. this budget includes trumpcare which the congressional budget office estimates would kick ten of millions of people off their health insurance. when it comes to curbing the hiv and opioid epidemics, president trump promised to fight the fire, but his budget actually fans the flames. it would make these crises far worse by cutting over a trillion dollars from medicaid over the next decade and repealing medicaid expansion. medicaid is the largest source of insurance coverage for people with hiv, covering more than 40% of people with hiv in care. and the 37 states that expanded
medicaid show how it can play an important role in addressing the opioid crisis as well. in some of these states, as many as four out of five people receiving treatment for opioid addiction are insured by medicaid. the centers for disease control and prevention also plays a very important role addressing these public health crises and many others, yet the trump administration proposes cutting its budget by a tenth. this proposes cutting immunization efforts by $78 million even amid an alarming measles outbreak in my home state and several others. it proposes cutting work on birth defects and disabilities by $44 million and proposes cutting efforts to combat antibiotic-e sis about the pathogens -- resistant pathogens and emerging infectious diseases by $10 3w million despite the world health organization labeling ark mr, quote, one of
the biggest threats to global health. and when it comes to medical research, this budget is a small step forward and a marathon sprint back. i do applaud the administration's call for more pediatric cancer research. for every new penny president trump proposes for pediatric cancer research, however, he proposes cutting a dollar from the national institute of health. cutting medical research by 13% as he proposed would slow our efforts to advance our understanding of alzheimer's disease, develop vaccines for hiv and flu and treatments and cures for every other kind of cancer. and at a time when our nation is facing a health professional shortage, it's proposing to cut almost $800 million from health care work force training the programs that support -- training programs that support tuition assistance, loan forgiveness and training for several hundred thousand health professionals annually. this budget also continues the trump administration's harmful
trend of putting ideology over women's health and reproductive freedom. its language specifically excluding planned parenthood from federal funding is just one of the many alarming steps backwards for women's health care from this administration. another is the recent announcement stripping title x family planning funds from several qualified planned parenthood affiliates despite their proven record helping millions of people struggling to make ends meet, get birth control, cancer screenings other basic health services. another example is the administration if's gag rule which will push planned parenthood out of the program altogether, interfere with patients' ability to learn about their full range of reproductive care options and prevent people from across the country from getting the care they need with the providers that they trust. once again the trump administration proposals eliminating safety net programs that provide critical assistance to millions of vulnerable
families like the low income home energy assistance program which helps families afford heating and cooling and the community services block grant which gives states resources to address the challenge of poverty. and eliminating funding for preschool development grants which provide high quality preschool to tens of thousands of families. it's clear that we are facing a childcare crisis in this country. parents struggle every day to find and pay for high quality programs. we need more investments in that, not cuts in early childhood education. and this budget continues to show disregard for families fleeing violence and extreme poverty in central america. this budget proposes a gimmicky $2 billion con tin general city fund on the mandatory side for the unaccompanied children program in addition to the base discretionary appropriation. let me be clear, i want to make sure that every child in hhs custody is well cared for.
but i have been deeply disappointed in president trump's treatment of migrant children from heartlessly separating children from their parents to attempting to undermine protections for migrant children. and i have been frustrated with your department for failing to sound the alarm on the lasting damage that family separation would cause, sharing information with the d. of homeland security so they can target potential sponsors for deportation and relying heavily on unlicensed temporary facilities which are three times as expensive as permanent beds in licensed centers. to say nothing of my concern that the office of refugee resettlement was tracking young women's reproductive health and is that former director scott lloyd was personally interfering with young women's decisions about a their bodies. finally, mr. secretary, i am concerned by a recent proposal you outlined in a letter to my office to restructure the office of the assistant secretary for
health. that restructuring would impact programs that serve adolescents, women, low income communities and more. and i'm very concerned that that proposal, much like this budget proposal, would serve very little purpose beyond prioritizing ideology over the health needs of families in this country. mr. secretary, finally, i just want to note it is inaccurate to claim the budget control act requires the president to submit his budget at sequestration levels. in fact, just two years ago president trump's budget proposed an increase to the caps for defense spending. so i hope you don't rely on that excuse for decisions in this budget. thank you very much, mr. chairman. >> thank you, senator murray. of -- so, secretary azar, you and i have talked about the -- >> [inaudible] >> oh, i'm sorry. we want your -- i'm sorry. [laughter] i'm so eager, i have so many questions i want to ask here. maybe you want to waive your opening statement. [laughter] go ahead with your opening
statement. >> welk thank you very much, chairman blunt and ranking member murray. thank you for inviting me to discuss the president's budget for fiscal year 2020. of it's an honor to have spent the year since i last appeared before this committee leading the department of health and human services. the men and women of hhs have deliver remarkable results during that time including record new and generic drug approvals, new affordable health insurance options and signs that the trend in drug overdose deaths is beginning to flatten and decline. the budget proposes $87.1 billion in fy-2020 discretionary spending for hhs while moving toward our vision for a health care system that puts american patients first. it's important to note that hhs had the largest discretionary budget of any non-defense department in 2018. which means staying within the caps set by congress has required difficult choices that i'm sure many will find quite hard to count nance. i know that members of this committee have delivered strong
investments in hhs' discretionary budget in the past, especially at the national institutes of health, and i want to be clear that hhs appreciates this work over the years. today i want to highlight how the president's budget supports a number of important goals for hhs. first, the budget if proposes reforms to help deliver americans truly patient-centered affordable care. the budget would empower states to create personalized health care options that put you, as the american patient, in control and insure you are treated like a human being and not like a number. flexibilities in the budget would make this possible while promoting fiscal responsibility and maintaining protections for people with pre-existing conditions. second, the budget strengthens medicare by, to help secure our promise to america's seniors. the budget extends the solvency of the medicare trust fund for eight years while the program's budget will still grow at a 6.9% annual rate. in three major ways, the budget
lowers cost for seniors and tackles special interests that are currently taking advantage of the medicare program. first, we propose changes to discourage hospitals from acquiring smaller practices just to charm medicare more. to charge medicare more. second, we address overpayments to post-acute care providers. and third, we will take on drug company that are profiting off seniors and medicare through a historic modernization of medicare part d. we will lower seniors' out of pocket costs and create incentives for lower list prices. i believe there are many lawyers of common ground on -- areas of common ground on drug pricing where we can work together to pass bipartisan legislation to help people. the efforts we've proposed around taking on special interests in the medicare program are so sensible and bipartisan, in fact, that even "the new york times" editorial board praised these ideas last week. we also protect seniors by transferring funding for graduate medical education and
uncompensated care from medicare to the general treasury fund so that all taxpayers -- not just our seniors -- share these important costs. finally, the budget fully supports hhs's five-point strategy for the opioid epidemic; better access to prevention, treatment and recovery services, better targeting the availability of overdose-reversing drugs, better data on the epidemic, better research on pain and addiction and better pain management practices. the budget billeds on appropriations -- builds on appropriations made by this committee, including the $1 billion state open owed response program -- opioid response program. the budget also invests in other public health priorities including fighting infectious disease at home and abroad. it proposes $291 million in new funding -- in funding for the first year of president trump's plan to use the effective treatment and prevention tools that we have today to end the
hiv epidemic in america by 2030. hhs also remains vigilant on other public health challenges including the current epidemic of teen use of e-cigarettes. in fact, i'm pleased to announce that today the fda is issuing warning letters to companies for making, selling or distributing liquids used for e-cigarettes that have misleading labeling or advertising that resembles prescription cough syrups. the trump administration supports a comprehensive, balanced policy approach to regulating e-cigarettes, closing the onramp for kids to become addicted to nicotine while allowing for the promise of an offramp for adult smokers of combustible tobacco products. this year's budget will advance american health care and help deliver on the promises we've made to the american people, and i look forward to working with this committee on our shared priorities, and i look forward to your questions today. thank you very much. >> well, thank you. now we'll get to those
questions. and i'm hopeful that we can get through most of our questions by the vote and leave some time shortly after 11:45, but if we don't, i'll come back. and there'll be a second round of questions for anybody that wants it. so i would ask everybody, including me, to stick with their time limit. so the first question i almost got into a moment ago is just about the new liver allocation policy, the solid organ allocation policy, something that senator moran and i have been very interested in. we had one meeting with the oregon transplant procurement network -- organ transplant procurement network group and, frankly, our view of that meeting was very different than a what they finally did. both the university of kansas and washington university are really among the leading stakeholders in this in terms of the transplants that they're part of. i guesses the problem is that
states in the midwest, states in the south, states that have lots of small communities tend to be much greater organ donors and, obviously, as long as we had a regional view of this, that was a benefit to their neighbors. there's been a dramatic decrease in availability of lung and liver transplants at barnes hospital at least since the new policy went into effect. and as my question, i think there'll certainly be a lawsuit filed here. will you commit today that you'll ask optn, the transplant group, not to move forward with this controversial policy until that lawsuit has been dealt with? >> well, mr. chairman, i am concerned about the liver allocation policy issue, as you
raised. frankly, any transplant organ allocation policy issues are quite difficult politically and as a matter of public health. and i actually, i received the letter from you and many others about the most recent organ -- the liver transplantation allocation policies out of optm, and requested of them to think of them and to insure especially -- i believe it was, was it the kansas and missouri providers that we wanted to insure especially that comments that came in at the last minute or perhaps came in late were fully considered by optm. we recently received a letter back in response to my challenge to them, which i believe your staff has access to. basically, they said they went through the procedures, they considered all of the comments, and they remain steadfast in their conclusion regarding the science and technical aspects of the allocation decision they made. i do believe my cards are played out here. congress deliberately set up the
optm system to keep people like me from dictating the policy allocations, but i'm happy to work with the committee on any other solutions here to look at and insure that the fair and scientificically valid treatment has been given here. >> well, i would think one of the reasons the old system worked was that people were more encouraged to be donors if they believed that people in their community would benefit from that. on liver transplants under the new policy, we think there'd be 32% fewer transplants in missouri. i think barnes hospital's number four or five in the country in france plants, and they have told me -- transplants, and they have told me since this started they're now having to send teams of doctors across the country to have, to get organs that would have been available under the old policy locally. i think it's further complicated
and added expense and precious time to the system. we're going to continue to watch that. let me is ask one more question here on a big issue, and that's your role in providing security and taking care of unaccompanied children. you have nothing to do with border security, but you wind up with great responsibility. would you talk about how that's changed in the last few months? >> absolutely, mr. chairman. we're in a tremendous crisis at the border right now. we are getting 300-350 unaccompanied alien children crossing the border and referred to hhs every single day right now. these are 10, 12,13, 15-year-old kids coming across the border by themselves. and this is -- these are historic levels for us. that's a 97% increase in february from the previous year
february. it's just not sustainable at9 this rate. i know the ranking member raised in her opening statement concern about temporary influx facilities. i will work with this committee to take care of the children appropriately, any ideas of how to insure we're doing that well, i would love to enhance our fixed permanent capacity. it's cheaper, it's more economical. we've been working on that. it's slow to do. you understand government contracting around leasing is slow. we need help. we need help. and at this rate, the funding even for this year will not be satisfactory, and i want to be transparent with this committee in particular about that. we are working with omb on what those total funding needs could be at the current rate, but it would exceed where we are even with the transfer and reframing that i notified the committee about. this is just, it's beyond belief, the level of children that are coming across the border right now. >> [inaudible] in your case the unaccompanied
children -- >> these are unaccompanied children. these are kids just coming across, they don't have a parent with them, they're coming by themselves. >> all right. i have more questions on this, but i'm going to stick with my time restraint. i have a feeling they'll bed asked -- they'll be asked by others. senator murray. >> thank you, mr. chairman. mr. secretary, despite continued assertions that your budget guarantees affordable health care and protects people with pre-existing conditions, the fact is that the administration is doing everything it can to actually sabotage health care, and this budget appears to be just more of the same. this budget continues to push harmful policies that undermine if health care for millions of people across the country. your budget calls for repealing and replacing the acc with the failed trumpcare bill which was rejected last congress, and in his clearest message yet to patients and families that he sees their health care coverage as nothing more than some kind
of political football, last week president trump sided with the ruling that all of the aca should be struck down. all of it. now, according to reports, you initially opposed president trump on that and issued a statement of support. so i wanted to ask you today, did you initially object to the president's decision to side with the texas court? because you know the impact that this would have, it'd be devastating for so many families? >> as you can appreciate, the advice of a cabinet member to the president of the united states is highly confidential, and it wouldn't be appropriate for me to comment on that. what i would say is the position the administration took in the affordable care act litigation is an appropriate decision supporting a district court's decision. reasonable minds can differ on this question of legal issues. this is not our policy position. that is a legal conclusion about the aca, and that litigation -- which we did not bring, we are a party, i'm the party in the litigation -- but we want to protect pre-existing conditions. if the litigation ends up in
that position, we want to work with you to secure better care for people and make sure all the types of issues you've raised are taken care of in any kind of new legislation. >> well, let me just ask you, as secretary of health, to you green -- do you agree that if this ruling is upheld as the administration is arguing for, it will result in tens of millions of people losing their coverage and allow insurers to discriminate against people with pre-existing conditions if it's upheld? >> well, the burden would be on us to work together to actually come up with a -- >> that's not the question. the question is if the court dose through with the ruling as -- goes through with the ruling as you have requested them to, will it result? >> well, you wouldn't have medicaid expansion, and you wouldn't have the exchange -- >> pre-existing -- >> unless you can come up with a better system that we think delivers better care -- >> i've heard that before. it would mean that people with pre-existing conditions. >> the president will never agree to any legislation that --
>> i'm not asking about legislation, i'm asking about the court decision. >> a legal, a legal interpretation of a court case is not a policy position about what we want to have happen for people with pre-existing conditions. >> well -- >> we're going to fight for people with pre-existing conditions under all circumstances, but a legal judgment filed by the justice department is different than a policy position to work with you to protect people with pre-ex. >> okay. well, it's pretty clear if that, if the administration goes after this in court and wins, people will lose their pre-existing conditions at that point. so let me, let me just go on. i wanted to ask you about title x, and as you know, i am really concerned about this administration's constant efforts to undermine the historically bipartisan title x family planning program. it's the only federal program dedicated to contraceptive health care and family planning services and actually helps four million people annually get
services like cancer screenings, contraception, crucial preventive health is services. your title x domestic gag rule will take effect very soon, and barring -- it will bar providers from talking to their patients about all the family planning options. the american medical association has actually called that rule, quote: a violation of patient's rights under the code of medical ethics, unquote. and they've actually joined planned parenthood to fight that in court. you also announced the title x grant recipients for 2019, dropped five planned parenthood affiliates, make it harder for tense of thousands of women get the care they need and awarded funding to an ideologically-driven family planning, your intent to authorize the offices that administer title x and teen pregnancy. if you could answer yes or no, i
wanted to ask you, is birth control an evidence-based family planning option? >> we support the full range of family planning. that's why we fully funded and kept it flat, kept the title x flat funding even as we cut other part obviously the budget. so we do support access to contraception and birth control and the full range of family planning options. >> and you believe birth control is part of -- >> it's part of the title x program, and we support that. >> so the one entity that you're referring to, actually, part of its grant application is required -- there are going to be seven federally-qualified health centers. these are always done as a program with a grantee and subgrantees, so they have to offer across the program the full range of family planning alternatives -- >> including birth control. >> yes. so they will have other providers in there, the seven -- >> so it'll make it harder for women to get pushed around.
i get it. all right. my time is up. >> thank you, senator murray. senator al zapper. >> thank you -- alexander. >> thank you, mr. chairman. welcome, mr. secretary. let me first pass a compliment to senator blunt and senator murray, the ranking member, and other members of the subcommittee for three consecutive years of significant -- four consecutive years of significant increases of funding for the national institutes of health. we see the results of that everywhere, and i fully support it, and i thank you for your leadership, senator murray, senator durbin and you have been consistent supporters of that. second, to the president and to you, i'm proud of the initiative that seeks to reduce hiv infections by 7 a 5% in -- 75% in the next five years, 90% in the next ten years. i hope you will focus especially on those parts of the country where that's a special problem. african-americans account for 43
% of hiv diagnosis. in 2016 more than 84% of the people in memphis with hiv were african-american and of estimate new hiv diagnoses in temperature, more than 25% -- in tennessee, more than 25% were in memphis alone. i want to call to your attention the medicare area wage index which i won't ask you a question about, but that's continuing to be a reason why hospitals especially in rural tennessee and other parts of rural america close, because of the unfairness of that index. now, mr. secretary, i heard the question by the senator from washington about the affordable care act. i think it's a pretty farfetched case, in my opinion, but i'm not the judge. i'm pretty sure that if there were any decision that resulted in the affordable care act being overturned, that the court would stay the effect of the decision
giving congress and the president time to do whatever they wanted to do. let me ask you this question. have you made any changes in the way you are administering the affordable care act as a result of the department of justice's position on this litigation? >> we have and will not make any changes to how we ad more the affordable care act in light of the litigation. it could be a year, two years before we get any final ruling by an ultimate, final court of jurisdiction. i have instructed my team, my organization we continue to implement the affordable care act faithfully and fully across the board without regard to litigation positions taken by the administration in court. >> so whether you like it or not, you recognize it's the law. >> absolutely. >> on a separate question, the committee that i'm chairman of and senator murray's the ranking member, the health committee, have been working with the finance committee, senator grassley and wyden, for the last several months to see if we
could identify a series of steps to reduce health care costs. testimony before our committee is that up to half of health care costs are unnecessary. we're working on that the same way we worked on opioids which means democrats and republicans working together, various committees working together, staffs working together. so far so good. our goal in the health committee is to see if we can produce a recommendation, a mark-up for the full senate by june or july. are you and the administration willing to work with us and support our efforts to address these issues like surprise medical bill, prescription drugs, direct primary care, transparency, rebates, other issues? if we're going to work in a bipartisan way, is the administration willing to support our efforts to get a
result in this way? >> we are fully supportive of the efforts of you, senator murray, chairman grassley, senator wyden working together on a bipartisan basis across all of those issues. >> on opioids, president trump asked the president of china to make all forms of ethanol illegal, and china has announced -- in china -- and china has announced that it will do that starting may the 1st. i want to congratulate you and the president for that and thank the officials of china for that, because our drug enforcement agency has told us that one way or the other most of the fentanyl that comes into the united states starts in china. i don't have time for you to answer a question, but as we think about opioids, i hope that you will keep an eye on the effect it's having on people
with pain while we're getting rid of opioids that are used inappropriately. we wanted to make sure -- we want the make sure they are used appropriately by doctors and the cdc guideline, about which there'll be a report in may and the fda report in august, should be seen as advice and guidelines leaving the decisions in the hands of individual doctors, and i hope you'll help us to that. thank you, mr. chairman. >> thank you, senator al alexander. and i want to say having you and senator murray on things like the health care issues and moving forward with nih research makes a real difference, having both of you here who also have the authorizing committee and your leaderships really matter particularly on what we've been able to do at nih. nobody's been more involved in that than during by. senator -- senator durbin. senator durbin? and congratulations to you and senator murray. four years of consistent growth
at nih is saving lives. the president's recommendation of making a cut in medical research, i believe, will be roundly dismissed by both political parties, and i hope that that's the outcome soon. i thank you all, including senator alexander. so, mr. secretary, i have so many questions, so little time, as they say. let me go to this unaccompanied children issue for a minute. when i asked the inspector general to investigate the zero tolerance policy of the trump administration which forcibly removed over 2800 children from their parents when they came to the united states, we were told that, in fact, the public announcement of this program actually postdated the initiation by as much as a year that there could have been thousands that a had not been disclosed prior to the announcement. were -- when did you first become aware, mr. secretary, of the president's zero tolerance policy? >> so i became aware of the
attorney general's zero tolerance initiative basically when he announced it in the public. i learned of it in the media in april when the zero tolerance was announced at that point. then subsequently as we have been going through this, i believe in the summer or late summer, maybe it actually might have each been through the inspector general's work that you asked for, learned of some of the previous piloting. >> how many children were affect by this piloting or demonstration effort? >> well, as the inspector general said, there was a surmise there only of numbers. there was no -- the inspector general just said there could be a couple of thousand but didn't know how many in that case. >> did you play any role in crafting this policy of zero tolerance? >> no. how could i if i learned about it in april when it was announced? this. >> so let me ask you about unaccompanied children now. you say there's an inflow of
300-350 unaccompanied children a day coming into the system. your web site says that you have facilities for placement of up to 14,000 children and currently some 12,000 are placed in your facilities. is that correct? >> so as of this morning we have 12,340 children in our care. we've got 428 available beds with another 114 beds summit to -- could be available, but usually it's an issue of getting adequate staff thing. we are very tight right now, senator. >> understood. and what is the outflow of children who are actually sent to families or placed outside your facilities? >> so our discharge rate has been quite high, we've really been prioritizing and working on that. our discharge rate on a 30-day reference has been 2.0 children per 100 children on discharge, and on the seven-day we're actually 2.4 children per 100.
i think if, as i've looked in the last couple of weeks, we are essentially adding almost 70-80 children per day just because of the inflow and outflow rates. >> the net -- >> net, exactly. >> so is it true, as we've been reading, that these children are primarily coming from three countries? >> that's absolutely correct. we get a -- it's guatemala, el salvador and honduras. one of the particular challenges lately has been we've been getting -- it's a lot easier for us to place children out where they have actually one parent here in the united states or a close relative because we can make that a faster process. it's a check on them. some of the children, we've been getting an increasing mix of guatemalan male teenagers who have no family connections here. those become extremely difficult for us to try to place out. >> i've, i understand that part of it. it is interesting to note that these children are coming from three countries. not nicaragua, not costa rica,
not mexico, but these three countries that the president now wants do cut off all foreign aid to these countries believing, in miss hind -- in his mind, that is going to solve the problem. i think it'll make it worse. i think it's important to note that the administration eliminated the program where children could go through the screening in home country at the u.s. embassy and consulate. and now many of these families in their desperation have no other recourse to test their status than come to the border of the united states and present themselves. so wouldn't you believe that it would be helpful if we had a system restored as it was under the obama administration for screening that begins in country? >> senator, i am not an immigration law expert. i had not known about that country, in country actually seems consistent with the discussions that aye heard from secretary nielsen about the desire to have asylum claims
adjudicated, i'd be happy to -- >> please do. i hope you will raise it. >> i'll look into it. >> i have a lot of really good questions on prescription drug pricing -- >> i hope we can keep working together, you and i, on -- and really appreciate your support on direct to consumer add a advertising. >> listing the price is favored by 88% of the american people. >> yep. >> thank you for, on a regulatory basis, for moving on this. we did include it in the appropriation bill in the last round -- >> we got close. >> we got close. it was killed in the conference in the house, but i'm hoping and praying that senator blunt and others will stand behind restoring that. >> i'd encourage you to take a look in the office of management and budget's rokus system which is where regulations are filed for review. there is a rule with a title referring to a final rule related to direct to consumer advertising pending at omb. >> thank you. >> thank you, senator. senator moran. >> secretary, thank you for being here.
let me raise just a topic, and then i want to continue where senator blunt left off in regard to transplant program. i want to highlight for you that we have three hospitals in kansas, horton, hillsborough and as weeing go, small rural hospitals, all of them critical access hospitals. the thing they have in common, they're owned by empower hms. empower hms is, has been investigated by cms for billing fraud. but as a result of that and other factors, business factors, management factors, those three hospitals are in various conditions either shut down or have a trustee in bankruptcy attempting to operate those hospitals. and i would, first of all, encourage you to take -- not to change your enforcement procedures or not to any way pursue fraudulent behavior any less, but recognize there's a consequence to a community hospital that regardless of who the owner of the hospital is who can be gone that night, the community is left in a
circumstance in which their hospital is no longer functioning. and so i would hope that cms and ores at -- others can have a plan in place that when you are creating a circumstance that forces a business out of business because of fraud, the end result is that the person who committed the fraud, the company who committed the fraud is who pays the price, not the community who no longer has a hospital. and i would welcome any thoughts that you or your folks at cms could provide in this particular case, but just generally there's a consequence for this bad behavior. and i hope that whatever bad behavior is determined if you determine that, that if appropriate, it's referred to the the president of justice. pause the -- the department of justice. because the consequences for this behavior is long-term generational consequences to communities and the people who live there. just of significant challenges now as a result of -- in addition to the challenges we just have of keeping hospital doors open generally in communities across kansas.
in regard to the liver allocation issue, mr. secretary, let me ask just a couple of questions and then express my concern and dissatisfaction. let me first ask if you believe that enough is being done to help individuals with end stage liver disease who are not yet on the wait list. so there's another population, those who are on a wait list waiting for a transplant, there are those who are not on the wait list yet. is enough being done to advance their well-being? >> i think the number one thing that we can all be doing is working, as the chairman referred to it earlier, increase the supply of livers that we have for transplantation. that's the most important thing we can do to help with advancing individuals. i hope that we're doing everything we can with regard to care for individuals awaiting transplant. if there are things we could be doing differently, please do let me know. i'd want to make sure we're
doing that. >> would you commit the department to a full public disclosure, a transparent public debate on this allocation, organ allocation transplant process? >> i'm happy to work with you on what that might look like. as i mentioned to the chairman, the challenge with this issue is that congress deliberately took that out of my hands to make it a non-political issue. and so when we don't like the conclusion, i'm fairly restricted in what i can do. but we certainly -- i believe the optm process was a public process with a public record but happy to work with you and your staff on any vehicle to insure that. >> mr. secretary, you're moving me to my complaining aspect by your comments. [laughter] because it was only after a lawsuit was filed, as i understand it, that this allocation process was then considered for change. and when you tell me that we
constructed the ground rules for you to be removed from the process, you do a appoint the hrsa director. the hrsa director has written a letter to optm encouraging them to quickly implement the decision that they made and encouraging them. i would also tell you that while from time to time in this job people tell me something that doesn't always turn out to be true, but in our meeting senator blunt and i had with the hrsa director, the request was that we make certain that our constituencies -- transplant programs in our states -- submit not just comments, but please bring us a proposal because we're so interested in listening to the proposal. don't just complain about the proposal that's out there, tell us how to do it better. and i can tell you that the end result of our programs doing that, they were not considered. and, in fact, the decision was
made before those comments were submitted, before that proposal was submitted by our constituents. and i quoted you, i wrote down what you said in a last minute or late, the computer program shut down because there were so many comments. the only lateness of our programs supplying their comments and proposals was because the computer was shut down because of commentary. and the decision was made before these were ever realize, and then they were approved with no changes thereafter. the original decision was made by the liver intestine committee and without ever seeing the comments of our constituents. and then secondly, it was approved immediately with no change even though you can claim -- perhaps correctly -- you can claim that the comments were then read a after the initial decision was made. my point is that while i'm
often -- perhaps i misunderstand what has been requested of me or what my instructions are of how i can be a help to my constituents, what i think we did was exactly what we were told to do with no beneficial thing happening as a result of following those instructions. so this process has been flawed, and it is a flaw that arises out of the fear of a lawsuit. and after a long period of time -- i know what you're saying, chairman blunt -- [laughter] the policy in place was changed almost overnight in response to a lawsuit. and you're right, the issue is more organ donation, and the policy that is being developed is contradictory to what you said is the goal. i'll be back for the second round. >> senator merkley. thank you, senate moran. >> thank you very much. you mentioned that there's a big influx of unaccompanied minors crossing the border. and are you referring to people
crossing between ports of entry? >> we will receive the 300-350 children from wherever they show up. if they show up at a border crossing alone, if they show up at a non-border crossing alone, their uacs, how they came across, or even if they were already a resident and come into federal authorities and they're unaccompanied alien children, they'll be referred to us no matter what, so i don't know where they cross the border. >> so they're in tijuana where you're saying that you can walk up to the port of entry and present themselves? >> if a child comes up to the border, presents themself and is a 12-year-old, a minor, and is an unaccompanied alien children, i believe at that point subject to whatever the rule of dhs are -- we'd have to ask secretary nielsen -- i believe if they're not immediately repatriate bl, they're sent to us. >> okay. so this is not the way it works, and i would encourage you to learn a lot more about this.
right now if an unawe companied minor comes to the boarder in san diego, they are not allowed to present themselves at the border. everyone who is 18 and up is instructed to return to mexico to get into the book. this is the metering process. but if you're under 18, you're not allowed to get in the book, and you're not allowed to cross the border. so we are leaving these people permanently exiled inty wan a that with really no choice about how to proceed that's a good choice. if they present if themselves to the mexican authority, they're deported back into horrific circumstances. if they stay in tijuana, they're subject to gangs and sex predators that have a big sex industry there. and so their best option is to cross the border illegally. so while the president of the united states is telling the world don't cross between ports of entry, we're blocking the minors from crossing through the ports of entry. do you think that's acceptable? >> i do not know border -- >> well, i encourage you to find
out. you're very directly affected by it. it's why so many miners are crossing between ports of -- minors are crossing between ports of industry. and the fact that you haven't educated yourself really is unacceptable. second, you said that you have sent a letter to congress to fund an expansion of the child prison system under this administration. what expansion level are you planning to go to? >> so we sent a funding and reprogramming request that -- not a request, but a, basically, a transfer message that we were transferring $286 million using the secretary's 15% transfer authority and reprogramming $99 million of money that is not needed for the refugee program within orr as part of the transfer and re-- >> so $385 million on top of the 266 million -- >> and at this current rate, as i mentioned to the chairman, that will not prove adequate for
this year. >> what is the capacity of the child prison system that you're seeking with this money? >> so that, actually, is supportive of to our current rates of about 14,000 beds, i believe, as well as our expected added -- we're trying to add as many fixed beds. you keep saying prison system. if you've got an alternative approach to how to care for these children, please tell us -- >> well, let me -- [inaudible conversations] >> if there are a better way, we want to be compassionate -- >> well, okay, you asked me, we'll have a little dialogue here. it's called sponsors, and the reason it's so hard to get sponsors is the administration is telling potential sponsors that all their information will be shared with i.c.e. therefore, people are not coming forward to be sponsors because they don't want to be stuck into our criminal -- >> i believe the congress actually passed an appropriations rider limiting the use of any information that would go to dhs as part of the background checking that we have to do, that we do as part of our sponsorship check -- >> but, unfortunately --
>> i think that's dated information. >> the families are still being told that their information could be used in this capacity. so as long as you're still telling families that, then they're discouraged -- >> i'll be happy to look at that -- >> please do. >> i wasn't aware they were being told that. >> these children belong in homes and schools and parks, not locked up. i call them prisons because they are locked up. i don't know if you have visit these facilities. >> i do frequently. >> well, then you understand what you're talking about. >> i completely agree with you. i do not want any child in our custody. i want every child out with an appropriate, safely-vetted sponsor in to our community. >> then please examine the reasons why it's so hard to recruit sponsors. it's also costing a huge expense. this temporary influx, $750 a day for a for-profit operator to run a former air base facility when a permanent facility costs much less? and with sponsors, it costs a
fraction, just a fraction to have a caseworker working with those families. not only is it much better for the children as they a await an asylum process, it's much better for the american taxpayer. and maybe it means less profits for these for-profit companies you're hiring to run homestead, but shouldn't you watch out for the taxpayers and the children instead? >> senator, i completely share your goal and my goal and the government's goal that these children should be with sponsors and not in our care. >> good. >> we can work together to make that happen, i am -- i will be delighted to work with anyone to make that happen. >> they're in homestead in florida they have not undertaken the address the child abuse and neglect checks for the staff members so that they can make sure that the individuals they hire, working with these kids, do not have a record of, as a sexual predator, and that's unacceptable. >> thank you, senator merkley. senator kennedy. >> thank you, mr. chairman. thank you, mr. secretary.
mr. secretary, do you believe in the rule of law? >> yes, i do. [laughter] especially as a trained lawyer. indeed. [laughter] >> is it illegal to come into our country illegally? >> it is, indeed, illegal to come into our country illegally. >> okay. do you dislike children? >> i love children, and i want to care compassion a nately for any child i'm ever entrusted with. >> are you trying to hurt children who are coming into our country at the border? >> not only that, but i am, i am proud to lead an organization of people and have grantees that are some of the most compassionate, caring child welfare people that i have ever interacted with who love these children and care deeply for these children. ..
the double what it was ten years ago or something like that. >> let me ask about the affordable care act. i remember when congress passed it we were promised, meaning i am an american like you are. we were promised two things, number one that it would make health insurance cheaper, more affordable. has there done that? >> we were promised it would cost half the cost of the time and during the tenure of double in cost. >> i remember vividly because i watched it on c-span i remember the congress also promised it would make health insurance more
accessible. the president has always supported replacing the affordable care act with something that is better. >> there's been some innuendo here. does he support getting rid of the affordable care act without a better plan in place? >> he insists there be a better plan in place. >> you would know anyone who supports the healthcare insurance program or delivery system that wouldn't cover pre-existing conditions?
does the president support a replacement plan for obamacare that would cover pre-existing conditions? >> he will never sign any plan that doesn't take care of people with pre-existing conditions. >> i want to look at the healthcare system from 30,000 for a second. here's what i don't understand. i keep reading that 10% of the american people spend about 67% of the healthcare dollars which makes sense because we all know that the chronically ill spend more money than others. when you run the numbers and consider that we've got 320 million people, more like 330 million people who take two
thirds of that 18% and divide it by 33 million what you come out with his $80,000 a person so for these people out of 333 million, we are spending about $80,000 a person. why can't we identify the 33 million, i'm only on this plan on time, mr. chairman. why can't we identify and manage their care better. >> we can do that for vehicles like insurance pools for example under the aca they've brought premiums down in the states anywhere from 9% to 30% by cleaning up the risk for those higher risk people and separately free ensuring that so
the burden isn't on all the other people. >> thank you, senator. >> thank you mr. chairman. ranking member mr. secretary, i'm worried about tobacco use among our young people and that's why i'm about to introduce the tobacco 21 act with senator young it would raise the minimum age from 18 to 21 for the purpose of tobacco products to include the sale of combustible cigarettes and e. cigarettes. the institute of medicine found raising the age of sales would reduce the tobacco initiation especially on kids 15 to 17 and lead to 12% prevalence with hundreds of localities have taken this action. tobacco use is a severe public health problem and do you commit
that we can work together on this legislation? >> thank you very much for that question and your work in this area. i am extremely concerned about tobacco use and the epidemic among our youth. i'm committed to working with you and other members of legislation to address tobacco use among the youth as well as taking any necessary regulatory action. the commissioners last day was today, and i've been very clear that while e. cigarettes may offer a lower risk alternative for adult smokers who still want access to nicotine, we cannot allow them to be in on-ramp to nicotine addiction for an entire new generation. the proposal into prioritized that are for sale in ways that t pose a greater risk for minors to access the products for instance they will consider whether the products are sold under circumstances in the verification and while we pursue changes to their bigotry policy
b.: the industry, manufacturers and retailers to step up with meaningful measures to reduce the access and the appeal. the epidemic level has prompted actions by the fda in both enforcement and public education so thank you very much for your help and i look forward to working with you on this. >> i know you were a big supporter of tele- health and noted the regulatory barriers. one section of the act would give you the authority to weigh out the barriers to the traditional reimbursement under the circumstances. if the services would reduce spending while maintaining quality or if the services would improve health care quality without increasing spending. can you talk about what that authority would mean in terms of public health and especially expenditures regarding public
health? stanek as you mentioned, i've been passionate in my advocacy and i think it is in part for states like hawaii and that our rural expanding access and also extending just the quality of care even more to make sure all of america shares centers of excellence. it was written in the 1960s before tele- health acces healto there are many barriers to voting they would look forward to working with you on anyways the flexibility could especially in ways that don't open the door to fraud abuse or waste beneficiary resources. >> we had a lot done with the senator's leadership and a bipartisan group. there are a few more things to do this is in the only one, but it's sort of the holy grail.
a final comment and question i was struck by the exchange between senator merkley and you in one particular way it got contentious because this is frankly the kind of thing that should cause people to be emotional, but to the extent there's a statute that provides for confidentiality and sponso sponsors. the fact seems to me to be a light bulb going off for all of us that we need to do a better job of communicating the sponsors and their confidentiality is protected and the family situation is protected and that we as a matter of government policy, whatever we think about the order wall and whose fault is what and all these other arguments, and have a minimum these kids need sponsors and to
the extent potential sponsors are afraid to do so because they are afraid they are going to end up in a database we need to do a better job of telling them that there is a law that protects the confidentiality and we can work together to follow up on that. >> thank you, mr. chairman. i certainly appreciate secretary being here today and answering the questions in a way that you were doing this. the senator from mississippi, we have so many rural hospitals in mississippi that are struggling. a recent report found that half of all rural hospitals in mississippi are at high financial risk of closing. i just read an article that mississippi has more rural hospitals at risk of closing than any other state in this country. when a hospital closes, obviously, the whole community
is affected in so many ways. model may be in play meant, but mainly what is most important it means no more access to emergency care for the community residents and in an emergency, timely care is tha of the essene and having by ) can mean life or death we just recently had a young lady in mississippi just a few weeks ago that died of an asthma attack. so, i guess my question is what is hhs giving to respond to these hospital closures that is very critical in my state? >> you have raised concerns about the rural hospital access to mississippi and in part because of the reference, i've created a task force across hhs to help come up with all of these ideas how we can help address the crisis areas one of
them we were discussing which is tele- health. how can we make sure we are expanding access into rural america because w we will wind p consolidating everybody living in urban areas if we can't provide them healthcare. so tele- health is important and we have to make sure providers are able to practice so we are not having artificial restraints on the competition blocking access in rural america. and we also have to make sure that our regulations or otherwise are not creating artificial barriers to economically viable models of hospitals in rural america. are we trying to force a 1960s model of hospitals through the payment systems and other regulations onto the orbital america so we are looking at how we even if conceived the needs of america from a hospital perspective. i was talking with the leader yesterday that the requirement we have which is you have to
have a surgeon on satellites to 20 surgeries are here. how does that still hold and is that a part of making deficit would be economically viable long term to be able to provide access in the community. so, this is a deep passion of mine we are working on and any ideas you have to be helpful we certainly want to be there. >> thank you very much. >> thank you, senators. senator baldwin. thank you mr. chairman. i want to tell you about zoe warren buffet con genital heart defect and she had open heart surgery at five days old. she will continue to get coverage and the care she needs thanks to the affordable care
act and its protections for people with pre-existing health conditions. when the republicans were working to repeal the affordable care act legislatively, i got a letter from her mom and she wrote to me and said it's like they are taking the american dream from her referring to her daughter. she wrote i am pleading with you as a mother to fight for those with pre-existing conditions. they are counting on you to protect that right. the administration recently decided to support a lawsuit aimed at striking down the affordable care act in its entirety and all of its protections. so, how do i explain a decision like that and by the way she
just celebrated her sixth birthday and this is more or less a rhetorical question how do you tell a little girl like that what's going to happen to her, and so i want to just confirm my understanding the affordable care act is struck down in entirety a position that your administration is supporting, what protections from discriminating against those with pre-existing conditions will still remain in the wall plaques >> there are the existing protections around pre-existing conditions that wouldn't be impacted for the employer-sponsored insurance, and then as i was mentioning with the ranking member we will be working within with congress to ensure they have protection.
>> in other words if it is struck down for a time there will be nothing in place to protect her and kids like her. they've promised by expanding the use of junk health plans and that is what i call them because they don't have to cover pre-existing conditions the very first sentence of the policy states pre-existing conditions diagnosed within 16 months for how immediately preceding such covert persons effective date.
no benefits or pitiable for the expenses were pre-existing conditions and described as a condition that, quote, would have caused an ordinarily prudent person to seek medical advice within 1 12 months immediately preceding the date of coverage. model made the decision to join the lawsuit to totally repeal and overturn the affordable care act, but the decision to proactively expand the use and availability of these plans is not a broken promise to protect people with pre-existing conditions. >> i assume you are referring to the plans which we restored to the obama administration. these plans are not for everyone and if a plan like that, i'm quite glad that the disclosures
that we had our making it so apparent that if you have a pre-existing condition those wouldn't be plans but you should choose. >> you are arguing in court to overturn the affordable care act so there won't be a marketplace. now i want to move on to something that you've discussed at length. if the administration is successful in the lawsuits and affordable care act struck down, the prescription drug reforms would also go down. your own pilot program is being tested through the center for medicare and medicaid created under the affordable care act so if the lawsuits succeed and the affordable care act is struck
down in court, they will cease to exist and so will this pilot. is that true or false? >> it is part of the affordable care act and my hope is any system would give the authorities to do demonstrations and pilot such as the ones we are committed to. you would have to find additional authority. >> thank you, senator. senator capito. >> thank you for being here. my first question from the state of west virginia we are lucky enough to be on the subcommittee. i've been ravaged by the opioid epidemic that we are starting to look at some of the ripple effects, and i know that you and your statement addressed the increase of hepatitis c and also hiv. could you tell me briefly how you are meeting the challenge is working with our public health officials in the state some of
them i think i've been very forward leaning and trying to master this. >> the ending hiv epidemic will be available in the focused efforts we see 10% of new cases coming out of injectable drug use. special funding as a part of the budget. they did for me with the venue w availability of different metrics it is quicker and more effective without.
the childhood cancer survivor access and research of 30 million in the budget and i would like to know what your department is doing on that enhancing the collection and beauty aids us in the research programs. also to conduct and support for childhoochildhood cancer survivp research efforts at the cbc. we are working to implement the registries so we look forward to the continued success of early case capture program that lets us identify children right away
and helps with the research programs. with a focus on the pediatric research, it's been neglected some of the leading hospitals in the state are putting a great focus. but i felt rather surprising because i don't think we think of ourselves like this as a country but the rising statistics of the maternal mortality in it if you are
quoted in werequoted in the stag over 700 women died in and around associated with childbirth we did pass with the bipartisan efforts to the maternal mortality accountability act piec these me them very preventable though rates have doubled over the past few decades. so much of it is about prenatal care and delivery and access getting adequate care also from
the cdc which you just mentioned that includes $12 million for the data collection and research to understand even better the cause of these. i think you'll find senator murray's leadership and others. thank you so much. >> what is the reality here of the budget that isn't going to be reflected in the lumber congress ultimately passes we would never support the
draconian cuts that are in it to make sure that this budget never ever sees the light of day to contrast the giant presence in this country about a year ago. it went fully implemented and will deliver 80% of the benefits of the top 1% of income earners and now we are seeing who's asked to pay for it they are going to have their heating heag shutoff in the winter because
the budget doesn't fund low income heating assistance program so that is at the heart of the frustration. it's not just that it doesn't reflect the values as it stands in contrast with the tax cut that isn't going to deliver results from the majority of americans. i want to talk about the effect of the budget on the opioid epidemic in your testimony you point to about $5 billion in funding that is directly dedicated to the academic that is largely money that was already in the budget, but it stands in contrast to $1.5 million in medicaid cuts and the budget including the wholesale elimination of the medicaid expansion. four out of ten that are dealing with opioid addiction are on medicaid so when you put $5 billion essentially in the flats on them for specific
opioid treatment next $1.5 trillion in cuts to the insurance program that allows the states to pay for treatment, the result is a devastating negative out of the opioid treatment system i guess i just want to be honest what we are doing here. they are still going to spend more money in real dollars but this is a $1.5 trillion cuts compared to what we expected the states to spend and i feel like we should be honest with u whats asks is for states to pick up a much bigger share of the burden for caring for people with addiction and that as a national emergency we declared it comes with an expectation of the federal government would do less and state would do more when we lose 100,000 people off the role
of the medicaid program other states may not be able to come up with those dollars so i just want to ask you that isn't that what we are doing asking them to essentially pick up the burden of the opioid epidemic given the comparison of the cuts in the bill to the $5 billion in specific opioid funding? >> we have a $1.5 trillion reduction in the medicaid expansion and affordable care act exchange subsidies we add back a $1.2 trillion program that would be state-based flexibility and i hope many other public health issues we deal with is the expansion of the able-bodied adults has taken us away and incentivized coverage those that are part of
the core medicaid my hope is with the $1.2 trillion program with the flexibility of the state on that money that they would focus that in areas like you just talked about where the needs are the greatest and prioritize on those areas and it might actually enhance coverage and access for those individuals that we care so much about. >> flexibility will allow states to enhance the coverage but it's a lot less money than they were getting today and states are begging for additional dollars to care for people with opioid epidemic asking them to focus better with less money. thank you mr. chairman. >> thank you. senator manchin followed by senator shaheen.
>> thank you mr. chairman and mr. secretary first of all for being here and also for your service we faced the largest per capita burden in the country and i think my dear friend senator shaheen is right behind us. the epidemic is costing our little state 8.8 billion a year and forcing us to do to get the largest share of gdp of any state which is 12%. i appreciate what you've done and everybody is concerned. the 15% set aside, i'm asking if you can do this you have to take into consideration the deaths per capita not just the total deaths. i've got counties if you look at the total debt we can't help
them. >> i appreciate you raising that issue. one thing would be where you helped us a lot with the support of the appropriations funding helping us with the formula fors to allow a focus on the highest burden states and if it is incidents per capita i need you to fix that issues in the state are happy to work with you and the government in west virginia to educate and focus on that area. >> you might want to expand what can be done and how quickly you can make this happen i know there are some hoops we have to trawl through thank you for
prioritizing the work in this area, and i am going to be speaking with the office of national coordinator to make sure that it's a priority to share these best practices that are part of the chassis all in the support act. we have to examine the part which were there aren't unintended consequences for instance where providers don't put information. i appreciate your diligence towards that and it means so much to all of us and very quickly, funding for this horrible disease i've introduced
life does year after year it basically says all pharmaceuticals producing opiates should pay 1 penny per milligram for the production fee and that would give permanent fund them. do we think we need all these products on the production fee to make sure we had a constant stream of money that goes to the areas that hit the hardest. the genesis of this crisis is the legal opioids and that is why i'm glad we've gotten that prescribing down by 20% and -- >> except 1 penny per milligram would be a tremendous help. finally, on affordable care act the president said he isn't going to do anything until after 2020. let's say the courts advocate
from this you hav have a lot of expertise and to bring an awful lot to the table. how would you fix what you have in front of you if that is all you have? nothing new, not reinventing the wheel. i've been hard-pressed to vote for what was in front of me and i would work to change a few things that we have integrated into the system how would you recommend? it's just how the insurance benefit is structured with issues i will give you an one example for three to one rating essentially you've made insurance for individuals who are healthy unaffordable and they walk through the market and that creates this kind of downward spiral that we've seen. >> it's higher than the three to one rate of people that are sick but that's what we get into.
they cannot come up with how you predict pre-existing conditions by the definition you said that they can't deny this pre-existing condition. that means we cannot afford what is out there. you are preventing them from being denied, you are not preventing them from being able to afford it. there are ways one can make sure it's affordable. senator kennedy and i had about the reinsurance vehicles that are quite well-established. >> i'm going to be introducing back since the bill isn't here
and we would love to have your support on that because we think that would be a big fix in reducing from the private pay from 20 to 40% overnight it is what was going to be the alexander murray package that would have csr funding. >> those bills have been laying on the majority leader desk of course we have a stumbling block and senator murray the funding would have the productions that ended up being the stumbling block for us at the end of the day. if you want to stay for a minute there will be more time for questions. >> thank you mr. secretary for being here. i would say becaus it is an agrt between both sides on the
alexander murray legislation and a strong list of bipartisan sponsors. it's unfortunate because there is opposition from the white house and opposition from the leadership in the senate that the bill wasn't able to come to the floor and i would encourage you, i think everybody that has been in the senate since we passed the affordable care act recognizes that we need to improve some things that are not working but the response is not to refuse to come to the table were returned the walls of people have no alternatives. it's to get it done and i'm very disappointed we haven't seen that kind of leadership either from the senate leadership or from the white house. there are things we can do together because so far that has been missing from the conversation. >> i want to just agree about
the importance of a set aside on the opioid funding it's been critical in a state like new hampshire where as you know because you are familiar with it we had a huge problem we are behind west virginia in terms of the overdose death rate but way too high we have way too many families who are affected and the pain you can't talk to anybody in new hampshire who doesn't know someone or hasn't been affected personally by this epidemic and those set aside the dollars that have been used have made a huge difference in new hampshire. it's allowed us to share and set up a system that keeps people within an hour from a place they can get treatment which is very important we are still waiting to see how this is going to work but it's an improvement but it's
something that wouldn't have been done without those dollars. there were states across the country who are directors of programs to respond to the opioid epidemic and i asked them all a question. one was from new hampshire. she had the recovery center and i said what happens if these federal dollars go away and she said i will go back to bake sales. some of the other folks that were more directed people thought i they could ensure the treatment and we could prevent some of those deaths the concerns senator murphy was raising about what the budget
goes to repeal the expansion and replace it with block grants it assumes them every state is going to come up with the funding to replace that, and i think that is the question then a lot of the country. so, can you talk about what we should say to those people who are running the programs to address the opioid epidemic about what they should do if these federal dollars go away? >> the president is adamant on the funding and support for the opioid epidemic and the work we have a share of resources they need to deal with this and in addition our budget proposes with medicaid that we would actually expand access for women postpartum for one year to have
eligibility postpartum supports one of the changes we've got in the budget and we continue to process the exclusion waivers. we are continuing to drive forward fully engaged and focused on the epidemic and we are seeing the results and we targeted the response grants to ensure access to that medication treatment, the gold standard and i think we are helping to really just expand capacity by making it clear this is the most evidence-based approach to people for treatment and lifelong recovery. >> i appreciate those changes. if the fundamental source and coverage source for people to get treatment goes away, then
those will make a small difference but they will not address the underlying problem. can i ask one more question yesterday a study from the kaiser family foundation found that it's been in grew by 840% between 2007 and 2017. diabetes is one of the most expensive chronic illnesses we have in the country in figuring out how to help patients with a cost is very critical, but it's also a question about how can we be most effective with our public dollars to address illness. i know your department has proposed rules to limit the impact of the benefit rebates difficult drive up the cost. can you tell us whether you think removing that link is going to help address things like those costs or do we need
to be doing something else? >> i would beat her to something else. i can tell you the rules that we have proposed to get these rebates out of the system and instead go as discounts to the patient at the pharmacy level would be revolutionary for the situation you are talking about especially for those like insulin or arthritis medicine for high-cost cholesterol medicines that are highly related now you might have a 70% rebate. imagine january 1 of 2020, when that patient walks in the pharmacy of the rule goes forward they would get a 70% discount every time they fill that prescription. it's a revolutionary change for the access and affordability if we can get this and i pray that we will have your support to do that. it's $29 billion of rebates are going to the pharmacy benefit
managers now that would go to patients starting january 1, 2020 if we can make this happen. >> i look forward to hearing more about it. >> senator murray. >> thank you for allowing us to ask one more question. mr. secretary, i did want to express my serious concerns about what's going on in the unaccompanied children program. most shelters as you know are working to provide excellent care to this horrible populati population. they are charged with the welfare of every child in its care and i'm deeply troubled by some of the reports of the forced drugging, sexual abuse of a substandard conditions at some of the temporary facilities, and i was especially appalled by the great length the former director went to prevent minors in custody from accessing reproductive care including cases where pregnancies were the result of sexual assault.
from obstructing access to abortion, a recently released a spreadsheet shows that it continued to track private reproductive health information from june 2018 and there is no indication the information collected in the spreadsheet is being used to ensure access to reproductive care. i wanted to ask you to they still keep a spreadsheet containing the reproductive health information of pregnant minors? >> i could not answer for him, but i believe the intention was the last menstrual. of days which we know that is vital to the care to know the gestational age of the child's not just the ongoing cycle information or that is my understanding but i doubt
there's any sort of central. we have ensured the delegation from the director level positions on significant medical procedures for the unaccompanied children to be career staff and i believe we are fully compliant with the order and injunction of faithfully executing on that. >> what are you doing to make sure that it complies in the court order? >> when there's a court order in place, we will apply that and the order that you are referring to we were in full compliance and if not, i would like to know but i certainly would give instructions that we would be in compliance. >> when were you first alerted that he was being briefed on the information it was contacting pregnant minors to discourage them from seeking abortions do you believe that is an appropriate role for the director and when did you know?
>> you and i spoke about this during the confirmation process if i remember correctly back in my first hearing in early or before i was in office so this was an issue of some controversy even then. they are the custodian of the child and we are delegated to make serious medical decisions of the parent or the child in consultation. >> this is important information. we sent last week a letter to you asking you to have your staff brief us fully on what you were doing and where that information is and how it is being used and we would like you to commit to having that.
>> thank you, senator. i have to think. there will be more for the record i'm sure but one is we are nearing the end of the two-year pilot period of eczema and mental health. it is our goal to come up with all the information we can about the impact. my request to you is we talk about maybe a two-year extension to get more information for the states to look at in the future. we have the data to help support
the sponsorship criteria is set in the trafficking victims protection act largely the categories of category one, two, three and four sponsors it should be a parent or guardian here in the united states already that we can place them with the three would be more distant relatives that we could place. there would be various red flags and we woul to do home inspecti. we always have the right to do fingerprints and other checks to assist with background checking of any individuals that's long been the case. we've had some height and requirements in part driven by
if you remember the colleague on the permanent subcommittee on investigations did some work on senator portman and senator carper on children who got laced with traffickers we want to make sure we are balancing keeping children in care as short a time as possible but also making sure when they are placed out, or placing them into a safe environment so we are always assessing any discretionary aspects of that fallon to strike back. we say they are household members for the level to sponsor. we decided in september we were not seeing enough hits in terms of information and information if merited the delay of people coming in as these household
members. we are always assessing what the needs are. >> the information is not to be shared with immigration service that information is shared with immigration to also get the immigration status we have previous administrations got the placement decisions not that they are precluded by being illegally in the country we don't do that but it's about to be deported and wouldn't be an adequate long-term. my understanding -- >> if someone is illegally in the country and not about to be deported, what do you do about
it? within the categorization of sponsors we placed the child most of the children are placed in the individuals that are illegally in the country. that information my understanding is that there is an appropriations rider that was passed as part of the large budget deal to end the closure of the government that actually restricts the use of that information over at dhs. but i have to defer to the dhs and its lawyers on that question. >> it is very transparent to all of us.
>> after the conversation with the liver transplant program in my state as a result of that activity, i've been amazed at the number of people from individuals in kansas and elsewhere who come to me to talk about the importance of this liver transplant policy. people who've had a liver transplant or are waiting for a liver transplant or want to be on a list, and again you and i would highlight and use the opportunity to highlight the importance of people being organ donors we need more to meet the demands but this is not just another consequences to a particular transplant program. this has significant consequences in fact life and death consequences for people across the country and finally i would remind you senator grassley along with almost half
the senate sent a letter to you which i don't believe at least i've not seen a refund an respoi would encourage you to respond. >> as my personal attention and that is what prompted me to ensure that we went and asked them to think again and to ensure full consideration of the comment out of kansas and missouri. that was in spite of the computer glitch and i understand the process was back in terms of the interactions with you and on behalf of the department, i apologize to you for any lack of courtesy and also just any problems in the process. my understanding is the comments in spite of the computer glitch were summarized in their decision making so it was part of the summary of the original decision-making. i understand that isn't necessarily everything you want
to hear in terms of if it were presented before any presumption was made that's why i went back and said please think again. please look at these comments and concerns. i've got a tremendou tremendousr every signatory on that letter and the letter of response that i got if there are further avenues that are appropriate and justifiable i am happy to consider them. >> i failed to get the results i am looking for. its results i'm looking for on behalf of the folks that definitely need a liver transplant. >> thank you, secretary. the record will stay open for an additional questions and the subcommittee stands in recess.