Transcript: HHS Secretary Alex Azar Testifies Before Congress - transcription powered by Happy Scribe

[00:00:00.01]
Budget numbers from the 2020 budget, I my first comment was the good news is you didn't get what you asked for. And hopefully that will be the case again this time. But you propose a 10 percent cut. Similar cuts that you proposed in the past and programs that I think we'd be very reluctant in the health care workforce programs, the medical research programs, the preparedness programs, all of which have been talked about even earlier today at the members briefing on the current virus, home energy, rural health care programs were unlikely to cut.

[00:00:41.09]
I frankly hope some of the cuts you suggested we can look at and decide that there are areas where we can re prioritize because we're going to need a little more money this year, in my view, than the top line number is likely to give us. I do appreciate that in this budget, unlike some in the past, the administration has actually tried to focus on poor and on priorities where we'd increase spending, ending the HIV epidemic. The effort to do that.

[00:01:11.03]
The effort to improve maternal health, to fight the opioid epidemic also disses maintain some of the other investments we made. But it also looks at high child, high quality child care headstart and child care development block grants and really suggests that they appreciate what they've been allowed in budgets in the past to happen there. Many of the increases this budget request are financed. Again, let me say by unrealistic cuts, cuts that we don't want to make. In my opinion and cuts that at the end of the day, you probably wouldn't really want us to make like eliminating children's hospital graduate medical education.

[00:02:02.07]
That's not going to happen. Eliminating lie heap highly unlikely to happen. It slashes, makes, proposes a cut in health care research that I think by now the last five years that I've shared this committee and Senator Murray and I've worked together on this topic on this committee. We're not likely to cut health care research. And I hope we can continue our pattern of increasing health care research at this incredible time. I think we're making a difference. We've seen life expectancy numbers go up and quality of life efforts for Americans go up because of what's happening with the real innovative opportunity in health care.

[00:02:49.02]
Americans life expectancy rose for the first time since 2014 last year. Cancer death decline. The first decline in a long time on opioid over those deaths were part of that new treatment. Screening tools, vaccines all make a difference. And this is such an incredible time to move forward in all of those areas based on what we know now and what we think is out there in the future with crisper technology and other things. I know you had to make difficult decisions with the budget number you had.

[00:03:27.05]
And we'll have to do the same thing. Hopefully we can work together to identify priorities and find common ground. And hopefully our committee will be able to work together as I think we've made a real effort to do for several years now. Two years ago, this subcommittee created an infectious disease fund to provide flexibility funding for the department for immediate response. You've used that money as intended. That first hundred and five million dollars lets you respond to the Corona virus in ways that you wouldn't have been able to respond otherwise.

[00:04:06.09]
However, you know, responding to this particular effort not only takes a rapid response, but if we're gonna be your partners in this, it takes a lot of sharing of information and I encourage you to continue to do that. We gave you broad authority, for instance, in the infectious disease upon a broad authority also includes broad responsibility to be forthcoming with information when we give you this kind of authority to spend money. I think all everyone on this committee would like a similar kind of treatment.

[00:04:42.04]
In your response to how that money is being spent, we've asked virtually every day for the department to give us specifics on spending money with the proposal that came out last night that you and I had a chance to talk about yesterday. I think. We have a better sense of the path forward than we would have had before. But whether it's your department or OMB that makes it hard for you to share information. I just encourage you one. Once again, this is going to work better.

[00:05:14.00]
If we have the kind of sharing that allows you to have, then the kind of flexibility that you would like to have. One of those things comes with, in my sense, an obligation for the other thing, the sharing of information to be part of that flexibility that we have given you. We're going to talk a lot today, I suspect, at least I am this morning about the virus, about the supplemental. Have the time that you think that supplemental fills the gap and what the backup plan would be if it's not adequate.

[00:05:50.06]
I appreciate your secretary, your strong leadership at both CDC and NIH as well as overall at HHS. I look forward to your testimony today. We have both the chairman and the. Vice chairman of the committee with us, and I know that Senator Murray and are glad to have both of them here. I think they'll have some comments to make. Sir, Murray Lisco, to you for your opening comments.

[00:06:17.02]
Well, thank you very much, Chairman. Blat secretaries are welcome. Thank you for being here. Mr. Secretary, let me just say at the top that I'm alarmed by the recent developments that we've seen in the Office of Refugee Resettlement and how it's handled children in its care following President Trump's inhumane family separation policy. I've raised questions with you about that before. I hope we can continue that conversation at Dell today as well as we review this administration's budget proposal.

[00:06:44.05]
And I hope today we can get a straightforward answer on many of the other health care issues that I'm hearing about from from my constituents in Washington state. Because when it comes to helping families across the country who are struggling today to afford health care, this administration has continually said one thing and done the opposite. And at the end of the day, none of the president's empty promises say as much about his health care priorities, frankly, as his decision to champion a partisan lawsuit that could be catastrophic traffic for families.

[00:07:15.06]
Because if Republicans get their way in court, they will strike down protections for preexisting conditions, strip away health care, families that got their health care through exchanges and Medicaid expansion, and give power back to the insurance companies to offer low quality coverage and leave patients, of course, with higher health care costs and much like that partisan lawsuit. President Trump's partisan budget exposes the truth behind that spin. Despite his promise to the contrary, this budget would slash $500 billion from Medicare and nearly a trillion from Medicaid.

[00:07:49.05]
Threatening millions of families access to high quality affordable care. In fact, on seemingly every page, this budget proposes taking huge steps backward on our nation's most urgent challenges, including the ones that the administration says they care about. It proposes a small step forward with additional investments to fight HIV transmissions. But it takes an enormously backwards with the cuts to Medicaid, which, by the way, covers more than two fifths of the patients with HIV care, not to mention slashing investments in combating HIV overseas.

[00:08:23.08]
These Medicaid cuts would take us in the wrong direction when it comes to addressing mental and behavioral health challenges like the ongoing drug overdose crisis or the increasing suicide rate by making it harder for people to get the care they need. In some states that have expanded Medicaid, the program covers four out of five people receiving treatment for opioid addiction. To make matters worse for behavioral health, the budget eliminates funding for the new suicide prevention initiative at the Centers for Disease Control and Prevention, which Congress included last year in our bipartisan spending bill.

[00:08:58.08]
And then there is the more maternal mortality rate, which is worse here in the United States than in any developed country in the world. Each year, 700 women in our country die from pregnancy related issues. Those deaths are mostly preventable and the impacted women are disproportionately black and Native American. Instead of treating this like the emergency that it is, this budget actually offers a sleight of hand. It proposes expanding the maternal mortality initiative Congress created in 2018 by $75 million.

[00:09:31.08]
And I appreciate that. But unfortunately, that pales in comparison to the proposal to cut over a hundred times that amount from Medicaid, which actually pays for nearly half the births in this country. And if that weren't bad enough news for women and families, this budget continues the Trump Pence administration's harmful trend of putting ideology over evidence and patient health by excluding Planned Parenthood from federal funding and eliminating the teen pregnancy prevention program at a time when our nation is facing a health professional shortage.

[00:10:06.03]
This budget proposes cutting nearly $800 million from programs that support tuition assistance, loan forgiveness and training for several hundred thousand health professionals annually. And at a time when too many families are already forced to choose between paying for health care or other basic needs. This budget seems to go out of its way to make things worse for people living on the brink of poverty. It eliminates safety net programs and critical assistance to millions of people like the Low-Income Home Energy Assistance Program, which, as we know, helps families afford heating and cooling and the community services block grant, which gives states resources to address the challenge of poverty.

[00:10:46.09]
It eliminates the social service block grant and greatly reduces programs which help families facing adversity from keeping their heads above water. Then, as it continues, the strong bipartisan investments in childcare and Head Start Congress secured in our last spending bill, this budget eliminates funding for preschool development. Grants which provide high quality preschool to tens of thousands of families. Finally, Mr. Secretary, as you know, I've been in close contact with health experts dealing with the 2019 novel Corona Virus Outbreak, which you declared a public health emergency last month.

[00:11:22.06]
As we work to bring hundreds of Americans from China's Hubei Province and affected cruise ships safely back home and quarantine them for two weeks at a cost of roughly six million dollars per flight. I've been pressing for more information on what resources are needed. I sent a letter to you in the Office of Management and Budget Director Mick Mulvaney earlier this month expressing my deep concerns about this. Now, you've finally sent an emergency supplemental request last night. Like I've been urging and I'm very concerned, this request is not enough to ensure that we are putting all the necessary resources towards this emerging threat, including making sure our states and local public health departments have what they need to respond to this crisis and being reimbursed for those costs.

[00:12:09.07]
And I'm very concerned about how thin the details on that are, because despite what this budget proposes, not a single public health expert has told me. The thing we really need to do right now is cut the c.D program, CDC program by 9 percent or cut critical global health programs by $80 million. The Infectious Disease Rapid Response Reserve Fund by $35 million or cut public health preparedness and response programs by $120 million. This is not going to help us deal with this.

[00:12:41.08]
So while I recognize the efforts happening across our department to contain this virus, I have to say this is unacceptable. It's important that we stay ahead of this crisis and we are ready when additional cases are detected in the U.S., meaning we cannot plan on the cheap or at the last minute.

[00:13:01.01]
I've always said a budget is a reflection of our values and that applies here. Well, President Trump may not always tell the truth about his values. This budget speaks volumes to all of us. It leaves no doubt that the president is not serious about fighting for women's or for families health care or addressing national crises like drug addiction, maternal mortality or suicide. He's serious about cutting Medicaid and Medicare and cutting critical public health programs and safety net programs and health care workforce programs.

[00:13:30.07]
And more families on across the country should know that we as Democrats have no intention of letting those cuts happen. We're going to continue to fight for patients and against these attacks. Thank you, Senator. Chairman Shelby, thank you. Thank you, Senator Bob.

[00:13:49.00]
Dr. Azar, you bring a lot of experience at the right time in your job. I thank you for your service.

[00:13:57.06]
I'd like to focus on the current crisis that we have faces in the world and could be here and and how are we going? How are you going to deal with it? And so forth to a lot of people. I think the American people are very concerned and should be. I'm concerned. This is a serious, serious disease that if he keeps spreading. You know what? He knows better than you what he could do here. It could be a an existential threat to a lot of people in this country.

[00:14:35.05]
This is not politics. This is doing our job for the American people. I don't know. I know the request you made, the supplemental one point to five billion and some others. But money should not be an object. We should be trying to source could contain and eradicate as much as we can. This in the U.S., make sure it doesn't spread in the US, but help our friends all over the world. But I was just tired.

[00:15:04.00]
Manage. Some people believe this is a low ball number here. I don't know, but I like I'd like to hear from you on this because this is not the time to try to shortchange the American people, own anything or say, oh, Hamby's done this and that, whoever it is or whatever administration, Democrat or Republican, this is the time to step up. I think you know this probably better than I do. There's a lot of concern in America today.

[00:15:37.00]
And we'll be. Oh, is this gonna spread? You know, we brought some people into this country. Where's it going? Go how we don't contain it. I'm looking forward to your testimony. I'm sure you don't have all the answers. You probably got more than a lot of people. Thank you for your service again. All right. Well, thank you, Chairman, and certainly do you want to wait for your question time or do you have an opening?

[00:16:08.02]
On a proposal made most recently, which is vague at best on the virus. All right, well, let's go ahead and secretaries, argan. Glad you're here. Glad you're here. And look forward to your opening statement and maybe you can answer some of these questions. Even in that statement.

[00:16:27.02]
Right. Thank you very much. Chairman Blunt, Ranking Member Murray and Chairman Shelby and Ranking Member Leahy. Vice Chairman Leahy, thank you very much for having me and inviting me to discuss the president's budget for fiscal year 2021. I'm honored to appear before this committee for budget testimony as HHS secretary for the third time, especially after the remarkable year of results that the HHS team has produced with support from this committee. This past year, we saw the number of drug overdose deaths declined for the first time in decades.

[00:16:56.07]
Another record year of generic drug approvals from FDA and historic drops in Medicare Advantage, Medicare Part D and Affordable Care Act exchange premiums. The president's budget aims to move toward a future where HHS programs work better for the people we serve, where human services programs put people at the center, and where America's health care system is affordable, personalized, puts patients in control. Treat you like a human being, not like a number. HHS has the largest discretionary budget of any non-defense department, which means that difficult decisions must be made to put discretionary spending on a sustainable path.

[00:17:34.08]
This committee has made important investments over the years, and some of HHS is large discretionary programs, including at the National Institutes of Health. And we're grateful for that work. The president's budget proposes to protect what works in our health care system and make it better. I'll mention two ways that we do that. First, facilitating patient centered markets and second, tackling key impactful health care challenges. The budget's health care reforms aim to put the patient at the center.

[00:18:02.00]
It would, for instance, eliminate cost sharing for Colon Oscar bes- a lifesaving preventive service. We would reduce patients costs and promote competition by paying the same for certain services, regardless of setting. And the budget endorses bipartisan, bicameral drug pricing legislation. These combined reforms will improve Medicare and extend the life of the hospital insurance fund by at least 25 years. We propose investing 116 million dollars in H.A. Justice Initiative to reduce maternal mortality and morbidity. And we propose reforms to tackle America's rural health crisis, including telehealth expansions and new flexibility for rural hospitals.

[00:18:44.01]
The budget increases investments to combat the opioid epidemic, including SAMHSA State Opioid Response Program. And we appreciate this committee's work with us to give states flexibility in that program to address stimulants like methamphetamines. We request 716 million dollars for the president's initiative to end the HIV epidemic in America by using effective evidence based tools thanks to funding appropriated by this committee. We've already begun implementing this initiative. The budget reflects how seriously we take the threat of other infectious diseases such as the China Corona virus.

[00:19:18.07]
By prioritizing funding for CDC is infectious disease programs and maintaining investments in hospital preparedness. We now have 14 cases of the China Corona virus detected in the United States involving travel to China or close contacts with those travelers. Three cases among Americans repatriated from Wuhan and 40 cases among American passengers repatriated from the Diamond Princess. While the immediate risk to individual members of the American public remains low, there is now community transmission and a number of countries, including outside of Asia, which is deeply concerning.

[00:19:56.09]
We are working closely with state, local and private sector partners to prepare for mitigating the virus's potential spread in the United States, as we will likely see more cases here today. NIH will announce the launch of the first U.S. clinical trial for an investigational anti-viral at the University of Nebraska Medical Center. Yesterday, OMB sent a request to make 2.5 billion dollars in funding available for preparedness and response, including for therapeutics. Vaccines. Personal protective equipment. State and local support and surveillance.

[00:20:30.05]
And I look forward to working closely with Congress on that. Lastly, when it comes to human services, the budget cuts back on programs that lack proven results while reforming programs like Tarnoff to drive state investments and supporting work and the benefits it brings for well-being. We continue the F.Y.I 2020 investments Congress made in Head Start and child care programs which promote children's well-being and adults independence. This year's budget aims to protect and enhance Americans well-being and deliver Americans a more affordable, personalized health care system that works better rather than just spends more.

[00:21:04.00]
I look forward to working with this committee to make that common sense goal a reality. Thank you, Mr. Chairman. Thank you, Miss Schecter. I will say for the members that their votes scheduled at. 11:30 and we will try to keep the hearing going through at least the first two of those votes, and so there'll be some effort made for members to leave and take the first vote and come back and and we'll see if we can't make that work.

[00:21:32.01]
Glad to have you. Glad to have your time. I want to ask two questions. One is on the liver allocation policy. Senator Moran and I sent you a letter on January 21st urging that you step in to present to prevent what we thought was a short sighted and ill thought out policy. Roughly 40 percent of the country will have a will be harmed by the new process, which goes from a regional allocation to a nationwide allocation. We've already seen the secretary increased cost per transplant, increased waste in what was already a complex system and organs that were discarded because people had to travel to 4 to get the organs to bring back to the recipient to fight.

[00:22:21.08]
Even the federal judge in the litigation referred to what would be a regional bias here. The government contractor on this effort provides no information. The committee on how the decision was made. They overruled experts in their own liver and intestine committee. Now they want to continue to have all the evidence in the litigation under seal. So my question to you is, one, what made you determined after our January letter that you couldn't do anything and to. Are you willing to do something to work to get the evidence and what supposedly should have been available to this outside contractor to make that evidence public?

[00:23:10.02]
So, Chairman, I share your concerns and frustrations. And HHS has actually requested APTN to reconsider their decision to ensure a full consideration of the comments that they received from Kansas and Missouri. As you know, HHS does not make decisions on organ allocation policy. The Organ Procurement Transplant Network is responsible for organ allocation policy. And while we're charged with oversight of APTN, those decisions by statute are delegated to the OPI TNN. I do not have the ability to change those decisions.

[00:23:42.00]
We continue to look for authorities that might do that and we certainly look forward to working with you. If there were legislative proposals, that might give me authority, but those have actually been walled off from the secretary. Of course, the number one thing we can do is increase the number of livers available. And that's why we're working to reform our organ procurement policies and our oversight policies and practices regarding the organ procurement organizations in the country so that we can dramatically increase the number of organs available in this country.

[00:24:10.00]
But I'm happy to keep working with on this liver issue. But my degrees of freedom are limited, quite frankly, by Congress in my ability to influence the APTN.

[00:24:18.07]
Well, let's continue to see if we can't find ways to help you have more ability and that oversight process to have oversight. Let's go to the. The. Supplemental request, the emergency supplemental, I understand it to be two and a half billion dollars, about half of that would be counted as emergency spending. And the other half would be paid for in various ways, like the hundred and five million dollars that you'll soon have gone through. The fund I mentioned earlier today the the reaction, the infectious disease reaction ability you didn't have before.

[00:24:56.00]
Talk to us a little about putting that together. Your thoughts for internal transfers. We're always concerned, as we should be, about big amounts of money being transferred under the secretary's authority in different ways than this committee and with the president's signature decided that money should be spent.

[00:25:14.03]
Yes. So first, let me be clear. We'd like to focus on the top line of the $2.5 billion in terms of the key strategic needs. We've, of course, put forward a supplemental that would allow offsets and transfers to pay for about half of that. But, of course, that's Congress's decision. And we look forward to working with you if those choices make sense to you or if there are other sources or offsets or approaches that you would like to take in terms of the top line, that $2.5 billion.

[00:25:43.01]
I focused my energies here in five key critical success factors. The first is we need to expand our surveillance system in the United States for the China Corona virus to be comparable to our flu surveillance system. This is the backbone of our effective public health response at the state, local and federal level to have that surveillance. Second, we need support for state and local governments while we provide almost half of the funding of state and local public health departments and six hundred and seventy five million dollars a year for emergency preparedness by those departments.

[00:26:16.03]
We do believe we need more money to support contact tracing, communications with impacted individuals and laboratory test work. And we have that in here. Third, we need. And fourth, we need to support the research, development and procurement of vaccines and and therapeutics. And so there's money in there to support both of those. And then finally, we need to support the acquisition of personal protective equipment, especially masks into the strategic national stockpile. Of those five key areas are where the funding is directed.

[00:26:51.00]
Thank you, Miss Surgery, based on again, the other challenges we're facing this morning. I'm going to keep my questions to five minutes and hope everybody will do their best to keep theirs. And if there's time for a second round and people want to stay for that. We'll have that. Be sure everybody gives everybody else the ability to have a first round. Senator Murray.

[00:27:10.09]
Thank you, Mr. Chairman. At the administration's briefing this morning on the coronavirus, we will we're told by the experts, NIH, CDC, that there is a very strong chance of an extremely serious outbreak of the coronavirus here in the United States. So I want to talk about the preparations of this administration and what you've been doing. You've had more than a month now to prepare for this increasing likelihood. And I want to ask you, is our country ready?

[00:27:39.04]
So our country is preparing every day and the effective aggressive containment measures that we've taken at our borders as well as working with our public, I'm here. Meantime, I bought us time to continue preparedness. One is always advancing preparedness every day. One advances those activities. Mr. Secretary, you said would only have a few minutes. Let me be really clear, because you sent over a supplemental that wasn't clear to me at all. You just mentioned a number of things from tracing state and local governments needing their health care's in hospitals ready for this.

[00:28:10.05]
You've talked about protective masks. You talked about surveillance system. I didn't see anything in that request that specifically says how much each of those are going to cost. And we know we've seen this outbreak in China. Now we know it is going to other countries. It quickly overwhelms a health care system. It puts patients who don't have the virus at risk, who suffer from other conditions. We know that medications become very difficult. Did you stockpile any of these critical supplies that we are told we need mask, protective suits, ventilators, anything is that stockpiled and ready?

[00:28:47.07]
So we do have in the strategic national stockpile ventilators. We have masks. We have that report. Well, of course, in order, we wouldn't be asking for a supplemental to seek more money to procure more of that for this for this circumstance. This is a very this is an unprecedented potential severe health challenge globally and will require these additional measures. Okay.

[00:29:08.01]
I didn't see any numbers in your requests. Well, we'll be briefing committee staff and members. This just came over last night and we'll be briefing you on those details as in a supporting kind of list of things that are needed, most of which we don't have, which you can't just buy tomorrow.

[00:29:25.02]
And I I am very concerned that this is not only inadequate in terms of numbers, but in terms of specifics of what we're gonna need. And we need to know that from your experts, you know. Health expect experts, including your own, tell us that this outbreak could be very long lasting. And this is a very vague request for simple mental mending. And I just think it's a band, a Band-Aid. And I want to know why we've we know this is coming.

[00:29:49.01]
We've been watching in China. Everybody's been telling this. What are the long term costs of a sustained response? Do we know that including the manufacturing, by the way, of diagnostics that we know we are not ready for right now?

[00:30:01.01]
Well, we have the details will be provided in the committee and the committee staff. And we want to work with you on this to ensure that's an effective supplemental that meet your needs. This funding request is for 2020 money only at this point it would have a permission for carry over into 21 2021 spend. But then we would work with the Congress, the appropriators, on adjusting any 2021 needs. As we learn, we're really learning day by day and week by week here of the contours of this disease, as well as the spread of the disease and its potential impact.

[00:30:29.07]
And that will help inform those 20 21 discussions that we would, of course, have with this committee going forward in the next couple of months.

[00:30:36.00]
Well, I just have to say, I'm very concerned about this administration's attitude towards this. If a pandemic Dimmock is coming and we are disregarding scientific evidence and relying on tweets and an emergency supplemental without details, and we're not stockpiling those things right now that we know we might possibly need for this or for any future pandemic, I'm deeply concerned that we are way behind the eight ball on this.

[00:31:04.08]
Well, we actually have been aggressively moving. It's been a month and a half since this situation arose and we have enacted the most aggressive containment measures in the history of our country in terms of our borders. I've used the first federal quarantine authority in 50 years of of an HHS secretary.

[00:31:19.06]
We've worked hard to secure every single American today that if this pandemic hits our shores, that we have everything available and we've stockpiled that and we're ready to go.

[00:31:30.00]
That's precisely why we need to work with Congress for additional appropriations to enable procurement. But right now, and we've been very clear, Dr. Fouchier's told you just this morning we don't have a vaccine. One can't have a vet. I'm not asking you yet. Well, I'm asking about diagnostics and testable one. Which one aren't we don't have enough chromed. Yes, we have a diagnostic. CDC invented a diagnostic in historic time. Within one week of the sequence arrive at, it is not available to the hundred and eighty seven.

[00:31:56.06]
It is you see, it is available now at CDC and then twelve sites have been able to validate it. We are working with FDA. CDC and FDA are working together on a modified version of the test that would enable qualified, qualified control of the third reagent stage or elimination of that if possible, to enable further spread of the diet.

[00:32:16.00]
I'm out of time, but I'm told that the diagnostic doesn't work. That's incorrect. Is simply, flatly incorrect. The diagnostic works at CDC and at 12 sites, it has been validated at other sites. We're working to get them validated. This is this is a working diagnostic in the up in the areas of the hundred and seventy labs where it was sent, there was a problem in the third reagents. Age of it. That led to inconclusive results against control, we're assessing right now what the FDA, whether that actual step is needed in the process.

[00:32:45.07]
And we have 70 private sector diagnostic manufacturers who are working to bring forward diagnostics and we will work with those arguing the authorization that we're not there yet. We are now, what, 50 days into it? This is historic. No administration, no CDC in American history is delivering.

[00:33:02.01]
I question that ad on and but I do question our ability with a very small, unspecified supplemental and the lack of preparedness that we have to be ready for this. Thank you, Mr. Chairman.

[00:33:14.06]
Senator Shelby. Mr. Secretary, I want to follow up on what Senator Murray is talking about. One, it seems to me, is that at the outset that this request for the money, the supplemental, is low balling it possibly. And you can't afford to do that. I hope the administrator we want to help the administration. We want to help you do your job. But if you lowball something like this, you'll pay for it later. But you're not only dealing with the crisis, you're dealing with the perception and the concern of the American people.

[00:33:50.03]
Right. Both at the same time. I know you can't develop a vaccine and immunize everybody in America from something that's just fallen on us all at once. And and the world really coming out, John. But what are you specifically doing? What what are your guidelines in this administration to contain this? In America, we do not want this to spread. If it spreads. It's gonna be hard to contain. Well, are you doing? What do you propose to do?

[00:34:26.04]
So we're taking your message to the American people. Have you watch in this area?

[00:34:30.06]
So the steps that the president has taken to the most aggressive containment measures ever in history in terms of travel restrictions on our borders, funneling passengers, restricting foreigners from coming into our country if they've been in China. Travel restrictions and advisories to countries. In addition, of course, the the solid state and local public health response, which actually identified all but one of the 14 cases here in the United States. One of them was identified through our aggressive screening measures at the eleven funneling airports.

[00:35:01.09]
So that's part of it. But then the aggressive measures we need now are we have a historic opportunity with the vaccine. We've developed a vaccine candidate that should Dr. Foushee talked about that in The Wall Street Journal today, go into clinical trials, we hope, within three months from development. That would be a historic development of a product we are supporting and working with manufacturers on potential therapeutics that could be cures or mitigation for individuals who contract the. So we work to contain as much as possible.

[00:35:32.07]
But at some point, if there is sustained human to human transmission, we also work to mitigate through our traditional public health tools. And that's what those are the steps that we would take. I was very clear when we enacted our containment measures at the border, we cannot her medically seal off the United States to a virus and we need to be realistic about that. And so this virus, we might have ozone in some form. It does. And we'll have more cases in the United States.

[00:35:57.03]
And we've been very transparent about that. And we will then work to mitigate the impact of those.

[00:36:02.02]
And when does it get to the point in the U.S., you say we're going, we'll have more cases. I think it's logical of where we're.

[00:36:14.01]
Over concerned, we're really concerned. Is it causes Brad city to city? Well, we always look for sustained human to human transmission to have these models. And we do. We do. So what we look for is sustained human to human transmission especially that's on UNIDENTIFIED. That's what's particularly concerning about Iran and Italy right now, is we've got apparently sustained human to human transmission with no identifiable, identifiable connection to existing cases. That is very, very concerning to see that in other countries.

[00:36:45.01]
And that's what we would certainly look for here right now. It's important to remember the 14 cases that we have that are in the U.S. as well as the 40 from the repatriated individuals from China and Japan in every single instance. We know why that person has the novel coronavirus. We know that is a product of the world's finest public health system that allows us to have that level of knowledge on this develop on this rapidly developing. So what's the treatment for it?

[00:37:12.03]
Right now, one has to simply because there's no treatment. One treats the symptoms as one does for for other or other therapies. There are some experimental products and clinical trials. One is a Gilliard product known as rem- Dasovich that some individuals have been treated under under an I.A.D. Protocol for a clinical trial. We have that product is being tested in two trials in China to 500 person arm trials in China as well as now as I mentioned this morning in the University of Nebraska.

[00:37:41.02]
And I believe also in Japan. Was secretary. I believe it is. Comedy Central lays here Central Blanton's Murray leaders, this committee. I believe that that will be of the mind set to fund this crisis, not too underfunded in any way. And I hope the administration would look at this as something that they cannot afford to let get out of hand. Period. Are the perception that isn't getting out of hand?

[00:38:12.09]
Well, Chairman, I want to assure you that I am fully supportive of this 2.5million billion dollar request. I was part of architecting it. It is what I believe we need for 2020. But of course, if Congress differs with the power of the purse, we will work with you, provide technical assistance to try to make sure it meets what you what view you view as the needs are.

[00:38:32.05]
Whatever. Thank you, Mr. Chairman. Thank you, Chairman. Certainly. Thank you, Mr. Chairman. Welcome, Secretary, like so many others up here, both Republicans and Democrats. I'm concerned with the budget the administration put forward for the problem. Health and Human Services. Obviously, you were involved with it, but it seems you've been drafted to hit an arbitrary target to slash funding without any realization of real war, world impact of the proposed cuts.

[00:39:09.07]
In fact, remove this completely confounding in the midst of the novel coronavirus outbreak. You wanted to slash funding and Empire 2021 to the very programs help us combat dangerous infectious diseases. And while we might talk about vaccination for the viruses, there's still about two years away. It spread to 30 countries. It's infected. More than seventy nine thousand people is caused at least 26 other deaths. Hundreds of Americans are restricted to U.S. military bases under a federal government quarantine.

[00:39:53.05]
And that's the first time in 50 years. But you've proposed to cut 3.1 billion from the National Institutes of Health. Nearly 700 million from the Centers for Disease Control and Prevention programs. Roughly 100 million from public health preparedness and response programs. These are very programs you're going to rely on to combat coronavirus and other infectious diseases. If Congress went along and made the cuts to you and the administration and asked for. You and me are to keep the public safe when the next threat emerges and one will.

[00:40:38.04]
So why would you propose such cuts? How does it make any sense?

[00:40:44.02]
Well, Vice Chairman, as you know, we have a tight budget environment, but we prioritized actually the infectious disease preparedness and emergency response. So, for instance, at CDC, those three activities were prioritized and actually increased the proposed funding by 135 million dollars in the 2021 budget.

[00:41:03.05]
Now, of course, the CDC Infectious Disease Rapid Response Reserve Fund, which we've created, how help you is running out of money, including the number. And now we see an increased number of infected people, 53 in the U.S. We ask, how is that being careful? These. Wasn't this going on for months? And last night we get this somewhat vague request for emergency funding.

[00:41:36.06]
If I was cynical, Vermonters never are. I might think it was restored just in time for your appearance before this committee this morning, and that's why it's bad enough. So the the infectious disease rapid response funded CDC was funded by Congress in 2020 as well as twenty nineteen. And so it's current year money, we're running out of that money, which is why we have sent over that we plan to do transfer and reprogramming using the existing authorities for 2020 appropriations.

[00:42:10.08]
And precisely why we're asking for an emergency supplemental to take you take I have a billion dollars out of the money appropriated for the Ebola threat.

[00:42:19.05]
Those are true. Those would be proposed offsets or tradeoffs for the emergency supplemental. If the appropriators don't want to do that, we'll that that's that's just an option for the appropriators.

[00:42:30.04]
You have any of your requests for supplemental funds request? You they told him you were in there, were denied by OMB.

[00:42:39.02]
Well, I'm not going to discuss internal I narrations that's not proper to discuss internal bills. Why is it not proper? I've heard that question asked by I during Democratic administrations, Republican administrations or my 40 years on this committee and has been answered.

[00:42:54.02]
I would never answer internal deliberations with the White House. But I will tell you, I am completely supportive of the $2.5 billion request. It does exactly what I want, which is to focus on those five critical success factor areas.

[00:43:06.00]
OK, so what you want is a proposal that would divert one hundred and thirty five million dollars from other important programs, including 37 million from Li'I. Millions from substance abuse. Seven million dollars from Medicare and Medicaid programs. So I want to ask you deliberation. But you just want to kind of whole lot of things we rely on. Well, those are those are options for funding half of the cost of the emergency supplemental. But if Congress makes a different choice, Congress makes a different choice.

[00:43:44.03]
There he is. Liner's the other half.

[00:43:46.08]
That would be emergency supplemental funding. New money that you would have to come up with.

[00:43:52.01]
Things you on? Some of the NIH funding, Ebola funding. Your recommendation? You're the expert. This is a cut that out.

[00:44:04.03]
It's a proposal of how to fund half of the cost of the total research. You agree is your proposal. That is our proposal. But if Congress disagrees with other approaches, there are other ways to get there. Thank you, sir. Senator Alexander. Thank you. Mr. Chairman, Mr. Secretary, welcome. Before I ask. Get in, coronavirus. I want to congratulate Senator Blunt and Senator Murray and Senator Durbin and Leahy and Shelby and members of the subcommittee for the last five years of funding for the National Institutes of Health.

[00:44:40.01]
Over that five years, discretionary spending, which is about a third of our budget that the federal government spends, has gone up 20 percent. But funding for the National Institutes of Health has gone up 39 percent. And I might add, the subcommittee that deals with the Office of Science in the Department of Energy that Senator Feinstein and I work on has gone up 38 percent. So the best kept secrets in Washington is the. Big increase of funding for biomedical research in science, and I want to congratulate this committee for its part of it.

[00:45:16.00]
I think one of our responsibilities as members of the Senate is to help the American people get a fair view of exactly how threatening to them individually. The Corona virus is looking around the world. There is reason for alarm. Ten days ago, for example, there were forty nine thousand confirmed cases in the world. Ten years ago in China, there are 48000 confirmed cases today in China. There 79000 confirmed cases in the world and there's 77000 China. And we read about problems in propping up in Italy, which could get across their borders and in Iran and other places, South Korea.

[00:45:59.07]
And not only do we have the problem of of a rapidly spreading virus which could jump into our country. We have to think about what items manufactured in those countries could mean for us with 13 percent of our of our prescription drugs. Are drugs being manufactured in China, for example. Are we going to have shortages? And even beyond that, with a quarter or so of everything that we use in this country being made in China? Well, we have supplies for our automobiles and our are other things that we make in this country and what will it do to our economy.

[00:46:37.08]
So looking around the world. There's reason to be alarmed. But now looking at home. Let me go through what the facts are at home. We've known about this for about two months, right? About 50 days.

[00:46:49.09]
Yes, about 50 days. And and and 10 days ago, if I'm right, we had detected 14 cases in the United States.

[00:46:59.07]
I believe that's correct.

[00:47:00.06]
And today we have detected 14 cases in the United States. In addition to the thirty nine cases of Americans who've been brought home from overseas and isolated in this country because they might have been infected, they're exactly the imported case.

[00:47:18.08]
And during that time, you have begun to develop a vaccine which won't be ready for a year or longer. But you're doing that more rapidly than any other time in the history of our country. That's correct. And my question is going to be with this alarming situation in the world. What have you been doing right at home? That caused us to see a situation where this huge country of ours, we only have 14 cases a year ago. I mean, of 10 days ago and 14 today.

[00:47:47.07]
My guess is, is 20 years of preparation by Democrats and Republicans on this committee and Democrats and Republican presidents to be ready for pandemics, number one. Number two, it's the extraordinary public health system we have in this country, state and local, doing their job. And number three, it's the first and most aggressive quarantine requirements that you've done in 50 years. So if we're alarmed about what's going on around the world, what can we learn about the last 50 days in this country that you've been doing?

[00:48:19.04]
Right. That makes this be able to say 10 days ago there were 14 cases and today there 14 cases at a time when around the world cases are going up.

[00:48:30.05]
So we are bearing the fruits, actually, of our pandemic flu preparedness activities, which I was one of the architects of in the Bush administration and that Congress funded. We're seeing the public health infrastructure from that that is come into for one of the most important things we did. As soon as alerted to this and as soon as we had a genetic sequence and understood the nature of the symptoms of this disease was to alert our state and local public health partners and our health professionals.

[00:48:55.08]
And that's why 13 of those 14 cases were identified by health care professionals, astutely seeing that these were individuals who had been in Hubei Province and presented with flu like symptoms, gotten the system and took advantage of that one week, develop CDC tests to confirm results. So that is that that kind of public health infrastructure, the world's best, is the backbone of our response activities here. In addition, we worked on the aggressive border containment measures and we've worked with China to try to get transparency and get information.

[00:49:24.08]
We still do not have, unfortunately, solid information to take to the bank on severity, on transmissibility, on incubation period, on asymptomatic transmit.

[00:49:36.06]
I'm out of time, but I think what I'm hearing say you would do more of what you've already done. Properly funded. Yes. Thank you, Senator Alexander, snapshots, shots. Thank you, Mr. Chairman. Thank you, Secretary, for being here. This committee has a. Long tradition of bipartisanship, and I know, Secretary, you and I have had a couple of disagreements in private and in public, so I want to kind of see whether we can find some common ground in fighting the Corona virus.

[00:50:05.00]
The president's budget cuts, the Infectious Disease Rapid Response Reserve Fund, the Public Health Preparedness and Response Fund, Hospital Preparedness Program and Epidemiology and Laboratory Capacity Program. So given everything that's happened over the last 50 days, I want to give you an opportunity and given the context here, which is last night you proposed a 2.5 billion dollar supplemental. Do you want to rescind those cuts to the base budget of your agencies that deal with this problem?

[00:50:38.06]
Well, it's a good question, Senator. As I mentioned to Chairman Blunt, this is a request focused on 2020 money, some money to be spent. Hold on. No, no, hold on.

[00:50:48.03]
I'm not asking you about the sup. I'm asking you about the president's budget, which cuts all those programs which I described. And the question is a simple one, because I have a couple of other questions I'd like to get to. Will you rescind those cuts? Will you ask us to restore those programs or will you not? So as I said to Chairman Blunt, we will work with you over the coming months as we learn more about this disease on whether to modify the 20 21 appropriation requests.

[00:51:14.05]
In light of that, we do increase by $135 million CDC budget around preparedness, emergency response, infectious disease and global health security.

[00:51:23.08]
I'm not going to get too much into the weeds there, but I will just offer that actually is a shell game. There are four key programs that deal with this problem. They are being cut. The CDC overall is being cut by 9 percent. And so you may have increased a line item or two, but that's a talking point. That is not the fact of the matter. And this committee will very likely reject these cuts. But it is absurd to me that you're proposing cuts at the same time that you're proposing a supplemental on the same topic.

[00:51:53.02]
So moving on. How many masks do we need in our strategic stockpile and how much will that cost? So we would need to determine through procurement what the cost would be of additional mass, I know that this morning in the briefing there was a reference to possibly as many as 300 million masks needed in the U.S. for health care workers. We wanted to find that better through procurement criteria. We have to frankly establish supply here in the United States, ability to manufacturer as well as to find sourcing of active ingredients such as the filtration materials, even the the nickel and copper nose joints that go onto the I-95 mask.

[00:52:30.07]
So I guess if we get the money, we can actually make that market and get capacity built here in the. Understood. Want to work with you on for the 2.5 billion dollars, the massan, the strategic stockpile, the test kit, all the all of your five lines of effort.

[00:52:45.05]
It seems to me you don't quite know how much each line of effort is going to cost. Is that accurate? We would have to do procurements to find out exactly what we would. Our per unit cost would be on the masks, but then we'd be scaling up domestic production. That doesn't fully exist right now. So one doesn't know until one actually procures that.

[00:53:04.06]
So how do you get to 2.5? Not knowing how how to compile. You have five lines of effort. You don't know how much. The first one I'm asking about you. So you've got to go through procurement. You've got to build a. I understand all that. So then how do you get to 2.5 with any degree of specificity or reliability? Is $2.5 billion sort of pulled out of a hat? No, not at all. The $2.5 billion that we're one of the major cost items, you don't know how much it's going to cost.

[00:53:30.04]
You don't know the precise per unit cost. But we're in the range of the hundreds of millions of dollars we're dealing with. That clearly would be sufficient. I think right now, acquisition cost and four and ninety five mass tends to be under a dollar. So that gives you a rough approximation. But with we have to scale up domestic production, that might have stopped. Do you have back of the envelope numbers that you haven't yet provided to the committee because.

[00:53:52.07]
Yes, I think you have. Well but it sounds like you have ballpark numbers. And I I got told by a staff person that this up now, I haven't gone through it with a fine tooth comb yet. But but I have been told that this is the least detailed supplemental that they've ever seen. Well, you've also. And so should we just consider this a marker and you'll get us the details later? Not in the least. There's a letter that went up last night which has the the number, the basic numbers in it.

[00:54:20.04]
And as I've told both the chairman and the vice chairwoman, we will work with your staffs to get you the details behind that. There is detail behind that. It just last night you got the initial letter. OK.

[00:54:30.04]
Final question on test kits. They were deployed into a bunch of locations. They didn't function properly.

[00:54:39.09]
Why in the world do we have test kits? Do we have tests that operate in Atlanta but can't be and and the country of Japan has test kits there that are reliable. Other places. First of all, other states, but also other countries have operating test kits. And given all of the preparedness work that you say you've been doing and all of the extraordinary work of all of our agencies, why can't we deploy test kits that function? And why does it have to be mid-March before states and especially ports of entry have functioning test kits?

[00:55:10.09]
So as I mentioned before, the CDC test was developed with historic speed. It has three reagent phases on it. The third one, it's unclear whether it's actually necessary. But what we do whenever it deploys out into the field or at CDC, what has to do the quality control and validate those results, that validation failed at the third stage. Not for false positive or false negative, but simply for inconclusive results against control. And one of the ninety two reagents slots.

[00:55:37.00]
Thank you. I am working on streamlining that process with FDA, so we hope to get those revised ones out very quickly. Thank you. Thank you, sir.

[00:55:44.05]
Shot Senator Kennedy. What you say. Thank you, Mr. Chairman. Thank you, Mr. Secretary, for being here. We have 14 active cases now excluding the thirty nine that were imported. That's correct, we have 14 and then we at the moment are at a total of 43 imported 40 from the Diamond Princess. Three from.

[00:56:10.07]
How did this 14 contract the virus?

[00:56:13.06]
The 14 contracted the virus. Twelve of them contracted it by travel in Wuhan, China. And the other two were spouses of infected. Of those twelve.

[00:56:23.01]
How is the virus transmitted? I don't want to play doctor on this. The the it is transmitted generally by respiratory symptoms. But I would like to defer if I could. We'll be happy to get you from scientists. The best assessment of transmissibility of the disease cannot be transmitted through food. We do not believe that there would be flight transmission through food. But we still are trying to learn of the sustainability of the virus on surfaces. That's what we call phone might transmission is.

[00:56:57.01]
And Dr. Foushee has said he does not believe that there is a reason to believe it should survive more than a couple of hours on hard surfaces so it can survive a couple of hours outside the body. That is what Dr. Foushee has said is the working assumption. But, of course, we do not have firm trial data on that yet. That's one of the things we're hoping to learn from the W.H.O. team. Anjana.

[00:57:21.05]
How is severity determined severity is determined usually by fatality rate against the number of people infected. Right. Obviously. Let me rephrase that. That one very artful question. Some people get really sick. Others don't. Why the difference?

[00:57:40.06]
Well, we don't know. That will deter. That will depend on the nature of this disease. For instance, with the 1918 flu, the so-called Spanish flu, it was interestingly your healthier young, middle aged adult males that seemed to have the worst reaction and greatest severity. Your top your diet or I don't want to get too far afield here. The short answer is we don't know. We don't know right now. Now. How many face masks do we have?

[00:58:08.06]
We currently have 30 million and ninety five respirators in the strategic national stock. How many do we need? Dr. Catholic mentioned to the Senate this morning and needing approximately 300 million for health care workers. We have 300 million health care workers in America.

[00:58:24.03]
Do we know that would be assuming the the need to swap out used ones? OK. What are your models show? About how many cases we're anticipating? Well, we don't know because we don't. We don't know the full attack rate in China. So, for instance, we've seen a high of 30 percent infection on the diamond princess approximately, which was a frankly, it seemed to be an incubator in Wuhan, China. It's very hard to know what the total accurate number of cases are.

[00:58:57.02]
We don't know and we don't know yet. Do you have models to try to try to answer this question? Well, we can only extrapolate based on the data we get from China. Is China telling you the truth? We are getting data from China as the world is. But whether that information is full and transparent, we just don't know what's the mortality rate of the crown of ours. It's shelling right now anywhere between 1 and 2 percent. But again, that's based on a denominator.

[00:59:22.06]
There may be many, many more cases in China that are low symptomatic or haven't secured treatment and hence aren't in the Chinese report, which is a mortality rate of influenza influenced seasonal influenza tends to be point one percent mortality. So we're talking about a substantially higher mortality rate.

[00:59:39.06]
It could be again, dependent on what that denominator is. That's why we need to use great caution in making predictions about the severity of this.

[00:59:48.00]
How how soon will we have a vaccine? Well, as I mentioned, Dr. Fouchier and The Wall Street Journal today talked about this going into clinical trial. Amazingly, within three months after Discovery, we could within a year have a vaccine. But we want to, through the supplemental, put multiple vaccine candidates out there. We have a billion dollars of proposed investment in vaccine through the supplemental.

[01:00:10.08]
The secretary of the Department of Homeland Security, which is charged. Would with keeping us safe, just testified about 10 minutes ago, a month and a half. Which is it? One could not develop a vaccine in a month and a half. That would. That's never happened in human history.

[01:00:27.06]
Maybe you ought to talk to the secretary of Homeland Security before he he spreads that too far. Are we getting the cooperation that we need from countries other than China and obviously Iran? Well, obviously not Iran. But but from other countries, yes, we believe so. So I am as germ. Thank you, Senator Sir Bowen. Thank you, Mr. Chairman. Secretary Azar, I want to tell you about a couple of constituents. Mary from Franklin, Wisconsin.

[01:01:10.00]
I attended a roundtable I had over the president's recess week on price, the price of medications, and she worked for Kenosha County for over 20 years, retiring as a child support caseworker. She has diabetes and the cost of her medications, including insulin, are over 15 hundred dollars a month. She said to me, I'm just one of millions of people that have this problem. There are people who are not getting their medication, who are dying because they can't get it, can't get their medication.

[01:01:46.01]
Who are deciding on food or medication or paying mortgages. At that same roundtable, I met a father whose son, young son, had a severe allergic reaction. He was treated at the hospital and then the physician prescribed epinephrine because of the child's tender age and weight. An EpiPen was not appropriate because it would contain too high of a dose. And when he went to fill the alternate prescription that had the right dose, the out-of-pocket cost would have been five thousand dollars.

[01:02:30.00]
Now, my I was in disbelief when I heard that he explained a little bit more and what he ended up doing was buying an epi pen and praying that his son will gain at least seven pounds before he next has any type of allergic reaction. But how frightening. So in December, the House of Representatives passed a comprehensive prescription drug pricing bill that included my bipartisan fare Drug Pricing Act, the Fair Drug Pricing Act. As you recall, passed out of the Senate Health, Education, Labor and Pensions Committee last June.

[01:03:10.05]
You noted in your testimony that the budget supports bipartisan drug pricing proposals. However, it does not support explicitly either the House passed bill or my bipartisan Fair Drug Pricing Act like. We've talked a lot about transparency in this industry. Do you think pricing transparency would make it harder or easier for Congress to oversee the drug corporations and enact sensible policy that would bring down prices?

[01:03:47.05]
We do support notions of drug price transparency. In fact, I tried to get a new all supported me. Thanks. Since particular to Senator Durbin's great work tried to get specific authorization to explicitly require that drug companies disclose their pricing in their direct to consumer advertising. And we're now having to rather astonishingly litigate that issue in courts as the drug companies are embarrassingly ashamed to talk about their prices. Right.

[01:04:14.09]
So the drug price, a fair drug pricing act would say if you want to raise the price, you issue a report to your agency with justification and full transparency. We talked probably around a year ago about whether we are even capable of showing a follow the dollar chart. When you say have a drug, that's price. Right now, list price is set by the drug corporation at $100. What what piece does the manufacturer take? What piece does the PBS take?

[01:04:46.09]
What piece does everyone along the way take of that? And then when they double it. How does that change? Where does the extra $100 go? We don't even know that. And and so I urge you to work with us to pass the bipartisan fare drug pricing Act. I think it will so help our ability to rein in these prices. In my few seconds left, I want to switch gears and talk about the vast expansion of junk plans that has occurred under this administration.

[01:05:20.08]
There was a study released just shortly ago that found these junk plans impose extraordinary costs on very vulnerable populations, those newly diagnosed with cancer. According to this study, a patient that's newly diagnosed with lymphoma and covered by one of these junk plans could pay anywhere from twenty three thousand to forty five thousand in out-of-pocket expenses in the first six months following their diagnosis. The other issue that I wanted to point out is we're talking about coronavirus. We just had reporting out of Florida that somebody who had recently traveled to China, presented for concerns that he might have contracted the Corona virus, may be charged thousands of dollars in out-of-pocket costs for seeking care because he is covered by a junk plan.

[01:06:16.08]
How does the expansion of junk plans by this administration help us during severe outbreaks like the one we're currently experiencing and is very frightening as the as we move forward? And how does it help somebody who incurs cancer, who was diagnosed with cancer?

[01:06:37.07]
So short term, limited duration plans are not right front. And we've been very transparent about that. And they existed under the Obama administration at the end of three months. Now, their three year actually know at the in the year. Right. And a midnight regulation, they they shorten them to three months.

[01:06:52.06]
And we restored that because they're not right down the rest of the market. Well, they're not right for everybody. And we've enhanced actually the consumer protection notices even from what the Obama administration had. But some insurance for some people might be better than not being able to afford any insurance. These are 60 percent often cheaper than Affordable Care Act plans for people who aren't subsidized. So it's an option, but it's not the right option for everybody. And we've tried to be very transparent about that.

[01:07:16.05]
Thank you, Senator and Senator Rubio.

[01:07:19.08]
First, I want to acknowledge how difficult this issue has been, because where it originated in China, they're less than transparent. Whatever numbers they put out every day, I can assure you the numbers are higher as the actual number of cases. But to today, at least, unless they shared it with the World Health Organization, they haven't shared the original viral sample. I know they put the code up online, but they didn't share the sample. They haven't really been forthcoming about best practices on a host of issues.

[01:07:44.07]
It's Komp. Our response is complicated by the fact that we're dealing with a totalitarian government that's more interested apparently in PR and in their image than they are and actually dealing with this the way we would if we had an outbreak of this kind that that is most certainly impeding our ability to develop things like a five vaccine and so forth.

[01:08:04.01]
We need full transparency and full cooperation from China as well as every country. And the W.H.O. needs to hold every country accountable, as they would the United States, for that type of transparency and cooperation.

[01:08:15.06]
Well, the second question is, have we done any estimates or do you have any view on what would happen if this virus makes itself to a underdeveloped country with poor or no public health? For example, Haiti or Central America and some nations in Central America in particular, the impact that that would have on those societies, not to mention many nations and the African continent, what it would mean for migration flows for the global economy that we viewed. Have we?

[01:08:40.09]
Do you have any thoughts about how destructive it would be? One thing is that it shows up in Italy or the Canary Islands or another thing is that it shows up in a country that already lacks any sort of basic public health and the ability to address it.

[01:08:54.06]
Obviously, it would be very concerning if this virus spreads, say, to Africa or other other areas that have less developed public health infrastructure because they won't be able to take the steps towards mitigation and containment that we can take here in the United States. And so it would spread quite rapidly. This is why it's actually so critical to get better data out of China so that we know the severity and the what the mortality rates really are here. So we know what we're dealing with in terms of impact.

[01:09:21.05]
Now, we know that 80 percent of active pharmaceutical ingredients in the United States come from China. And I wrote a letter about this to the FDA commissioner, and I know there's a lot going on, but we've yet gotten a response. So I wanted to know a few things. Does the FDA have tools and information to track potential medical device or pharmaceutical shortages or.

[01:09:45.08]
We do under for danger for to be able to track with pharmaceuticals, they have to report to us if there's any potential shortage. And we've not received any reporting yet about potential. Shortages connected to the China situation. The medical device companies do not have to make those same kinds of proactive reports, and that's actually part of what we've suggested in legislation.

[01:10:05.05]
What can we do or what would we do to mitigate shortages of particular critical medicines if in fact we saw one coming?

[01:10:12.00]
It's a very it's a very difficult challenge because the supply chains with drugs, as with the rest of our economy, are very much globalized and entwined with China and elsewhere. And one doesn't. One can't stand up a manufacturing facility for pharmaceuticals just overnight. And so if a drug company happened to have multiple manufacturing facilities that were qualified, we would they could transfer their manufacturing and we would certainly work at FDA to expedite any type of inspection, regulatory approval to support them.

[01:10:41.08]
Have we coordinated with any non-Chinese suppliers of products, at least in an effort to sort of think forward about what we would do if, in fact, suddenly we face again, we're not dealing with the most transparent government in the world and China. So if this thing came upon us fairly quickly, what option would we have to work with non-Chinese suppliers of these key ingredients?

[01:11:00.03]
Well, we can work with any supplier that is FDA approved. One can't just secure FDA approval overnight for either a generic a.d.a or for a for the manufacturer, of course, of of a of an innovative product. And so we would work with those companies that hold licensing and hold patent rights to be able to to expand there.

[01:11:19.09]
But have we done any work just sort of putting some of that in place just in case this comes on as a weakling?

[01:11:24.08]
We are aggressively and proactively working with all of the drug companies and device companies. And we've made it clear we're available to help them. None of them have signaled any potential problems in terms of supply. There are a couple of manufacturers that do work in Hubei Province, the epicenter, but they report that they have large stockpiles of supply already of of of product already. But we're aggressively working on this because it is it's a concern when one has this global supply chain that is intermingled throughout the world, including in China, just as the last point.

[01:11:59.09]
I think this instance calls to mind that perhaps it's not the greatest idea for the health for Americans and needed health care to have 80 percent of our active ingredients come from one place in the world where it can potentially serve a strategic leverage done point down the future. But is but is but is vulnerable to this sort of disruption at a minimum, you would agree that this is a sort of a wakeup call, that perhaps we're overly dependent on the supply chain so heavily concentrated in one place in the world.

[01:12:29.03]
It is and has been. And you've been at the forefront of calling attention to this issue. The challenge is what the appropriate remedies are for that, because if we start dictating where companies make product, that could increase costs, which would increase health care and drug costs in the United States. But we're happy to work with you in Congress on if they're our supply chain management approaches that we should take that are more directive that Congress won't authorize.

[01:12:54.02]
Thank you, Senator Rubio, Senator Murphy. Thank you very much. Good morning, Mr. Secretary. We can agree that when you're dealing with a response to a pandemic. Days and weeks matter. Correct.

[01:13:11.04]
We try to take advantage of every day we've been able to buy through our aggressive containment efforts and our public health response. Absolutely.

[01:13:18.05]
You presented a briefing to members of the Senate three weeks ago in which many of us expressed alarm that the administration had not sent a supplemental request to Congress at the outset of this epidemic. We were told in that briefing that the administration believed that it had ample existing resources to handle this epidemic. That didn't make sense to many of us who saw what was coming. Last night, you sent word that you are now requesting that supplemental funding. And we are hopeful to get some meat put on the bones so that we can get to work very quickly.

[01:13:57.02]
That was a mistake. Now, in retrospect, to not request that funding. Weeks ago, at the beginning of this pandemic, correct?

[01:14:05.00]
No, not at all. We had $105 million that we are spending from the Infectious Disease Rapid Response Fund. We haven't even started on the hundred and $36 million from the transfer authority that I've sent over to. I think last night we sent notice of the reprogramming and transfer plans that we have for that one. Three weeks ago was just two weeks into even knowing about this virus, which we've been very transparent, were briefing and working with you on one can't know the contours or nature of the disease or the progression to even know what to request at that point and what that would involve.

[01:14:38.01]
And indeed, today we've seen one of one of your colleagues was questioning if we even know enough to make a request at this point. And so we're making the request. We believe we know enough to do that now. Well, I think having given our money.

[01:14:50.02]
His point was in response to your statement regarding your inability to. Create a market until you have the funding, which speaks to the the the long process from the request of funding to Congress to the creation of a market that wouldn't answer some of the concerns that Senator Rubio has.

[01:15:11.08]
And so what was knowable three weeks ago is that when you make a request of Congress, the money doesn't occur and be created overnight. It's a process to come up with that legislation. And then you acknowledge yourself that even once you get that funding, you then need to go out and create markets for some of the products that have shortages. And so many of us did see the need early on because we knew that it would take a long time in order to get this funding through the process.

[01:15:42.09]
And I think we've lost critical days and weeks. And there were many people in that briefing who were asking you to present this earlier. Can I ask you about a program that the CDC was running? I think largely with previous supplemental dollars that was I've heard it referred to as an epidemic prevention account, global health security initiative, operating in about 50 countries. Reports from about a year and a half ago suggest that as that money ran out and the CDC didn't replace it with other funds, the number of countries in which we were forward deployed trying to train local public health staffs to identify pet nomics and respond to them were reduced from 49 countries to 10 countries.

[01:16:35.02]
At the time, you received a letter from about 200 different public health organizations asking you to backfill and request new resources to make sure that those programs remained open. You may not have an answer to today, but can you confirm that that program is only running today in 10 countries compared to the 49 that it was running in when that supplemental funding was still available?

[01:17:04.08]
So what's happened is the is the Ebola supplemental money was going down. We were increasing the global health security agenda funding through CDC. So, for instance, for twenty one appropriation, we've request a hundred and seventy five million, which is a 50 million increase there as we slope that up in terms of the countries, we are very committed to global health security agenda, as are you. The number of countries our focus has moved to try to have a regional footprint and also to as we've built labs and build capacities in countries, they stand on their own and we moved other countries removed a regional approach.

[01:17:36.02]
We can get you the precise the precise countries where we're operating in now. But that's been the philosophy. It's not been a retrenchment. It's, though, been to have a regional deployable force instead of permanent infrastructure in every single country. The chairman isn't here, but I think the answer is that we are operating today in perhaps one fifth the number of countries that we were several years ago. And we were operating in 50 countries because we recognized we had a lot of work to do to train up staffs, especially in developing countries, to identify these outbreaks and treat them at the outset.

[01:18:10.00]
So they didn't ultimately reach our shores. And many of us have been, I think, sounding this alarm for years of that budget cut after budget cut, proposed budget cut after proposed budget cuts to the CDC was going to have an effect. And I don't think today we can draw a straight line between the number of countries that have been cleaved off of this global pandemic prevention program and the outbreak that we're dealing with today. But it is another alarm bell for us.

[01:18:36.02]
We cannot continue to close our eyes to these developing pandemics. We are going to have to be partnering with many other countries. And under this administration, unfortunately, we're going the wrong way. We are operating in less countries abroad, not more countries. But I will appreciate hearing the more detailed information from you in the coming days.

[01:18:55.06]
Thank you, Senator Murphy, Senator Hyde Smith. Thank you, Mr. Chairman. Secretary a_s_r_, thank you so much for being here today. And I want to start by making a few comments before I go to my question. First, I know you've heard from Chairman Blunt repeatedly about his concerns regarding the allocation of livers for transplant. I share the chairman's concerns. Our only transplant program in Mississippi at the University of Mississippi Medical Center just completed its 250 liver transplant this past Friday, which is a very important milestone for us since the program started in 2013.

[01:19:35.06]
It isn't so much to critically ill Mississippians to be able to get this lifesaving care close to home. And I'm worried now the new liver policy will undercut that you in MSA program. I hope you will work with us to address these concerns and ensure the continued viability of. Liver transplant programs just like the ones that we have in Mississippi. Secondly, I want to thank you for your focus on lowering the cost of prescription drugs for all Americans. Whenever I'm in Mississippi, I constantly hear from constituents who are concerned about high out-of-pocket costs for their prescription drugs.

[01:20:15.01]
But both you and the president have made this same issue of priority. And I certainly thank you for that. Third, I was very pleased to see your budget request include legislative provisions from the Connect for Health Act to help expand telehealth at community health centers, rural health clinics and Indian health services facilities as one of the six senators on the Senate Telehealth Working Group. I was very glad to be able to introduce this bill and I am working to get it enacted into law.

[01:20:46.05]
Your support is extremely critical in that at this hearing last year, you and I discussed struggling rural hospitals in Mississippi. This continues to be a problem not only in my state, but across the nation. The most recent data just released from 2019 shows that nearly 50 percent of rural hospitals are still operating in the red. Last year, I was so pleased when you testified that in part because of some efforts from my office, you had established a rural health task force at H.H.

[01:21:20.01]
to find all the ideas to help address the crisis in access in rural America. I've also been pleased to support some of the early work on the task force, including changes to the Medicare wage index that meant so much to our rural hospitals in Mississippi. But I know the task force has been working very hard in recent months to do even more. Can you provide us with an update on the task force work and specifically how this subcommittee can help support you and your office in that?

[01:21:52.03]
Thank you, Senator. And yes, on the rural task force, we've now matured into the point that rural health care is the centerpiece of the president's health care agenda and a centerpiece on the budget proposals. There really four pillars to it. The first is rural health care has to have a sustainable business model. We can't just patch over it. It's got to be something that economically works in our rural communities. Second, we've got to have prevention and health promotion in rural communities.

[01:22:20.04]
Third, we have to take advantage of telehealth and other innovation. And fourth, we need health professionals such as P P A's, physician assistants, nurse practitioners and others who are able to practice at the full extent of their training and licensure in these rural communities where we can't often find just doctors to practice. So we have many proposals in the budget. One of them, which I'm very excited about that would help with rural hospital closures, would allow critical access hospitals to convert to emergency facilities with an emergency room and outpatient and not have to bear the burden of continuing inpatient bed facilities and also get payment supplements on that.

[01:23:00.00]
So I think that that could be a real lifeline to our rural communities if we can get that approved. We also have several provisions we've proposed on expanding access to health, telehealth and compensation both in rural America but also in Indian country for four facilities there. And we all. And then we also want to modernize our payment for rural health clinics because our community health centers and rural health areas in rural areas can be an important backbone of our system also.

[01:23:27.06]
So we've got a whole suite of legislative proposals in there for rural health in combined with our budget increases that we'd we'd love to work with you on. Thank you very much. Thank you, Senator Hyde Smith, Senator Shaheen. Thank you, Mr. Chairman. Secretary Tzar, thank you for being here. I don't have any questions about the Corona virus because I was at the briefing this morning and I appreciated your comments to clarify some things. The question that I have for you and whoever else in the administration or in the Senate is why that briefing was closed.

[01:24:03.06]
I have met with a number of constituents. In fact, right after the briefing who were very concerned that they didn't have information. And I think it would be very helpful to the public to be able to hear what's being said. And I didn't hear anything this morning that I haven't read the newspaper already. So I think to have some of those briefings open so the public can hear them would be a great benefit. And I hope there will be something on Web sites to help companies prepare their employees to help the public understand what's going on.

[01:24:33.07]
So I give that to you to take back what I did, actually, if I might. My understanding is Chairman Byrd, the chairman of the Senate Intelligence Committee, asked that that briefing be held at the top secret level to ensure complete transparency with members of the Senate on any information. I think what what was found was in the discussion, we're not relying on classified information. We tried to have radical transparency. So I think by the end of it, it was realized nothing classified had been discussed.

[01:25:00.00]
And so that label was taken off of it. But, yes, we've we've tried to be completely transparent about what we know. So and we we would be how support that kind of public. And I don't want to cut you off, but I'm about out of time. So my clock is running. And New Hampshire has been really hard hit by the opioid epidemic, as you know. And it has become very clear that the Medicaid expansion has been our best tool in combating the epidemic.

[01:25:28.00]
According to the most recent data available, 23000 Granite Staters have excess substance use disorder treatment through the Medicaid expansion. But your HHS buzz budget proposal would slash Medicaid funding by $920 billion, including 744 billion in cuts that appear to get the Medicaid expansion on page 112 of your budget. It says that, and I quote, As part of the president's health reform vision, Medicaid spending will grow at a more sustainable rate by ending the financial bias that currently favors a be able bodied working adults.

[01:26:03.04]
End quote. So the only way I can read that is that you're suggesting that Congress should eliminate the match that R is currently provided to states who participate in the Medicaid expansion. Am I reading that correctly?

[01:26:18.05]
Well, we do believe I've said this for a couple of years that the enhanced match for Medicaid expansion for able-bodied adults actually prejudices against pregnant women, children aged blind and disabled in traditional Medicaid. And we think that needs to be corrected. So, yes, yes, you are reading that correctly.

[01:26:34.02]
And so are you suggesting that we should that? We should eliminate the match that can go to Medicaid expansion for. So we've suggest ait's to use it for treatment for substance use disorders, for example.

[01:26:47.06]
So what we've suggested in the budget is an allowance that would have us work with Congress to look at issues like that around what is the appropriate federal matching rate for expansion compared to traditional Medicaid populations. What's the sustainable growth in that population, that expansion population, as well as what flexibility states would require. So we it's meant to be collaborative with working with Congress, but there is a problem here, which is there is a real prejudice in the Medicaid system now in favor of able bodied adults and state support of them because of the 90 percent match versus the average 60 percent federal match for those core traditional populations of Medicaid, like pregnant women, children, aged and blind and disabled.

[01:27:32.02]
There is it's a real disparity in the system that we need to address. Well, I hear that to address it in a way that would eliminate the match certainly puts at risk those thousands of people in states like New Hampshire across this country where they're getting their treatment for opioid disorders. And without that Medicaid, they would not be getting treatment. There would not. There is no alternative in a place like in states like New Hampshire for providing that treatment.

[01:28:01.02]
So I I'm not gonna ask you to comment on that, but just I hope that that's something that you will think about and you will share with states like New Hampshire before making any changes. And I'm sure Congress will want to weigh in.

[01:28:13.07]
And I don't believe we've suggested a limited but rather regularising compared to traditional Medicaid.

[01:28:20.05]
I want to go now to the. Issue with e-cigarettes and vaping, because I have been very disappointed at the flip flop that we have really seen from the FDA and from. The effort to try and scale back on. What vaping products are available to young people and to the public? And, you know, I I thought initially the FDA was pretty clear that it was going to take all flavored vaping products off the market, including menthol. And yet they have failed to do that.

[01:29:03.08]
So I wonder if you can talk about. What you're seeing in addressing vaping. Yes. So I share your passion on the cigarette challenge and keeping these away from kids. Just to explain why there was a change in what we initially announced on September the 11th. We with our original data set that we had, which was the National Youth Tobacco Survey, had tobacco flavor in one category and Mitton menthol together showing Mitton menthol as a group was being used by kids that actually troubled our public health people because we have significant menthol combustible users want to make sure there's an exit avenue for them that's available.

[01:29:42.03]
We then got after the announcement, the Monitoring the Future survey that finally gave us a breakdown of Mitton menthol. Sheung was really meant driving it and menthol was comparable to tobacco flavors. And so we were able to leave menthol on the market, go after the mint there. And so that was the basis for why we made that change.

[01:30:03.03]
Well, my time is out. But as I'm sure you know, there's legislation that would mirror what's in the budget with respect to fees on e-cigarette companies. And I hope that we can enact that and we support that also here.

[01:30:17.08]
Thank you.

[01:30:18.07]
Thank you, Senator Shaheen. We'll go to Senator Merkley. But on on your comment about the briefing this morning, as the secretary said, the request for a briefing, a top secret briefing was made at the request of the chairman of the Intelligence Committee and other senators who wanted to make sure that senators knew there weren't any secrets. We weren't being told and and we were both there. But as a result of that, I think what we learned was that everything we were told had already been available to the public.

[01:30:55.05]
So that was the motive. That was the motive for it. Senator Merkley. Thank you, Mr. Chairman. And welcome, Mr. Secretary. The administration has proposed a rule that would scrap the floor as agreement that sets humanitarian standards for the treatment of refugee children. And one of those changes, instead of requiring 72 hours to move a child to the least restrictive setting, would allow the indefinite detention of a child is an indefinite imprisonment of a child, a human rights abuse.

[01:31:34.07]
So, Senator, I I appreciate your concern there. That would be a DHS regulation. The HHS floras regulation, I believe largely tracks our requirements under the under the flora settlement agreements like I can speak to that I I can't really speak to the DHS regulation.

[01:31:54.05]
The. Well, OK, we'll leave that there then. But I'll follow up with you. I want to switch to my team. Loaded your team. I was going to ask you about a situation where a child has been trapped in or ours custody for six years now. And originally it was approved for her to go to live with her aunt in in 2014. She finally, after six years, signing an agreement to be deported without ever being informed that her family extended family was still waiting and happy to accommodate her, that too many things about this bother me.

[01:32:33.03]
But one is that six years in detention is an incredible impact on a on a child. A just it's a whole childhood disrupted or destroyed. A second is that essentially by not informing her that her family wanted her? It was extraordinarily misleading. On top of everything else, she's gone. She's gone through. She should've at least had the basic information for that decision. I'm not asking you to comment on this individual case, but I am asking you outside of this hearing to put this case on the top of your stack, because it's just every now and then a situation arises.

[01:33:13.02]
It's so horrific where someone's fell between the cracks and been treat in such a manner that none of us would want this for anyone we know or any child anywhere at any time. Would you be willing to take a close look at this, this this case and try to make sure that we don't continue this, that that we get some perhaps really high level attention and fair treatment for this child?

[01:33:38.07]
Absolutely. In fact. Thank you. I'm glad you I had not seen the media report until your you and your staff raised this to us about this. And I, of course, can't validate anything in the media report. But I have asked the team I want to dig in on this one, find out what's going on. I I completely agree with you. We we certainly don't ever want a child to be with us for that length of time.

[01:33:59.05]
But there are sometimes and I can't speak to this individual circumstance. There are cases where sometimes there are there is not family. Family may not be willing to take someone in. There may be an unsuitability there. But the shorter time a kid is with us, we've talked about this before, the better it is for the child. And we want kids with us for a short a time as humanly possible, consistent with their safety. So I will dig in on.

[01:34:22.03]
I will dig in on that personally to find out. I want to make sure she's treated fairly. Her family treated fairly.

[01:34:27.06]
I would like to be able to get weekly updates on where this case stands. If that's if that's something you can commit to, I'll work.

[01:34:35.00]
I want to make sure I'm able to do that consistent with the child's privacy, individual rights here. But but we'll work to get you as transparent information as we can about her situation, because I do want to make sure she's treated well.

[01:34:46.01]
OK. I wanted to turn back to the the Flores agreement. One of the proposed rule features, in addition to an indefinite imprisonment, is to replace a hearing before a Department of Justice immigration judge with an hearing before an HHS officer. But only if the child requests it. How would any child ever know that they could request such a hearing? Well, all of our kids have the right to legal counsel. And I believe there actually are phone banks as part of the counseling case management process at the at the grantee facilities to ensure connectivity with with counsel.

[01:35:30.06]
This is this is one of the this is one of the changes that was made in the regulation compared to the way it's set up and the floor as agreement. And I believe it has to do with a modification when get you more information about this. But a modification in terms of the Justice Department and what they believe they're actually legally able to do in terms of administering hearings. But happy. We're happy to get you more information about that. It wasn't it?

[01:35:55.05]
It really was, I think, just a response to where DOJ felt they had to be on these hearing processes.

[01:36:01.04]
I have visited the children in the internment camps. I've visited the children in the child prisons. And they have no idea that they would have this kind of right. Most of them did not have access to counsel. Many of them don't speak the same language as they will there. It's it's it's a fantasy to think a child would accept in rare circumstances. No. To requests such a hearing. So that that disturbs me because it strips a fundamental protection in the system away from these these children.

[01:36:33.06]
My time is expiring. So I'll just know this is the thing that the Flores settlement said. It could be replaced by a regulation that implements the Flores settlement. But this regulation crushes it strips it, scraps it, shreds it. It doesn't implemented. And thus, as you can imagine on behalf of these refugee children, all I'll be opposing it in every possible way. And I hope that as you study it, you might come to this the same point of view.

[01:37:04.00]
Thanks. Thank you, Senator Merkley. Mr. Secretary, Senator Blunt has indicated we should go ahead and wrap up the hearing at this point, which I will do in just a moment, but I want to ask you a question and make a couple of comments and then we'll conclude the hearing. You're familiar with the lower health care costs bill that passed this committee 20 to 3, and I think you're very well aware that the House Energy and Commerce Committee in this committee worked on an agreement and we pretty well came together between the House and the Senate committees on a version of that bill, which includes ending surprise billing and about 40 more provisions that would lower health care costs, focusing on competition, transparency and prescription drug costs.

[01:37:57.06]
The House Education Workforce Committee, chaired by Bobby Scott with Virginia Fox, the ranking member, came up with basically a similar proposal. And now the Ways and Means Committee in the House has also come up with a version that's a little different on ending surprise billing. So we have two House committees in this committee in agreement. We have that Ways and Means Committee headed in the same direction. We have the president's support, which is the question I'm coming to.

[01:38:31.00]
So when you have this committee, 20 to 3 was the chairman and Senator Murray. When you have Chairman Pelon and and Ranking Member Walden, when you have Bobby Scott and Virginia Fox all agreeing with the president's support and you have the Ways and Means Committee headed in the same direction, it seems to me that's a good candidate for for action to lower health care costs, especially since ending surprise billing the other 40 provisions or so that would encourage competition, transparency and lower drug costs and save enough money to fully fund community health centers for five years.

[01:39:14.01]
That could all be done by the end of May. When the Community Health Center funding expires. So my question for you, is this high on the president's priority list and will you continue to work with this committee and the three House committees to get a result on ending Surprized billing, which includes the air ambulance and other provisions, as well as the community mental health centers? This is a health centers. So they as you know, this is a very high priority for the president, ending surprise medical bills.

[01:39:48.08]
And we're very happy that we actually have consensus about the core, which is protecting the patient from surprise medical bills. And what we're just trying to do is work with the committees on who then bears that cost insurers, providers, hospitals, et cetera, and the back on the back side. And we want to work with you to try to bridge that, because you're right, it does need to get through. We want to get that that we want to get.

[01:40:14.01]
We want to get a bipartisan, bicameral solution passed. Thank thank you. And now hear my comments and you don't need to respond to these if you don't want to see the chairman is here and I'll let him have his own committee back. But he he made the mistake of giving me the chair, so.

[01:40:36.05]
Genomic information of newborn babies. Blood taken from them is used importantly in research. And many members think that parents ought to give informed consent to that. Some of the researchers are afraid that will limit the opportunity for research. My own view is I think the researchers are wrong about that. I think when parents go into the hospital and fill out all their forms and one of the forms says, can the blood that we get from your newborn baby be used for research?

[01:41:08.06]
I think overwhelmingly they're going to agree to that. And I would hope you would take a look at that and try to help us balance the privacy. Right. And the research opportunity. I think it helps the researchers to go ahead and do this because that that locks in the steady supply of that blood for research and avoids coming up and having a big problem with it sometime later. And the other issue is interoperability. We dealt with that over in our authorizing committee.

[01:41:42.05]
We had a whole lot of hearings about medical information blocking and make it easier for patients to get their own health care data. And the two things I'd like to ask you to focus on is the one area where we had a lot of concern had to do with third party people getting information from these things without us thinking about that very much. And the final rules need to balance patient access and the privacy that needs to be addressed. In other words, we didn't think the existing federal rules really dealt with that issue very expertly.

[01:42:24.01]
We want to go ahead and give patients that access, but we want to make sure that we deal with the privacy question and then the other. And this is my own bias about interoperability. I tried to get the Obama administration to slow down on implementing the various rules and expanding about medical health care information, because I thought it involved too many people and they are going too fast. We all all want to get the same place. So I hope that you will not try to do too much too fast.

[01:42:54.07]
I think our goal with interoperability is to get there. But if we try to go too fast to get there, we may create more problems than we than than we saw. So that's just admonitions from having dealt with this for several years. I just want to take this opportunity to mention those two issues to you. Now, I'll ask the chairman if he wants to have his committee back. Let's get vertical information and thank him for letting us know if I do have critical.

[01:43:32.00]
Thank you, sir. Alexander. Pleasure. Well, if you were going to pick any individual on our committee, you had a wide enough range of interest to keep, but keep your answering questions for the time everybody was gone. You would start with Senator Alexander. So thank you. We've got a few people that may come back. We're not going to go a whole lot longer here. Secretary, you talk a little about mental health. One of the things I've been interested in, as you know, is trying to get mental health on a truly e-gov even basis with all other kinds of health.

[01:44:12.00]
We have a pilot that Senator Stabenow and I worked on establish in a few years ago in eight states, the F.Y.I 20 bill included $200 million for certified community behavioral health clinics. You've actually proposed that that be increased by 25 million. I was pleased to see that increase. Also something that we asked for in that bill. It was a little more information about. What changes were seen in overall health cost when people's mental health is being treated like all other health?

[01:44:53.01]
My goal with this pilot. Was not to have the federal government take over mental health, but to try to create the kind of whole health information that would make it more easy for states to determine what this really meant, are they spend a no money extra when they treat mental health like all other health, which I think may be possible. Are they saving money, which may be possible? Are they spending only a little more money when they treat mental health like all other?

[01:45:28.06]
Also just always same as secretary? Totally logical to me that if you're dealing with somebody whose mental health problem, that you're more likely to be able to deal with any other health problem they have in a much more cost effective way. I do know that on the opioid effort in our state and the other seven states that have excellence in mental health pilots' that the ability to have mental health assistance unlimited by 14 days or seven days or whatever would have been certainly making a difference in people's ability to deal with their opioid problem.

[01:46:07.07]
If you don't have a mental health problem when you become addicted to drugs, you certainly have one after you become addicted. So what I really need from you all is a more is this as quick a response as you can give? We asked for a response to that in 30 days. It's been about sixty seven days I think now. But the reason that I'd like to see that is to see if we're headed in the right direction and if there's another way we need to be compiling information so that you and I both have in the Congress and state of state governments have what they need to look at to know the difference it really makes.

[01:46:46.08]
You want to respond to that a little bit. We certainly agree that taking care of mental health is critical to overall health. And we'll work on getting you that information as soon as possible. As you know, and I think you alluded to this, the president's budget proposes a major change here, which would be to lift the IMT exclusion at a state option for mental illness or serious mental illness of inpatient mental health facilities beyond the current IMT limit. And so as we have done for substance use disorder, but actually make it a state option to buy to get into that.

[01:47:19.08]
And that would make it so that I don't think it would then be exempted from budget neutrality and some other restrictions that we have. So very excited about that possible change for mental health in the United States.

[01:47:31.03]
I don't know if you've had a chance to talk about the president's HIV initiative much today with everything else that's going on, but we didn't fully fund Sermo and I work together. We work with our colleagues in the House to fully fund what was believed to be the number that was needed last year. What kind of. Progress. Are you making there in H in the. And HIV initiative and what should we be thinking about as we look at the number you asked for this year?

[01:48:03.09]
So what we did up until the appropriation came out in December was supporting in the target counties the preparation activities. So we've got, of course, for most of our new half of our new cases are occurring in fifty seven target jurisdictions. And so we worked there to get their plans in place and ready. We had for jump start jurisdictions that we were able to start moving on. Now that you funded it, we're now actually implementing the the initiative in terms of diagnosing, treating, preventing and responding with the new money.

[01:48:36.06]
So for twenty one would be year two of the full initiative that that would be 716 million dollars for your two. That's just the scale up, the $450 million scale up as we now implement those plans. So that's that's expanding for the community health centers that are in the fifty seven target jurisdictions, expanding their ability to to treat as well as to prescribe prep and get people on prep. It involves outreach to individuals and adherence programs to ensure people take their prep, get on it, stay on it, and that individuals who are diagnosed get on their antiretrovirals, expanding Ryan White capabilities in the target jurisdictions.

[01:49:17.06]
Also at CDC, having the rapid response team able to go and deploy into clusters where we see new clusters of HIV of HIV coming out. So really across that at CDC and hers is now its implementation.

[01:49:32.06]
So with the money you got us in December where we're beginning that state by state implementation and this would be the second year with just full scale up into that in a meeting yesterday in my office where the topic came up on HIV, if you'd said get on their prep and stay on it where this might be an area where some kind of time released medication where you took it once a week or once a month, then it released on its own would have some real potential.

[01:49:57.08]
Certainly any kind of long acting on prep would be great. I don't know if the manufacturers are pursuing that. I haven't seen if that's a formulation that they're working on. But yes, you would see that if you saw a monthly, for instance, that would be fantastic.

[01:50:10.04]
Now, Senator Durbin, thanks for chairman vectorized. Thank you for your patience and waiting with the roll calls. You and I have had so many good conversations about the issue of vaping in e-cigarettes. The president and first lady in the Oval Office in mid-September of last year made some very strong and encouraging statements about dealing with this. Unfortunately, a few months later, when the policy was announced, there were some things in there that concern me. The president's promise to remove all flavored e-cigarette products from market within a matter of weeks didn't happen.

[01:50:44.06]
Instead, the president decided to exempt cheap, disposable e-cigarettes like Mr. Fog's bubble gum flavor puff. I can keep with the names these things puff bars, o m g flavor and Stig's Mango bomb. flavor. Not necessarily a product for people who are hardened smokers trying to quit. It's a product to attract kids and over 80 percent of kids are attracted to that kind of junk and end up with the nicotine addiction. I think it was a mistake to exempt these cheap disposable products from the president's so-called flavor ban.

[01:51:21.04]
I'm concerned about his decision to extend more than 15000 flavors in the open tank vaping system. I'd like to get on the record what you've told me personally and privately about monitoring what's going to happen next and what the response would be from you and the FDA. If it turns out that the extent of the ban, the extent of the restrictions are not adequate to stop this youth epidemic. Yes. First, Senator Durbin, thank you for your partnership on the cigarette issue, you've been really it's been wonderful to work with you to just keep this focus on keeping these e-cigarettes away from children.

[01:51:58.05]
In terms of the disposables, as we talked about, enjoy, which I believe is the largest disposable manufacturer, did pull off its flavored disposable products from the marketplace, respecting the spirit of what we were trying to do here. These other products, if they're targeted at kids and as we get if we get data showing that they're that kids are using these products, we're going to go after them with enforcement with the full weight that we've got. We've even talked to companies like Google to use advanced analytics that they have to help us get even earlier warning signs than, for instance, the National Youth Tobacco Survey, which is more retrospective.

[01:52:36.08]
So we can see trends there.

[01:52:38.05]
Let me ask you this by court order in May that the FDA is going to have to it's going to receive applications for those who want to keep their devices and flavors on the market. Do you believe that an e-cigarette application should be rejected by the FDA unless the company proves with scientific and medical evidence that the product actually helps adults quit smoking tobacco cigarettes does not cause youth to start smoking and does not harm the user.

[01:53:08.07]
So on the first part of your question, which is smoking cessation, that would be imposing a drug approval criteria in there because of course the smoking cessation device is an NDA, a new drug approval that would be a different bar than what the Tobacco Control Act has. And I believe the standard is that it promotes public health.

[01:53:28.03]
I believe it's something like that in terms of the standard for adea not appropriate for the protection of public health is at least one one reference. Right. Right. But of course, it isn't that the marketing message, if it is if in e-cigarettes and vaping you give tobacco cigarettes, if they use a smoking cessation messaging without drug approval for their product.

[01:53:50.06]
We will enforce against them. And in fact, we did issue a warning letter against a major manufacturer that was doing that was putting smoking cessation claims or implicit claims connected to their product.

[01:54:01.03]
If I could switch to a much different topic. Thanks for your kind words on DTC. I want to talk about the zero tolerance issue and the fact that I joined with Senator Murray and others dealing with what happened to the kids who were forcibly separated from their parents at the border. And there was a study done at our request, but it came back and said we can't even find many of these kids or their parents. Can you tell me at this point how many children are currently still separated from their parents pursuant to that zero tolerance policy or the preceding policy which had the same impact?

[01:54:39.08]
I want to I want to make sure and I'll ask if we could get you for the record. I want to be sure of this. But I believe that we do not have in our care at 0 are any age children that remain as a result of the zero-tolerance family. The zero, zero tolerance policies. So I believe that to be the case, I thought we were down to zero of them. But I want to make will. We'll make sure and get you that for the road, that information for the record.

[01:55:05.01]
And so as you sit there, you believe that every parent whose child was taken into HHS custody has been reunited with their child.

[01:55:13.01]
They've either been reunited or they have not been parents or they're unfit for reunification or they have disclaimed their rights to reunification. I do. I want to be careful because I know there was one instance where there was an individual, I think, in Guatemala that we were still having trouble finding the parent. But I I believe that was resolved. And that's why I want to be very careful to get back to you and on the record to make sure we got every bit correct.

[01:55:38.02]
My closing point and I hope we look into this. I hope we're sensitive to this. The Remain in Mexico program, which has now involved thousands of people and children. There have been reports from human rights organizations about terrible abuse, including sexual abuse of children and adults who were on the Mexican side of the border waiting for some sort of resolution of their status here in the United States. Do you accept some responsibility to monitor that program in terms of its impact on these people?

[01:56:07.08]
So I am not involved in the in the DHS. My Mexico migration policy. That's not our authority doesn't go to that. Our authority really is just the unaccompanied children. If they come across by themselves or if a parent leaves a child here on that returning to Mexico side of things.

[01:56:25.04]
I understand the jurisdictional issue, but I just hope I know you're a caring person to understand that when we turn away asylees, people seeking asylum and leave them in Mexico, we at least have some role in this and should accept some moral responsibility for the outcome. Thank you, doctor. Senator Urban, if you want to stay for a minute, we're going to wrap up, but we have another question we could, you know, misnomer, the six year.

[01:56:51.09]
I want to follow up on what Senator Durbin brought up, because I'm really frustrated by the department's failure to protect migrant children against harmful policies, especially when it comes to sharing information with the Department of Homeland Security over the past couple of months. We have learned from news reports the White House hatched a plan to embed ICE agents within the Office of Refugee Resettlement and use information from unaccompanied children's potential spot sponsors to target them for deportation. And then we heard reports that ISIS implementing a widespread policy to fingerprint unaccompanied children who turned 14 while they're in HHS custody without legal representation present.

[01:57:37.04]
And now we're hearing another bombshell that HHS has been sharing migrant children's confidential therapy notes with ICE, who has then used them to weaponize that information to not to deny asylum claims. Now that I'm extremely worried about this, where in the past the care and protection of children was purposely separated from immigration enforcement. And this is really alarming to me that that these actions are are being taken. So just one question and I'll follow up with you later. But I understand children were told that their conversations with their therapists were confidential.

[01:58:15.03]
Is it department now making clear anything children say in these sessions will be shared with ICE?

[01:58:21.06]
Those notes from therapist or mental health counselors talking to children should not be disclosed absent the child's consent or limited the most limited information possible in the event of a threat to themselves or others that's disclosed these wooded areas that. So that would be the therapist, the sharing of that information that occurred. We discovered this in August of 2019 that there had been a problem since a guidance that was issued in 2016 where some of our work therapists notes were being provided over.

[01:58:55.08]
What should happen properly is limited information about the child's protection or about the child's threat to others should go into a serious incident report in the system. That should be the minimal information needed. We found that some of our therapists were grantee therapists, were cutting and pasting notes, putting them in the ESSI R's or accident or incorrectly.

[01:59:17.05]
Or are you telling no therapist now that they cannot share information with ice?

[01:59:21.07]
Or conversely, are you telling the children that anything they say on those confidential notes as of as of as of August twenty nineteen, we clarified our instructions that these notes should not be shared with anybody absent a child's consent, and that any in it will add any or of course there. But that's not the child is it okay if I Cheryl's with somebody you'd never met. Yeah.

[01:59:45.03]
No they don't. That wouldn't I wouldn't hang up on that. They're not being shared unless a child were to consent. The information in these serious since in order here would be if they threatened themselves or others that would be put in the essi are.

[01:59:58.02]
And I'd go over that idea legally at saying to a child that this may be shared means nothing to them. Now, we're not saying it may be shared. We're saying it's the standard mental health professional requirements that if you threaten yourself or others, that fact is disclosing all and that would be disclosed. I'm a we stop this. We we. This was in error that those notes were going over. And that was stopped in August of twenty nineteen long before it became a media story.

[02:00:26.00]
OK, I hear that. But you also said that if the child consents, then they will be shared. How can a child consent? I'd ask my attorney over here.

[02:00:34.04]
It's been a long time since a precious law. But if your child and don't have the capacity, how are you going to make this consent awarded? What does it mean to a child?

[02:00:44.00]
Well, it would be working. Our children have legal counsel, and so they would that we pay for. And so we'd be working with them on that. I'll get back to you about that.

[02:00:51.05]
I certainly think you may have.

[02:00:52.08]
But the most important issue is that this was a mistake. It should not have been happening as it was identified, it was stopped. We do respect the privacy of these mental health conversations. As Chairman Blunt knows, we I'm very passionate about access to mental health care. We want to make sure this happens and that kids are protected. And it was a mistake. We fixed it. And on a going forward basis, it shouldn't be happening.

[02:01:13.09]
Kate, can you get back to Senator Durbin and I guess play as possible what the policy is, how you ask the child and when they're shared? You bet.

[02:01:24.04]
Secretary, thank you for staying with us. Thank you for the time you spent today in your leadership at the at the agency record will stay open for one week for additional questions, I'd like to be included on any response on that last question. I think that probably is something that when you look back at your answer, there's a we need some clarification on that. The committee will stand in recess.