[Senate Hearing 115-246]
[From the U.S. Government Publishing Office]
S. Hrg. 115-246
PRESIDENT'S FISCAL YEAR 2018
HEALTH CARE PROPOSALS
=======================================================================
HEARING
before the
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
JUNE 8, 2017
__________
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
______
U.S. GOVERNMENT PUBLISHING OFFICE
30-210 PDF WASHINGTON : 2018
COMMITTEE ON FINANCE
ORRIN G. HATCH, Utah, Chairman
CHUCK GRASSLEY, Iowa RON WYDEN, Oregon
MIKE CRAPO, Idaho DEBBIE STABENOW, Michigan
PAT ROBERTS, Kansas MARIA CANTWELL, Washington
MICHAEL B. ENZI, Wyoming BILL NELSON, Florida
JOHN CORNYN, Texas ROBERT MENENDEZ, New Jersey
JOHN THUNE, South Dakota THOMAS R. CARPER, Delaware
RICHARD BURR, North Carolina BENJAMIN L. CARDIN, Maryland
JOHNNY ISAKSON, Georgia SHERROD BROWN, Ohio
ROB PORTMAN, Ohio MICHAEL F. BENNET, Colorado
PATRICK J. TOOMEY, Pennsylvania ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada MARK R. WARNER, Virginia
TIM SCOTT, South Carolina CLAIRE McCASKILL, Missouri
BILL CASSIDY, Louisiana
Chris Campbell, Staff Director
Joshua Sheinkman, Democratic Staff Director
(ii)
C O N T E N T S
----------
OPENING STATEMENTS
Page
Wyden, Hon. Ron, a U.S. Senator from Oregon...................... 1
Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman,
Committee on Finance........................................... 3
ADMINISTRATION WITNESS
Price, Hon. Thomas E., M.D., Secretary, Department of Health and
Human Services, Washington, DC................................. 5
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Grassley, Hon. Chuck:
Letter from Senator Grassley, et al. to Administrator Verma,
May 19, 2017............................................... 45
Hatch, Hon. Orrin G.:
Opening statement............................................ 3
Prepared statement........................................... 46
Price, Hon. Thomas E., M.D.:
Testimony.................................................... 5
Prepared statement........................................... 48
Responses to questions from committee members................ 51
Wyden, Hon. Ron:
Opening statement............................................ 1
Prepared statement........................................... 99
Communications
American Academy of Family Physicians (AAFP)..................... 101
National Family Planning and Reproductive Health Association
(NFPRHA)....................................................... 106
Oral Health America.............................................. 107
(iii)
PRESIDENT'S FISCAL YEAR 2018
HEALTH CARE PROPOSALS
----------
THURSDAY, JUNE 8, 2017
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 9:54 a.m.,
in room SD-215, Dirksen Senate Office Building, Hon. Orrin G.
Hatch (chairman of the committee) presiding.
Present: Senators Grassley, Roberts, Thune, Isakson,
Toomey, Heller, Scott, Cassidy, Wyden, Stabenow, Cantwell,
Nelson, Carper, Cardin, Brown, Bennet, Casey, and McCaskill.
Also present: Republican Staff: Chris Campbell, Staff
Director; Brett Baker, Health Policy Advisor; Kimberly Brandt,
Chief Health-care Investigative Counsel; Jay Khosla, Chief
Health Counsel and Policy Director; Jennifer Kuskowski, Health
Policy Advisor; and Preston Rutledge, Tax Counsel. Democratic
Staff: Joshua Sheinkman, Staff Director; Laura Berntsen, Senior
Advisor for Health and Human Services; Anne Dwyer, Health-care
Counsel; and Elizabeth Jurinka, Chief Health Counsel.
The Chairman. The committee will come to order. We are
going to first listen to the distinguished Senator from Oregon,
who has to go to another committee hearing, so I will show that
deference to him.
I welcome everybody to this morning's hearing on the
President's proposed budget for fiscal year 2018 with specific
attention to the Department of Health and Human Services.
I want to thank Secretary Price for being here. These
hearings are an annual event for the Finance Committee.
Secretary Price, since this is your first time around, I will
just warn you that these hearings can be a little grueling,
so--of course, you already know that.
I am grateful that the President and HHS are eager to work
with Congress to fix our health-care system in order to ensure
Americans are able to access affordable health coverage.
With that, I am going to turn to the ranking member, who
needs to get to another hearing, and we will show that
deference.
OPENING STATEMENT OF HON. RON WYDEN,
A U.S. SENATOR FROM OREGON
Senator Wyden. Mr. Chairman, thank you very much for this
courtesy. And I know this is a busy morning, and I am very
grateful to you for doing this.
I also want to say ``thank you'' to Senator Stabenow, who
in my absence is going to do an excellent job, as she always
does.
This administration from day one has preferred
``alternative facts'' and convenient spin to the truth. One of
the most recent examples was its budget proposal which double-
counted $2 trillion to maintain some whiff of fiscal
responsibility while it slashed health programs and protections
for basic and essential needs.
The budget math is fake, but the extreme agenda that would
deprive millions of Americans of access to health care and wipe
out living standards is not. Unfortunately, this morning I am
going to be splitting my time between the Finance Committee and
the Intelligence Committee, so I will be brief.
There are several issues in the budget and the
administration's agenda that I am going to touch on. First is
Medicaid. Secretary Price is the captain of the President's
health-care team. He has been the premier advocate for
Trumpcare, a bill that cuts Medicaid by $834 billion in order
to pay for massive tax breaks for the wealthy.
Fourteen million Americans would lose coverage, and
millions more would see caps on their care. And if that was not
enough of a cut, the budget proposal that came out a few weeks
ago goes even further.
It slashes hundreds of billions more from Medicaid. In a
program that covers nearly half of all births, 37 million kids,
millions of working families and people with disabilities, and
two out of three nursing home beds in America, these cuts would
be a staggering blow to Americans of all generations.
These facts and figures have been met by a wave of the hand
from Secretary Price. When asked if his proposed cuts would
result in millions of Americans losing access to Medicaid, he
responded, ``Absolutely not.'' He went further, claiming
``there are no cuts to the Medicaid program,'' and he also
said, ``nobody will be worse off financially.''
I have heard Secretary Price and others make the baffling
argument that people are actually worse off when they have
Medicaid coverage--that their health does not improve as a
result of Medicaid coverage. Often this argument is based on a
brief and outdated study performed in my home State.
Here is the bottom line on Medicaid. Seventy-four million
Americans rely on this program for basic health needs--parents
with sick kids, people with disabilities, seniors in nursing
homes who have nobody to turn to for help if their benefits
disappear, and in addition, thousands of Oregonians who are
healthy under my home State's model.
It would be a tough sell to convince those people they are
worse off being enrolled in Medicaid, or that the program needs
more than a trillion dollars in cuts. And public opinion is
very clear: two out of three enrollees are happy with the
program. Seven out of ten Americans say Congress ought to leave
it as it is--no block grants, no per-capita caps.
Fortunately, the budget proposal hit the wall here in the
Congress, and there is a lot of debate left to be had on
Trumpcare. But right now, the administration is causing turmoil
in the insurance markets, and it is already having disastrous
effects for millions of families.
The President issued a day-one executive order undermining
the Affordable Care Act, and nobody on the Trump team can give
a straight answer about whether the administration will
continue making cost-sharing reduction payments that are key to
making insurance affordable for working families. Because of
this sabotage, insurers are pulling out of the markets, and
people are left without plans to choose from.
You do not have to take my word for it. The insurers are
very clear about why they are making these decisions.
Furthermore, on the campaign trail, the President said he
would not cut Medicare. The Trumpcare bill shrinks the life of
Medicare, and the budget proposal extends the mandatory cuts
under the budget sequester by more than $30 billion. The Food
and Drug Administration, the Centers for Disease Control, and
the National Institutes of Health are all slashed in the
budget. The same is true of programs aimed at basic human
needs, programs that fund Meals on Wheels, child care, and
foster care. This is the budget you write if you think seniors
and working families have it too easy.
I want to thank the Secretary for joining the committee. I
apologize again for the hectic schedule. It is never an easy
appointment for a Cabinet Secretary, and I think he knows there
is going to be some vigorous discussion this morning.
I also again want to express my thanks to the chairman for
his very gracious and ongoing courtesies on these kinds of
matters. Thanks, Senator Stabenow, for being willing to fill
in, and I look forward to returning with our colleagues, and
again, I thank the chair.
The Chairman. Well, thank you, Senator.
[The prepared statement of Senator Wyden appears in the
appendix.]
OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM
UTAH, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. Let me just say I am grateful that the
President and HHS are, in essence, working on this effort, and
are, in essence, eager to work with Congress to fix our health-
care system in order to ensure Americans are able to access
affordable health coverage.
This may not be something that is going to be that easy to
do. And as we know, time is of the essence in regard to this
effort.
Earlier this week, we received word that Anthem is pulling
out of Ohio's Obamacare marketplace, potentially leaving more
than 10,000 patients and consumers in 20 counties without any
insurance options on Ohio's exchange for 2018. Now, this news
is particularly frightening as we expect to hear similar
notices from Anthem as they reevaluate their participation in
Obamacare exchanges throughout the United States, our whole
country.
Now, this recent story is just the latest in a long line of
failures, but my colleagues on the other side seem to want to
continue under the guise that this is working. It is not
working. All of these failures demonstrate the need to move
forward with repealing Obamacare and replacing it with a more
workable approach, one that will take seriously the ballooning
health-care costs impacting every American family.
Let me talk for a few minutes about the specifics of the
President's budget. The budget assumes $250 billion in total
savings from the repeal and the replacement of Obamacare.
Despite some insinuations to the contrary, the budget does
not incorporate the specific legislative proposal, the American
Health Care Act, that is before Congress right now. Therefore,
it is not accurate to associate the specific Medicaid savings
the CBO has estimated from enactment of the AHCA with the
President's budget. To do so would assume a level of
specificity that, for obvious reasons, is just not there.
Moreover, the President's budget does not cut $1.5 trillion
from Medicaid. Nor does it assume that the specific Medicaid-
reform proposals from the AHCA will be enacted into law. I am
quite certain that we will hear a lot about that today, but any
attempt to make that connection is simply unfounded. And any
Senator who harps on the AHCA Medicaid numbers here today
either does not understand the explicit language and estimates
provided in the President's budget, or they are simply
attempting to muddy the waters in order to scare Americans who
rely on Medicaid for health-care coverage.
Ultimately, the President's budget appears to accept the
reality that the Senate will need to come up with its own
health-care reform proposal that includes a fundamental fix to
Medicaid, which is, quite frankly, long overdue. And anybody
who does not agree with that just is not living in the real
world.
In addition to the savings assumed from the repeal of
Obamacare, the budget also explicitly assumes $610 billion in
savings from putting Medicare on a sustainable fiscal path by
capping funding in fiscal year 2020 through per capita caps or
block grants at the States' option.
All told, most of the budget's overall Medicaid savings
would be achieved by returning the focus of Medicaid to serving
those with the greatest needs--the elderly, the disabled, and
needy mothers and children--and by giving States more
flexibility to run their own Medicaid programs.
Any Senator who would like to argue that the Federal
Government should spend more Medicaid dollars to provide
coverage for non-disabled, childless adults at the expense of
disabled patients who remain on waiting lists should explain
why. Furthermore, any Senator who would like to argue that the
States are ill-equipped to handle their Medicaid programs
should explain why that is the case, given that the
overwhelming consensus we have heard from Governors nationwide
over the last several years is that States want more
independence and flexibility to tailor the Medicaid program.
Washington needs to stop measuring the success of a Federal
program by how much money it spends, or how many other programs
are a part of it. Instead, Washington needs to focus on how
well a Federal program helps those it is intended to serve and
how efficient the program is at fulfilling its mandate.
Long story short, we need to stop focusing on spending and
pay more attention to outcomes, because we may not be able to
spend more. It does not appear that we are going to be able to.
The rate things are going right now under the current system,
it is a national tragedy.
I think the President's budget, while it is by no means
flawless, largely recognizes this reality, and the President
and the administration deserve credit for that. Now, I look
forward to having an open and frank discussion with Secretary
Price about his thoughts on these and other matters.
[The prepared statement of Chairman Hatch appears in the
appendix.]
The Chairman. But before we get to that, I would like to
say today that we have the pleasure of being joined by
Secretary Thomas E. Price.
Secretary Price, I want to thank you for coming. Secretary
Price was sworn in as the 23rd Secretary of Health and Human
Services on February 10, 2017.
As a policymaker and a physician--a surgeon, in
particular--he brings to the Department a lifetime of service
and dedication to advancing the quality of health care in
America.
Secretary Price first began his career in care for patients
as an orthopaedic surgeon. He followed in the footsteps of his
father and grandfather, and began a solo medical practice in
Atlanta, GA. Since its founding, that practice has grown to be
one of the largest non-academic orthopaedic practices in the
country.
Hoping to make a different type of impact on health care,
Secretary Price ran for public office and was elected to four
terms in the Georgia State Senate, and I believe would have
continued on forever if he wanted to. During his tenure there,
Secretary Price served as Minority Whip and later as the first
Republican Senate Majority Leader in the history of Georgia.
Most recently, Secretary Price served as U.S.
Representative for Georgia's sixth congressional district from
2005 to 2017. During his time in the House, Secretary Price
served in various roles, including chairman of the House Budget
Committee, chairman of the House Republican Policy Committee,
and chairman of the Republican Study Committee.
Secretary Price received his bachelor and doctorate of
medicine degrees from the University of Michigan, after which
he completed his orthopaedic surgery residency at Emory
University.
Now, Secretary Price, we are grateful to have you here and
will be happy to have you proceed with your testimony here
today.
STATEMENT OF HON. THOMAS E. PRICE, M.D., SECRETARY, DEPARTMENT
OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC
Secretary Price. Thank you so much, Mr. Chairman and
Ranking Member Stabenow and members of the committee. I want to
thank you for inviting me today to discuss the President's
budget for the Department of Health and Human Services for
fiscal year 2018. It truly is an honor to be with you.
Whenever a budget is released, the most common question in
this town, in Washington, is ``how much?'' How much does the
budget spend on this program, how much does it cut from the
other program?
And as a former legislator, I understand the importance of
this question. But too often, it is treated as the only
question that is worth asking as it relates to the budget, as
if how much a program spends is more important, or somehow more
indicative of whether the program actually works.
President Trump's budget request does not confuse
government spending with government success. The President
understands that setting a budget is about more than
establishing topline spending levels. Done properly, the
budgeting process is an exercise in reforming our Federal
programs to make sure that they do their job and use tax
dollars wisely.
The problem with many of our Federal programs is not that
they are too expensive or too underfunded. The real problem is
that many of them simply do not work. Fixing a broken
government program requires redesigning its structure and
refocusing taxpayer resources to better serve those most in
need. And that is exactly what President Trump's budget will do
at HHS and across the government. Consider Medicaid, which has
been discussed, the primary source of medical coverage for
millions of low-income American families and seniors facing
challenging health circumstances.
If the amount of government spending were truly a measure
of success, Medicaid would be hailed as one of the most
successful programs in history. Twenty years ago, actual
spending on Medicaid was less than $200 billion. Within the
next decade, it is estimated to top $1 trillion a year.
Despite these significant investments, one-third of
physicians who ought to be seeing new Medicaid patients do not.
Some research shows that enrolling in Medicaid does not
necessarily improve your health outcomes for the newly eligible
Medicaid population.
This suggests that we need structural reforms that empower
States to serve their unique Medicaid populations in a way that
is both compassionate and sustainable. Now under current law,
Federal rules prevent States from focusing on their most
vulnerable communities and from testing new ideas to improve
health outcomes and access to care. This budget changes that.
HHS's mission of protecting the health of the American
people involves far more than overseeing the Nation's health
care and insurance programs. HHS is the world's leader in
helping the health-care sector prepare for cyber-threats and
responding to and protecting against public health emergencies.
Recently, I witnessed this important work firsthand
visiting Ebola survivors in Liberia and representing the United
States at the G20 Health Ministerial Meeting in Berlin and the
World Health Assembly in Geneva. To support HHS's unique
Federal role in public health emergencies, preparedness, and
response, the President's budget provides $4.3 billion for
disaster services coordination and response planning,
biodefense and emerging infectious disease research, and
development and stockpiling of critical medical
countermeasures.
In addition, today America faces a new set of public health
crises that we have been far less successful in resolving.
Those are serious mental illness, the opioid crisis, and
childhood obesity.
As Secretary, I am committed to leading HHS to address each
of these three challenges, and the President's budget calls for
investments in policy reforms that will enable us to do that.
The budget calls for investments in high-priority mental health
initiatives for psychiatric care, suicide and homeless
prevention, and children's mental health, focusing especially
on those suffering from severe mental illness.
In 2015, over 52,000 Americans died of overdose, most of
them from opioids. This budget calls for $811 million to
support the department's five-point strategy to fight this
epidemic.
To invest in the health of the next generation and help
nearly the 20 percent of school-aged children who are obese
lead healthy and happier lives, the President's budget
establishes a new $500 million America's Health Block Grant.
Additionally, the President's budget prioritizes women's
health programs by investing in research to improve health
outcomes for women and increasing funding for the Maternal and
Child Health Block Grant and Healthy Start. Across HHS, funding
is maintained for vital programs serving women, including
community health centers, domestic violence programs, women's
cancer screenings and support, mother and infant programs, and
the Office of Women's Health. This budget demands some tough
choices, and in this challenging fiscal environment, there are
no easy answers. With this budget, however, the new
administration charts a path toward a sustainable fiscal future
and ensures the dedicated resources provided enhance and
protect the health and well-being of the American people.
Members of the committee, I want to thank you for the
opportunity to be with you today and your continued support of
the Department of Health and Human Services. It is my
incredible privilege to serve as its Secretary.
[The prepared statement of Secretary Price appears in the
appendix.]
The Chairman. We are proud of you, and we know that you
were an excellent member of the House. And so far, it looks to
me like you are getting on top of what these problems are,
although you were pretty well on top of them before as a member
of the House.
The opioid crisis seems to be spreading across the country,
affecting families and communities in unprecedented ways. In
fact, The New York Times reported earlier this week that
overdose deaths are at an all-time high. Tackling this crisis
is a priority for you and for President Trump. So can you
describe the efforts HHS is undertaking to address the ongoing
opioid epidemic in the United States?
Secretary Price. Mr. Chairman, this is one of the scourges
across the Nation that tears your heart out. In 2015, 52,000--
as I mentioned--fellow Americans died of an overdose, 33,000 of
those of an opioid overdose. We hear this day after day after
day. What the Department has done is put in place a five-part
strategy to make certain that we are identifying the kind of
treatment and recovery efforts that work in assisting the
States.
We want to make certain that we have the overdose-reversing
drugs available wherever they need to be available and know
that we are trying to surveil and make certain that we know
prior about strong drugs getting to the street, from a law-
enforcement standpoint.
There is a public health aspect to this, obviously, to try
to determine what the heck is going on. Why is this scourge as
large as it is? And we are putting resources into that.
In addition, we want to make certain we are doing the
highest level of research to try to identify those pain
treatments that are able to make it so that there is not a need
for individuals to seek pain medication for its euphoric
effect.
And then finally, fifth, it is important to look at how we
manage pain in this Nation. Twenty years ago, we started down
this road of measuring pain as a fifth vital sign. Let me
suggest to you that that has resulted in significantly greater
use of opioids and prescription medication than would have
otherwise been the case.
So we have this five-part strategy. You have been
incredibly helpful, Congress has been incredibly helpful, to
make certain, through 21st Century Cures and otherwise, to
provide resources so that we can allow the States to identify,
again, those evidence-based programs that they have in place
that can help mitigate this challenge.
But we continue to move in the wrong direction, Mr.
Chairman, and we will not rest at the Department or in the
administration until we bend that curve in the other direction.
The Chairman. Well, thank you so much.
HHS recently published a report using the previous
administration's data showing just how much health insurance
premiums in the individual market have increased since 2013.
Could you tell us what are the principle findings of that
report?
Secretary Price. Well, thank you so much.
I know that when I visited with folks in my previous
position, and then since I have been privileged to serve as
Secretary, I hear over and over again how folks are just so
terribly concerned about the cost of health coverage for them
and their family. And there was this disconnect--you are going
to have the individuals talking about the wonders of the
program that was in place, but then you had all of these
individuals who were so concerned because they did not have the
ability to afford the coverage, or they did not have the
ability to get the care.
So this study that we undertook, that was undertaken at the
Assistant Secretary for Planning and Evaluation group within
HHS, identified that the average premium increase over the last
4 years has been over 100 percent. It was 105 percent, so more
than double, across the country. In fact, in three States, the
increases were tripled--in Alaska, in Alabama, and in Oklahoma.
And what that means is that there are individuals who (1)
cannot afford the coverage, and (2) even when they can afford
the coverage, the deductibles have increased to a significant
degree so that they may have an insurance card, but they do not
have any care, because they cannot afford the deductible.
So that is the challenge that we are trying to address and
make certain that Congress addresses so that individuals are
able to afford the kind of coverage that folks want for
themselves and for their families.
The Chairman. Well, as you may be well aware, this
committee has for several years now been keenly interested in
the large backlog of Medicare claims under appeal at HHS. The
most recent reports we have heard indicate that the backlog has
been reduced from a high of nearly 1 million claims to a
current number closer to 750,000 claims. Now, that number is
still unacceptably high.
Can you tell me what HHS is doing to address the
unnecessary backlog of Medicare claims?
Secretary Price. Yes. These are appeals where providers
have said that they do not believe that the Federal Government
is providing the kind of resources necessary for them to be
able to care for their patients. And as you mentioned, the
numbers are staggering: nearly a million claims. We are down to
about 700,000 now.
We can take care of somewhere around 20,000--up until
recently--a year. What we have done is met with the
individuals, and they are high-quality folks. These are folks
just trying to get these appeals through the process and trying
to make the right decision.
We put a focus on that. We have encouraged them to talk to
the stakeholders, talk to the individuals out there about why
we have this increase in claims. There is a problem there. It
means that the system is not working to the degree that it
should to allow those individuals to care for those patients
and be compensated for that care.
We have identified the opportunity for the administrative
law judges to be able to review higher claims and move in the
direction of having magistrate judges review lower claims so
that we can hopefully get through a larger volume of claims on
an annual basis.
And then we have tried to decrease the burden of reporting.
We are working on trying to decrease the burden of reporting
for the providers so that there is a less likely possibility
that they would feel the need or desire to file a claim.
So this is a major problem. We are working through it, and
we are committed to getting that number down to a reasonable
number.
The Chairman. Well, I am happy to listen to you. You have
inherited a tremendous number of problems, and I know that you
are fully capable of solving those problems. I think you are
well on your way.
The distinguished ranking member has agreed with me to
allow Senator Isakson to go next.
Senator Isakson. Thank you, Mr. Chairman.
Dr. Price, welcome back. The last time you were here, we
were confirming you, and now we are getting a lecture from you
on what we need to do to help you. And we are here to help you.
Secretary Price. Thank you.
Senator Isakson. All of the Georgians are proud of you and
your service to our State.
You just returned from your first trip overseas as
Secretary, and you began that in Liberia, if I am not mistaken.
Secretary Price. I did.
Senator Isakson. What did you learn, particularly with
respect to our response to the Ebola outbreak, which ground
zero, I think, was Liberia?
Secretary Price. It was indeed, Senator. Thank you so much.
I appreciate your support and your service to our great State.
My first trip overseas was--we stopped first in Liberia. I
wanted to do that, because I wanted to express our appreciation
to the Americans who were working over there, especially during
that Ebola crisis, and to also demonstrate our continued
commitment for global health security and to thank the Liberian
government for what they had done to elevate and increase their
ability in the area of infectious disease.
What I saw was incredibly inspiring. And you all would be
so remarkably proud of the American people who are forward
deployed--if you will--in global health, individuals from the
CDC, from the NIH, from HRSA, who are doing all that they can
to make certain that we address the health challenges that
exist around the world, especially around infectious disease.
It paid off in absolutely remarkable benefits, and we saw
that because of the most recent outbreak of meningitis that
occurred in Liberia, and that outbreak--the surveillance that
was done, the detection that was done, the prevention of spread
that was done, and the treatment that was done, was only
possible because of the work that had been done in Liberia
since the Ebola outbreak and since that challenge was resolved.
So I was just uplifted and inspired by the incredible work
of the American people who are dedicating their lives to
assisting the health of individuals overseas.
Senator Isakson. Well, CDC did a phenomenal job, as did
HHS.
Secretary Price. Absolutely.
Senator Isakson. I want to point out that the President's
budget cuts by $136 million the Preparedness Fund, a lot of
which went to the initial response to Ebola in Africa, along
with a partnership with Emory University to have the first
place we could actually bring some of those victims to the
States. We need to work to see to it that the funding is there
so we can have the same type of response the next time an
outbreak takes place, wherever it is in the world, because we
are the world's clinic, if you will, for emergencies and
disasters like that.
Secretary Price. Yes.
Senator Isakson. Secondly, you had a partner by the name of
John Knox, if I am not mistaken. Is that right?
Secretary Price. I did.
Senator Isakson. You may remember, John operated on my son,
Kevin, 30 years ago and saved his leg from a terrible injury
and a terrible accident. It took him 9 months to recover. Eight
of those months he recovered at home.
My wife and I went to school. We took lessons in how to
clean ports and put the antibiotic drips into him so he could
fight infection in his bone marrow while he recovered at home.
Since 1989 when that accident took place, over time
reimbursement for antibiotics and home infusion went away. In
fact, there was a push to drive everybody into the hospital to
recover and not as much reimbursement to encourage people to
stay home.
Fortunately, Senator Warner worked closely with us to see
to it that we began focusing on reimbursement for durable
medical equipment in the 21st Century Cures Act. I hope you
will work with us to see to it we can expand coverage to get
home infusion, wherever practical and possible, covered as a
benefit so that we can have more people recovering in a less
expensive, more hospitable environment than in hospitals and
hospital facilities.
Secretary Price. This is really important, Senator, because
what we find--health care and medicine are dynamic. They change
all the time. So what used to be able to be done only in a
hospital, now can oftentimes be done as an outpatient or, in
the instance of recovery, oftentimes at home. And home- and
community-based services are absolutely imperative for us to
have the flexibility to be able to do that.
So that is one of the things that we are trying to
concentrate on from a waiver standpoint in many different
programs, as well as trying to incent the flexibility within
existing programs so we can cover those kinds of treatments,
not necessarily just in the venue that was previously selected
when that was the standard of care, but in a new venue because
it works better for the patient.
Senator Isakson. Lastly, I just want to underscore what you
said about experimenting to have our Medicaid coverage
available and robust for our citizens. Your State and my State,
Georgia, we have 1.9 million people on Medicaid--1.3 million of
them are children. Fifty percent of all the live births in
Georgia are paid for by Medicaid.
So, as we go through the reforms that are necessary in
Medicaid, we have to remember that we are talking about, first
and foremost in our State--and I think in most others--children
who benefit from those programs being robust or are hurt if
they are cut. I look forward to working with you to see to it
that we continue to provide the coverage that is necessary and
experiment with ways to incentivize the program to meet the
needs for our children in Georgia.
Secretary Price. Thank you, Senator. Thank you for your
leadership.
Senator Isakson. Thank you, Mr. Secretary.
The Chairman. Senator Stabenow?
Senator Stabenow. Well, thank you very much, Mr. Chairman.
Welcome, Secretary Price. There are so many things that I
would like to talk to you about and actually debate with you in
terms of what has been said and the positions of the
administration. But I want to start with, I think, a very
important basic assumption that you have made, and that is that
the Affordable Care Act is falling apart. ``Oh my gosh, look
what is happening. We have to dismantle it. Do something
different, because it is falling apart.''
And yet we know--to me it is like pulling the rug out from
under somebody and saying, ``Oh my gosh they fell down.'' We
have seen consistent moves by the administration, whether it
was cutting in half the number of days that citizens have to
sign up for insurance, whether it is no longer aggressively
doing outreach to younger, healthier people, making sure
everybody is in the pool so that costs do not go up, or whether
it is doing what has been done to take away the commitments
made to the insurance industry to make sure that they would be
covering pre-existing conditions and have no caps on services,
and so on.
And it is laid out this morning in The Washington Post,
when we look at the question of whether or not the White House
is going to let the health-care system die. I want to just
quote a little bit from there, because this is coming from the
industry. The biggest source of industry anxiety right now is
whether the administration and Congress will continue to fund
cost-sharing subsidies that help 7 million Americans with ACA
plans afford deductibles and co-pays, and, ``Absent that
funding, I don't know if we are going to have much
participation in the exchange market in 2018,'' said Tennessee
Insurance Commissioner Julie Mix McPeak, a Republican who also
serves as president-elect of the National Association of
Insurance Commissioners.
The uncertainty--the uncertainty is one of the top reasons
insurers have cited when explaining why they are posting higher
rates for the next year or withdrawing from markets altogether.
Two weeks ago Blue Cross Blue Shield of North Carolina filed a
rate increase of 22.9 percent. They said it would have been 8.8
percent, not 22.9 percent, if the administration had committed
to paying and basically keeping the commitments that were
passed as part of health reform.
And then finally, on Tuesday Anthem Blue Cross Blue Shield
announced it was pulling out of the Federal exchange. You have
mentioned that in Ohio. The President seemed to cheer that
yesterday. I do not know why we are cheering that people are
going to have less opportunity to have health care.
If we spent a tenth of the time that has been spent
undermining the health-care system working to make it better,
we would be making terrific strides to lower costs for people.
But here is what was said by Brad Wilson, the North
Carolina chief executive of Blue Cross Blue Shield. ``We have
to take a snapshot in time, which is right now. A lack of
action by the administration,'' he added, ``yields a result we
are currently seeing, higher premiums rather than lower
premiums.''
And so my question, Mr. Secretary, is, why do you believe
it is in the best interest of American families to sabotage the
health-care system that is today allowing American parents to
take their children to the doctor?
Secretary Price. Thank you, Senator.
Well, let me just correct a few statements. Nobody is
interested in the system dying. What we are interested in is
making certain that the system works for patients and families
and doctors. Nobody----
Senator Stabenow. Then why are you not willing to--excuse
me, but why are you not willing, then, to indicate that as long
as we have the system we have, you are going to keep the
commitments and reimburse the insurance companies so they have
certainty?
Secretary Price. Nobody is interested in sabotaging the
system. Nobody is cheering the challenges that we have in the
system.
In your State alone, premiums were up 90 percent before
this President came into office. The number of insurers was
down before this President came into office. In your State,
so----
Senator Stabenow. Well, I can assure you, after meeting
with the head of Blue Cross and Blue Shield of Michigan, they
are going to file two rates when they file their rates: one if
the administration keeps their commitments, and one if they do
not. And if they do not, they are going to be much higher.
So I think the question is, why would you not keep the
commitments made? I understand you have a different view in
terms of what the system should look like, which I disagree
with. But in the meantime you have insurers--insurers--that are
saying the reason the rates are going up is because of
uncertainty and instability created by the administration. Why
is that a good idea?
Secretary Price. Actually, Senator, if you read further in
that article, it talks about the increase in costs and
decreasing insurance availability for individuals across this
country before this administration came into office.
So what we are trying to do is to fix the challenges that
we have----
Senator Stabenow. Well, let us start by keeping our
commitments. I have more questions for another round, but let
us start by making sure that the administration is keeping the
current commitments, following the current law while we debate
what should happen next.
Thank you, Mr. Chairman.
The Chairman. Did you have enough time to answer that
question?
Secretary Price. Yes, sir.
The Chairman. Do you need more time?
Secretary Price. No, I am fine. Thanks.
The Chairman. Okay.
Then we will turn now to Senator Cassidy.
Senator Cassidy. Hello, Dr. Price.
Secretary Price. Hello.
Senator Cassidy. There are a couple of things I am
encouraged by in your budget. Senator Cantwell and I last year
put in a bill regarding direct primary care. For those
unfamiliar with it, as physicians you and I know the way you
lower cost is to empower the patient/physician relationship so
that if the patient has a problem, instead of going to the ER,
she can call her physician, and her physician can give her the
advice.
Direct primary care is a contractual relationship, and so
there is more investment, perhaps, than in the other
relationships that are out there, say an urgent care center
where you might see the person once and never see them again.
So Senator Cantwell and I put that together. And I like it,
because it can decrease utilization. And by decreasing
utilization, you decrease health-care costs, and ultimately we
do not decrease the cost of insurance unless we decrease both
utilization and the costs of health care.
Secretary Price. Absolutely.
Senator Cassidy. Do you have any comments on that direct
primary care model and how robust you all plan to make that?
Secretary Price. Well, it is an incredibly helpful program,
and it gets to the point of the dynamism of health care.
The opportunity that individuals may have to be able to
have a personal physician, a primary care physician in all
settings across our health system, would be, I think,
absolutely beneficial to the ability for that patient, that
individual patient, to get the kind of care that he or she
needs.
Right now, you cannot do that. So what we want to do is
move toward a system that allows for more personalized care,
and the DPC model--the direct primary care model--is one that I
think holds great promise.
Senator Cassidy. Now, if you will, it aligns the incentive
between the patient and the physician.
Secretary Price. Absolutely.
Senator Cassidy. Let me talk a little bit about the per
capita cap or, as I prefer to call it, the per beneficiary
payment. And just a little history for those who may not know,
it was first introduced by President Clinton as a concept, and
Senators Phil Gramm and Rick Santorum simultaneously, as a way
to align incentives between the patient, the State, and the
Federal Government.
I think we are actually seeing almost a modified version of
that now as States are going to Medicaid managed care, aligning
the incentive between the State as a payer with the Medicaid
managed care company, and then the patient. I guess the way I
look at the per beneficiary payment--because as you know, I
introduced a bill in 2010; I do not know when it was, 112th
Congress--which kind of brushed off the Phil Gramm-Bill Clinton
proposal and updated it, if you will. It will align the
incentive between the Federal and the State government.
Secretary Price. Exactly, and it is so important because,
as you know, having taken care of--as I did--Medicaid patients
in our practices, the Medicaid population is not a monolithic
population. There are individuals in the Medicaid population
who are, as Senator Isakson said, healthy moms and kids. There
are also individuals in the Medicaid population who are
seniors, low-income seniors, and disabled, blind and disabled
individuals.
All of those individuals need to be treated uniquely,
because they are unique individuals. And what we do as a
system, by and large, is say, you have to take care of every
one of those people exactly the same way, which does not allow
for that kind of dynamism and flexibility in the program so
that States can tailor their Medicaid programs to suit their
Medicaid population.
Senator Cassidy. And let me just say again I do not know if
this is in the House bill, because the way we do the per
beneficiary payment is a little bit different, is somewhat
different than what the House does.
But as an example of aligning incentives, as we know right
now, if States recover waste, fraud, and abuse, they have to
give back to the Federal Government the portion that the
Federal taxpayer put in. So if it is a 60-percent State--40-
percent State, 60-percent Federal Government--60 percent of
that recovery goes back to the Federal Government.
That works to disincentivize the State to go after waste,
fraud, and abuse, because they have to kick it back. Under the
per beneficiary model that we put forward, the State would keep
100 percent of recovered waste, fraud, and abuse, if you will,
aligning the incentive for them to wring out that waste, fraud,
and abuse.
Secretary Price. It is those kinds of modifications and
improvements to a system that I believe we all ought to be
embracing, because it is those kinds of things that will then
allow us to align the incentives, as you suggested, but also
make certain that every individual in that interaction is
working for the benefit of the patient, making certain that
there is not the fraud and abuse, making certain that the
patient is able to see the physician that he or she wants to
see, making certain that the patient is able to have the kind
of treatment that he or she desires.
Senator Cassidy. Let me also point out that under the
Medicaid Accountability and Care Act which I introduced, and
then again in the Cassidy-Collins plan or the Patient Freedom
Act, we have incorporated--States like California actually get
more money, and some big blue States actually do well. Florida
does better in terms of having more dollars for certain
categories of patients in order to improve health care.
So when I hear folks condemn it without understanding it, I
feel like this could be an incredible missed opportunity to
align those incentives to improve patient care, but also to
protect the Federal and the State taxpayer.
I look forward to working with you, and hopefully you will
have folks on the other side of the aisle.
I yield back.
The Chairman. Okay.
Senator Carper?
Senator Carper. Thanks, Mr. Chairman.
I want to take a moment just to began, if I could, Mr.
Chairman, to commend you and Senator Grassley for something you
did--gosh, I want to say 24 years ago. And what you did is, you
cosponsored legislation authored by Senator John Chafee that
called for creating in every State marketplaces, exchanges. You
called for not only establishing the exchanges and marketplaces
in every State, but to also say that, in order to make sure
that the insurance companies had a healthy pool of people to
insure, there would be an individual mandate, that people had
to get coverage. You cannot force people to get coverage, but
you say, you have to get coverage and fine them somehow if they
do not, incentivize them to get the coverage.
I want to congratulate you on cosponsoring legislation that
provided for an employer mandate and that also provided for the
idea that insurance cannot deny coverage to people who have a
pre-
existing condition.
All those ideas are a part of Romneycare in Massachusetts.
And frankly, all of those are a part of the Affordable Care
Act.
And the parts of the Affordable Care Act that the
Republican Congress seem to like the least are those ideas. I
think there is a real irony in all this. I like those ideas. I
studied economics at Ohio State. I was a Navy midshipman. I
like market forces. I like trying to harness market forces and
make them work.
You came up with a good idea in 1993. And I just wish to
heck that you would work with us to try to make sure that those
good ideas have a chance of working. And the reason why the
marketplaces are failing in places like you mentioned, in Ohio,
in your statement, Mr. Chairman--the reason why they are not
working is, we have basically undermined the individual mandate
so that people know they do not really have to get coverage.
The young people are not.
We have taken off the training wheels, so to stabilize the
marketplaces and insurance companies--they lost their shirts in
2014 because of it. The lost less money in 2015. It got better.
They raised their premiums, they raised their copays, they
raised their deductibles, and they did better.
A Standard and Poor's column said, rather than the
marketplaces being in a death spiral at the end of 2016, they
were actually recovering until our new administration came in
and said, well we are not sure if we are going to enforce the
individual mandate, and by the way, we do not know for sure
whether we are going to extend the cost-sharing arrangements.
That provides unpredictability, lack of certainty for the
insurance companies. What do they do? They say, we are going to
raise our premiums more. Well, you are destabilizing the very
idea that these guys came up with 24 years ago.
The Chairman. Well, if I could just interrupt for a second.
Those were ideas that were against--it was part of the
anti-Hillarycare bill.
Senator Carper. They were good ideas. I commend you for
them. If my life depended on it, I could not tell you what
Hillarycare did. I could not tell you, but I know what your
bill did. And frankly, they were good ideas.
And now we are undermining, undercutting them. Why? Dr.
Price, why?
Secretary Price. Senator, I appreciate the observation. I
would add to that that there are significant challenges out
there, and there were before this administration started. In
your State alone, premiums were up 108 percent before this
administration started. In your State alone, there were fewer
insurance companies offering coverage on the exchange before
this administration started.
So what we are trying to do is address, especially, that
individual and small group market that is seeing significant
increases in premiums, increases in deductions----
Senator Carper. What are you doing? What are you doing to
do that? How are you stabilizing the marketplaces? There are
some good ideas. The three Rs, what are you doing on those--
reinsurance, risk adjustment, risk--what are you doing there?
Secretary Price. We passed--we put in place a market
stabilization rule earlier this year that identified the
special enrollment periods and the grace periods to make
certain that they were more workable for both individuals and
for insurance companies.
We allowed the States greater flexibility in determining
what a qualified health plan was to try to provide greater
stability for the market. We put out word to all Governors
across this Nation on both 1115 and 1332 waivers with
suggestions regarding what they can do to allow for greater
market stabilization in their States.
And we look forward to working with you and other Senators
to try to make certain that all those individuals, not just in
the individual and small group market, but every single
American has the opportunity to gain access to the kind of
coverage that works for them and their families.
Senator Carper. Let me just mention Medicaid. When I came
to the Congress a long time ago before I was Governor, I used
to think that Medicaid was health-care coverage for mostly
women with children, poor women and children. You know where we
spend most of our money--you know this. Most of the money we
spend in Medicaid today is for old people, and they are in
nursing homes, and a bunch of them have dementia.
When we talk about cutting $800 billion out of the program,
it is not just the poor women and children who are going to get
hurt, it is those old people. And it is a lot of people between
the ages of 50 and 65 who are white males who are going to be--
so it is a lot of veterans. Their only hope and only chance of
getting, in some cases, access to medical care, because they
cannot get it--they do not qualify for VA coverage--is through
Medicaid.
The last thing I want to say is this. Mr. Chairman, here is
an idea. This is--I extend this idea with good intent. I spent
8 years as a Governor. I loved being a Governor. I love being a
part of the National Governors Association.
John Engler and I, Governor of Michigan, used to come here.
And here in the Ways and Means Committee in the House, we used
to testify on welfare reform. And we would say, these are the
views of the Governors, Democrat and Republican. This is what
we think we ought to do.
This is an issue that cries out for getting Governors to
sit at the table and say, here is how this is going to affect
us. This is the way the system works or why it does not work.
This is why we like the idea of per capita caps and why it does
not work.
That is what we ought to be doing. I must say, the 13 folks
who have been picked to help figure out a Republican
alternative to the House-passed mess--it would be a lot more
informative if we could have that kind of hearing. This is
fine. I am happy to see you, Dr. Price, but that is actually
something that might move us to a principle of compromise and
get things done. People want us to get stuff done, and the idea
that we are going to do it all Democrat or all Republican is
crazy.
Thank you for joining us.
Secretary Price. Mr. Chairman, if I may just comment on
that, because I think it is important for people to appreciate
the work that the Department is doing.
We met with the National Governors Association, met with
Governors on both sides of the aisle to try to solicit their
input in the kinds of suggestions that they would have
regarding 1115 and 1332 waivers, those that affect the Medicaid
program and the individual market. So we are doing all that we
can to try to make certain that States are able to address the
challenges.
Senator Carper. Dr. Price, just to be clear. When Barack
Obama left office--was it a perfect administration? No.
When he left office, there was an insurer in every county
of every State in this country. Thank you.
The Chairman. Senator Cardin?
Senator Cardin. Secretary Price, thank you very much.
I have heard your commitment to make sure that you will do
everything you can to help all people in this country get
access to quality health care. And that is something that we
all agree on; that is what we want to get done.
I want to get to some of the practical problems here. I was
in Federalsburg on Monday. It is closer to where Senator Carper
lives than where I live. It is on the Eastern Shore of
Maryland, Caroline County. It is a very rural community.
They do not have the same access to health-care providers
that we have in our urban centers. And I visited the
Federalsburg Elementary School Wellness Center, where we have
the Choptank qualified center that provides direct services to
our children within the elementary school.
And they are capable of doing that. This is, for many of
these children, their only real ability to get access to
primary care and to have someone who can check up on their
health. And Choptank is able to do that under current law. But
they tell me, as the legislation is passing from the House to
the Senate, that that direct reimbursement would be cut off.
They also told me that if they cannot continue their flows
through the Medicaid program, they will clearly not be able to
continue the services that they are providing today in Caroline
County.
So my question to you--I understand your commitment to help
all areas. Today our qualified centers are providing lifelines
in many communities. They rely upon creative ways to provide
care in rural areas, including within school settings. And they
depend greatly on the reduced numbers of uninsured and those
covered under the Medicaid program for comprehensive
reimbursement in order to be able to maintain their presence.
So how do we ensure that, as we go through this transition
that the administration is talking about, the children in
Caroline County are going to be able to continue to get their
health-care needs met?
Secretary Price. Well, I appreciate that, Senator. There
are significant challenges in the rural areas of our Nation for
the provision of health services, and those have been present
for a long, long time. And there is a strong commitment on the
part of our department, and certainly on the part of the
President, to make certain that rural health services are
available.
So whether it is through grants to the States, whether it
is through an opportunity for various health programs within
schools or elsewhere to make certain the children have the kind
of health care, and not just coverage, that they need, then we
are absolutely committed.
One of the things that our budget includes is something
called a New American Health Block Grant, which would provide
resources to States to do just this sort of thing, to make
certain that folks in rural areas of States have the
opportunity to gain the kind of coverage and care that they
need.
So I look forward to working with you to make certain that
we are able to make that happen.
Senator Cardin. The other area that I want to cover, you
and I talked about in my office during the confirmation
process, and I will bring it up again today. I want to know
about your commitment to deal with minority health and health
disparities.
We have separate agencies today to deal with it. We have an
institute at NIH. And as I go around and look at some of the
historic discriminations within our health care and recognize
that health care is not equally available, and our focus has
not been to all communities equally--and we are trying to
compensate for that today--I worry about what you are doing, in
Medicaid particularly.
Every minority community I go to, they mention to me
Medicaid, and that there is no capacity at the State level to
pick up the slack if the Federal Government withdraws its
commitment, either in the numbers of people who are covered or
in the benefits that are reimbursed.
So how do you square a commitment to continue down the path
to reduce minority health disparities in this country and, not
only the reduction in the bill that passed the House, but also
the President's budget with such a large cut in Medicaid?
Secretary Price. This is incredibly important, and I cannot
remember whether I mentioned it in this committee for my
confirmation hearing or in the other one, in the HELP
Committee. But the disparities and health outcomes are
absolutely unacceptable to all, because what we see is its--and
it is not just necessarily rural versus urban areas.
There are areas within urban centers--I know of one in
Atlanta where there is a zip code where the health outcomes,
the disparities, are absolutely astounding in terms of the
mortality that exists, the addiction that exists, the chronic
disease that exists. And that is not because of lack of
services close by, because it is in the center of the city. But
imagine, if you would, please, a system that allowed for the
Medicaid program in the State of Georgia to provide increasing
resources to that zip code to provide a case manager--if you
will--for every single individual in that zip code who has a
chronic disease within the Medicaid program. That is now not
possible. You cannot do that.
That is the kind of waiver, that is the kind of
partnership, that I think is so incredibly important to make it
so that we actually identify those folks who need greater
assistance if we are going to end the disparities that are out
there, which you and I both have a commitment to ending.
Senator Cardin. I am all for flexibility for the States. I
appreciate that, but I also know the pressures on State
budgets.
And I know in my State of Maryland, where our Governor and
legislature have been pretty aggressive in helping the Medicaid
population, they cannot pick up the slack. A waiver will not
give them what they need to be able to make that type of
commitment to underserved areas.
Thank you, Mr. Chairman.
The Chairman. Okay. Senator Casey?
Senator Casey. Thank you, Mr. Chairman.
Secretary Price, good to be with you this morning.
I want to start by referencing a letter that I and, I
guess, 14 other Senators sent to you recently about the House
bill H.R. 1628. But in particular, I wanted to reference the
Congressional Budget Office report that just came out on the
24th of May. Of course, this is a nonpartisan report by the
Congressional Budget Office assisted by the Joint Committee on
Taxation.
I just delivered to the table, next to you there, a copy of
the CBO report so you could go to the page. I direct your
attention to page 17 of the CBO report. On that page, the
following statement is set forth there: ``Medicaid enrollment
would be lower throughout the coming decade, culminating in 14
million fewer Medicaid enrollees by 2026,'' a reduction of
about 17 percent from current numbers.
It then references this chart which you will see on page 19
showing the numbers going down for Medicaid over that time
between 2018 and 2026, all bars going down.
I reference that in the context of what you said on CNN on
May 7th. I am quoting you now, and the transcript is right in
front of you. ``There are no cuts to the Medicaid program.''
That is what you said.
Do you still stand by that statement being made on CNN?
Secretary Price. The Medicaid program under the President's
budget would increase by----
Senator Casey. Secretary Price, ``yes'' or ``no''? You can
explain after that, but ``yes'' or ``no''? Do you stand by that
statement you made on May 7th on CNN?
Secretary Price. What I stand by is the statement that the
President's budget----
Senator Casey. Do you stand by that statement? That is a
very--I think there are eight words.
Secretary Price. What is the baseline?
Senator Casey. ``There are no cuts to the Medicaid
program.'' Do you stand by that statement?
Secretary Price. What is the baseline?
Senator Casey. I am not----
Secretary Price. If there are no cuts, it is relevant.
Senator Casey. You have the statement in front of you.
Secretary Price. Yes, I stand by that statement.
Senator Casey. Okay.
Secretary Price. It is relative to something.
Senator Casey. Go ahead. You can--go ahead.
Secretary Price. If the baseline is today's amount of money
being spent on Medicaid, the President's budget provides for an
increase, a CPI medical or CPI medical plus-one increase, in
Medicaid spending for the programs----
Senator Casey. Are you saying the statement in the CBO
report on page 17 is not accurate?
Secretary Price. I am saying that the statement that CBO
made does not include the constellation of activities within
the administration regarding how we would move forward on
health care.
Senator Casey. CBO says there will be 14 million fewer
Medicaid enrollees. So that is one.
Secretary Price. Do you have the CBO report on the ACA when
it was proposed in 2010, because what they said then----
Senator Casey. I am talking about the House Republican bill
that was passed. That is what we are talking about today.
Secretary Price. I am talking about what the CBO did,
because they had a similar graph about the number of
individuals who would be covered now, and in fact, they were--
--
Senator Casey. Let me direct your attention to the same CBO
report you have in front of you, page 13. On the top of that
page, it says the following; the introductory sentence is,
``The total deficit reduction includes the following amounts
shown in table 3 at the end of the document.'' The first bullet
under that is, ``A reduction of $834 billion in Federal outlays
for Medicaid.'' So do you still assert in light of that and in
light of the previous CBO statement--do you still assert that
there are no cuts to the Medicaid program? Do you stand by that
statement?
Secretary Price. Senator, as you understand, it depends----
Senator Casey. All I am asking you to do, Mr. Secretary, is
to tell us whether you stand by that statement or not.
Secretary Price. I stand by that statement.
Senator Casey. Okay.
Finally, let me go to a statement that was made in the CBO
report. Now I am going to page 19 and 20, which you have in
front of you. At the bottom of page 19, the following is set
forth: ``Under the act''--meaning under the Republican bill
passed in the House--``premiums for older people could be five
times larger than for those younger people in many States, but
the size of the tax credits for older people would only be
twice the size of credits for younger people. As a result''--
and here is the first bullet point--``for older people with
lower income, net premiums would be much larger than under
current law on average.''
Then it refers to table 5 at the end of the report. So I
ask you, in the context of another statement you made--now,
this is ``Meet the Press'' in March--March 12th. You said that
``nobody will be worse off financially as a result of the
bill.'' Do you stand by that statement?
Secretary Price. I do not believe that statement was in
reference to the bill. It was in reference to the health-care
plan that we have put forward, and I stand by that statement.
The Chairman. Senator, your time is up.
Senator Casey. Well, I hope that you focus more on, not
just the proposed reforms you talk about for Medicaid, but I
hope you focus on people like the 15 million Americans who get
Medicaid because they have a disability.
We are all for a discussion about making programs better.
But I think you should focus more intensively on those people
and be truthful when you are commenting about something as
important to American lives as the Medicaid program.
And I would argue, sir, you have been deliberately
misleading based upon those statements.
Secretary Price. Senator, with respect, that is precisely
what we are focusing on. The American people understand and
appreciate that the health-care system that we currently have,
for many of them, is not working. For many of them in the
Medicaid program, it is not working.
And what we are trying to do--and we would love to have
your support. What we are trying to do is to make certain that
we have a system that responds to the wishes and needs and the
health-care needs of all Americans.
Senator Casey. We all agree on that. But I think you have
to start being straight with people about what will happen.
These are major cuts. The CBO said it in more ways than
one. I think you should be truthful about that.
The Chairman. Senator McCaskill?
Senator McCaskill. Thank you, Mr. Chairman.
Let me start by saying, Mr. Chairman, that you and Senator
Grassley I have a great deal of respect and admiration for.
So my first question that I would make of the chair is,
will we have a hearing on the health-care proposal?
The Chairman. Will we?
Senator McCaskill. Yes.
The Chairman. We have already had one, but----
Senator McCaskill. No, I mean on the proposal that you are
planning to bring to the floor of the Senate for a vote. Will
there be a hearing?
The Chairman. Well, I do not know that there is going to be
another hearing, but we have invited you to participate and
give your ideas and----
Senator McCaskill. That is not true, Mr. Chairman. Let me
just say, I watched carefully all of the hearings that went on
on the Affordable Care Act. I was not a member of this
committee at the time, although I would have liked to have
been.
Senator Grassley was the ranking member. Dozens of
Republican amendments were offered and accepted in that hearing
process. And when you say that you are inviting us, and I heard
you, Mr. Secretary, just say, ``We would love your support.''
For what? We do not even know. We have no idea what is being
proposed.
There is a group of guys in a backroom somewhere who are
making these decisions. There are no hearings in the House.
I mean listen, this is hard to take, because I know we made
mistakes on the Affordable Care Act, Mr. Secretary. And one of
the criticisms we got over and over again was that the vote was
partisan. Well, you could not have a more partisan exercise
than what you are engaged in right now.
We are not even going to have a hearing on a bill that
impacts one-sixth of our economy. We are not going to have an
opportunity to offer a single amendment.
It is all being done with an eye to try to get it by with
50 votes and the Vice President. I am stunned that that is what
Leader McConnell would call ``regular order,'' which he
sanctimoniously said would be the order of the day when the
Republicans took the Senate over.
We are now so far from regular order that new members do
not even know what it looks like. And I know that does not make
you happy, Mr. Chairman or Senator Grassley, because you have
been in the Senate so long. You know the value of the hearing
process and the amendment process.
And even though the vote ended up being partisan, just as
yours will be, the amendment process was not. Both of you had
amendments that were put into that bill, as did other members
of this committee. I want that opportunity. Give me that
opportunity. Give me an opportunity to work with you. That is
what is so discouraging about this process.
So, Mr. Secretary, I want to ask you. There is a 27 year-
old young man who lives in Jefferson County, and he is finally
making enough money that he can do one or two things. He can
either buy a health insurance policy or he can buy a new
Harley. And which do you think he is going to buy?
Secretary Price. You tell me.
Senator McCaskill. I think he is going to buy the new
Harley, because he feels young and invincible. And he has
wanted a Harley his whole life.
He buys a new Harley. He lays it on the pavement on the
interstate. An 18-wheeler cuts him off, and he is life-flighted
to the hospital. Do you believe that hospital should treat him?
Secretary Price. Absolutely. We have an obligation to do
so.
Senator McCaskill. In America, we treat you whether you are
insured or not; correct?
Secretary Price. Yes, and there is a mandate that he buy
insurance right now.
Senator McCaskill. Okay, but you are going to do away with
that. So we are now----
Secretary Price. In your scenario, is it working?
Senator McCaskill. That is not my question. I am saying----
Secretary Price. It was my question.
Senator McCaskill. I am saying under your scenario, he does
not have to buy insurance. He buys the Harley, he is life-
flighted to the hospital. He has traumatic brain injuries, and
we deliver $3 million worth of care for him.
My simple question to you, Mr. Secretary, is, who pays for
it?
Secretary Price. Well, sadly it is spread among the entire
system, and frankly, nobody pays for it from the Federal
Government standpoint.
Senator McCaskill. Correct. So people pay for it.
Secretary Price. Or people provide the services without any
compensation whatsoever.
Senator McCaskill. Well, they have to make it work out at
the end of the year. So what the hospital does is, they call
the insurance company and they say, ``We had X amount of
uninsured care this year. We are going to have to raise your
prices for labor and delivery, or we are going to have to raise
your prices for an angioplasty.''
And then that insurance company calls the small business
down the road and says, ``I have bad news for you. We are going
to have to raise your premiums because the hospital is charging
us more, because we have to cover the uninsured care.''
Secretary Price. And in your State, premiums were up 145
percent between 2013 and 2017.
Senator McCaskill. That is not true.
Secretary Price. Yes, ma'am.
Senator McCaskill. No.
Secretary Price. We will be glad to show you the numbers.
Senator McCaskill. I will be glad to debate you on the
numbers. But the point is that when we add 24 million more
uninsured, who is going to pay the bills?
Secretary Price. Well, we will not be adding 24 million
uninsured.
Senator McCaskill. So you disagree with the CBO score?
Secretary Price. Absolutely.
Senator McCaskill. Okay.
But if there are any more uninsured, if anybody is kicked
off Medicaid, who pays those bills? I want to make sure
everybody understands, we are just passing along these costs to
people who have insurance policies.
Secretary Price. There are 20 million individuals in
America right now who do not have insurance under the current
system. That is a problem.
Senator McCaskill. I know, and we are paying their bills by
higher premiums.
Secretary Price. Exactly. And so what we are trying----
Senator McCaskill. So we are going to increase that and
create even more uninsured.
Secretary Price. On the contrary.
The Chairman. Okay. Okay. Your time is up.
Secretary Price. We are trying to decrease the number----
The Chairman. Senator Grassley has one question. He has
been waiting here patiently, and----
Senator McCaskill. Well, I was only over by 35 seconds, Mr.
Chairman. I think I did okay. [Laughter.]
The Chairman. You have done so much better than the rest of
your colleagues. I am very proud of you.
Senator Grassley?
Senator Grassley. Mr. Secretary, I only have one question,
because I have to run to another meeting. So I am going to ask
you this one question and then submit other questions for you
to answer in writing.
The Rural Community Hospital Demonstration program was
established in a bipartisan manner to protect patients' access
to health care. These hospitals are collectively called
``tweeners.''
Another bipartisan piece of legislation, the 21st Century
Cures Act, extended this program. The language was very, very
clear. The program was to be extended beginning on the date
immediately following the last day of the initial 5-year
period.
Despite this clear language, CMS proposes to begin
implementation of this extension on or after October 1, 2017.
This gap in implementation is inconsistent with congressional
intent, which requires a seamless extension of this critical
program. Furthermore, it is inconsistent with the way the
agency implemented the first 5-year extension of this program.
I have a bipartisan letter to Administrator Verma asking
her to look at the alternative payment timing that was included
in the proposed rule. I would like to submit the letter for the
record, Mr. Chairman.
The Chairman. Without objection.
[The letter appears in the appendix on p. 45.]
Senator Grassley. And by the way, you, Mr. Secretary, were
cc'd on this letter.
So, Dr. Price, a very simple question. I hope you can give
consideration to this request in this letter, because in
several States, many States, this is an issue, particularly
rural States. One of them is Alaska, as an example. I hope you
can help us make sure that we have a seamless implementation of
this program.
Secretary Price. Absolutely, Senator. And we will get back
with you, because my understanding in looking into this is that
the proposed rule was put out in April of this year and allowed
for rural hospitals to apply to this program, literally, as we
speak. I think the deadline was the latter part of May.
But we have a commitment to it, and it is so incredibly
important for rural areas. We will get back with you, and I
look forward to working with you on it.
Senator Grassley. Thank you.
I yield back my time.
The Chairman. Thank you.
Senator Brown?
Senator Brown. Thank you, Mr. Chairman.
Mr. Secretary, thank you for joining us.
You call the opioid epidemic a key public health priority,
and you highlight how this year's budget proposes a $50-million
increase in funding over previous levels, up to $811 million.
Eight hundred eleven million dollars might seem like a lot of
money, and it is. But do you know what is a bigger number? Nine
hundred thirty-nine million dollars--$939 million is the amount
of money one State, my home State of Ohio, spent on fighting
the opioid epidemic last year alone. Nine hundred thirty-nine
million dollars my State spent.
This chart came from the Ohio Department of Medicaid's
website, Republican Governor Kasich's website. In 2016, Ohio
invested $939 million in fighting this opioid epidemic.
Now, do you know where 70 percent of that total $939
million came from? Six hundred fifty million dollars came from
Medicaid, $650,200,000 came from Medicaid. Despite this
investment, despite Governor Kasich investing nearly $1 billion
in prevention, education, medication, assisted therapy, and
other treatment, eight people--if today is like most days--
eight people in my State will die from an opioid overdose. Four
thousand Ohioans died from overdoses last year. We are on track
to far exceed that number. In some counties, we have already
exceeded the number of the year before, and this is only June.
Forty-three people died in Cuyahoga County, the State's
largest or second-largest--it is really close now--county in
the State. Forty-three people since Memorial Day.
This epidemic continues to devastate communities in my
State. I know you know that. I agree with what you wrote in
your testimony: we are not winning this fight against this
epidemic.
But I am confident we would lose far more people, far more
lives, have far more families turned upside down, if we were
not spending this money, if Medicaid were not spending this
$650 million. Do not take my word for it. Two weeks ago, my
colleagues--both members of this committee--Senator Portman, my
Ohio friend, Republican, and Senator Carper, my Delaware
friend, Democrat, held an important hearing about this epidemic
to discuss proposals.
I want to quote from a couple of people. The witnesses on
the second panel of that hearing were a doctor and a police
chief from Newtown, OH, the most conservative part of our
State. He was the former head of drug control policy and
coroner from Cuyahoga County. Both voiced opposition to either
ending the Medicaid expansion or cutting the program.
The four experts brought by Senator Portman to his
committee all said, do not cut Medicaid--do not cut it and do
not end the expansion.
The Cuyahoga County coroner noted anything like Medicaid
expansion being eliminated that limits people's access to
health care--I cannot see any good coming from that in this
crisis, especially with the high rates of mortality. The police
chief from Newtown, OH, a little town near Cincinnati, he is on
the front lines of this fight. He said we should not be
decreasing Medicaid.
He talked about one of the programs that his teams are
doing in the Hamilton County area, signing people up for
Medicaid, then getting them into treatment. You sign them up
for Medicaid, then you get them into treatment.
Right now, 200,000 families in Ohio are getting opioid
addiction treatment who have insurance because of Medicaid. Yet
your administration continues to talk down, to criticize
Medicaid expansion and to suggest cuts in Medicaid.
He went on to say, taking away Medicaid would make this
fight even more difficult. I do not even want to imagine the
number of overdose deaths we would have had in Ohio if our
Republican Governor--I am proud of what he did, and he has
gotten a lot of criticism from President Trump, and a lot of
criticism from your party--had not expanded Medicaid to those
700,000 families.
The budget proposal your team put together cuts Medicaid by
$600 billion. That is in addition to the House ACA repeal which
cuts Medicaid by $800 billion. Medicaid covers one-third of all
substance abuse treatments in communities across Ohio. In Ohio
it covers 50 percent of all medication-assisted treatment.
You sit in front of us. You have taxpayer-funded health
insurance. We have taxpayer-funded health insurance. The 200-
plus Republican members of the House who have taxpayer-
subsidized health insurance are all willing to take it away
from these 200,000 Ohioans getting opioid treatment.
You say you are interested in fighting the opioid epidemic,
but your policy proposals tell a different story. You flat-fund
substance abuse treatment grants. You actually reduce spending
on prevention programs in the National Institute on Drug Abuse.
You cannot treat the disease with just grant funding. You
have all of a sudden found that we can do all kinds of things
with grants. No you cannot. Compare it to the size of this
problem. It is like, maybe you do not know many--but I do not
want to go there.
I think probably Senators do not meet enough people who are
in these programs and who are benefitting from them. But you
would never propose we fight cancer and pay cancer treatments
through a $50-million increase in a grant program.
You said in a recent op ed, and I appreciated it, in The
Charleston Gazette Mail that increasing access to substance-use
disorder treatment, including medication-assisted treatment, is
part of your department's plans to address the opioid crisis.
What you are not telling your West Virginia readers, Donald
Trump's second-best State in the country, you are not telling
them what you are really doing.
So my question is--sorry for the preface, but how do you
plan to increase access to treatment when you cut the single-
biggest source of funding for treatment by $600 billion in your
budget? How does that possibly add up in the Trump math, the
Trump-Price math of 2017?
Secretary Price. Yes, Senator, you know that I visited your
State, the southwest corner of your State, to visit with
victims of opioid addiction, the parents of kids who died. One
mom told me about her son who died in the bathroom of a Macy's
from an overdose.
The scourge that we have running across this country right
now is absolutely unacceptable to you. It is unacceptable to
me. It is unacceptable to the President.
Our commitment is to make certain that what we put in place
is a program that actually works. You have seen the graphs. The
numbers continue to go in the wrong direction.
So if we are going to be married to a system that has
resulted in 52,000 overdose deaths in 2015, that is not a
system I want to be married to. What I commit to you, and what
I look forward to working with you on is a system that actually
works for the parents who are suffering today because they have
lost a loved one. What I commit to working with you on is a
system that actually works for those who are addicted who want
to gain recovery and treatment. So that is the system that I
look forward to working with you on.
Whether or not it is paid for through the Medicaid system
or whether or not it is paid for through--imagine a system that
actually isolates the individuals' treatment for addiction and
takes it out of the current system that we have so that we can
focus resources on those individuals who have the addiction.
Imagine that kind of system, what that would do for (1) the
ability to treat those folks, but (2) the ability for the
system to actually thrive in a better way fiscally as well.
Imagine a system that works better than the one that
results in 52,000 Americans dying of overdoses.
Senator Brown. It is a little curious to blame Medicaid, as
you seem to be doing, for the system that has resulted in
50,000 deaths. It is not because of Medicaid.
I mean, how do you do this when 200,000 people right now
are getting treatment in my State? They are getting treatment.
They are not all successful. We know people are in and out, and
it often takes three, or four, or five times, but if you cut
Medicaid, as you want to bludgeon Medicaid, how are you--you
can talk about a grant program and all of this good talk, and I
know you mean it in terms of wanting to take care of people.
You are a physician. I know all of that, but how does this
possibly work if you are going to cut the biggest revenue
stream that takes care of these families and puts them in these
treatment programs?
The Chairman. I will allow you to answer that. You are way
over your time, Senator. Answer that, and then I am going to go
to Senator Cantwell.
Go ahead.
Secretary Price. That is what I am trying to encourage us
to look at, is a system that actually works for the individuals
who are suffering from this addiction, a system that actually
focuses attention and focuses treatment on it, a system that
recognizes that we need greater public health surveillance, a
system that recognizes that pain management in this Nation is
flawed, a system that has not put the kind of resources into
research so that we can turn this curve in an appropriate
direction, which is down.
We continue to tolerate a system that allows for these kind
of addiction and overdose deaths in this Nation. It is
unacceptable to me, and I will not stand for it.
The Chairman. Senator Cantwell?
Senator Cantwell. Thank you, Mr. Chairman.
Secretary Price, I have a couple of questions. There have
been press reports that the Department is working on a rule
that would deny birth control for employees. Are you aware of
this?
Secretary Price. There is a proposed rule that is out
currently on conscientious objection in the contraceptive
mandate.
Senator Cantwell. You are proposing that you will allow
employers to discriminate against woman in having birth control
be part of an insurance policy provided by employers?
Secretary Price. What is currently occurring is
solicitation of input, and in that process we are--I am not
able to make any further comment.
Senator Cantwell. You cannot make a comment whether you
think that birth control should be part of basic health offered
in insurance plans?
Secretary Price. I think that for women who desire birth
control, it ought to be available.
Senator Cantwell. Are you promulgating the rule?
Secretary Price. There is a proposed rule that has been put
forward.
Senator Cantwell. So you think that employers should offer
birth control as part of insurance programs, and not be able to
just say on a conscientious basis they do not believe in
providing it?
Secretary Price. No. I believe that women who desire to
have access to birth control ought to be able to have access to
birth control.
Senator Cantwell. Through their employer?
Secretary Price. I believe that women who desire to have
access to birth control ought to have access to birth control.
Senator Cantwell. Okay. This is a very big problem. Women
cannot be discriminated against by their employer who wants to
cherry-pick various aspects of women's health. So if this is
the intent of this rule, I guarantee you, there will be a big
fight on this issue.
I want to ask you about proposed Medicare cuts, because I
know the administration had said that they were not going to
cut Medicare, but my understanding is that the budget includes
a 2-year extension, a mandatory sequestration, which would
impose a 2-
percent cut on Medicare providers, such as hospitals and rural
hospitals. The extension of the mandatory sequester would be
about a $30-billion cut from the Medicare program. So does your
budget include that?
Secretary Price. I think that what you are referring to is
the continuation of current law, and the budget accommodates or
reflects current law.
Senator Cantwell. So you are saying that the extension of
the mandatory sequester is not a cut to Medicare?
Secretary Price. Again, it is the same kind of question
that Mr. Casey had. It depends what your baseline is. If your
baseline is current law, then there are no reductions.
Senator Cantwell. Okay. And so you believe we should be
making these reductions to rural health-care facilities?
Secretary Price. I believe that what we should do is make
sure we have a health-care system that is financially viable
and feasible and makes it so that the American people have
access to the kind of care that they need.
Senator Cantwell. And you are behind the cut--okay. I will
just take that as a ``yes,'' that you are behind this
particular cut. And I would just say that our rural hospitals
are struggling to make sure that we are providing good care.
There are lots of efficiencies with the delivery system. I
had a chance to ask you about this issue of rebalancing on the
Medicaid budget. I do not know if you have had more time to
look at that, to rebalance from nursing-home care to community-
based care. That is something that we wrote into the Affordable
Care Act that States are doing, and it is a huge savings to the
budget.
Is that something that you think the administration can get
further behind?
Secretary Price. Yes. As I mentioned in answer to a couple
other questions, the dynamism of the health-care market is so
important to embrace, because we ought to be allowing and
accommodating in our system for individuals to receive care
where it best suits them and their providers.
So you have identified an area where we ought to be able to
accommodate that, and the system should allow for it.
Senator Cantwell. Thank you, Mr. Chairman.
The Chairman. Thank you.
Senator Nelson?
Senator Nelson. Thank you, Mr. Chairman.
Good morning, Mr. Secretary.
Secretary Price. Good morning.
Senator Nelson. Mr. Secretary, I just want to ask you, for
clarification, about some things that are in the budget, in
your proposed budget.
Something that we have heard a lot about are the cost-
sharing reduction subsidies. Seventy-two percent of Florida's
Affordable Care Act consumers benefit from these, and that is
why I am asking.
Now, it is hard to get a clear answer on this. The private
market providers under the exchanges cannot take the
uncertainty of knowing whether or not the subsidies are going
to be there. Insurers have confirmed this to my questions, when
proposing rate hikes or even pulling out of the markets because
of the uncertainty.
So can you confirm that the administration will continue to
reimburse insurers for these subsidies that help so many of my
constituents see a doctor? I notice it is in your budget
through fiscal year 2018. What should we believe?
Secretary Price. Senator, as you know, the answer may not
prove satisfying to you, but the current court case is now
House v. Price, and so I am the defendant in that case. So what
I can tell you is just what you said, and that is that the
budget reflects the payment of the CSR payments through 2018.
Senator Nelson. So does that answer mean if the court case
went in the favor of the administration that, basically, those
subsidies would be cut?
Secretary Price. What I can tell you--and again, I would
like to be able to share more, but as the defendant in the
case, I am not able to do so. But I can tell you, as you noted,
that the budget accommodates and reflects CSR payments through
2018.
Senator Nelson. And the unfortunate dilemma is, Mr.
Chairman, that because of the uncertainty, it predicts an
outcome that--the ACA, the Affordable Care Act, is in the
exchanges which are bringing health insurance to millions and
millions of people who otherwise could not afford it. The
uncertainty of whether or not those subsidies will be there in
the future, in fact, is undermining the ability of insurers to
be able to project what their premiums are going to be and,
therefore, to protect themselves. What they are doing is
jacking up their premiums, which is undercutting the whole
reason for having the subsidies in the first place.
Let me shift to the Zika virus, Mr. Secretary. As we
discussed, you know there are a bunch of cases, 1,400 in
Florida alone. And your administration's 2018 budget states,
``Outbreaks like Zika will not be a onetime event. Capacity
building at all levels as well as innovation in diagnostics are
needed to prevent and control these outbreaks and understand
more about these vectors.''
Yet, the administration slashes the very programs designed
to bolster capacity at all levels. So, Mr. Secretary, does your
budget cut more than $7.2 billion from NIH?
Secretary Price. As it relates to Zika, I cannot tell you
how proud I am of the work that is being done at NIH to work on
a vaccine. We are in the phase 2-B trials of a vaccine.
The CDC is doing phenomenal work to make certain that the
surveillance and detection is out----
Senator Nelson. I understand all of that. Does the budget--
--
Secretary Price. We believe that the budget accommodates
for handling any challenge that may exist from the Zika threat.
Senator Nelson. I understand. But the question is, does it
cut $7.2 billion from NIH?
Secretary Price. The proposed budget identifies reductions
that we believe can be accomplished at NIH, and savings that
can be accomplished at NIH, by increasing efficiencies and
making certain that we have the core mission of NIH
accomplished through the resources that are made available.
Senator Nelson. Right. Efficiencies are great. But I just
want to know black or white, does it cut $7.2 billion from NIH?
Secretary Price. The reductions--I think your number is
accurate. It depends, again, what the baseline is, but I think
your neighbor is accurate.
Senator Nelson. Okay.
The Chairman. Okay.
Senator Bennet?
Senator Nelson. Wait a minute, Mr. Chairman. I have a
couple other questions, just simple ``yes'' or ``no''
questions. May I get----
The Chairman. Why don't you go ahead, but your time is up.
Senator Nelson. Well, I understand, but----
The Chairman. Go ahead. Go ahead.
Senator Nelson [continuing]. It is hard to get a ``yes'' or
``no'' answer.
The Chairman. Go ahead.
Senator Nelson. Thank you.
Does the budget cut more than $600 billion from the
Medicaid program on top of the cuts included in the House-
passed health care bill?
Secretary Price. No.
Senator Nelson. Your budget does not. Okay.
Does it cut more than $1.3 billion from the CDC?
Secretary Price. It is about a 10-percent reduction in
resources available to CDC through appropriate priorities and
identifying efficiencies within CDC. We believe strongly that
the CDC budget is what is needed to continue to protect, not
just the United States, but the world.
Senator Nelson. So is that a ``yes,'' it cuts $1.3 billion
from CDC?
Secretary Price. What it is is a statement that affirms the
President's desire to get folks to appreciate that you do not
measure success of a program by the amount of money that is
going into it. You measure it depending on whether or not the
outcome and the mission are accomplished.
And if we can accomplish the mission, the appropriate
mission of CDC, with less resources, then one would think that
that would be something to celebrate.
Senator Nelson. Mr. Chairman, I understand all the
reasoning behind it. I just want to know, does it cut $1.3
billion from CDC?
Secretary Price. As I said, there is about a 10-percent
reduction in resources going to CDC.
Senator Nelson. Does that equate to $1.3 billion?
Secretary Price. I think your number is accurate.
Senator Nelson. Great. Does it cut $850 million from the
Food and Drug Administration?
Secretary Price. I do not believe so. The FDA--what we
envision in the FDA is to shift the resources coming to FDA,
and I think, in fact, there is about a $500-million increase in
resources coming to the FDA through a modification and an
improvement in the user fee process.
The Chairman. Senator, you are way over your time. You can
submit questions in writing. I am sure the Secretary will
answer them.
Senator Bennet?
Senator Bennet. Thank you, Chairman Hatch. If it is okay
with you, I think I will yield to Senator Roberts who has been
here waiting. And then I would like to go after him, if that is
okay.
The Chairman. That is very gracious of you, because he has
been waiting.
So I will go to Senator Roberts, and then I will come back
to you.
Senator Roberts. Mr. Chairman, are we under the 10-minute
rule now, or 5, or 6, 7? What are we doing? I am assuming we
are under the 5-minute rule.
The Chairman. Right.
Senator Roberts. I want to get in the weeds a little bit.
Welcome back, Doctor.
Secretary Price. Thank you. It is good to be back.
Senator Roberts. There are statements that you are
responsible for people dying in Ohio, all of the current
problems in the Affordable Care Act for the last 8 years,
reductions in funding in rural areas--which of course, I am
very much interested in--the entire budget by the President, or
to be more accurate, OMB. And the chairman has been chided for
not having regular order where what we have in the Senate today
is called cloture and delay. That is not regular order. And
then I sort of lost my place--oh, the Zika virus--hindering
eradication of the Zika virus.
Are you enjoying yourself?
Secretary Price. The job is a great challenge, and I am
enjoying the challenge, yes, sir.
Senator Roberts. I am going to get in the weeds here a
little bit. In your prior life on this side of the witness
table, I know you shared my frustration with the implementation
of the competitive bidding program. I am not going to go too
much further into this, except we do not have the providers
that we used to have, and people are having to drive 150 miles
with regards to durable medical equipment and access to it.
Last year, we passed a 21st Century Cures Act. We sought to
reduce, at least temporarily, the impact of these payment
changes. So to preserve the intent of the program to improve
the effectiveness of payment amounts and reduce the beneficiary
costs, save the Medicare program money, do you think the agency
needs to provide additional regulatory changes to its
implementation and--what I am trying to do is get a sense of
whether legislation is needed.
Secretary Price. Legislation would be welcome that moved in
the direction of allowing the durable medical equipment
providers out there a greater opportunity to provide services
to their clients, to the patients across the land. Regardless
of whether legislation is forthcoming, the Department is
looking very seriously at the issue of DME, because we believe
strongly that the previous program that has been put in place
is limiting the access to appropriate services for folks all
across this land, especially in rural areas.
Senator Roberts. I appreciate that. I have been sitting
here listening to my friends across the aisle with regard to
their concerns with what is happening to our health-care
system. I had a question that could be repetitive. The chairman
is here somewhere, and you have talked about it, about what is
happening with our premiums and our copays--here it is. Blue
Cross Blue Shield of Kansas City announced they are pulling out
of Obamacare exchanges next year, leaving Kansas with less
options. In Kansas and nationwide, premiums have doubled; in
three States they have tripled.
And yet I hear my colleagues saying ``stay the course'' or
``full steam ahead,'' full funding, if, in fact, we could do
that--keep funding what is not working.
I must say that is 180 degrees from what has happened, and
trying to pin it on you is rather amazing. This is like blaming
Butch Cassidy and the Sundance Kid for jumping off the cliff.
Or to be more accurate, we are in the Obama car, and it is a
lot like being in the same car with Thelma and Louise, and we
are going into the canyon.
We have to get out of the car. I think that is what you are
trying to do. And I wish you well in that. I do not think you
are responsible for the entire budget that has been proposed by
OMB.
I am not really in favor of some of the things with regard
to agriculture. And we plan to change that. We hope to get a
budget. I do not know of any time the Senate has considered
seriously any budget that came from a President since Reagan.
And then this other business of regular order, with regard
to the chairman. I was here during that whole episode of when
we put Obamacare together, and days and nights, and days and
nights. It started in the HELP Committee. That product is
sitting on a shelf somewhere gathering dust.
I had one amendment. It was on rationing--you know what I
am talking about, with IPAB and all the rest of them. It failed
on a party-line vote.
And I came here. And again I had the same amendment on
rationing. It failed on a party-line vote. And then the product
went to the floor of the House and went behind closed doors in
the Leader's office--sort of like Charlie Rich, singing
``Behind closed doors.'' And out came Obamacare. And we have
had 8 years of this now, and I just think blaming you for all
of these deficiencies that we are trying to correct on a
bipartisan basis has been over the top.
And my time, sir, has expired.
The Chairman. Well, thank you. And I endorse what you just
said.
Senator Bennet?
Senator Bennet. Thank you, Mr. Chairman. I really am
grateful for you holding this hearing.
Mr. Secretary, it is great to see you again.
Secretary Price. Good to see you.
Senator Bennett. I want to start just by understanding the
Medicaid cuts, or however you want to characterize them. But
the numbers as I understand them are that there is about $834
billion of cuts in the House bill, the House health-care bill.
And there is about $610 billion in savings or cuts to the
Medicaid program in the budget. Is it right to add those
numbers together, or is there overlap among those numbers? I
just want to make sure we are accurate.
Secretary Price. I do not believe it is correct to add
those numbers together. My understanding is the budget does not
assume passage of the House bill.
Senator Bennet. My understanding is that it absolutely does
assume passage of the House bill.
Secretary Price. It assumes as it relates to Medicaid.
Senator Bennet. Yes.
Secretary Price. It assumes that what is put in place is a
per-cap or a block-grant program that will reflect over a 10-
year period of time a savings of $610 billion.
Senator Bennet. Okay. If we could work together, I would
appreciate the opportunity to work with your staff to see
whether in the end we are talking about $834 billion or $1.4
trillion. In either case, it is a huge cut to the Medicaid
program. I mean, even if it is just $834 billion, I think that
is a 25-percent cut to Medicaid.
I would ask you--I asked the Governor's office in Colorado
to tell me who is on Medicaid in my State. And here is what
they said, and I would like to ask you whether you dispute any
of this.
They said that when you look at who is on Medicaid in
Colorado, nearly half the program are children. Does that
strike you as probably right?
Secretary Price. That is in the ballpark for most States.
Senator Bennet. And more than 40 percent of our Medicaid
spending supports the disabled and seniors, many of whom are in
long-term care facilities. So these are people in general who
have spent down their life savings for the privilege of being
in a nursing home funded by Medicaid. Would you agree that that
is right?
Secretary Price. It sounds a little higher than most
States, but I think it is in the ballpark.
Senator Bennet. Rough justice.
And they say of the remaining adults on Medicaid, the vast
majority work but still cannot afford health insurance on their
own. Does that sound familiar to you in terms of Colorado or
other States?
Secretary Price. There are certainly individuals who have
Medicaid coverage who are employed.
Senator Bennet. Well, what they would say is, there is a
tiny residual percentage of people who are not disabled, are
not elderly, are not children, and do not work, but are on
Medicaid. There is some small percentage of such people. Is
Colorado different from other States, or do you think that is--
--
Secretary Price. We can get you the numbers for your State,
I am sure.
Senator Bennet. That would be great, but do you see any
reason to dispute what I just said?
Secretary Price. I suspect that is----
Senator Bennet. So here we have the Secretary--and I
appreciate your candor--saying that Medicaid is not supporting
a whole bunch of people who should be working and are not
working. Would you agree with that?
Secretary Price. I think it varies from State to State.
There are certainly individuals who are able-bodied without
kids on Medicaid who are not working.
Senator Bennet. But that is a very small percentage of the
people. I do not want to have to walk back through the list. I
mean, I think we have agreed that that is a very small
percentage.
So I think it is important, because this is the Secretary
of Health and Human Services, and he is not saying there are a
whole bunch of Americans out there who are lazy, who are on
Medicaid because they do not want to work. It does not comport
with the evidence. It is not true, and it certainly is not true
in my State.
So the question then becomes, if we are going to cut the
program by 25 percent, if you were running Colorado's Medicaid
program--and I have a story that I will share with your staff
from The Denver Post yesterday or the day before, a front-page
story about the $700 million a year by 2023 that the State is
going to have to come up with to compensate for the withdrawal
of the Federal Government, the Medicaid reductions that are in
just the House-passed bill, not your budget, but the House-
passed bill.
What is your advice to us in our State about how we ought
to handle those cuts, that $700 million to our State? When 40
percent of the people on the program are poor children, when
you have a whole bunch of people who are in nursing homes, when
you have a whole bunch of people who are working but
unfortunately cannot afford private insurance, what is my State
supposed to do?
Secretary Price. I think, again, the constellation of
programs that we would envision would provide for greater
opportunity for individuals to get health coverage as opposed
to less right now. I would remind folks that, again, there are
20 million Americans without health coverage. I do not know
what the number, specifically, is in Colorado, but there is a
significant number of individuals who do not have health
coverage.
What we would envision is a system that actually responds
to those folks and individuals who find that it is better for
them not to be covered on the Medicaid system, but on a system
that actually is more responsive to them.
Senator Bennet. My time is up. And with respect--and I do
respect you a lot for your service in the House and the fact
that you are a doctor--to believe what you just said, you would
have to first reject the findings of the Congressional Budget
Office that the House bill throws 23 million off insurance,
that it creates 23 million more people who do not have
insurance. You would have to believe that, and you would have
to believe that, despite a 25-percent cut to Medicaid, which
covers poor children, people in nursing homes, people who are
already working and cannot afford insurance are somehow
magically going to be able to buy health insurance under a
system that no longer regulates the insurance industry.
That is what we are being asked to believe. And I can tell
you this, Mr. Secretary and Mr. Chairman--because the
Republicans in the Senate have not yet taken up the bill, and I
hope that we will--if you set out to design a bill less
responsive to the critics of Obamacare in Colorado, to
Republican critics of Obamacare, you could not write a bill
less responsive than the House bill.
So my hope is that--in the Senate you could not do it. My
hope is that in the Senate, we will not do this in a partisan
way, but we will come together as Democrats and Republicans and
address the health-care system in a way that is actually
believable to the people whom I represent.
What you just have said is just not believable in any
respect to people at home, and I am talking about Republicans,
to say nothing of Democrats or Independents.
The Chairman. Thank you, Senator.
Senator Heller?
Senator Heller. Mr. Chairman, thank you.
Secretary Price----
Secretary Price. Senator, how are you?
Senator Heller. Thanks for taking time and taking some of
our questions. I want to talk a little bit about Nevada and the
AHCA, obviously; that seems to be the topic of discussion here.
Our legislature just finished Monday. So as of 2 or 3 days
ago, it adjourned for the next 2 years. One of the questions
and comments that is being made is that if the AHCA in its
current form, what came out of the House, were to pass, then it
would put a $250-million annual hole in Nevada's budget.
And these numbers and indications, I am getting out of the
Governor's office also, from the State of Nevada. I would like
your reflection on that. If it is $250 million a year, that is
$500 million during a biennium, and we do not go back into
session, obviously, for another couple of years. Their concern
is that they will have to call a special session, obviously, in
order to correct that kind of a budget offset.
Do those figures sound accurate to you?
Secretary Price. I do not think so, because--and again, the
House bill does not, as I understand it, it does not anticipate
any significant changes until 2019. So from a financing
standpoint, 2020 would be the time when the majority of changes
would come into play.
So we would be happy to review the genesis of those numbers
and see whether or not they are accurate, and if so, how we can
address that.
Senator Heller. Have you had an opportunity to do some
research on Nevada? The reason I ask you this question is
because we had a member of our delegation on the House who said
that--he had a conversation with you and the Director of CMS.
Between the two of you, you were able to convince him that
these numbers, perhaps, are not as accurate or as dreadful as
they come out of the Governor's office.
Secretary Price. That is correct.
Senator Heller. What kind of reflection did you have? Do
you recall what kind of conversation you had?
Secretary Price. Yes, in fact, I think that there was
specific language that accommodated that concern. Which is why
I say I do not believe that any changes would occur over the
ensuing 2 years. But again, we would be happy to talk with you
and work with you and the Governor and your State to see where
they believe those numbers are coming from and determine their
accuracy.
Senator Heller. What do you anticipate being the growth
rate of health-care costs over the next 10 years? What have you
calculated?
Secretary Price. It depends what population you are talking
about. The Medicaid population annual growth rate has been in
the range of 2.6, 2.8 as I recall, annually.
Senator Heller. That is historic. What do you guys
anticipate over the next 10 years?
Secretary Price. I can get back to you on the specific
amount. I think it is increasing a little bit, but I can get
you the exact number. I do not have it on----
Senator Heller. Are you working with leadership on our side
as we go through the changes? I am going to guess that
leadership on our side has had discussions with you, CMS, on
some of the particular changes we are looking at.
In other words, it is including growth rates. I do not know
what the growth rate is going to be, if it is going to be CPI
medical plus one, as they did in the AHCA, whether it is just
CPI medical, or inflation for that matter.
Have you had any discussions? I am trying to find an answer
to this question, and I cannot get it out of our meetings. I
was just wondering if you had any insight as to what the rate
may be that we are proposing over the next couple of weeks to
send to CBO?
Secretary Price. Well, as it relates to Medicaid, the
proposal within the budget is the CPI medical plus one for
those aged and disabled, CPI medical for the others.
Senator Heller. Do you still endorse that?
Secretary Price. That is what is accommodated in the
budget.
Senator Heller. If it was anything below that, would you
support it? In other words, if they went to inflation rate,
would you support that?
Secretary Price. I think it depends what the entire program
looks like. If we are accommodating anybody who would have
challenges with that in a supplemental manner, if you will,
then I would have to look at that. But what I support, and what
I think is important, is to make certain that every single
American has access to the coverage that they need.
Senator Heller. CPI plus one you said is for the disabled?
Secretary Price. CPI medical plus one.
Senator Heller. For disability, and what was the other----
Secretary Price. Aged.
Senator Heller. Now if that were to change, just to CPI
medical or just inflation, would you oppose that?
Secretary Price. As I said, it depends what the entire
program looks like. In isolation, I think that might be a
challenge.
But that does not address what the entire constellation of
whatever the program is, because there are other ways to
accommodate individuals who need financial assistance. And we
are committed to making certain that that happens.
Senator Heller. Over the next 10 years, what is the rate
increase overall then? What is the rate increase overall, over
the next 10 years?
Secretary Price. We will get that to you. I do not have it
on the tip of my tongue.
Senator Heller. If it is below that, would you have a
problem with it? In other words, we figure it out, you tell me
what it is, and if we have a proposal that is less than that,
would you oppose it?
Secretary Price. I think what is important in this
conversation is to make certain that we accomplish the goals
that we have set out, and that is to make certain that every
single American has access to the coverage that they want. And
when you have that as your goal, then it requires that you
provide resources in an array of different ways to make certain
that that is accomplished.
Senator Heller. I just want to make sure with medical
inflation, as it increases over the next 10 years, that the
funding mechanism we have is not below that, because if it is,
then we do not meet your goals.
Secretary Price. In insolation, I would agree.
Senator Heller. Okay. Thank you.
Thank you, Mr. Chairman.
The Chairman. Your time is up.
Senator Thune?
Senator Thune. Thank you, Mr. Chairman.
Secretary Price, thanks for being here today. I appreciate
the budget's attention to the need to repeal and replace the
collapsing Affordable Care Act, the need for medical liability
reform, as well as the budget program's integrity provisions.
We have a number of important issues to tackle in the health-
care space. So again, I thank you for your work.
Secretary Price. Thank you.
Senator Thune. I want to--I discussed this with you at your
confirmation hearing, but I have serious concerns, I think as
you know, about the Indian Health Service. We continue to see
significant problems even after two IHS facilities in South
Dakota entered the systems improvement agreement with the
Center for Medicare and Medicaid Services.
CMS continues to find serious deficiencies at both
facilities, with the Pine Ridge emergency department in
immediate jeopardy status after a recent unannounced site visit
from CMS. These systemic problems over the years are what
prompted Senators Barrasso, Hoeven, and I to introduce the
Restoring Accountability in the IHS Act.
The bill will give IHS the flexibility to terminate poorly
performing employees, streamline the hiring process so IHS can
recruit talented medical professionals more quickly, and create
incentives so those folks will stay on the job longer.
My question is, will the Department commit to working with
us on this legislation and other reforms to improve the quality
of care at IHS?
Secretary Price. Absolutely, Senator. I have been impressed
with the commitment of individuals in IHS and the resources
that we are trying to identify for new facilities, one of
them--as you know, in South Dakota--to make sure that we are
living up to our responsibility and the commitment that we have
as a Nation in the IHS arena.
Senator Thune. We would love to give you more tools to
create the kind of accountability we need, and I think our
legislation accomplishes that, so we would look forward to
working with you on that.
Last year you and I both worked on legislation to address
the application of Medicare competitive bidding rates and
noncompetitively bid areas. Ultimately, the 21st Century Cures
Act provided a temporary delay in this reimbursement change and
required the Department to study and report to the committees
of jurisdiction on how payment adjustments affect beneficiary
access. And that was supposed to have been done by January 12th
of this year.
I am just wondering if you could provide an update on the
status of that report for the committee?
Secretary Price. Yes. I think it remains in process, and we
have a significant commitment to make certain that the DME
program is functional and works for folks all across this land,
especially in the rural areas.
Senator Thune. And I guess I would say additionally, as you
discuss regulatory relief--which I know is the priority for the
administration, something that we very much agree with--what
might the Department's approach be for addressing these
beneficiary access challenges that are posed by the current
reimbursement structure? Is there something you could do in the
interim that would help bring some relief?
Secretary Price. Absolutely. You cannot have a system that
awards--as you well know--contracts to entities that have never
provided services in a geographic area. And that is the system
that we currently have, one that awards contracts to servicers
or providers that have never demonstrated the capability to
provide that service. And sadly, that is the system that we
have in place right now.
So what we are looking at is the entire array of the DME
system. And again, the goal is to make certain that all
Americans, regardless of where they live, have access to the
kind of services, whether it is hospital beds, whether it is
wheelchairs, whether it is home oxygen, whatever it may be in
the DME space--these are quality of life issues for so many,
many people. From my perspective, we have failed to date in
making certain that we ensure the kind of accessibility that
folks need.
Senator Thune. Yes; thank you.
And finally, during your confirmation hearing, we discussed
CMS's 2009 rule requiring that all outpatient therapeutic
services be provided under direct supervision, which has been
delayed annually since then for small and rural hospitals. You
expressed an interest in working with me on a permanent
extension of the non-enforcement of this policy.
I am wondering if you have an update on where things stand
from the Department's perspective? I think the permanent non-
enforcement is part of a bill that we have out there, and we
have been trying--we can sort of kick the stone down the road
each year, but I am hoping that we can get a permanent solution
somewhere. Could you tell us where you see things from your
department's standpoint?
Secretary Price. Senator, it is an area of significant
interest, and I can tell you that it is a work in progress.
Senator Thune. All right. Well, we hope that we can get
some permanent relief there, and we look forward to working
with you and your team on that going forward.
Thank you, Mr. Chairman.
Secretary Price. Yes, sir. Thank you, Senator.
The Chairman. Thank you, Senator Thune.
Senator Stabenow has a question or two, and we will wrap
this up.
Senator Stabenow. Well, thank you, Mr. Chairman. First I
want to thank you for your courtesies this morning in allowing
us to have thorough opportunities to ask questions.
And Secretary Price, again, thank you for being here. There
are so many issues that I continue to have great concerns
about, and certainly when we look at this budget that in
practicality cuts Medicaid, nursing home services, children's
health care, rural health care, research on lifesaving drugs--I
could go on and on.
But one type of cut that I know we need is not in this
budget, and that is a cut in the costs of prescription drugs.
President Trump repeatedly stated he wanted to drastically
bring down prescription drug prices through Medicare
negotiation, saying pharmaceutical companies were getting away
with murder.
I support Medicare negotiation. I have for a long time, and
90 percent of Americans support that. But this budget does not
include any major proposals to bring down the cost of
prescription drugs, whether it is Medicare negotiating, safe
importation of prescription drugs, transparency, or any other
policy for that matter, even though the prices of the most
popular drugs have increased by 208 percent--208 percent in the
last 10 years.
However, the House Republican health care plan, and I
assume the Senate one, that is proposed does give drug
companies a huge $25-billion tax cut paid for by the people who
are seeing their prescription drug prices go up: middle-class
families and seniors.
Given that this budget is the major policy document from
the administration, is it fair to say that lowering
prescription drug prices is no longer a priority?
Secretary Price. No, absolutely not, Senator. In fact, we
have, at the Department--the President has made this an
absolute priority and has charged us with making
recommendations to his office on reducing drug prices.
And over the past 6 weeks, 8 weeks, we have had a half-
dozen to eight stakeholder meetings with all sorts of
individuals. We have charged HRSA and FDA and CMS with coming
up with specific proposals to make certain that we can provide
the President with the most effective way to be able to reduce
the increase in drug prices.
So, no. It is an absolute priority, and we look forward to
working with anybody who is interested in holding down or
bringing down drug prices for the American people.
Senator Stabenow. Should a family have to pay $700 for
EpiPens for their child?
Secretary Price. Well, regarding EpiPen, what has occurred
in the past is that the ability for competition to hold down
those prices, or to bring down those prices, was prevented by a
previous decision through the previous administration. So we
are looking, through the FDA, at exactly those kinds of things,
because our goal is to make certain that the American people
have access to the kind of medication that they need at a price
that they can afford.
Senator Stabenow. Which I wish was in this budget, because
it is not in the budget at this point. But should someone who
learns they have Hepatitis C have to pay $80,000 to get the
drug they need to be cured?
Secretary Price. Well, you are identifying a drug that is
saving lives.
Senator Stabenow. Eighty thousand dollars in order for
someone to have the opportunity to save their life?
Secretary Price. The question is, what is the right price
for that drug?
Senator Stabenow. Is that the right price?
Secretary Price. There is a way to determine that price.
And the question is, what is the right price for that, and how
do we make certain that we incentivize innovation, and make it
so that, in fact, companies are able to identify these
remarkable cures that are out there?
I do not know what the right price is, but I know how you
figure out what the right price is.
Senator Stabenow. Okay. Well, I will be anxious to know
what you think the right price is.
If you have cystic fibrosis and need the latest drug to
improve lung function, should you have to pay $300,000?
Secretary Price. No. What I think we ought to be doing is
celebrating the incredible invention and work that individuals
are doing to save lives in the area of cystic fibrosis.
Senator Stabenow. I celebrate that. It is difficult if
someone cannot afford what is put forward on the market. So we
certainly celebrate innovation. That innovation needs to be
affordable so that people actually have access to treatment
that can save their life.
Secretary Price. I would agree.
Senator Stabenow. Is it appropriate to give pharmaceutical
companies a $25-billion tax cut in the health-care reform bill
when there is nothing to bring down the cost of prescription
drugs in that bill?
Secretary Price. Well, regarding what is in that bill as it
relates to drug pricing, I am not sure that----
Senator Stabenow. I am talking about the tax cut. Do you
think it is appropriate to give a $25-billion tax cut to the
pharmaceutical industry in a bill that is actually taking away
health care from people and does nothing about lowering the
cost of prescription drugs?
Secretary Price. I do not know that that is what it does.
What I am--what I do believe----
Senator Stabenow. I do know that is what it does.
Secretary Price. Well, then you do. What I do believe is
that it is imperative that we have a system in place that
incentivizes innovation so that we can realize the remarkable,
remarkable productivity and entrepreneurship and innovative
spirit of the American scientists at NIH and elsewhere who are
discovering these wonderful kinds of drugs to save lives.
Senator Stabenow. Well, I totally agree with that. Do you
think that the industry should be spending more on R&D today
than they spend on advertising drugs to us?
Secretary Price. I think that, again, the system needs to
be such that it incentivizes innovation so that we can realize
the benefit of wonderful inventions.
Senator Stabenow. Okay.
Well, just for the record, all those ads are written off,
and we pay for them as taxpayers. I would love to be helping
them write off much more on R&D.
Mr. Chairman, as I close, let me just say for the record--
we do not have to debate it today--but, Mr. Secretary, you have
talked about a study, over and over again, about prices. And I
just want for the record to say, this is a highly disputed
study that you have been talking about that compares two
different kinds of systems, does not include the tax credits
that have substantially brought down out-of-pocket costs for
real people.
And so another day I look forward to debating with you what
I believe and what I know, in Michigan, are very flawed
numbers.
Thank you, Mr. Chairman.
The Chairman. Well, thank you.
Let me just say that I have been in this health-care
business for 41 years. And every year we demand more and more
money, more and more spending, more and more Federal
Government, more and more interference, more and more
intrusion, and we wonder why it costs us so much.
Now all I can say is, we have never had a better Secretary
than you.
Secretary Price. Thank you.
The Chairman. Nor have we had anybody more patient in
answering all of these questions. Now I want to thank you for
participating the way you have. I especially want to thank you,
Secretary Price, for attending today. I think we can all agree
this is certainly not the most enjoyable activity that you
could have participated in today. But it is nevertheless
extremely important, and my colleagues have extremely important
questions that they have asked.
As I have said many times before, I would like to work with
anyone, Republican or Democrat, who would like to resolve these
important and pressing issues. Health care is no joke to any
American, and to those with diminishing access, it means the
world.
So I look forward to hearing from each of you in the coming
weeks, and I hope we can find ways to work together.
Now for any of my colleagues who have written questions for
the record, I ask that they submit them by June 15th----
Senator Stabenow. I am sorry. I do not mean to interrupt,
but Senator Carper----
The Chairman. Oh, no, I am not going to--this is going to
have to be it. I do not have any more time.
Do you have to ask questions, Senator?
Senator Carper. I have only been waiting for 2 hours, Mr.
Chairman. That is okay.
The Chairman. Well, you used 10 minutes before----
Senator Carper. Well, 9.
The Chairman. Excuse me?
Senator Carper. Nine. [Laughter.]
The Chairman. Well, you can----
Senator Carper. He came in large part so he could answer
one of my questions--it is not really a question. I just want
to say one thing if I could. It will be very, very brief.
The Chairman. Sure.
Senator Carper. Mr. Chairman, I mentioned earlier that my
colleagues get tired, Dr. Price, of hearing me describe myself
as a recovering Governor, but I am. And I have enjoyed as a
Governor sitting right where you are sitting, past Governor,
and trying to provide a Governor's perspective on issues just
like this one--just like this one.
And one of the things we asked for--John Engler and I asked
for for welfare reform--we said, give us the opportunity to
have waivers. You guys pass the law, but give us the
opportunity to apply for a waiver on what we are going to do on
welfare reform. And that was granted.
We asked for, when we did the Race to the Top, the
education reform stuff in the last administration, we said,
well, let us make sure the States can apply for waivers to the
Federal law. And we do.
And as it turns out with Medicaid, if I am not mistaken,
States can apply for waivers. I think almost every State, maybe
every State, has at least one or more waivers with Medicaid.
There are some cases in the law where you cannot get a
waiver, States cannot get a waiver. I think we ought to have a
good discussion with Governors about whether that makes sense
or whether there should be some further broadening with respect
to waivers.
As Governor, I always liked to have some flexibility, find
out what works best in my State and maybe well in others, maybe
not. But I think that could be a helpful thing to do.
The other thing I want to ask for--just a UC request, Mr.
Chairman--I have something here from Blue Cross Blue Shield of
North Carolina, ``Premiums to rise in 2018 for Affordable Care
Act.'' They say it in quotes. I will say just one sentence.
``The single biggest reason''--this is Blue Cross Blue Shield,
North Carolina--``the single biggest reason for the sharp
increase in rates is lack''--again in the exchanges--``of
Federal funding for cost-sharing reductions beginning in
2018.''
This is the program we have been talking about earlier. In
the administration's budget, to their credit, they fund cost
sharing. The President keeps talking it back in his tweets and
other things. He is opposed to it, does not want to do this,
raising questions. It is the questions, it is the lack of
certainty, predictability for the insurance companies that
drives up the prices, and so let us just keep that in mind.
The Chairman. Well, thank you, Senator. You always add a
great deal of understanding to these issues, and I appreciate
you doing that.
Senator Carper. In that case, could I have a couple more
minutes, Mr. Chair? [Laughter.]
The Chairman. No. I am going to kill you if you keep this
up. [Laughter.]
Senator Carper. I would die happy.
The Chairman. No; I think you are doing a great job.
Mr. Secretary, you have been very patient, and I personally
really admire you. I know you know this field very, very well.
I know you know the problems. I know you know how difficult it
is to solve these problems, and I know you know that there are
no quick answers to some of these questions that have been
asked.
You have handled these very well today, and I just want to
personally thank you.
With that, we will adjourn this meeting.
Secretary Price. Thank you, Mr. Chairman.
Senator Stabenow. Thank you, Mr. Chairman.
[Whereupon, at 12:06 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Letter Submitted by Hon. Chuck Grassley,
a U.S. Senator From Iowa
Congress of the United States
Washington, DC 20515
May 19, 2017
The Honorable Seema Verma
Administrator
Centers for Medicare and Medicaid Services
200 Independence Avenue, SW
Washington, DC 20201
RE: Rural Community Hospital, IPPS Proposed Rule (CMS-1677-P)
Dear Administrator Verma:
The Centers for Medicare and Medicaid Services (CMS) is conducting the
Rural Community Hospital Demonstration Program (RCH), which was
initiated by the Medicare Modernization Act of 2003 (MMA). The RCH was
extended under the Affordable Care Act (ACA) and most recently under
section 15003 of the 21st Century Cures Act. Congress directed CMS to
create this program in response to the financial concerns of small
rural hospitals.
As you know, the goal of the program is to evaluate cost based
reimbursement for small rural hospitals with fewer than 51 beds. Each
year since 2004, CMS has reported on the progress of this program.
Eligibility is based on States with the lowest population densities and
currently includes: Alaska, Arizona, Arkansas, Colorado, Idaho, Iowa,
Kansas, Maine, Minnesota, Mississippi, Montana, Nebraska, New Mexico,
North Dakota, Oklahoma, Oregon, South Dakota, Utah, and Wyoming.
Section 15003 of the 21st Century Cures Act extended the duration of
this program by changing the language in the ACA from ``5 years'' to
``10 years,'' beginning on the date immediately following the last day
of the initial 5-year period. Despite this language, CMS proposes to
begin implementation of this extension on a hospital's first cost
reporting period beginning on or after October 1, 2017, following the
announcement of the selection of additional hospitals to the RCH. This
will result in a gap in the reasonable cost payment methodology paid to
hospitals that previously participated in the program of up to 3 years.
In the proposed rule, CMS recognized the problem this gap creates for
previously participating hospitals and an alternative approach was
proposed. In that proposal, previously participating hospitals would
begin the second 5 years of the 10-year extension period and the cost-
based payment methodology on the date immediately after the date the
period of performance under the first 5-year extension period ended.
For example, a hospital whose 5-year period of performance authorized
by ACA ended June 30, 2016, the extension of the period under section
15003 of Pub. L. 114-255 would be effective July 1, 2016. In the
proposed rule, CMS states ``we believe that this alternative approach
would be consistent with the language of section 410A of Pub. L. 108-
173 (as amended) . . .'' and we concur. We strongly encourage you to
consider congressional intent as you finalize the rule.
The RCH program has been a lifeline for certain rural hospitals at risk
of closure. Since 2010, more than 60 rural hospitals have closed
nationwide. According to a report by iVantage Health, 673 more rural
hospitals are at risk of closure.
For one rural hospital in Iowa, the delay in implementation of the
extension will result in a loss of $1.1 million dollars. A second rural
hospital will lose nearly $5 million. These rural hospitals operate on
minimal margins and will not be able to keep the doors open if those
losses continue. This will greatly impact the ability of Iowans to
receive medical care in a timely manner.
One of the regional hospitals in Juneau, Alaska faces nearly $5 million
in projected losses due to delay. The hospital is located in a
geographically isolated area and has limited ability to take advantage
of economies of scale due to a small population base, making programs
like RCH critical to the hospital's success. The citizens that benefit
from this hospital come from communities throughout Southeast Alaska by
boat or plane and would be forced to travel even farther from home to
receive care otherwise.
This gap in implementation is inconsistent with congressional intent,
which requires a seamless extension of this critical program. It is
also inconsistent with the way the agency implemented the first 5-year
extension of this program. Most importantly, however, this proposal
would cause financial hardship for many of the hospitals that have been
participating in the RCH. As a result, we are concerned these hospitals
will be forced to reduce or eliminate the services they offer to their
communities, thereby further threatening access to health-care services
for individuals living in these rural communities.
As the sponsors of the Rural Community Hospital Demonstration Extension
Act of 2015--the basis for section 15003 of the 21st Century Cures
Act--we encourage you to address this issue expeditiously and provide
certainty to the previously participating hospitals as well as the new
enrollees.
Sincerely,
Charles E. Grassley Joni Ernst
United States Senator United States Senator
Lisa Murkowski Dan Sullivan
United States Senator United States Senator
Michael Bennet Don Young
United States Senator Member of Congress
David Young Dave Loebsack
Member of Congress Member of Congress
Rod Blum Steve King
Member of Congress Member of Congress
cc: Secretary Tom Price, Department of Health and Human Services
______
Prepared Statement of Hon. Orrin G. Hatch,
a U.S. Senator From Utah
WASHINGTON--Senate Finance Committee Chairman Orrin Hatch (R-Utah)
today delivered the following opening statement at a hearing examining
the Trump administration's fiscal year (FY) 2018 budget request for the
Department of Health and Human Services (HHS):
Welcome to this morning's hearing on the President's proposed
budget for fiscal year 2018, with specific attention to the Department
of Health and Human Services.
I want to thank Secretary Price for being here. These hearings are
an annual event for the Finance Committee. And, Secretary Price, since
this is your first time around, I'll just warn you that these hearings
can be a little grueling.
Of course, you already know that.
I am grateful that the President and HHS are eager to work with
Congress to fix our health-care system in order to ensure Americans are
able to access affordable health coverage. And, as we know, time is of
essence in regard to this effort.
Earlier this week, we received word that Anthem is pulling out of
Ohio's Obamacare marketplace, potentially leaving more than 10,000
patients and consumers in 20 counties without any insurance options on
Ohio's exchange for 2018. This news is particularly frightening as we
expect to hear similar notices from Anthem as they reevaluate their
participation in Obamacare exchanges throughout the United States.
This recent story is just the latest in a long line failures, all
of them demonstrating the need to move forward with repealing Obamacare
and replacing it with a more workable approach, one that will take
seriously the ballooning health-care costs impacting every American
family.
Let me talk for a few minutes about the specifics of the
President's budget.
The budget assumes $250 billion in total savings from the repeal
and replacement of Obamacare.
Despite some insinuations to the contrary, the budget does not
incorporate the specific legislative proposal--the American Health Care
Act--that is before Congress right now.
Therefore, it is not accurate to associate the specific Medicaid
savings the CBO has estimated from enactment of the AHCA with the
President's budget. To do so would assume a level of specificity that,
for obvious reasons, is just not there.
Moreover, the President's budget does not cut $1.5 trillion from
Medicaid. Nor does it assume that the specific Medicaid-reform
proposals from the AHCA will be enacted into law.
I'm quite certain we'll hear a lot about that today. But any
attempt to make that connection is simply unfounded. And any Senator
who harps on the AHCA Medicaid numbers here today either does not
understand the explicit language and estimates provided in the
President's budget, or they are simply attempting to muddy the waters
in order to scare Americans who rely on Medicaid for health-care
coverage.
Ultimately, the President's Budget appears to accept the reality
that the Senate will need to come up with its own health-care reform
proposal that includes a fundamental fix to Medicaid, which is, quite
frankly, long overdue.
In addition to the savings assumed from the repeal of Obamacare,
the budget also explicitly assumes $610 billion in savings from putting
Medicaid on a sustainable fiscal path by capping funding in FY 2020
through per capita caps or block grants at the States' option.
All told, most of the budget's overall Medicaid savings would be
achieved by returning the focus of Medicaid to serving those with the
greatest needs--the elderly, the disabled, and needy mothers and
children--and by giving States more flexibility to run their own
Medicaid programs.
Any Senator who would like to argue that the Federal Government
should spend more Medicaid dollars to provide coverage for non-
disabled, childless adults at the expense of disabled patients who
remain on waiting lists should explain why.
Furthermore, any Senator who would like to argue that the States
are ill-equipped to handle their Medicaid programs should explain why
that is the case given that the overwhelming consensus we've heard from
governors nationwide over the last several years is that States want
more independence and flexibility to tailor the Medicaid program.
Washington needs to stop measuring the success of a Federal program
by how much money it spends, or how many other programs are a part of
it. Instead, Washington needs to focus on how well a Federal program
helps those it is intended to serve and how efficient the program is at
fulfilling its mandate.
Long story short, we need to stop focusing on spending and pay more
attention to outcomes.
I think the President's budget, while it is by no means flawless,
largely recognizes this reality, and the President and the
administration deserve credit for that.
I look forward to having an open and frank discussion with
Secretary Price about his thoughts on these and other matters.
______
Prepared Statement of Hon. Thomas E. Price, M.D., Secretary,
Department of Health and Human Services
introduction
Chairman Hatch, Ranking Member Wyden, and members of the committee,
thank you for inviting me to discuss the President's budget for the
Department of Health and Human Services (HHS) in fiscal year (FY) 2018.
It is an honor to be here.
Whenever a budget is released, the most common question asked in
Washington is ``how much?'' How much money does the budget spend on
this program, how much does it cut from that other program?
As a former legislator, I understand the importance of this
question. But too often, it's treated as the only question worth asking
about a budget--as if how much a program spends is more important than,
or somehow indicative of, whether the program actually works.
measuring success, not spending
President Trump's budget request does not confuse government
spending with government success. The President understands that
setting a budget is about more than establishing topline spending
levels. Done properly, the budgeting process is an exercise in
reforming our Federal programs to make sure they actually work--so they
do their job and use tax dollars wisely.
The problem with many of our Federal programs is not that they are
too expensive or too underfunded. The real problem is that they do not
work--they fail the very people they are meant to help. In Aid to
Families with Dependent Children, we had a program that undermined
self-sufficiency and work. Congress did well when it realized the
devastating long-term harm this program had on children, in particular,
and took action by creating Temporary Assistance for Needy Families
(TANF)--a program that promoted the empowerment of parents through
work. By helping more Americans climb out of poverty, TANF caseloads
have declined by 75 percent through FY 2016. Under the TANF program,
the employment of single mothers increased by 12 percent from 1996
through 2000, and even after the 2008 recession, employment for this
demographic is still higher than before welfare reform. In the wake of
the recession, the emphasis on work in TANF has increased the job entry
rate, retention rate, and earnings gain rate for program participants.
Our budget reduces TANF spending in part because we understand that
the amount spent in the program has not been the key to its success.
Our goal is to continue and even expand on the progress made since
enactment of Welfare Reform. Toward that end, we would welcome an
opportunity to work with Congress to further strengthen TANF so that
States, Territories, and Tribes can empower more low-income families to
achieve financial independence.
Fixing a broken government program requires a commitment to
reform--redesigning its basic structure and refocusing taxpayer
resources on innovative means to serve the people that the program is
supposed to serve. And sometimes it requires recognition that the
program is unnecessary because the need no longer exists or there are
other programs that can better meet the needs of the people that the
program was originally designed to serve. That's exactly what President
Trump's budget will do, at HHS and across the Federal Government.
Consider Medicaid, a critical safety net program that is the
primary source of medical coverage for millions of low-income American
families and seniors facing some of the most challenging health
circumstances.
If how much money the government spends on a program were truly a
measure of success, Medicaid would be hailed as one of the most
successful in history. Twenty years ago, annual government spending on
Medicaid was less than $200 billion; within the next decade, that
figure is estimated to top $1 trillion.
Despite these significant investments, one-third of doctors in
America do not accept new Medicaid patients. Some research has shown
that enrolling in Medicaid does not necessarily lead to healthier
outcomes for the newly eligible Medicaid population. The Oregon Health
Insurance Study replicated a randomized clinical trial by enrolling
some uninsured people in Medicaid through a lottery. Comparing this
population to those who remained without coverage, the data showed an
increase in emergency room use for primary care, the probability of a
diagnosis of diabetes, and the use of diabetes medication, but no
significant effects on measures of physical health such as blood
pressure, cholesterol, or average glycated hemoglobin levels (a
diagnostic criterion for diabetes). However, the same Oregon data
showed a significant reduction in rates of depression among those
enrolled in Medicaid.
This mixed impact of Medicaid coverage on health outcomes suggests
we need structural reforms that equip States with the resources and
flexibility they need to serve their unique Medicaid populations in a
way that is as compassionate and as cost-effective as possible.
saving and strengthening medicaid through state innovation
That's exactly what the President proposes in his budget. Under
current law, outdated, one-size-fits-all Federal rules prevent States
from prioritizing Federal resources to their most vulnerable
populations. States are also limited in testing new ideas that will
improve access to care and health outcomes. The President's budget will
unleash State-level policymakers to advance reforms that are tailor-
made to meet the unique needs of their citizens.
Over the next decade, these reforms will save American taxpayers an
estimated $610 billion. They will achieve these savings by harnessing
the innovative capacity of America's Governors and State legislators
who, informed directly by the people and those providing the services,
have a proven record of developing creative, effective ways to meet the
health-care needs of friends and neighbors in need, while empowering
them to manage their own health.
Furthermore, the budget includes provisions to extend funding for
the Children's Health Insurance Program. The budget proposes to
rebalance the Federal-State partnership through a series of reforms,
including ending the Obamacare requirement for States to move certain
children from CHIP into Medicaid and capping eligibility at 250 percent
of the Federal Poverty Level to return the focus of CHIP to the most
vulnerable and low-income children.
These reforms will go a long way toward improving access to health
care in America. But there is more work to be done. That's why the
President's budget commits to working with Congress to transition from
the failures of Obamacare to a patient-centered system that empowers
individuals, families, and doctors to make health-care decisions.
hhs advances the health security of the american people with a focus on
preparedness and response for medical and public health emergencies
As everyone here knows, HHS's mission of protecting and promoting
the health of the American people involves far more than overseeing the
Nation's health-care and insurance systems.
For generations, HHS has been the world's leader in responding to
and protecting against public health emergencies--from outbreaks of
infectious disease to chemical, biological, radiological, and nuclear
threats--and assisting the health-care sector to be prepared for cyber-
threats. I recently had the privilege of seeing the importance of this
work during an international trip to Africa and Europe.
Visiting with Ebola survivors in Liberia and representing the
United States at the G20 Health Ministerial Meeting in Berlin and then
the World Health Assembly in Geneva reinforced just how vital a role
HHS plays in preparing for, and responding to, domestic and global
public health emergencies. To support HHS's unique Federal role in
public health emergency preparedness and response, the President's
budget provides $4.3 billion for disaster services coordination and
response planning, biodefense and emerging infectious diseases
research, and development and stockpiling of critical medical
countermeasures. These investments help ensure that State and local
governments have the support and resources they need to save lives,
protect property, and restore essential services and infrastructure for
affected communities.
key public health priorities: serious mental illness,
substance abuse, and childhood obesity
In addition, today America faces a new set of public health crises
that--if we're honest with ourselves--we have been far less successful
in resolving. Those crises are: (1) serious mental illness; (2)
substance abuse, particularly the opioid abuse epidemic; and (3)
childhood obesity.
As Secretary, I am committed to leading HHS to address each of
these three challenges. The President's budget calls for the
investments and policy reforms that will enable us to do just that.
The budget invests in high-priority mental health initiatives to
deliver hope and healing to the 43.1 million adults with mental
illness,\1\ including nearly 10 million Americans suffering from a
serious mental illness,\2\ as well as the 19.6 million adults with both
mental and substance use disorders,\3\ the 3.0 million adolescents who
have experienced a major depressive episode,\4\ and 350,000 adolescents
with both a major depressive episode and substance use disorders.\5\
These initiatives will target resources for psychiatric care, suicide
prevention, homelessness prevention, and children's mental health. For
example, the budget proposes $5 million in new funding authorized by
the 21st Century Cures Act for Assertive Community Treatment for
Individuals with Serious Mental Illness. The budget also includes a
demonstration within the Children's Mental Health Services program to
test the applicability of new research from the National Institute of
Mental Health on preventing or delaying the first episode of psychosis.
---------------------------------------------------------------------------
\1\ Center for Behavioral Health Statistics and Quality (2016). Key
substance use and mental health indicators in the United States:
Results from the 2015 National Survey on Drug Use and Health (HHS
Publication No. SMA 16-4984, NSDUH Series H-51). Pg. 27, retrieved from
http://www.samhsa.gov/data/.
\2\ Center for Behavioral Health Statistics and Quality (2016). Key
substance use and mental health indicators in the United States:
Results from the 2015 National Survey on Drug Use and Health (HHS
Publication No. SMA 16-4984, NSDUH Series H-51). Pg 27, retrieved from
http://www.samhsa.gov/data/.
\3\ Center for Behavioral Health Statistics and Quality (2016). Key
substance use and mental health indicators in the United States:
Results from the 2015 National Survey on Drug Use and Health (HHS
Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://
www.samhsa.gov/data/.
\4\ Center for Behavioral Health Statistics and Quality (2016). Key
substance use and mental health indicators in the United States:
Results from the 2015 National Survey on Drug Use and Health (HHS
Publication No. SMA 16-4984, NSDUH Series H-51). Pg 38, retrieved from
http://www.samhsa.gov/data/.
\5\ Center for Behavioral Health Statistics and Quality (2016). Key
substance use and mental health indicators in the United States:
Results from the 2015 National Survey on Drug Use and Health (HHS
Publication No. SMA 16-4984, NSDUH Series H-51). Page 40, retrieved
from http://www.samhsa.gov/data/.
According to the Centers for Disease Control and Prevention (CDC),
during 2015 drug overdoses accounted for 52,404 U.S. deaths, including
33,091 (63.1 percent) that involved an opioid. To combat the opioid
epidemic sweeping across our land, the budget calls for $811 million--
an increase of $50 million above the FY 2017 continuing resolution--in
support for the five-part strategy that has guided our Department's
---------------------------------------------------------------------------
efforts to fight this scourge:
(1) Improving access to treatment, including Medication-
Assisted Treatment, and recovery services;
(2) Targeting availability and distribution of overdose-
reversing drugs;
(3) Strengthening our understanding of the epidemic through
better public health data and reporting;
(4) Providing support for cutting edge research on pain and
addiction; and
(5) Advancing better practices for pain management.
This funding increase will expand grants to Health Resources
Services Administration (HRSA) Health Centers targeting substance abuse
treatment services from $94 million to $144 million. Also within this
total, the budget continues to fully fund the $500 million for State
Targeted Response to the Opioid Crisis Grants that were authorized in
the 21st Century Cures Act, which expand access to treatment for opioid
addiction. Using evidence-based interventions, these grants address the
primary barriers preventing individuals from seeking and successfully
completing treatment and achieving and sustaining recovery.
Finally, the President's budget invests in the health of the next
generation by supporting services that promote healthy eating and
physical activity, especially among the nearly 20 percent of school-
aged children in America who are obese. The budget establishes the new
$500-million America's Health Block Grant, which will provide
flexibility for States and Tribes to implement specific interventions
that address leading causes of death and disability facing their
specific populations. This could include interventions to spur
improvements in physical activity and the nutrition of children and
adolescents, and to treat leading causes of death such as heart
disease.
other budget highlights
The President's budget prioritizes women's health programs through
investing in research to improve health outcomes, maintaining support
for women's health services, empowering women and families, and
emphasizing prevention. For instance, funding for the Maternal and
Child Health Block Grant and Healthy Start is increased to improve the
health of mothers, children, and adolescents, particularly those in
low-income families. In addition, funding is maintained for a variety
of vital programs serving women across HHS, including, community health
centers, domestic violence programs, women's cancer screenings and
support, mother and infant programs, and the Office on Women's Health.
conclusion
Members of the committee, thank you for the opportunity to testify
today and for your continued support of the Department. It is an
incredible privilege to serve the American people as the Secretary of
Health and Human Services and support its mission to protect the health
and well-being of all Americans.
______
Questions Submitted for the Record to Hon. Thomas E. Price, M.D.
Questions Submitted by Hon. Chuck Grassley
vaccines
Question. In 2006, Iowa was the center of one of the largest mumps
outbreak in the United States.
This past December, another increase in the number of cases of
mumps was reported in Iowa.
Mumps is a highly contagious disease that is easily passed from one
person to another. It can have serious consequences. The good news is
that it is preventable with vaccination.
Dr. Price, State and local authorities often depend on Federal
dollars to ensure protection against preventable diseases.
Will you work to prioritize funding for these programs?
Answer. Vaccines are one of the greatest success stories in public
health and are among the most cost-effective ways to prevent disease.
For example, for each dollar invested in the U.S. childhood
immunization program, there are over $10 of societal savings and $3 in
direct medical savings. Moreover, childhood immunizations over the past
20 years have prevented 322 million illnesses, 732,000 deaths, and
nearly $1.4 trillion in societal costs.\1\
---------------------------------------------------------------------------
\1\ ``Benefits from Immunization During the Vaccines for Children
Program Era--United States, 1994-2013,'' Centers for Disease Control
and Prevention, Morbidity and Mortality Weekly Report, April 25, 2014/
63(16);352-355.
The discretionary Immunization Program plays a fundamental role in
achieving national immunization goals and sustaining high vaccination
coverage rates to prevent death and disability from vaccine-preventable
diseases. It is the backbone of our Nation's public health immunization
system that supports the science that informs our national immunization
policy and programs; provides a safety net of vaccines for uninsured,
poor adults and use in outbreak response; monitors the safety and
effectiveness of vaccines; educates providers and the public about the
benefits of vaccines and the diseases they prevent; and conducts
surveillance, laboratory testing, and epidemiology to respond to
---------------------------------------------------------------------------
disease outbreaks.
The CDC Immunization Program provides funding to all 50 States, the
District of Columbia, 5 major cities and 8 territories. Currently, 90
percent of immunization programs are entirely funded by Federal funds.
At the funding level proposed in the FY 2018 President's budget
request, CDC will continue to provide vaccines and funding for
immunization infrastructure to the 64 awardees, but at a reduced level.
CDC will continue providing technical assistance and laboratory support
to States and local communities responding to vaccine-preventable
disease investigations, including outbreaks, but at a reduced level.
hearing aids
Question. Dr. Price, as a physician you know that hearing loss is
serious issue for the Medicare population. But hearing aids cost over
$4,600 a pair on average and 80 percent of the people that need them,
don't get them--mostly because of the expense. There is a market-based,
regulation-reducing solution. Both the National Academies of Science
and the President's Council of Advisors on Science and Technology have
recommended that FDA should allow hearing aids to be sold OTC for mild
and moderate hearing loss, and FDA agrees.
Senators Warren and I, along with Senators Isakson, Collins, and
Hassan, have a bill that would direct FDA to do exactly that, S. 670.
This legislation has the support of the Academy of Doctors of
Audiology--experts in the recognition and treatment of hearing loss.
The bill also has the support of AARP and the Hearing Loss Association
of America.
Bills don't get much better than this!
This is a common-sense solution to provide high-quality hearing
aids to the 80 percent of people who need one and don't get one under
the current system.
So I want to commend the FDA and ask that you support their
efforts.
I have letters of support from the audiologists, AARP, and the
Hearing Loss Association.
Answer. Thank you for your leadership in considering the creation
of a class of over-the-counter hearing aids. The under-treatment of
hearing loss in the United States is a significant public health issue.
The President recently signed the Food and Drug Reauthorization Act of
2017 which, thanks to your involvement, includes a section relating to
the establishment of a category of over-the-counter hearing aids. The
administration looks forward to the implementation of this section
which has the potential to provide consumers with additional options in
treating their hearing loss.
______
Question Submitted by Hon. Patrick J. Toomey
Question. Through legislation like the 21st Century Cures Act and
recent appropriations bills, Congress has worked to strengthen our
Nation's investment in medical research at the National Institutes of
Health (NIH). These investments have shown incredible results in the
related fields of scientific study and in my own Commonwealth, where
brilliant researchers like Dr. Carl June at the University of
Pennsylvania have used that funding to spur breakthroughs in using
immunotherapies to fight against cancer. Increased investments in the
NIH also will play a key role in unlocking the secrets of Alzheimer's
disease, which already affects 5.5 million Americans and has no cure,
effective treatment, and is 100-percent fatal.
Will you work with me to reduce spending in other areas, so that we
can preserve and hopefully increase our country's commitment to medical
research?
Answer. The Department is committed to medical research, including
Alzheimer's disease research. The Department will assess and allocate
funding to ensure that HHS invests in activities that are core to its
mission and not duplicative of other efforts across the Federal
Government.
______
Question Submitted by Hon. John Thune
Question. Recently, Veterans Affairs Secretary David Shulkin
announced that the VA plans to adopt a new Electronic Health Record
(EHR) system and move away from using its current Veterans Health
Information System and Technology Architecture (VistA) program. While I
applaud the VA's efforts to improve its EHR system, I want to ensure
work that has been done to improve IHS and VA coordination,
particularly the sharing of medical records, is not undone during this
transition. What steps can your Department take to ensure that changes
to the VA EHR system doesn't degrade IHS-VA coordination? Will IHS also
migrate to the new VA EHR system?
Answer. The move by the Department of Veterans Affairs (VA) will
impact the Indian Health Service (IHS) as the IHS Electronic Health
Record (EHR) system is dependent on the VA's VistA system through
shared software development. IHS adopted software developed by the VA
and adapted it for use in its EHR without having to expend funds on the
development.
IHS will continue to have technical support for Resource and
Patient Management System (RPMS) as long as the VA continues to produce
new software patches. However, the VA will begin shifting from
development that adds functionality to software development that
focuses narrowly on patches that address patient safety and readies the
system for archive.
Prior to the announcement by the VA, IHS formed a workgroup to
examine our current EHR platform. The workgroup is comprised of a broad
range of stakeholders who offer various viewpoints based upon their
role and interaction with our systems. The workgroup is expected to
make recommendations by fall 2017 regarding the future of our EHR
system. As the transition continues to evolve, IHS and VA will maintain
open lines of communication to maintain our strong collaborative
relationship.
______
Question Submitted by Hon. Pat Roberts
Question. The Protecting Access to Medicare Act of 2014 included a
provision to reform the Medicare Clinical Laboratory Fee Schedule
(CLFS) so that it becomes a ``market-based'' fee schedule. While a
market-based fee schedule should ultimately provide certainty for
clinical laboratories and patients, my office has received reports that
some labs found CMS guidance confusing and that most large hospital
outreach laboratories were excluded from reporting, meaning that this
segment of the laboratory community wouldn't be included in setting the
payment rates. Can your office provide this committee with a summary of
how many laboratories reported private market rates under PAMA and, of
those labs, how many were hospital labs versus physician office labs or
independent laboratories? Further, can your office detail efforts to
protect against data errors that may lead to flawed rates?
Answer. CMS is committed to the successful implementation of the
new private payer rate-based clinical laboratory fee schedule (CLFS)
and looks forward to working with the laboratory industry to ensure
accurate payment rates. On March 30, 2017, CMS announced that it would
exercise enforcement discretion until May 30, 2017, with respect to the
data reporting period for reporting applicable information under the
CLFS and the application of the Secretary's potential assessment of
civil monetary penalties for failure to report applicable information.
Since the enforcement discretion deadline of May 30th has now passed,
CMS is currently performing a comprehensive analysis of the CLFS data.
The administration will continue to review the operations of the
program and look forward to feedback on how to improve the program.
______
Questions Submitted by Hon. Dean Heller
Question. Earlier this year when you came before this committee for
your confirmation, I asked if I had your commitment to working with
Congress and members of this committee to protect access to care for
patients in Nevada, particularly the more than 600,000 Nevadans that
are currently on Medicaid. Is this budget--which includes over $600
billion in cuts to Medicaid--a reflection of that commitment?
Answer. The administration remains committed to the mission of the
Department to protect the health and well-being of the American
people--the elderly, children, pregnant women, and individuals with
disabilities--and working with States to ensure they are able to make
the most use of available resources to serve their citizens. As you
know, Medicaid is the primary source of medical coverage for millions
of low-income American families and seniors facing health challenges.
However, its costs have been growing drastically without improvement in
outcomes. The problem isn't lack of funding; the problem is lack of
flexibility. The FY 2018 budget puts Medicaid on a path to fiscal
stability by restructuring Medicaid financing and reforming medical
liability laws.
Rigid and outdated Federal rules and requirements prevent States
from pioneering delivery system reforms and from prioritizing Federal
resources to their most vulnerable populations, which hurts access and
health outcomes. The President's budget will give States as much
freedom as possible to design reforms that meet the spectrum of diverse
needs of their Medicaid populations.
Question. To review, this budget proposes cutting Medicaid spending
by $610 billion over 10 years--which is on top of the more than $800
billion in cuts called for under the House-passed American Health Care
Act. These are staggering numbers, and for me, it's a reminder of the
more than 600,000 Nevadans, including the 200,000 newly eligible under
Medicaid expansion, who rely on this program to meet their health-care
needs. Under this budget proposal, can Nevadans be assured that their
access to care will be protected?
Answer. The President's FY18 budget does not incorporate specific
legislation that was before Congress at the time of the hearing.
Therefore, it is not accurate to apply the specific Medicaid savings
the CBO has estimated for legislation before Congress to the
President's budget. To do so would assume a level of specificity that
does not exist in the budget. The budget calls for refocusing Medicaid
on the elderly, children, pregnant women, and individuals with
disabilities. In fact, under the budget, Medicaid spending will
continue to grow over the next decade.
Question. In my home State of Nevada, there are 1.3 million people
with
employer-sponsored health care who will be impacted by Obamacare's 40-
percent excise tax on employee health benefits, also known as the
Cadillac tax. In the January 24th Finance hearing to consider your
nomination, you committed to working with me to fully repeal the
Cadillac tax, which I consider to be an unduly onerous tax. Is this
still your commitment?
Answer. Our budget calls for Congress to repeal and replace
Obamacare, including the Cadillac tax. The administration looks forward
to working with you to reform our health-care system.
Question. As the Senate works to craft our own health-care
legislation, there has been a lot of discussion on how to ensure
Americans with pre-existing conditions will continue to have affordable
coverage. As someone who hears from constituents on a daily basis on
this issue, I am committed to ensuring Nevadans with pre-
existing conditions have the coverage they need. Since the House
passage of the AHCA, this is a topic that you have addressed at length.
Do you agree that individuals with pre-existing conditions should have
access to affordable, high-quality insurance? Do you believe the House-
passed AHCA achieves this goal?
Answer. The President's first principle of health reform is to
ensure that no one will be denied insurance coverage for being sick.
The House-passed AHCA explicitly prohibited insurers from denying
coverage to individuals with pre-existing conditions.
Question. The Children's Health Insurance Program (CHIP) is up for
reauthorization this year. This is a vital program that provides
medical coverage and care to more than 23,000 children in my home
State. I'm encouraged that the administration favors a renewal of CHIP
and proposes to extend CHIP funding for 2 years. I'm hopeful that
Congress will act to reauthorize this critical program. Will you commit
to working with Congress to ensure that children who rely on CHIP will
have access to high-quality, affordable health coverage?
Answer. As you noted, CHIP funding will expire at the end of FY
2017, and without an extension of funding, children could lose health-
care coverage. This proposal would extend CHIP funding for 2 years
through FY 2019. The administration remains committed to working with
Congress to provide budgetary stability and additional flexibility to
States while focusing the program on lower-income families.
______
Questions Submitted by Hon. Ron Wyden
women's health
Question. Under the Affordable Care Act (ACA), a record-number of
women have gained access to health-care coverage and preventive care at
no cost; maternity care was established as an essential health benefit
(EHB); women were no longer discriminated against by health insurers
for having a pre-existing condition, such as a previous Cesarean
section or history of breast cancer; and health plans were not allowed
to charge a woman more because of her gender.
With the massive budget cuts proposed in the President's budget,
how will you lead HHS to continue the progress the ACA achieved for
women's health?
Answer. (See answer provided below.)
Question. Medicaid funds nearly half of all births in the country.
With the proposed cuts in the hundreds of billions to Medicaid, how
will you assure the country's most vulnerable women will have access to
maternity care?
Answer. The budget calls for refocusing Medicaid on the elderly,
children, pregnant women, and individuals with disabilities. In fact,
under the budget, Medicaid spending will continue to grow over the next
decade.
In addition, the budget increases funding for the Maternal and
Child Health Block Grant by $30 million above the FY 2017 Continuing
Resolution. The Maternal and Child Health Block Grant supports services
to more than half of the pregnant women and nearly one-third of all
infants and children in the country. The additional funding will
support greater State investment to improve the health of all mothers,
children, and adolescents, particularly those in low-income families.
The FY 2018 budget also provides a $10 million increase above the FY
2017 Continuing Resolution for the Healthy Start Program, which
connects individuals with services that can reduce infant mortality and
improve perinatal outcomes, while allowing grantees to tailor services
according to community need.
Question. According to a leaked draft of an HHS rule which you
confirmed was proposed during the hearing, employers and insurers who
have a religious or moral objection to providing birth control and
related services would not be required to offer contraception to their
employees or enrollees. This turns back the provision in the ACA that
offers preventative benefits, including contraception, at no cost. What
is the status of this leaked rule? Will you abide by procedures under
the Administrative Procedure Act (APA) to solicit public comment before
finalizing the rule? How will you consider the religious liberty of
women who are seeking contraception when drafting this rule?
Answer. The administration is not at liberty to discuss the details
of pending regulations.
Question. If enacted into law, the House-passed AHCA would defund
Planned Parenthood health clinics of all Federal funding sources. The
law injects funding into Community Health Centers (CHCs) as a
substitute for Planned Parenthood health clinics. However, experts have
repeatedly reported that CHCs do not have the capacity to absorb 2.4
million Planned Parenthood patients. Additionally, the President's
budget includes a rider to prohibit Planned Parenthood from
participating in Federal programs. If Planned Parenthood is defunded,
how will you assure access to health care for the women in the 21
percent of America's counties that rely on a Planned Parenthood health
center as a safety-net family planning provider? If CHCs are unable to
absorb patients from Planned Parenthood health centers, what steps will
you take to assure the 6 in 10 women who rely on these centers as their
main source of health care that they will have access to primary care?
Answer. The mission of the U.S. Department of Health and Human
Services (HHS) is to protect the health and well-being of all
Americans. The administration takes our mission seriously, and will
work to support access to quality, affordable health care for all
Americans. Health Centers have delivered affordable, accessible,
quality primary health care to patients regardless of their ability to
pay for more than 50 years. In 2015, Health Centers served 16.8 million
female patients ages 15-65, of 24.3 million that they served.
short-term plans
Question. Recently, 14 Republican Senators sent you a letter asking
the Trump administration to reverse a regulation (Excepted Benefits;
Lifetime and Annual Limits; and Short-Term, Limited-Duration Insurance,
81 FR 75316) on the term of coverage for short-term, limited-duration
health insurance plans. This regulation was initially promulgated to
protect consumers from misconceptions about how limited short-term
coverage can be and to align the duration of short-term policies with
individual responsibility payment requirements, helping consumers make
informed choices about their health coverage. The regulation
effectively limits short-term coverage to 3 months and requires
insurers to warn consumers that short-term coverage does not satisfy
the individual responsibility to have adequate health coverage. You
have previously stated that you do not want people with a pre-existing
illness or injury not to be covered, but short-term plans don't abide
by the same consumer protections as Qualified Health Plans under the
Affordable Care Act.
How do you plan to respond to the Republican Senators' letter on
short-term plans? Do you support expanding the use of short-term plans
or making any changes to the regulation?
If you plan to expand the use of short-term plans, do you retract
your comments about protecting those with pre-existing conditions when
allowing for the expansion of this type of coverage that doesn't offer
essential consumer protections to those with pre-existing conditions?
How will you protect consumers from purchasing short-term coverage
without knowing the risks?
Answer. The administration remains committed to relieve Americans
from Obamacare's burdensome regulations and mandates. The
administration is evaluating policy options to restore choice and
competition to the individual and small group markets, while increasing
availability of health insurance options so that all Americans can
purchase coverage that meets their needs while continuing to protect
individuals with pre-existing conditions.
medicare sequester
Question. During the campaign, President Trump promised: ``I'm not
going to cut Social Security like every other Republican and I'm not
going to cut Medicare or Medicaid.'' He also tweeted: ``I was the first
and only potential GOP candidate to State there will be no cuts to
Social Security, Medicare, and Medicaid. Huckabee copied me.''
On page 50, the HHS FY18 budget in Brief states that ``[t]he budget
does not include any direct Medicare cuts.'' However, in fact, the
President's FY18 budget proposes to extend the sequester on mandatory
spending--including Medicare--for an additional 2 years through 2027.
At the hearing, Senator Cantwell asked you whether the President's
budget includes ``a 2-year extension of mandatory sequestration, which
would impose a 2 percent cut on Medicare providers.'' In response to
her question, you stated that the President's budget reflects only the
``continuation of current law.''
Isn't it true that--under current law--the sequester on mandatory
spending ends in 2025?
Isn't it also true that the President's FY18 budget proposes
extending the sequester on mandatory spending for an additional 2 years
(through 2027)?
How do you reconcile those facts with your response to Senator
Cantwell that the President's budget reflects only the ``continuation
of current law''--when, in fact, the President's budget includes a 2-
year extension that does not exist under current law?
In total, how much would payments to Medicare providers, suppliers,
and plans be cut as a result of the President's proposal?
Answer. The President's budget reflects current law. In addition,
the budget proposes to continue current law by extending sequestration
by 2 years. This is not a cut to what Medicare currently pays to
providers and does not change benefits or prices charged to
beneficiaries generally.
value of medicaid
Question. You have previously stated that Medicaid costs are
growing without improvements in health outcomes. However, studies
indicate that Medicaid has increased access to health services,
including preventative care among formerly uninsured adults, a critical
step to achieving improved health outcomes in the long run.
For example, in a literature review, the Kaiser Family Foundation
reported in April 2016 that Medicaid helps to improve access to health
services, boost utilization of preventive health services, and reduce
cost-sharing among beneficiaries. Several studies confirmed that
Medicaid enrollees were able to access health services comparable to
those offered under employer-based insurance, and that these services
were accessed at a significantly lower per-person cost. For example, a
2013 study published by Teresa Coughlin et al., at the Urban Institute
reported that Medicaid beneficiaries' health-care costs would be over
25 percent higher if they used employer-sponsor insurance. This was
true even while Medicaid beneficiaries had similar access to and use of
services like inpatient care, prescription drugs, and primary care
doctors when compared with employer-insured individuals. Coughlin et
al., also noted that out-of-pocket spending would increase threefold
for Medicaid beneficiaries if they switched to private insurance,
rising from $257 to $784 on average per year. This may in part be due
to the fact that per capita spending for Medicaid enrollees has
remained stable over time, as reported by John Inglehard and Benjamin
Sommers in a 2015 New England Journal of Medicine study. The authors
noted that Medicaid spending growth was driven primarily by increased
enrollment in the program, and that per capita Medicaid spending stayed
flat between 1998 and 2014 when adjusted for inflation.
Do you agree that increasing access to primary care and
preventative services has the capacity to save costs to the health-care
system and improve health outcomes for beneficiaries over time? If so,
would you agree that Medicaid has the capacity to protect and improve
the health outcomes of covered individuals?
Proposed cuts to Medicaid under the AHCA would compromise
individuals' access to preventative and primary care services,
especially for the 14 million low-income Medicaid beneficiaries who
will be left uninsured and without access to affordable, comprehensive
coverage. How will you use your capacity as the Secretary of Health and
Human Services to provide these individuals with affordable coverage to
access these services should the Medicaid expansion be repealed?
If individuals are unable to access primary and preventative care,
we could see an increase in the utilization of emergency departments to
address medical conditions. How do you plan to allocate resources to
compensate for the potential rise in costs associated with these
emergency services?
Answer. The FY 2018 budget calls for refocusing Medicaid on the
elderly, children, pregnant women, and individuals with disabilities.
The administration's goal is to ensure that all Americans have access
to affordable coverage that best meets the needs of themselves and
their families so that they can receive preventive care from the doctor
of their choice in a primary care setting. The Department looks forward
to collaborating with States to explore ways to support further
adoption of Medicaid Direct Primary Care (DPC), which provides an
enhanced focus on direct physician-patient relationships through
enrolling Medicaid patients in DPC practices. Existing DPC practices
enhance physicians' focus on patient care by simplifying healthcare
payments for patients and doctors. DPC arrangements also often include
benefits such as extended visits and electronic communication, which
allow for improved patient access to primary care services.
implications of direct primary care initiative
Question. In its FY 2018 budget, the administration proposed a
Medicaid Direct Primary Care Initiative to encourage State Medicaid
programs to use Direct Primary Care practices. Under this model, a set
price is paid to providers in exchange for improved access to primary
care services. Some State Medicaid programs are currently experimenting
with this model of primary care payment.
Over 75 percent of Medicaid beneficiaries are enrolled in private
plans that manage their care. Since so many Medicaid beneficiaries are
enrolled in managed care, how would consumers enrolled in Medicaid
managed care plans participate in the Direct Primary Care Initiative?
Would there be a pathway to participation for Medicaid managed care
plans?
The Centers for Medicare and Medicaid Services (CMS) recently
approved several Medicaid waivers testing new delivery system reforms
that rely on provider-led organizations, such as in Alabama and New
Hampshire. How would these new delivery models and organizations be
affected by the Direct Primary Care Initiative?
Would Medicaid beneficiaries have cost sharing obligations under
the Initiative? If so, how would they be implemented?
How does CMS plan to support States in these initiatives? It does
not appear any new Federal support is made available under the proposal
in the President's budget for such initiatives. Lack of Federal support
coupled with hundreds of billions of dollars in cuts to Medicaid under
the President's budget would hugely hamper States' ability to implement
new innovative models of care delivery.
Answer. The Department looks forward to collaborating with States
to explore ways to support further adoption of Medicaid Direct Primary
Care (DPC), which provides an enhanced focus on direct physician-
patient relationships through enrolling Medicaid patients in DPC
practices. Such practices enhance physicians' focus on patient care by
simplifying healthcare payments for patients and physicians. DPC
arrangements also often include benefits such as extended visits and
electronic communication, which allows for improved patient access to
primary care services. Working with States and primary care physicians,
HHS will support the development of DPC practices, identify barriers to
their entry into Medicaid, and outline flexibilities under existing
authorities to facilitate these innovative approaches to strengthening
the relationships between patients and physicians. As the Department
partners with States to advance this initiative, we look forward to
gathering feedback about how this initiative will interact with the
existing Medicaid program and State-based waivers and programs.
cms priorities
Question. In addition to the President's proposals to cut Medicaid
and the Children's Health Insurance Program (CHIP) by over $600
billion, the President's FY 2018 budget includes a 10-percent cut to
the budget of the agency running those programs and Medicare.
How will proposed cuts to discretionary administration spending be
distributed across CMS? How was this distribution determined?
What staff positions will be eliminated as a result of these
proposed cuts to discretionary administration spending? How would the
loss of these positions impact the programs they support?
How would the proposed cuts impact CMS programs' ability to meet
their statutory objectives?
How would CMS ensure its programs would be able to continue to meet
the needs of their current beneficiaries?
How would the administration measure the impact of the proposed
cuts on vulnerable populations, including older Americans and people
with disabilities?
Answer. The FY 2018 discretionary budget request for CMS Program
Management is about $3.6 billion, a decrease of $379 million below the
FY 2017 Annualized Continuing Resolution level. This request will
enable CMS to continue to effectively administer Medicare, Medicaid,
and the Children's Health Insurance Program (CHIP). The FY 2018 budget
reflects CMS's key priorities to: reduce costs through contract
efficiencies; prioritize customer service; invest in program integrity;
and strengthen the Federal workforce. Additionally, for FY 2018, the
budget requests $723 million for CMS Federal administrative costs, $10
million below the FY 2017 Annualized Continuing Resolution level. Of
this total, $651 million will support a direct full-time equivalent
level of 4,370, a decrease of 155 full-time equivalents below the FY
2017 Annualized Continuing Resolution level. With this level of staff,
CMS will be able to effectively and efficiently support operations,
successfully carry out the Secretary's priorities, and focus on
improving CMS's traditional programs. The reduction in workforce will
occur through natural attrition across CMS.
testimony concerning premium hikes
Question. During the June 8, 2017 hearing on the President's Fiscal
Year 2018 budget, you cited statistics to demonstrate evidence of
increasing health insurance premiums. For example, in one instance
during an exchange with Senator McCaskill, you stated that premiums in
Missouri had increased by 145 percent between 2013 and 2017.
These statistics appear to have been drawn from a May 23, 2017
report released by the Assistant Secretary for Planning and Evaluation
(ASPE), which sought to measure the Affordable Care Act's (ACA's)
impact by comparing Medical Loss Ratio data from 2013 and CMS
Multidimensional Information and Data Analytics System data from
HealthCare.gov in 2017. However, since its release, this report has
been criticized by health-care experts for its methodology and
misleading conclusions.
Fundamentally, the comparison of premiums between 2013 and 2017 is
inappropriate, as the ACA's reforms and affordability programs did not
go into effect until 2014. This means that individual plans in 2013 are
simply not comparable to those in 2017. In 2013, many plans failed to
cover critical health services now included as Essential Health
Benefits, including maternity care and mental health services.
Moreover, before the ACA's consumer protections were in place, plans
were permitted to exclude individuals with preexisting conditions.
Finally, ASPE failed to take into account the use of subsidies in the
ACA Health Insurance Marketplaces, which significantly lowers the
actual cost of plans for individuals purchasing coverage through the
Marketplaces. In fact, an earlier ASPE report released on October 24,
2016 stated that 8 in 10 Marketplace enrollees can obtain insurance for
$100 a month or less after subsidies are applied.
Do you agree that by failing to take into account subsidies offered
to individuals on the marketplace, the May 23, 2017 ASPE report does
not accurately describe the average amount paid by consumers to acquire
insurance on the individual market?
Do you agree that plans in 2013 are not comparable to those offered
to individuals in 2017 for individuals due to substantial protections
for consumers and more comprehensive coverage?
Do you agree that the American people have a right to sufficient
and unbiased information to help them make apples-to-apples
comparisons? If so, do you believe that the administration has a duty
to provide it?
Answer. Obamacare is a disaster, delivering high costs, few
options, and broken promises. Americans across the country have seen
their health insurance choices disappear and premiums spiral out of
control, increasing by double and triple digits. This administration is
committed to empowering consumers with providing more choices and
access to the health care they want and deserve.
csrs and rising premiums
Question. Since April, insurers in California, Colorado,
Connecticut, Iowa, Maryland, New Hampshire, New Mexico, North Carolina,
Pennsylvania, and Washington have expressed serious concerns about
uncertainty in the private insurance market caused by the
administration's actions and rhetoric.
The specific actions from the administration include:
A January 20th executive order to delay or halt the
implementation of the ACA, which could undermine enforcement of the
individual mandate;
The administration's decision in January to stop advertising
for open enrollment and to slash the budget for marketing and outreach
by 20 percent for FY 2018;
Threats directly from the President to let the marketplaces
``explode'';
And repeated warnings from the administration to buck the
cost-sharing reduction payments (CSRs) owed to insurers who cover low-
and moderate-
income Americans enrolled in marketplace plans.
This last point is particularly urgent. Under the CSR program,
insurers subsidize plans for individuals earning up to 250 percent of
the Federal Poverty Level (FPL) to reduce their deductibles and out-of-
pocket expenses. Insurers report to HHS on how many enrollees they have
provided CSRs, and then the Treasury Department reimburses insurers for
these payments. More than 6.4 million individuals were enrolled in a
CSR-eligible plan last year. Though the Trump administration has
continued to reimburse insurers each month since taking office, the
administration now refuses to state whether it will honor its financial
commitment to insurers.
Without this clarity, insurers have been unsure how to price
premiums for the future, causing instability in the health-care market
and driving up premiums across the country. Uncertainty surrounding CSR
funding has also threatened the continued participation of insurers in
the marketplace. In early June, Anthem withdrew from 20 counties in
Ohio, citing these uncertain CSR payments as a key reason for its
departure.
In your testimony before the Senate Finance Committee on June 8,
2017, you repeatedly made reference to rising premiums under the ACA.
Do you agree, however, that the administration's refusal to honor these
CSR payments has contributed to uncertainty in the marketplace and
contributed to insurers' decisions to raise their premiums for 2018?
Has HHS done any internal analysis to estimate the cost of this
uncertainty to the taxpayers?
The Kaiser Family Foundation has reported that a refusal to pay
these subsidies could end up costing the Federal Government $2.3
billion in added premium tax credits. Is refusing to reimburse insurers
for the CSR program fiscally responsible for the Federal Government?
Have rising premiums and insurers exiting the marketplace due to
the administration's decision to withhold CSR payments already
jeopardized the ability of Americans to continue accessing affordable
coverage?
The President's budget assumed $6.3 billion to continue funding
CSRs. Do you agree with the President's budget that the Federal
Government should honor its financial commitment to reimburse CSRs made
by insurers? Will you commit to ensuring CSRs are paid in full by the
Federal Government to insurers?
Answer. The administration has emphasized the importance of
reforming our health-care system to one that works better for patients
and their providers, and The administration's budget calls for Congress
to repeal and replace the Affordable Care Act. In the interim, we are
evaluating policy options to relieve Americans from Obamacare's
burdensome mandates and to restore choice and competition to the
individual and small group markets, increasing availability of health
insurance options so that all Americans can purchase coverage that
meets their needs.
Question. Rising premiums and the exit of insurers could have
particularly dire consequences for patients residing in bare counties
where no insurers are offering Marketplace plans. Do you agree that
facilitating the ability of insurers to offer Marketplace plans in
these counties would help patients better afford their medical care? Do
you agree that facilitating the ability of insurers to offer these
plans is a responsibility of HHS?
Do you commit to encouraging insurers to offer plans to patients
residing in bare counties? How do you plan to fulfill this commitment?
Answer. Obamacare is a disaster, delivering high costs, few
options, and broken promises. Americans across the country have seen
their health insurance choices disappear. The administration is
committed to empowering consumers with providing more choices and
access to the healthcare they want and deserve.
The administration recognizes that States are the primary
regulators of health insurance, and it remains imperative for the
executive branch to empower States with more flexibility and control.
Among other regulatory actions and guidance documents, the Department
also finalized a Market Stability Rule in April, which tightened
special enrollment periods, made it more difficult for enrollees to
skip premium payments, adjusted the open enrollment period to align
with other healthcare markets, lifted one-size-fits-all requirements
regarding network access, and widened the actuarial value bands within
which insurers can offer plans to patients.
mylan taxpayer recovery (epipens)
Question. The FY 2018 request increases funding for program
integrity initiatives. Ensuring providers properly report relevant
information and pay rebates to Medicaid under the Medicaid drug rebate
program has been the topic of renewed focus following revelations that
Mylan overcharged the American public by $1.27 billion by classifying
EpiPen as a generic drug instead of a name-brand product. According to
the Centers for Medicare and Medicaid Services (CMS), CMS informed
Mylan they were misclassifying EpiPen several times, but Mylan failed
to correct the classification of the product. In October, Mylan
reported that it had reached an agreement in principle with the United
States to pay $465 million. To date, the settlement has not be
finalized.
What are the specific activities that the U.S. Department of Health
and Human Services (HHS) will employ to recover the remaining lost
taxpayer money that the HHS Office of Inspector General (OIG)
identified? Will HHS push for any further action against Mylan?
Why was Mylan able to continue misclassifying the status of the
EpiPen for purposes of the Medicaid drug rebate program and continue to
pay a lower rebate based on that misclassification after they were made
aware of the error?
What additional provisions are being put in place to help prevent
similar future errors?
Mylan has also recently drawn public attention for price gouging
its EpiPen product, raising the price six fold since 2007. What efforts
will the administration make to protect Americans from similar price
gouging on life-saving medications and help contain the costs of drug
coverage?
Answer. The U.S. Department of Health and Human Services (HHS) is
actively reviewing the findings of the Office of the Inspector General
and have also been in discussion with Members of Congress regarding
their concerns over the EpiPen price. As you are aware, the public
disclosure of any discussions on potential recoupment of funds or
future decisions on classification could impact our ongoing efforts to
evaluate the program. Please contact the Office of the Assistant
Secretary for Legislation so that they can schedule a briefing to
candidly inform you of our ongoing activities.
medicaid and coverage for individuals with disabilities
Question. For millions of Americans with disabilities, Medicaid is
a critical program that allows them to access the services and care
they need. Nationally, people with disabilities make up roughly 15
percent of all Medicaid enrollees but account for approximately 40
percent of all Medicaid spending.
On June 6, 2017, NPR gave a face to these individuals with a
profile on Mr. Evan Nodvin, a Medicaid beneficiary living in Georgia
with Down syndrome. Mr. Nodvin, who works at a local fitness community
center, credits his independence to the State's Medicaid program.
For Mr. Nodvin and many families across the Nation like his, the
proposed cuts to Medicaid spending contemplated in the FY 2018 budget--
$627-billion-plus in additional cuts to Medicaid--have caused serious
concern as to what their future care will look like. Moreover, the
proposed restructuring of Medicaid in the American Health Care Act
would lead to $834 billion in cuts to Medicaid and an effective cap on
care for individuals with disabilities.
Will you commit to ensuring that individuals with disabilities are
able to access the services and care they need to maintain the highest
level of independence possible? How do you intend to fulfill this
commitment in light of these proposed reductions to Medicaid spending?
Do you anticipate the creation of additional Federal programs or
requirements to protect these individuals' access to health services?
If additional flexibility is granted to States in administering
their Medicaid programs, how do you plan to maintain requirements to
ensure adequate access to needed programs or services for people with
disabilities?
Answer. The administration remains committed to the mission of the
department, to protect the health and well-being of the American
people--this includes individuals with disabilities. The budget
recognizes that States understand the unique needs of their citizens
far better than Washington, and we intend to provide States with
maximum flexibility to ensure that Medicaid prioritizes the most
vulnerable Americans.
prescription drug prices
Question. As the Secretary of the U.S. Department of Health and
Human Services (HHS), you have broad power, independent of Congress, to
impact the cost of prescription drugs. The agency is able, for example,
to initiate rulemaking regarding payment for physician-administered
drugs, while the Centers for Medicare and Medicaid Services has broad
authority to test new payment models for prescription drugs.
On January 18, 2017, in a hearing before our colleagues at the
Senate Committee on Health, Education, Labor and Pensions, you
committed to working with Congress to ``make sure drug pricing is
reasonable.'' However, the President's FY 2018 budget proposed no
policies to stop the rise of prescription drug prices.
If the President is committed to lowering drug prices, why are
there no proposals (even proposals he claimed to support on the
campaign trail) included in the President's budget aimed at lowering
drug prices?
In responding to a question by Senator Stabenow, you stated the
Department of HHS has held approximately 6-8 stakeholder meetings to
discuss the issue of drug pricing. Could you please provide the
individuals and organizations who attended those meetings?
Also during that exchange with Senator Stabenow, the price of the
Hepatitis C drug Sovaldi was discussed. In discussing whether or not
Gilead's price is acceptable, you stated, ``I don't know what the right
price is but I do know how to figure out what the right price is.'' Can
you please provide the committee with how you would ``figure out the
right price'' of Sovaldi and other high-cost prescription drugs coming
on to market in the near future?
Answer. High drug prices and costs are an issue of major concern
for HHS and for the American people. This includes the millions of
seniors who rely on Medicare for their drug coverage, and the taxpayers
who have to foot the bill for government spending on this program. As
you know, the President has made prescription drug prices an absolute
priority and has charged the U.S. Department of Health and Human
Services (HHS) with making recommendations to his office on reducing
drug prices. HHS has been meeting with stakeholder groups from across
the health-care spectrum over the past several months in order to
understand where there are areas of consensus.
It is important that we move forward quickly, but also carefully,
so that our policies do not have unintended consequences. We need to
balance the goal of ensuring affordability and access with the mandate
to continue supporting development of lifesaving innovations.
chip funding extension
Question. In FY 2016, the Children's Health Insurance Program
(CHIP) covered nearly 9 million children in families who earn too much
to qualify for Medicaid but still lack access to affordable private
coverage. While this successful, bipartisan program is permanently
authorized, funding is set to expire later this year. Secretary Price,
during your nomination hearing you called for an 8-year extension of
Federal funding for the Children's Health Insurance Program (CHIP).
This multi-year extension is in line with other calls to renew the
program for multiple years by the National Governor's Association, the
Bipartisan Policy Center, and the independent Medicaid and CHIP Payment
and Access Commission (MACPAC) in order to provide much deserved
certainty to States and families. However, President Trump's budget
proposes to extend Federal CHIP funding by only two additional years
with additional cuts to the program including a cap on coverage for
currently enrolled children in working families.
Do you still support an 8-year extension of CHIP funding?
Did you advise the President on his CHIP policy proposals? If so,
what factors led the administration to decide that a 2-year extension
was sufficient.
The President's budget also includes a 20 percent cut in Federal
support to States for CHIP. How does the administration plan for States
to continue being able to provide valuable coverage to families in need
despite these cuts?
Children make up nearly half of those enrolled Medicaid. With
billions of dollars in proposed cuts to the Medicaid program and a 20
percent cut to Federal CHIP funding, how will you assure America's
children continue to have access to affordable, comprehensive health
care that meets their child-specific needs?
Answer. The CHIP program needs to be looked at and extended. The
budget proposes to extend funding for CHIP for two additional years
through FY 2019. Extending CHIP funding for 2 years provides stability
to States and families while the future of the program is addressed
alongside other health reforms. This funding guarantees that the most
vulnerable children will continue to have coverage.
The budget also proposes a series of improvements that rebalance
the State-
Federal partnership and increase State flexibility. This proposal ends
the 23-
percentage point increase in the enhanced Federal match rate and the
current law maintenance of effort requirement after FY 2017. The budget
also proposes ending the Obamacare requirement for States to move
certain children from CHIP into Medicaid and capping the level at which
States could receive the CHIP enhanced Federal matching rate at 250
percent of the Federal Poverty Level. These provisions would return the
focus of CHIP to the most vulnerable and low-income children.
alaska reinsurance waiver
Question. As you note in your March letter to Governors, Alaska
significantly decreased projected premium increases for 2017 through a
2-year reinsurance program. This program reduced both premium costs for
consumers and tax credit expenditures by the Federal Government. In
December 2016, Alaska released its application for a State Innovation
Waiver under section 1332 of the Affordable Care Act (ACA) to
sustainably implement the Alaska Reinsurance Program. The ACA's 1332
waivers require States to maintain high standards for access to
quality, affordable coverage while giving them the flexibility to
improve market stability and lower costs for consumers.
Given the benefits of reinsurance that you highlighted using
Alaska's program, why has the pending Alaska reinsurance waiver not yet
been approved?
Does the March letter guidance still reflect the current position
of the administration?
Answer. The Centers for Medicare and Medicaid Services and the
Department of Treasury announced approval of Alaska's section 1332
waiver application on July 11, 2017.
The administration stands ready to work with States to implement
solutions that work for their local markets.
aca marketing and outreach
Question. On January 26, 2017, the White House ordered the U.S.
Department of Health and Human Services (HHS) to prematurely stop
advertising for open enrollment for the Affordable Care Act's (ACA)
health insurance marketplaces. This decision was made without clear
explanation from the administration, other than a statement from HHS
that the agency was looking for efficiencies. However, former officials
under President Obama's administration confirmed news reports that
these advertisements had already been paid for.
Please provide an explanation for stopping the administration's
marketing for open enrollment before its scheduled end date.
What impact was anticipated by HHS prior to freezing marketing and
outreach efforts? Please provide HHS's analysis used to make this
decision, including money spent on advertisements that were not run.
Do you agree closing advertising for open enrollment prematurely
could have caused fewer individuals to sign-up for ACA coverage,
especially younger individuals who historically sign up closer to the
deadline?
Do you agree that enrolling more individuals in the ACA marketplace
helps distribute risk within the health insurance marketplaces? If so,
would you agree that deciding to prematurely halt advertising for 2018
enrollment could have been one of the sources of uncertainty that
causes insurers to raise their premiums?
In 2016, how much did HHS spend on marketing for enrollment for
2017? How much is HHS projected to have spent this year for 2018
enrollment?
Were the marketing plans and contracts withdrawn in January
previously paid for by President Obama's administration? If so, was HHS
able to recapture the funds paid towards these outreach efforts? If
not, was the loss of these funds considered in making the decision to
prematurely halt advertising for enrollment? If these funds were
recouped, where has the agency redistributed these funds, or where does
the agency plan to allocate these funds in the future?
The President's budget for Fiscal Year 2018 proposed a $310-million
cut to the budget for the Federally-Facilitated Marketplace, which may
hinder outreach efforts for future enrollment periods. In light of
these cuts, how will you ensure that reduced funding will not lead to
depressed enrollment for the future?
Will you commit to engaging in full and uninterrupted outreach and
marketing efforts to encourage individuals to enroll in ACA Marketplace
plans during future open enrollment periods?
Answer. Until Congress can act to repeal and replace Obamacare, the
administration is carrying out its responsibilities under current law,
including funding and maintenance of the exchange call center, even
within a lean and efficient budget request. However, this budget
reflects the goal of moving control of the health insurance market back
to States and issuers. This includes recognition of the traditional
role of States to perform outreach to their citizens, and the value of
experienced agents and brokers to enroll individuals into health
insurance. The Federal Government should not be duplicating these
efforts.
oregon experiment
Question. During the June 8, 2017 hearing on the President's FY
2018 budget before the U.S. Senate Committee on Finance, you testified
that Medicaid coverage does not lead to healthier outcomes for the
newly eligible Medicaid population by reference to the Oregon
experiment.
However, I think it is important to talk about what the Oregon
health experiment actually found. The study found that those who gained
Medicaid coverage were more likely to get primary and preventive care,
including screening and treatment for depression and diabetes. In
addition, new Medicaid beneficiaries were 40 percent less likely to
have suffered a decline in their health in the previous 6 months and 40
percent less likely to go into medical debt or leave other bills unpaid
to cover medical expenses, nearly eliminating all catastrophic out-of-
pocket medical expenditures. Finally, although the researchers also
found that some patients' cholesterol levels fell, the small sample
size and short duration of the study made it difficult to draw concrete
conclusions about health outcomes.
It's also important to note that since this study was conducted
nearly a decade ago, Oregon has seen a transformation of its health-
care system to one of coordinated care and expanded Medicaid coverage
to hundreds of thousands of low-income Oregonians--all while continuing
to improve care. This has meant fewer emergency room visits, a 75-
percent increase in enrollment in patient-centered primary care homes,
substantial increases in substance use disorder treatment, and
reductions in preventable hospital admissions.
Instead of focusing on what works and improving care, the House-
passed AHCA bill and the President's budget would rip health care away
from millions of Medicaid beneficiaries, including as many as 465,000
Oregonians. Millions more Americans could see caps and cuts to their
coverage, including 65,000 Oregonians who rely on Oregon's Community
First Choice option to receive community-based long-term care services
and supports.
While you cited the Oregon health experiment as providing evidence
that Medicaid expansion leads to increased use of emergency departments
for primary care, results from the Quarterly Legislative Report of
Oregon's Health System Transformation demonstrate that Oregon's
Medicaid program is increasing preventative care and reducing emergency
department utilization among Oregon's Medicaid beneficiaries. Given
this evidence and your reliance on Oregon's Medicaid program to draw
your conclusions, do you plan to change your position on the effects of
Medicaid for millions of Americans?
According to the independent Congressional Budget Office, 14
million Americans will lose Medicaid under the repeal of the Medicaid
expansion included in the House-passed AHCA bill and end up uninsured,
including hundreds of thousands of Oregonians. How do you think the
health outcomes for these individuals would change when they no longer
have access to affordable, comprehensive health care? Do you expect
that these 14 million low-income Americans without insurance or access
to affordable coverage would need to rely on emergency rooms even more
than they do today? How do you think increasing the number of uninsured
individuals in the United States by 23 million would impact rates of
emergency room use across the country?
Answer. As you know, Medicaid is the primary source of medical
coverage for millions of low-income American families and seniors
facing health challenges. However, its costs have been growing
drastically without corresponding improvement in outcomes. The problem
isn't lack of funding; the problem is lack of flexibility. The FY 2018
budget puts Medicaid on a path to fiscal stability by restructuring
Medicaid financing and reforming medical liability laws.
Rigid and outdated Federal rules and requirements prevent States
from pioneering delivery system reforms and from prioritizing Federal
resources to their most vulnerable populations, which hurts access and
health outcomes. The President's budget will give States as much
freedom as possible to design reforms that meet the spectrum of diverse
needs of their Medicaid populations.
The administration is committed to making sure that States have the
flexibility to design their Medicaid programs to meet the needs of the
most vulnerable in their State. By strengthening the Federal and State
Medicaid partnership, we will empower States to develop innovative
solutions that meet their unique demographic, budgetary, and policy
needs, rather than telling States how they should run their programs.
epm rule
Question. On January 3, 2017, the Department of Health and Human
Services (HHS) published a final rule implementing three new Episode
Payment Models (EPMs) for Medicare Parts A and B and a Cardiac
Rehabilitation (CR) incentive payment model through the Center for
Medicare and Medicaid Innovation. Under the three new EPMs, acute care
hospitals in certain selected geographic areas will participate in
retrospective EPMs targeting care for Medicare fee-for-service
beneficiaries receiving services during acute myocardial infarction
(AMI), coronary artery bypass graft (CABG) and surgical hip/femur
fracture treatment (SHFFT) episodes.
On May 19, 2017, HHS published a final rule delaying the start date
for the EPMs and CR from July 1, 2017, to January 1, 2018. The May 19,
2017, final rule also reiterated HHS's position that ``these models
will further [its] goals of improving the efficiency and quality of
care for Medicare beneficiaries receiving care for these common
clinical conditions and procedures.''
Given HHS's statement that these models will further the goals of
improving the efficiency and quality of care for Medicare
beneficiaries, will you commit to implementing these EPMs and CR--
without any substantive changes--and adhering to the new January 1,
2018 start date without any further delays?
Answer. On March 21, 2017, the U.S. Department of Health and Human
Services (HHS) published an interim final rule with comment period that
delayed the effective date of the final rule titled ``Advancing Care
Coordination Through Episode Payment Models (EPMs); Cardiac
Rehabilitation Incentive Payment Model; and changes to the
Comprehensive Care for Joint Replacement Model (CJR)'' to May 20, 2017,
the applicability date of certain EPM regulations to October 1, 2017,
and the effective date of certain CJR regulations to October 1, 2017.
We received public comments suggesting changes to the overall design of
the EPMs, CR incentive payment model and CJR model that were
unfortunately outside of the scope of the March 21, 2017 IFC
regulation. These comments touched on participation requirements, data,
pricing, quality measures, episode length, CR and SNF waivers,
beneficiary exclusions and notification requirements, repayment,
coding, and model overlap issues. We consider these public comments to
be outside of the scope of the March 21, 2017 IFC; and therefore, we
did not address them in the May 19, 2017 final rule, which finalized
the effective date of the rule as May 20, 2017 and the applicability
date of certain EPM regulations and certain CJR regulations as January
1, 2018. We may consider these public comments in future rulemaking.
medicaid additive effects
Question. The President's FY 2018 budget proposes $627 billion in
spending cuts to Medicaid. However, the President's budget also
includes language that these $600-plus-billion in Medicaid reductions
are on top of ``additional savings to Medicaid as a result of the
administration's plan to repeal and replace Obamacare.'' According to
the independent Congressional Budget Office, the American Health Care
Act (AHCA) would reduce Medicaid by $834 billion, the result of which
would be the removal of 14 million beneficiaries from the program and
cuts to care for millions more.
Secretary Price, for the record, what is the total amount of
Medicaid cuts under the President's budget? Please note, I am not
asking about government-wide savings target or total savings from
``repeal and replace.'' I am simply asking the administration to
clarify the total amount of assumed reductions to Medicaid under the
President's budget. Without an exact number of the Medicaid-specific
cuts assumed by the President in his budget, one can only assume that
the ``additional savings to Medicaid as a result of the
administration's plan to repeal and replace Obamacare'' is the over
$800 billion in cuts included in the House-passed AHCA bill. If that is
not accurate, please provide the total amount of Medicaid cuts in the
budget combined with the AHCA.
Answer. The President's FY 2018 budget does not incorporate
specific legislation that is before Congress. Therefore, it is not
accurate to apply the specific Medicaid savings the CBO has estimated
for legislation before Congress to the President's budget. To do so
would assume a level of specificity that does not exist in the budget.
The budget calls for refocusing Medicaid on the elderly, children,
pregnant women, and individuals with disabilities. The budget specifies
savings of $610 billion by providing additional flexibility to States
by reforming the fiscal structure of Medicaid, allowing a choice
between per capita cap or a block grant, beginning in FY 2020. In fact,
under the budget, Medicaid spending will continue to grow over the next
decade.
section 1115 and 1332 waivers
Question. Section 1115 of the Social Security Act provides the U.S.
Department of Health and Human Services (HHS) Secretary with the
authority to approve demonstration projects that promote the objectives
of Medicaid and the Children's Health Insurance Program (CHIP).
Section 1332 of the Patient Protection and Affordable Care Act
(ACA) provides the Secretary with broad authority to approve waivers to
certain ACA marketplace provisions. Applications must meet four
criteria: individuals must get insurance coverage at least as
comprehensive as provided under the ACA; insurance coverage offered to
individuals must be at least as affordable as it would be under the
ACA; as many people must be covered as would be under the ACA; and the
proposal must not increase the Federal deficit.
You have indicated your intention to streamline waiver rules and
procedures. What changes, if any, does the administration intend to
implement in its consideration of 1332 and 1115 waivers relative to
standing guidance?
What are HHS's internal controls for ensuring compliance with
transparency as well as notice and comment requirements for 1332 and
1115 waivers?
What is your goal for the length of time it takes HHS to approve a
waiver while upholding the letter of the law?
Answer. In March, U.S. Department of Health and Human Services
(HHS) sent letters to America's 50 Governors regarding 1332 waivers
announcing the Department's commitment to letting States develop
innovative strategies to adapt many of the Affordable Care Act's
requirements to suit the State's specific needs. HHS and CMS
Administrator Seema Verma then sent a separate letter to the Governors
announcing our commitment to ushering in a new era for Federal and
State Medicaid partnership where States have more flexibility to design
programs that meet their unique needs.
To receive approval for a 1332 State Innovation Waiver, a State
must demonstrate that a proposed waiver will provide access to quality
health care that is at least as comprehensive as would be provided
without the waiver, will provide coverage and cost sharing protections
against excessive out-of-pocket spending at least as affordable as
would be provided without the waiver, will provide coverage to at least
a comparable number of residents of the State as would be provided
coverage without a waiver, and will not increase the Federal deficit.
Further, before submitting its section 1332 waiver application the
State must also provide a public notice and comment period, including
public hearings, sufficient to ensure a meaningful level of public
input, and have in place a law providing for its implementation of the
waiver.
HHS and the Department of Treasury jointly oversee and set
standards for the application, review, and reporting process. Upon
receipt of a State Innovation Waiver application, the Departments will
work with the State on the review and approval process. A preliminary
review by the Departments will occur within 45 days of submission to
determine if the application is complete and a final decision will be
issued no later than 180 days after the determination that an
application is complete.
CMS established a new ``fast-track'' process for reviewing
proposals from States to extend established Medicaid and CHIP 1115
demonstrations that reauthorize longstanding policies with proven
program outcomes. States that want to be considered for the fast-track
process must use the streamlined extension application for the 1115
extension pathway under which it is requesting to be extended. The July
24, 2015 CMCS Informational Bulletin contains additional guidance and
information on the ``fast-track'' Federal review process.
medicaid and substance use disorder treatment
Question. Medicaid is the single largest payer of substance use
disorder services in the Nation and pays for a third of all medication-
assisted treatment (MAT) in the United States. Many States with the
highest opioid overdose death rates have used Medicaid to expand access
to MAT including Kentucky, Maine, Pennsylvania, Ohio, and West Virginia
as well as many other States being devastated by the opioid epidemic
like my home State of Oregon. Under the ACA's Medicaid expansion, one
out of three people covered through the Medicaid expansion have a
mental illness, substance use disorder, or both. In fact, independent
researchers estimate that repealing the Medicaid expansion would cut
$4.5 billion from mental health and substance use services for low-
income Americans. In fact, according to SAMHSA, the Affordable Care
Act, including the expansion of Medicaid, is expected to increase total
spending on behavioral health by more than $7 billion per year by 2020.
Unfortunately, the House-passed AHCA bill would undermine this
investment and progress in addressing the opioid epidemic by causing 23
million more individuals, including 14 million on Medicaid, to become
uninsured.
As Secretary of HHS, how do you intend to protect the gains in
access to SUD treatment achieved through Medicaid expansion if Medicaid
is cut by over $800 billion and the Medicaid expansion is repealed?
One of the critical ways in which we see the importance of access
to SUD treatment is by looking to the spread of the opioid epidemic,
particularly in rural regions of the country. How do you plan to combat
this epidemic if millions of Americans lose coverage for mental health
and SUD treatment? Given the fact that this epidemic is particularly
devastating for rural communities, do you have plans to combat opioid
abuse that will target individuals in these regions?
The House-passed AHCA bill repeals the requirement that States
provide certain Medicaid beneficiaries with access to the essential
health benefits including substance user disorder coverage. This
coupled with the increased financial pressure placed on States through
the repeal of the Medicaid expansion and conversion of Medicaid into a
capped program may lead States with no option but to drop coverage for
this critical benefit. How do you plan to work with States to ensure
that they do not limit or drop coverage for substance use disorders?
Answer. The U.S. Department of Health and Human Services (HHS) is
keenly aware of the devastating impact that opioid addiction is having
on our families and communities. The administration is committed to
doing all that we can to end the scourge of opioids that is sweeping
across this Nation.
The administration is committed to bringing everything the Federal
Government has to bear to address the health crisis opioids pose. The
budget calls for $811 million in support of the five-pronged strategy
guiding our Department's efforts to fight this scourge:
1. Improving access to prevention, treatment, and recovery
services, including the full range of medication-assisted treatments;
2. Targeting availability and distribution of overdose-reversing
drugs;
3. Strengthening our understanding of the crisis through better
public health surveillance;
4. Providing support for cutting edge research on pain and
addiction; and
5. Advancing better practices for pain management.
This funding increase will expand grants to Health Resources
Services administration (HRSA) Community Health Centers targeting
substance abuse treatment services from $94 million to $144 million.
Also within this total is $500 million for State Targeted Response to
the Opioid Crisis Grants that were authorized in the 21st Century Cures
Act, which expand access to treatment for opioid addiction. Using
evidence-based interventions, these grants will help to address the
primary barriers preventing individuals from seeking and successfully
completing treatment and achieving and sustaining recovery.
One of the key pillars of our approach is improving access to
treatment and recovery services, including medication-assisted
treatment (MAT) with naltrexone, buprenorphine, or methadone. As
mentioned above, through the State Targeted Response to the Opioid
Crisis grants authorized in the 21st Century Cures Act, HHS is
expanding access to opioid addiction treatment through evidence-based
interventions, including MAT. We are targeting the primary barriers to
seeking and successfully completing treatment and achieving and
sustaining recovery. This funding is critical to reversing the opioid
epidemic.
impacts of the ahca on rural and older americans
Question. In a May 24th report, the nonpartisan Congressional
Budget Office (CBO) provided an estimate of the coverage and budgetary
effects of the House-passed American Health Care Act (AHCA). According
to the CBO analysis, the AHCA would lead to 23 million more uninsured
Americans, 14 million of which would lose insurance after only 1 year.
Under the AHCA, insurers would be allowed to charge older Americans
five times more than younger Americans for the same insurance plan. The
AHCA would also replace the Affordable Care Act (ACA) ACA's tax credits
with credits that raise premium costs for older and rural Americans.
This is confirmed by CBO's analysis, which concluded that younger and
healthier consumers would be able to obtain skimpier policies with
lower premiums, while older and sicker enrollees would face higher
costs. In addition, because the AHCA's tax credits do not account for
local variation in health-care costs, rural Americans are more likely
to face higher premium costs than non-rural Americans.
A recent State-by-State analysis by the National Academy for State
Health Policy (NASHP) confirmed the predicted negative effect of the
AHCA on rural and older Americans. For example, with tax credits, a 60-
year-old in the Portland-metro area could see an increase in their
premium from $2,480 under the ACA to $8,590 under the AHCA, a nearly
400-percent increase, while a 27-year-old could only face premiums as
low as $1,340. Meanwhile, in rural Umatilla County, a 60-year-old would
see an increase in their premium from $2,480 under the ACA to $15,770
under the AHCA, an over 600 percent increase, while a 27-year-old would
pay premiums of $3,240.
President Trump promised, ``We're going to have insurance for
everybody. . . . There was a philosophy in some circles that if you
can't pay for it, you don't get it. That's not going to happen with
us.'' Secretary Price, the AHCA clearly would not keep President
Trump's promise, especially for rural and older Americans. Does the
administration support the AHCA even though it violates the President's
promises?
The MacArthur amendment would allow States to apply for waivers
that would permit insurers to charge older Americans even more than the
five times what they charge younger Americans for the same plan. These
waivers would harm older adults and likely price them out of their
coverage, again violating the President's promises. Does the
administration support the MacArthur amendment to the AHCA even though
it violates the President's promise?
How do you defend the President's statement that no one would lose
health insurance under his administration when CBO makes clear that 23
million Americans will lose coverage?
In a meeting with Republican senators, the President reportedly
told them that the AHCA is ``mean.'' Do you agree with the President
that the AHCA is mean? If not, please explain why causing 23 million
Americans to lose their health coverage, causing older Americans to pay
five times as much for coverage as younger Americans and cutting more
than $800 billion from the Medicaid safety net--all to pay for tax cuts
for the affluent--is not ``mean.''
Answer. Americans across the country have seen their health
insurance choices disappear and premiums spiral out of control,
increasing by double and triple digits. Last year alone, 73 insurers
left the exchanges. In one-third of counties, Americans have only one
choice for a health-care provider on the exchanges. Without action,
Americans are stuck with Obamacare's higher costs and fewer choices.
The administration is committed to working with Congress to repeal
and replace Obamacare. The budget proposal represents the President's
commitment to rescue Americans from the failures of the Obamacare. The
President supports a repeal and replace approach that provides
individuals and families tools to choose the coverage that best meets
their needs.
actuarial soundness in medicaid managed care
Question. In April 2016, the Centers for Medicare and Medicaid
Services (CMS) posted the final rule for Medicaid and CHIP Managed
Care. This rule finally updated Medicaid managed care regulations, the
first formal update in over a decade. One of the key principles of the
final rule was to update the standards for actuarial soundness in
Medicaid managed care plans. In short, actuarial soundness requirements
assure health plan rates are sufficient to reimburse provider networks
for services they provide to Medicaid beneficiaries. Ensuring rates are
actuarially sound is essential to ensuring beneficiaries can access the
care they need under the Medicaid program, an issue you have
highlighted as an area of focus in your past statements.
Will you commit to ensure that Medicaid managed care plans achieve
the Federal standard of actuarial soundness established in the Medicaid
and CHIP Managed Care Final Rule?
Will you uphold Federal oversight of rate-setting to assure health
plans achieve Federal actuarial soundness requirements in all States
and that beneficiaries have access to the care they need as required
under the Medicaid statute?
Answer. The U.S. Department of Health and Human Services (HHS) is
conducting a full review of managed care regulations in order to
prioritize beneficiary outcomes and State priorities.
benefits of and funding for tanf and ssbg
Question. You describe TANF as a program that promotes empowerment
of families through work. However, only 8 percent of States' TANF funds
are directed toward work.\2\ Rigorous studies also show that the
employment gains from work requirements were short-lived: within 5
years, recipients who were not subject to the work requirements were
just as or more likely to work as those who were subject to them.\3\
Very few States collect data on the employment of families when they
leave the welfare rolls, but the few that do show that the vast
majority of former recipients are stuck in low-wage jobs or not working
at all. Overall, few States have made steady progress toward increased
earnings and more stable employment.
---------------------------------------------------------------------------
\2\ http://www.cbpp.org/sites/default/files/atoms/files/4-8-
15tanf_0.pdf.
\3\ http://www.cbpp.org/sites/default/files/atoms/files/6-6-
16pov3.pdf.
Do you still believe that TANF, in its current state, is a program
---------------------------------------------------------------------------
that promotes empowerment of families through work?
Answer. TANF's fundamental focus on requiring work and establishing
time limits on assistance has been transformative in changing the
welfare policy landscape. These two pillars of the TANF program
continue to be integral to TANF's framework. While there are areas of
TANF that could be strengthened, this core framework continues to
promote the empowerment of families through work. The administration
looks forward to working with Congress to strengthen the work
requirement to increase participant engagement in activities that will
better help adult participants find jobs, remain employed, and advance
in the workforce.
Question. You tout the fact that so few families receive TANF as a
sign of success: for every 100 families in poverty, only 23 receive
cash assistance from TANF, down from 68 in 1996 when TANF was
created.\4\ But, one of the consequences of welfare reform is a
significant increase in the number of families who are deeply poor,
including many who have no access to any stable income from either work
or cash assistance, which we know has lifelong negative consequences
for children.
---------------------------------------------------------------------------
\4\ http://www.cbpp.org/sites/default/files/atoms/files/6-16-
15tanf.pdf.
Do you believe that caseload decline, even if it puts children in
---------------------------------------------------------------------------
harm's way, is an adequate measure of success?
Answer. Caseload decline is only one piece of the TANF story and is
not an adequate measure of success on its own. The goal is to move
families off of TANF through work. Under the TANF program, the
employment of single mothers increased by 12 percent from 1996 through
2000, and even after the 2008 recession, employment for this
demographic is still higher than before welfare reform.
TANF's primary measure is the work participation rate, which
measures the degree to which families with a work-eligible individual
receiving cash assistance are engaged in specified work activities.
States must engage families to meet their target rate or face a
financial penalty. The goal is to help families prepare for and go to
work in a way that increases their capacity to support their families
financially and reduce their dependency on public benefit programs.
Question. How do you reconcile your view that the TANF caseload
decline is a measure of success with the scientific evidence that
exposing children to high levels of stress negatively impacts their
growth and development and has long-term negative consequences?
Answer. The administration wants to support States in their efforts
to move families from welfare to work. The administration believes the
achievement of gainful employment and economic independence is
critically important for the well-being of parents and their children.
More than just a means of income, work creates opportunities for
individual growth; instills personal dignity; promotes health and well-
being; and provides low-income families with a clear pathway to
financial self-
sufficiency.
Question. In your January 2017 responses to questions for the
record related to TANF, you stated, ``I think the best way to measure
the success of the law is to see where the Nation was prior to its
passage and where we are now.'' The Center on Budget and Policy
Priorities (CBPP) has reported that extreme poverty has more than
doubled since the passage of TANF in 1996.\5\ HHS has also previously
referred to TANF as an ``anti-poverty program.''
---------------------------------------------------------------------------
\5\ Ibid.
How do you reconcile your view that the TANF caseload decline is a
measure of success with evidence that extreme poverty has more than
---------------------------------------------------------------------------
doubled since the passage of TANF?
Answer. As stated above, caseload decline is only one measure, and
is not an adequate measure on its own. The administration believes the
emphasis should be on moving families from welfare to work. On that
score, TANF has been a clear success. The employment rate for never-
married mothers rose from 49 percent in 1995 to 66 percent in 2000 and
has never returned to pre-welfare reform lows.
As a result, the official poverty rate for single mothers and their
children fell from 44 percent in 1994 to 33 percent in 2000 and,
despite a still-recovering economy, the poverty rate for this group in
2015 (36.5 percent) was still below the rates seen prior to welfare
reform.
Nevertheless, poverty--and in particular deep poverty--remains too
high in our country, and we must implement policies that will build on
the progress TANF made in helping many families experience financial
stability and security through employment. The administration looks
forward to working with you to find better ways to help low-income
Americans rise out of poverty.
Question. If you still believe that TANF is successful, then why,
under your budget, would it face $22 billion in cuts over the next
decade?
Answer. TANF's success is not the result of the amount of dollars
spent; rather its success comes from its restructuring of a welfare
system to create a program that provides time-limited assistance,
promotes empowerment through work, and fosters innovation.
As you know, TANF is a State-run program that offers flexibility in
the use of funds to achieve the program's purposes. While this
flexibility has been essential to allowing States to create innovative
and effective strategies for helping families gain self-sufficiency,
States have also been able to use their funds for benefits that fail to
serve the core intent of the program. For example, States have used
their TANF funds on services that are not targeted to a low-income
population, and have even replaced existing State spending with TANF
dollars in an effort to fill State budget gaps. Over time, States have
reduced the portions of their block grants spent on work programs.
Under the budget proposal, States will be able to maintain and
strengthen services that promote employment, family stability, and
self-sufficiency--and thereby reduce the need for TANF cash assistance
benefits--by renewing attention to the core purposes of the program.
Question. Clearly if States could no longer transfer TANF funds to
SSBG, they would spend their flexible TANF dollars within the purposes
of TANF. It seems clear that the justification for cutting TANF as to
``align'' with the proposed elimination of SSBG is nothing more than
window dressing for reducing funding. How would you respond to
governors across the Nation who are concerned by the proposed $22
billion in cuts to funding that their States, citizens and service
providers have come to rely upon?
Answer. Many States are not sufficiently investing their current
dollars in TANF's key welfare-to-work activities. In Fiscal Year 2015,
States spent only about 28 percent of their total TANF and State
maintenance-of-effort funds on the combination of work, work supports
such as child care and transportation services, and case management
services. States do not need more money in the TANF program; they need
to use taxpayers' money more effectively to help move families
dependent on public resources into stable work that can lead to self-
sufficiency, to the benefit of both parents and children.
Question. In January 2017, you stated, ``As a 2011 GAO report
pointed out, SSBG is a program of fragmentation, overlap, and
duplication.'' You additionally stated that ``there is not a one-size
fits all approach to how States might react should there be an
elimination of any Federal program.''
Could you specifically describe which 2011 GAO reported that SSBG
is identified as a program of ``fragmentation, overlap, and duplication
and provide page numbers to support this claim?''
Answer. On March 1, 2011, the GAO released its report,
``Opportunities to Reduce Potential Duplication in Government Programs,
Save Tax Dollars, and Enhance Revenue'' (GAO-11-318SP). Its supplement
report, ``List of Selected Federal Programs That Have Similar or
Overlapping Objectives, Provide Similar Services, or Are Fragmented
Across Government Missions,'' was released on March 18, 2011. On page
14 of the supplement report, SSBG is cited as one of 80 Federal
programs providing transportation services for transportation-
disadvantaged persons.
tpp biologics/stock trading
Question. During your confirmation process before the Finance
Committee, you were asked about meetings you may have had related to
your holdings and purchases in an Australian pharmaceutical company--
Innate Immunotherapeutics (``Innate''). On June 1st, ProPublica
reported in an article (``Tom Price Bought Drug Stocks. Then He Pushed
Pharma's Agenda in Australia,'') that you discussed the pharmaceutical
industry's trade agenda in meetings with Australian officials. Such
discussions could have impacted the business of Innate and other
pharmaceutical companies you held at the time of the meetings.
Please describe any communications between you (or your staff) and
the Office of the United States Trade Representative, representatives
of the Government of Australia, or Members of Congress or their staff,
with knowledge of the negotiations and implementation discussions
regarding the TPP biologics commitments and their implementation by
foreign governments between December 2015 and August 31, 2016. For each
communication, please indicate the approximate date of the
communication and the information provided.
Please provide the itinerary for the April 2016 congressional
delegation to Australia and the Philippines described in the ProPublica
article noted above.
Did you discuss biologics commitments and their implementation
under the Trans-Pacific Partnership when you met with Australian
government officials in April 2016? If so, please identify the meetings
in the itinerary in which biologics commitments were raised, and
describe the nature of any such discussion.
Did you or your staff discuss biologics commitments and their
implementation under the Trans-Pacific Partnership with any U.S.
Government officials between December 2015 and August 31, 2016? If so,
please identify the meetings in the itinerary in which biologics
commitments were raised, and describe the nature of any such
discussion.
Answer. The administration is aware of the following
communications/meetings that were undertaken between December 2015 and
August 31, 2016 with individuals in the Office of the U.S. Trade
Representative (USTR), representatives of the Australian Government,
and Members of Congress (and staff) who may have had knowledge of the
negotiations and implementation discussions regarding the Trans-Pacific
Partnership (TPP) biologics commitments and their implementation.
Office of the United States Trade Representative
The House Committee on Ways and Means hosted a members-only
briefing with USTR Michael Froman on December 2, 2015.
The Secretary and Warren Negri (Policy Advisor) met with USTR
Michael Froman on April 29, 2016.
House Committee on Ways and Means
The House Committee on Ways and Means hosted a members-only
briefing on TPP on December 1, 2015.
The House Committee on Ways and Means hosted a members-only
briefing with USTR Michael Froman on December 2, 2015.
Angela Ellard and Stephen Claeys, from the House Committee on
Ways and Means, met with the Secretary and Kyle Zebley (Legislative
Director) on March 23, 2016, to conduct a briefing on TPP prior to the
Congressional Delegation (CODEL) trip to Australia in the spring of
2016.
Kyle Zebley (Legislative Director) conducted a phone call with
Stephen Claeys on April 26, 2016, prior to the meeting with USTR
Michael Froman on April 29, 2016.
The Government of Australia
The Secretary's only interaction with the Government of Australia
between December 2015 and August 31, 2016 took place during a CODEL
from March 29, 2016 through April 7, 2016. The purpose of the CODEL was
to meet with U.S., Australian, and Filipino defense officials and
service members to evaluate U.S., ally, and partner installations,
operations, and training in the Pacific region, with a particular focus
on new U.S. programs, deployments, and installations in support of the
Pacific rebalance. A complete manifest of the CODEL has been included.
Congressional staff had no interaction with the Government of
Australia between December 2015 and August, 31, 2016.
______
Questions Submitted by Hon. Debbie Stabenow
mental health and substance abuse
Question. Research from Harvard Medical School and New York
University shows that eliminating Medicaid expansion increases the
addiction treatment gap by 50 percent and takes away $5.5 billion per
year from treatment for substance use disorders and mental health.
Do you agree that the cut to Medicaid in the HHS budget will reduce
access to substance use disorder and mental health services?
Do you support the waivers in the American Health Care Act that
would allow insurance companies to end the requirement that plans cover
addiction services and mental health treatment?
Answer. Addressing serious mental illness across our Nation and
combating the opioid epidemic are two of the Department's top
priorities. The U.S. Department of Health and Human Services (HHS) is
keenly aware of the devastating impact that opioid addiction is having
on our families and communities. The administration is committed to
doing all that we can to end the scourge of opioids that is sweeping
across this Nation.
The administration is committed to bringing everything the Federal
Government has to bear to address the health crisis opioids pose. The
budget calls for $811 million in support of the five-pronged strategy
guiding our Department's efforts to fight this scourge:
1. Improving access to prevention, treatment, and recovery
services, including the full range of medication-assisted treatments;
2. Targeting availability and distribution of overdose-reversing
drugs;
3. Strengthening our understanding of the crisis through better
public health surveillance data and reporting;
4. Providing support for cutting edge research on pain and
addiction; and
5. Advancing better practices for pain management.
This funding increase will expand grants to Health Resources
Services Administration (HRSA) Community Health Centers targeting
substance abuse treatment services from $94 million to $144 million.
Also within this total is $500 million for State Targeted Response to
the Opioid Crisis Grants that were authorized in the 21st Century Cures
Act, which expand access to treatment for opioid addiction. Using
evidence-based interventions, these grants will help to address the
primary barriers preventing individuals from seeking and successfully
completing treatment and achieving and sustaining recovery.
One of the key pillars of our approach is improving access to
treatment and recovery services, including medication-assisted
treatment (MAT) with naltrexone, buprenorphine, or methadone. As
mentioned above, through the State Targeted Response to the Opioid
Crisis grants authorized in the 21st Century Cures Act, HHS is
expanding access to opioid addiction treatment through evidence-based
interventions, including MAT. We are targeting the primary barriers to
seeking and successfully completing treatment and achieving and
sustaining recovery. This funding is critical to reversing the opioid
epidemic.
healthy michigan plan
Question. Last week in Lansing, business leaders, the Michigan
Department of Health and Human Services, the State budget office,
hospitals, health-care providers, and others held a meeting on
Medicaid. There was widespread agreement that Medicaid is working in
Michigan.
The State's Budget Director said about our Healthy Michigan Plan:
``This is not only the right thing to do, it's the smart and fiscally
responsible thing to do. Reductions in delayed and uncompensated care
and increase in healthier lifestyles provide benefits to us all in so
many ways.''
The HHS budget would cut Medicaid funding in half 10 years from
now, and the American Health Care Act ends Medicaid expansion entirely.
Do you think Michigan's Budget Director incorrectly assessed
Michigan's Medicaid expansion?
Do you disagree with research that shows Medicaid expansion in
Michigan has led to job creation, cost savings, and insurance coverage?
Answer. (See response below.)
Question. The State's Budget Director said that the Medicaid cuts
would create an $800-million per-year hole in the budget it could not
afford.
Do you agree that Michigan couldn't continue to fund health care,
and that cuts would have to be made?
Answer. The administration remains committed to ensuring that
Medicaid is available for eligible beneficiaries, and working with
States to ensure they are able to make the most use of available
resources to serve their citizens. As you know, Medicaid is the primary
source of medical coverage for millions of low-income American families
and seniors facing health challenges. However, its costs have been
growing drastically without improvement in outcomes.
The problem isn't lack of funding; the problem is lack of
flexibility. Rigid and outdated Federal rules and requirements prevent
States from pioneering delivery system reforms and from prioritizing
Federal resources to their most vulnerable populations, which hurts
access and health outcomes. The administration is committed to giving
States as much freedom as possible to design reforms that meet the
spectrum of diverse needs of their Medicaid populations.
Question. The budget doesn't include any information on the impact
of Medicaid cuts.
Has HHS evaluated what these cuts would mean for Michigan?
Answer. The FY 2018 budget calls for refocusing Medicaid on the
elderly, children, pregnant women, and individuals with disabilities.
In fact, under the budget, Medicaid spending will continue to grow over
the next decade.
______
Questions Submitted by Hon. Maria Cantwell
affordable care act contraceptive benefit
Question. On May 31, 2017, the media released a draft interim final
rule by your department that in my understanding would allow any
employer in the country to easily deny birth control to their
employees. Multiple studies show that access to birth control without
cost-sharing leads to better health, economic security, and lower rates
of unintended pregnancies.
Are you aware of the reports about this interim final rule?
Are you familiar with the document that was released by the media?
Is your department planning an interim final rule on this matter?
Answer. The administration is not at liberty to discuss the details
of pending rules and regulations.
mandatory sequester and effect on medicare reimbursement
Question. President Trump has repeatedly promised the American
people that he won't cut Medicare.
Does the President's FY18 budget propose to extend the mandatory
sequester beyond OMB's current law baseline?
Does the mandatory sequester reduce the aggregate amount of
Medicare reimbursement that providers would receive, compared to an
assumption of current law?
Do you consider the mandatory sequester a cut to Medicare
reimbursement?
Answer. The President's budget reflects current law. In addition,
the budget proposes to continue current law by extending sequestration
by 2 years. This is not a cut to what Medicare currently pays to
providers and does not change benefits or prices charged to
beneficiaries generally.
Questions Submitted by Hon. Bill Nelson
Question. President Trump repeatedly promised that he would protect
the Medicare and Medicaid programs from cuts during his campaign.
Proposals to cut billions of dollars from the Medicare program,
increase the Medicare eligibility age, turn Medicare into a voucher
program, or increase out-of-pocket costs for seniors on Medicare would
affect the over 4 million Floridians who depend on the program for
financial security.
The administration's budget extends the across-the-board cuts in
Medicare provider payments by 2 years, effectively cutting $30 billion
from the Medicare program. Do you agree that this is a cut to the
Medicare program?
Answer. The President's budget reflects current law. In addition,
the budget proposes to continue current law by extending sequestration
by 2 years. This is not a cut to what Medicare currently pays to
providers and does not change benefits or prices charged to
beneficiaries generally.
Question. Last month, OMB Director Mulvaney made comments
indicating that he would advise the President to not keep his promises
to protect the Medicare program from cuts.
As the President's top advisor on Medicare, do you agree with
Director Mulvaney that next year's budget should cut Medicare?
Answer. For 51 years, Medicare has played a crucial role in
providing health care for America's senior citizens. Unfortunately,
Medicare trustees have consistently told us that the Medicare program
is in financial trouble. In light of that fact, my primary concern has
always been to protect the program for seniors today and the
generations to come. At HHS, we take seriously our responsibility to
protect Medicare for this generation and those to come, and we are
pursuing all available avenues to improve Medicare's sustainability in
ways that put patients first.
The Congressional Budget Office's (CBO) estimate for H.R. 1628, the
American Health Care Act, shows just how much of a disaster this bill
would be for American families. According to CBO:
14 million Americans will lose their health insurance next year.
$834 billion would be cut from the Medicaid program.
Older Americans will pay more for less. In fact, the bill will
result in ``substantially raising premiums for older people.''
The uninsured rate ``would be disproportionately larger among
older people with low incomes.''
For example, in 2026, a 64-year old who earns just over $26,000
in a non-waiver State would pay $16,100 in premiums rather than $1,750
under the Affordable Care Act.
Question. You stated that ``nobody will be worse off financially''
under the health plan. How is the bill better for Floridians? It ends
the Medicaid program as we know it, charges older Americans more for
less coverage, and ends the guarantee of coverage for people with
preexisting conditions.
Answer. Americans across the country have seen their health
insurance choices disappear and premiums spiral out of control,
increasing by double and triple digits. Last year alone, 73 insurers
left the exchanges. In one-third of counties, Americans have only one
choice for a health-care provider on the exchanges. Without action,
Americans are stuck with Obamacare's higher costs and fewer choices.
The administration is committed to working with Congress to repeal
and replace Obamacare. The budget proposal represents the President's
commitment to rescue Americans from the failures of Obamacare. The
President supports a repeal and replace approach that provides
individuals and families tools to choose the coverage that best meets
their needs.
Question. The administration's budget states, ``Outbreaks like Zika
will not be a one-time event.'' Yet, the administration's budget cuts
the very programs designed to respond to and prevent public health
emergencies like the Zika virus. Please answer the following questions
on the Zika virus with a yes or no answer, unless otherwise specified.
Does your budget cut more than $7.2 billion from the National
Institutes of Health (NIH)?
Answer. The budget includes a total of $25.9 billion to support the
highest priority biomedical research within the National Institutes of
Health (NIH). NIH is the largest public funder of biomedical research
in the world. NIH expands the biomedical knowledge base by funding
cutting-edge research, improves health by seeking new treatment and
prevention options, supports the training of the current and future
biomedical workforce, and drives economic growth and productivity.
The FY 2018 budget presents an opportunity for HHS and NIH to
reexamine how to optimize Federal investment in a way that best serves
the American people. The budget was developed to enhance the
stewardship of taxpayer dollars by focusing our resources on innovative
scientific research. The Department assessed opportunities within the
NIH to determine where greater efficiencies may be possible.
Additionally, the administration will propose a package of reforms
to streamline Federal compliance requirements and reduce burden on NIH
grantees. These targeted policies will reduce the time and expenses
that grantees must currently spend to comply with overly burdensome
Federal grant requirements, thus lowering grantees' administrative
costs and mitigating the impact of lower reimbursements. The approach
will also seek to develop a uniform indirect cost rate to all grants
that mitigates the risk for fraud and abuse by simplifying and
uniformly applying the rate for grantees.
Question. Does it cut more than $600 billion from the Medicaid
program, on top of many of the cuts included in the House-passed
health-care bill?
Answer. No. The President's FY 2018 budget does not incorporate
specific legislation. Therefore, it is not accurate to apply the
specific Medicaid savings the CBO has estimated for legislation before
Congress to the President's budget. To do so would assume a level of
specificity that does not exist in the budget. The budget calls for
refocusing Medicaid on the elderly, children, pregnant women, and
individuals with disabilities. The budget specifies savings of $610
billion by providing additional flexibility to States by reforming the
fiscal structure of Medicaid, allowing a choice between per capita cap
or a block grant, beginning in FY 2020.
Question. Does it cut more than $1.3 billion from the Centers for
Disease Control and Prevention (CDC), including $35 million from the
National Center of Birth Defects and Developmental Disabilities; $65
million from the Center for Emerging and Zoonotic Infectious Disease;
and $135 million from the Office of Public Health Preparedness and
Response?
Answer. The FY 2018 budget for CDC and the Agency for Toxic
Substances and Disease Registry (ATSDR) is $11.1 billion. This total
includes $5.1 billion in budget authority, $841 million from the
Prevention and Public Health Fund, and $143 million in Public Health
Service (PHS) Evaluation Funds.
At this funding level, CDC will continue to protect the Nation and
the world by: detecting, responding to, and stopping new and emerging
health threats; preventing injuries, illness, and premature deaths; and
discovering new ways to protect and improve the public's health through
science and advanced technology. The budget prioritizes funding for key
areas where CDC can have the greatest impact, including: continuing the
fight against opioid abuse, misuse, and overdose; supporting efforts to
combat childhood obesity; protecting the Nation's national security
through medical countermeasure stockpiling; and investing in CDC's
infrastructure to ensure the safety, security, and productivity of CDC
staff.
The budget provides CDC with increased flexibility to allocate
resources and implement policies that best support mission-critical
activities based on current science and public health expertise. This
programmatic flexibility will enable the CDC to focus on programs that
have been proven effective, while reducing costs and improving the
efficient use of resources. The budget establishes the new America's
Health Block Grant, reforming the model of existing State-based chronic
disease programs to increase flexibility, allowing States to focus on
leading public health challenges specific to their State.
Question. Does it cut $850 million from the Food and Drug
Administration and propose to replace this loss of budget authority
with user fees? Under current law, user fees cannot currently be used
to support public health work. Does this change under the
administration's budget?
The FY 2018 budget requests a total program level of $5.1 billion
to support FDA's core mission to protect the Nation's public health by
enhancing the safety of food and ensuring the safety and effectiveness
of medical products. FDA's jurisdiction of products and activities is
vast, ranging from analyzing the latest in medical technology to
ensuring the safety of the Nation's food supply. The challenge of
ensuring the safety and effectiveness of these products increases in
complexity within a growing global market.
In a constrained budget environment, the budget acknowledges
medical product industries have sufficiently matured to assume a
greater share of costs associated with FDA's administrative actions.
User fees have been instrumental in allowing FDA to build capacity and
improve the timeliness of the medical product review process without
compromising the agency's high standards. The FY 2018 President's
budget recalibrates FDA medical product user fees to over $2.5 billion
in 2018, an increase of $1.2 billion over the annualized CR level. The
budget supports, through 100-percent user fee funding, medical product
review and approval activities associated with the prescription and
generic drugs, biosimilar, medical device, and animal drugs programs,
including operational and support costs associated with White Oak
campus operations, rent payments to the General Services
Administration, other commercial rent and rent-related charges, as well
as anticipated FY 2018 inflation for rent costs. Legislative revisions
will be needed for all of these programs to ensure continuity of review
and approval activities. To support speeding patient access to safe and
effective medical products, the budget also includes a portfolio of
administrative actions to achieve regulatory efficiencies through
program and process improvements.
The FY 2018 budget request also includes reductions totaling $127.2
million in budget authority, targeted to certain areas where better
tools and policies will allow FDA to do more with less, while
preserving core mission activities. These reductions will be coupled
with policy efforts to improve the efficiency of the programs that see
reductions, to improve effectiveness and take a risk-based approach to
FDA's consumer protection mission.
Question. Florida is relying on Medicaid to help prevent the spread
of the Zika virus and treat those affected. With the broad Medicaid
cuts outlined in both the administration's budget and the House-passed
health-care bill, the State of Florida will have to choose between
prevention and treating those affected by an epidemic, continuing to
serve seniors in nursing homes, and caring for Florida's medically
complex children.
How would you recommend that States handle a public health threat
like Zika, if their Medicaid funds are capped?
Answer. Rigid and outdated Federal rules and requirements prevent
States from pioneering delivery system reforms and from prioritizing
Federal resources to their most vulnerable populations, which hurts
access and health outcomes. The President's budget will give States as
much freedom as possible to design reforms that meet the spectrum of
diverse needs of their Medicaid populations.
The administration is committed to making sure that States have the
flexibility to design their Medicaid programs to meet the needs of the
most vulnerable in their State. By strengthening the Federal and State
Medicaid partnership, we will empower States to develop innovative
solutions to challenges like Zika, rather than telling States how they
should run their programs.
Question. The opioid crisis is devastating Florida and the rest of
the Nation. Over 2,500 Floridians died from opioids in the first half
of 2016 alone. Yet the administration's budget cuts over $600 billion
from Medicaid, in addition to many of the cuts included in the House-
passed health-care bill; cuts 9 percent from the Substance Abuse and
Mental Health Services Administration; cuts $355 million from the
National Institute of Mental Health; and cuts $235 million from the
National Institute on Drug Abuse.
During his campaign, President Trump promised to give people
addicted to opioids access to the help they need. Given the cuts
outlined above, how does the administration's budget prioritize giving
people with opioid addiction the help they need?
Answer. (See answer provided below)
Question. As the single largest payer for substance use services
and treatments, Medicaid plays a critical role in the fight against the
opioid epidemic. Changing the Medicaid program through block grants or
caps, as the administration's budget proposes, will shift costs to
States, eliminate critical Federal protections, and hurt the more than
4 million Floridians who rely on the program, including those with
opioid addiction.
If these cuts are made, how do you propose States like Florida
provide the necessary services to help individuals with substance use
disorders?
Answer. Addressing serious mental illness across our Nation and
combating the opioid epidemic are two of the Department's top
priorities. The U.S. Department of Health and Human Services (HHS) is
keenly aware of the devastating impact that opioid addiction is having
on our families and communities. The administration is committed to
doing all that we can to end the scourge of opioids that is sweeping
across this Nation.
The administration is committed to bringing everything the Federal
Government has to bear to address the health crisis opioids pose. The
budget calls for $811 million in support of the five-pronged strategy
guiding our Department's efforts to fight this scourge:
1. Improving access to prevention, treatment, and recovery
services, including the full range of medication-assisted treatments;
2. Targeting availability and distribution of overdose-reversing
drugs;
3. Strengthening our understanding of the crisis through better
public health surveillance data and reporting;
4. Providing support for cutting edge research on pain and
addiction; and
5. Advancing better practices for pain management.
This funding increase will expand grants to Health Resources
Services Administration (HRSA) Community Health Centers targeting
substance abuse treatment services from $94 million to $144 million.
Also within this total is $500 million for State Targeted Response to
the Opioid Crisis Grants that were authorized in the 21st Century Cures
Act, which expand access to treatment for opioid addiction. Using
evidence-based interventions, these grants will help to address the
primary barriers preventing individuals from seeking and successfully
completing treatment and achieving and sustaining recovery.
One of the key pillars of our approach is improving access to
treatment and recovery services, including medication-assisted
treatment (MAT) with naltrexone, buprenorphine, or methadone. As
mentioned above, through the State Targeted Response to the Opioid
Crisis grants authorized in the 21st Century Cures Act, HHS is
expanding access to opioid addiction treatment through evidence-based
interventions, including MAT. We are targeting the primary barriers to
seeking and successfully completing treatment and achieving and
sustaining recovery. This funding is critical to reversing the opioid
epidemic.
The administration's objective is ensuring all Americans have
access to the best and highest quality coverage and care. Having
coverage is not meaningful if one cannot access the care they need or
the quality of care leaves them worse off--we must work toward both
coverage and care.
Question. I recently heard from a constituent whose son has Down
Syndrome. After years of being on the Medicaid waiver list, he finally
began receiving benefits. At this point, his life drastically changed
for the better. He began to participate in an adult supervised day
program. He receives transportation so that he can socialize with his
peers. Overall, his quality of life has improved.
Have you considered what a Medicaid cap or block grant would look
like for this constituent and his family? Limiting State Medicaid
funding will force States to limit eligibility and/or benefits, and
create lengthy waiting lists for Floridians who are sick and/or
disabled. What do I tell his parents when programs that improve their
child's quality of life are cut? What about all of the other Floridians
who rely on Medicaid?
Answer. The administration remains committed to ensuring that
Medicaid is available for eligible beneficiaries, and working with
States to ensure they are able to make the most use of available
resources to serve their citizens. As you know Medicaid is the primary
source of medical coverage for millions of low-income American families
and persons with disabilities. However, its costs have been growing
drastically without improvement in outcomes.
The problem is not lack of funding; the problem is lack of
flexibility. Rigid and outdated Federal rules and requirements prevent
States from pioneering delivery system reforms and from prioritizing
Federal resources to their most vulnerable populations, which hurts
access and health outcomes. The administration is committed to giving
States as much freedom as possible to design reforms that meet the
spectrum of diverse needs of their Medicaid populations.
Question. For 20 years, the Children's Health Insurance Program
(CHIP) has provided low-cost health coverage to children in families
that earn too much money to qualify for Medicaid.
The Medicaid and CHIP Payment and Access Commission (MACPAC)
recommends a 5-year extension of CHIP funding through fiscal year 2022.
MACPAC also recommends extending the enhanced 23-percentage-point
Federal match and Maintenance of Effort requirement through fiscal year
2022.
At your confirmation hearing, you recommended an 8-year extension,
as did CMS Administrator Verma. Despite its critical need, CHIP is
extended for just 2 years in the administration's budget. The budget
proposes to end the enhanced 23-percent Federal match for States, as
well as the Maintenance of Effort requirement.
What is the rationale for attempting to disrupt a stable source of
health coverage for 8.4 million children, including 375,000 in Florida?
Answer. The budget proposes to extend funding for CHIP for 2
additional years through FY 2019. Extending CHIP funding for 2 years
provides stability to States and families while the future of the
program is addressed alongside other health reforms. This funding
guarantees that the most vulnerable children will continue to have
coverage.
The budget also proposes a series of improvements that rebalance
the State-
Federal partnership and increase State flexibility. This proposal ends
the 23-
percentage point increase in the enhanced Federal match rate and the
current law maintenance of effort requirement after FY 2017. The budget
also proposes ending the Obamacare requirement for States to move
certain children from CHIP into Medicaid and capping the level at which
States could receive the CHIP enhanced Federal matching rate at 250
percent of the Federal Poverty Level. These provisions would return the
focus of CHIP to the most vulnerable and low-income children.
Question. ALS is a progressive neuromuscular disease that typically
leads to death within 2 to 5 years of symptom onset. Studies by the
National Institutes of Health (NIH) and Department of Defense (DOD)
have documented that military veterans are about twice as likely to die
from ALS. We know this because the National ALS Registry, housed at the
CDC, analyzes information from the DOD, the Department of Veterans
Affairs, NIH, and CMS, as well as from individuals living with ALS.
The National ALS Registry is a critical resource for (1) providing
data to researchers focused on developing treatments and prevention
strategies; and (2) matching patients to potential clinical trials.
Unfortunately, the administration's budget called for the elimination
of the National ALS Registry.
I'm concerned that if funding for the National ALS Registry were
eliminated, people living with ALS would lose their opportunity to be
contacted directly for a wide range of clinical trials and other
important research. Moreover, public and private researchers would lose
their access to the unique data and patients needed to drive
understanding of the disease and development of therapies.
Do you think we should keep this unique and valuable resource that
researchers and patients rely on?
Answer. In a constrained budget environment, difficult funding
decisions must be made to ensure that HHS invests in activities that
are core to its mission and not duplicative of other efforts across the
Federal Government. NIH-funded research on ALS will continue, and
external researchers may still use biospecimens previously obtained
from the ALS biorepository.
Question. The Pandemic and All Hazards Preparedness Act (PAHPA)
created the office of the Assistant Secretary for Preparedness and
Response--a leader in preventing and responding to public health
emergencies like the Zika virus. Unfortunately, the administration's
budget cuts $25 million from this critical office and many other
programs that are critical to our Nation's public health emergency
preparedness.
How do you intend to use lessons learned from past public health
emergencies, like Hurricane Matthew, Ebola, and now the Zika virus, to
improve coordination and communication among Federal agencies involved
in emergency preparedness?
Answer. Incorporating lessons learned into policies, plans, and
procedures is a vital component of emergency preparedness. It ensures
that issues identified in past events do not reoccur during future
responses. ASPR is continually evaluating its responses to public
health and medical events, developing lessons learned, and implementing
actions to improve coordination and communication. Such lessons are
also provided to emergency response planners and are incorporated into
future exercises and responses. Lessons learned from past natural
hazard incidents and disease outbreaks such as Hurricane Matthew, Zika,
and Ebola, guide strategies for improvement throughout the Department,
including information sharing; intra/inter-agency coordination; State,
local, tribal, and territorial coordination; and the management of
public health and medical assets.
Following the Ebola response, HHS initiated and participated in a
number of actions to improve interagency coordination. For instance, we
recognized a need to codify how infectious disease emergencies are
managed under the National Response Framework (NRF). This was
accomplished through significant updates and alignment of the
Biological Incident Annex (BIA) to the NRF. The BIA now provides the
overarching framework under which the interagency (the Federal
executive departments and agencies) organizes and coordinates. This
includes identifying the thresholds for triggering such coordination,
particularly for a high-consequence event/threat. The final draft BIA
was approved by the interagency Domestic Resilience Group (DRG), which
was convened by the White House in January 2017.
In addition, HHS has collaborated with the Department of Defense
(DoD) to leverage their Interagency Transportation Support Framework
(ITSF) Concept of Operations (CONOPS), which is an agreement between
HHS and DoD (NORTHCOM) to facilitate the rapid airlift of personnel and
equipment during a domestic response. This new ITSF CONOPS (post-Haiti
response) allows HHS to request DoD airlift much faster than previous
responses because HHS personnel and equipment are now planned and
integrated into DoD transportation (airlift) systems prior to a
response.
Building on lessons learned during the Ebola response, early in the
Zika outbreak, ASPR convened partners in HHS and across the U.S.
Government with a goal of sharing information about the supply chain
and planned procurements of Zika insecticide, traps, and repellents. In
each of those working groups, members determined how to coordinate to
make the desired products more readily available to the private sector
and non-Federal government partners. ASPR is now developing a
formalized mechanism for coordination of purchases with the Critical
Infrastructure Partnership Advisory Council.
Another example of using lessons learned from Ebola is the approach
taken for planning during the initial stages of the Zika outbreak. HHS,
led by ASPR and CDC, has developed a draft Federal operational plan
that builds on the HHS Zika Virus Disease Preparedness and Response
Goals and Objectives. The Zika planning construct displays the
connections and relationships between the HHS-led Zika plans and other
planning efforts. The U.S. Government Zika Virus Disease Contingency
Response Plan describes the Unified Coordination Group's operational
coordination and synchronization, as well as the steps necessary among
Federal agency partners and State representatives to assist HHS in
response activities. In the event of a large scale Federal response
where the impact of a particular incident overwhelms State and local
resources or the lead Federal agency, HHS would determine whether
interagency support is or will be required.
Finally, the Department has utilized the lessons learned from the
2009/2010 pandemic experience and other public health responses to
ensure that the Department is better prepared for the next pandemic
influenza incident. The Department recently published its 2017 update
to its Pandemic Influenza Plan. Originally adopted in 2005 and last
updated in January 2009, the 2017 Pandemic Influenza Plan Update
applies the public health lessons learned since January 2009.
______
Questions Submitted by Hon. Robert Menendez
autism cares act programs
Question. The Autism CARES Act of 2014, which I authored and which
was passed unanimously by Congress, reauthorized Federal autism
programs through fiscal year 2019. These programs include training
programs, research, and State systems grants. The proposed budget
eliminates all funding for these programs, despite the well-recognized
and growing need for the services they facilitate.
The Leadership Education in Neurodevelopmental and Related
Disabilities (LEND) program supports the interdisciplinary training of
graduate-level professionals in improving the quality of care to fit
the unique needs of young people with disabilities. This program
currently funds 52 projects in 44 States across the country, including
at Rutgers University in my home State of New Jersey. Collectively,
these projects share information with each other as part of a national
network. Does the department believe that supporting the training of
professionals to provide care for people with autism and other
disabilities is no longer a Federal responsibility?
Answer. The President's budget prioritizes programs that support
direct health-care services and give States and communities the
flexibility to meet local needs. Some of these activities could be
continued by States using their Maternal and Child Health Block Grant
awards.
Question. The Interdisciplinary Technical Assistance Center (ITAC),
authorized by the Autism CARES Act, provides technical assistance to
LEND programs and Developmental-Behavioral Pediatrics (DBP) programs
and helps to coordinate activities at programs that receive funding as
a result of the Autism CARES Act. Do you believe that funding the
coordination and sharing of information between LEND and DBP programs
is no longer a Federal priority?
Answer. The President's budget prioritizes programs that support
direct health-care services and give States and communities the
flexibility to meet local needs. Some of these activities could be
continued by States using their Maternal and Child Health Block Grant
awards.
Question. The fiscal year 2018 HHS budget justification for Autism
CARES Act programs States, ``The budget prioritizes programs that
support direct health-care services and give States and communities the
flexibility to meet local needs.'' Do you believe that the challenges
that a person with autism faces are any less a priority based on if
they live in a specific State or community?
Answer. The President's budget continues support for programs, such
as the Maternal and Child Health Block Grant, which enable States and
communities to determine how to best support training of professionals
to provide care for people with autism and other disabilities in their
State.
supporting diversity in the health professions
Question. The FY18 proposed budget eliminates funding for programs
such as the Health Careers Opportunity Program, Centers of Excellence,
and Scholarships for Disadvantaged Students. These programs have
collectively assisted in the education and training of tens of
thousands of health-care professionals from under-
represented minority populations.
Federal programs that provide funding to facilitate the education
and training of under-represented minorities in the health professions
have historically been shown to have increased the number of health-
care professionals willing to practice in medically underserved areas.
The fiscal year 2018 HHS budget justification for these programs states
that the budget is prioritizing funding for clinicians who serve ``in
areas of the United States where there is a shortage of health
professionals.'' Aren't medically underserved areas by definition
suffering from a shortage of health professionals?
Answer. The budget prioritizes funding for training and education
programs that include a service obligation which ensures that
clinicians are serving these medically underserved communities. The
budget's investment in scholarships and loan repayment programs ensures
a direct impact on the provision of services in areas experiencing
shortages of providers.
In addition, the budget also proposes funding for the Teaching
Health Center Graduate Medical Education (THCGME) program in which
approximately 77 percent of residents received training in medically
underserved communities and approximately 23 percent of residents
reported coming from a financially or educationally disadvantaged
background, characteristics which are both correlated with likelihood
of practicing in underserved areas. In fact, 50 percent of THCGME
residents report that they intend to practice in a medically
underserved and/or rural area.
Question. The Association of American Medical Colleges released a
survey in 2016 on diversity in medical education. In 2015, over 51
percent of matriculating students at medical colleges who were black or
African-American reported that they were planning on practicing
primarily in a medically underserved area. Over 39 percent of Hispanic
or Latino students, 37 percent of American Indian or Alaska Native
students, and over 34 percent of Native Hawaiian or other Pacific
Islander students reported the same. This compares to 22 percent of
white and Asian students, who together comprise 71 percent of all
matriculating students at U.S. medical colleges. In the absence of
Federal programs whose primary goal is to assist under-
represented minority populations achieve careers in the health
professions, how does the Department intend on addressing the needs of
medically underserved areas, some of which have to do with cultural
competency?
Answer. HRSA's key loan repayment and scholarship programs, the
National Health Service Corps (NHSC) and NURSE Corps, improve the
health of the Nation's underserved by recruiting and retaining health-
care providers to serve in health professional shortage areas. These
programs tend to attract higher percentages of health professions
students and clinicians who are underrepresented minorities and from
rural and disadvantaged backgrounds relative to the broader health
workforce.
Diversity Among Physicians, Dentists, and Nurse Practitioners Within the
NHSC as Compared to the National Workforce
------------------------------------------------------------------------
Hispanic/ American Indian/
African American Latino(a) Alaskan Native
------------------------------------------------------------------------
Total NHSC 13.5% 12.2% 2.6%
Field
------------------------------------------------------------------------
MD/DO
NHSC 17.2% 18.1% 1.3%
National 4.1% 4.4% 0.4%
------------------------------------------------------------------------
DDS
NHSC 15.2% 14.0% 1.7%
National 2.9% 8.1% ---
------------------------------------------------------------------------
NP
NHSC 17.6% 7.4% 2.9%
National 8.2% 2.5% ---
------------------------------------------------------------------------
NHSC providers have higher retention in poorer and less educated
communities, where participants select into Health Professional
Shortage Areas based on their preferences for serving underserved
populations.\6\ Former NHSC participants also are more likely than non-
participants to serve low-income patients--they tend to have high
levels of Medicaid participation, practice in community health centers,
and locate in areas with a health professional shortage (and counties
with high percentages of minorities and people living in
poverty).\7\, \8\, \9\
---------------------------------------------------------------------------
\6\ Sebastian Negrusa, Projesh Ghosh, and John T. Warner.
``Provider Retention in High Need Areas.'' Prepared for Assistant
Secretary for Planning and Evaluation. Submitted by The Lewin Group,
Inc. December 22, 2014. https://aspe.hhs.gov/report/provider-retention-
high-need-areas.
\7\ Bhatavadekar, N.B., R.G. Rozier, et al. (2011). ``Holding up
the oral health safety net: the role of National Health Service Corps
alumni dentists in North Carolina.'' Int. Dent. J. 61(3): 136-43.
https://www.ncbi.nlm.nih.gov/pubmed/21692784.
\8\ Porterfield, D.S., T.R. Konrad, et al. (2003). ``Caring for the
underserved: current practice of alumni of the National Health Service
Corps.'' J. Health Care Poor Underserved 14(2): 256-71. https://
www.ncbi.nlm.nih.gov/pubmed/12739304.
\9\ Probst, J.C., M.E. Samuels, et al. (2003). ``The National
Health Service Corps and Medicaid inpatient care: experience in a
southern State.'' South. Med. J. 96(8): 775-83. https://
www.ncbi.nlm.nih.gov/pubmed/14515918.
Diversity Among Registered Nurses, Nurse Faculty, and Nurse Practitioners Within the PNURSE Corps (NC) as
Compared to the National Workforce
----------------------------------------------------------------------------------------------------------------
American
African Hispanic/ Asian Indian/ N.
American Latino(a) Hawaiian
----------------------------------------------------------------------------------------------------------------
Total NC Field 16% 6% 5% 2.7%
----------------------------------------------------------------------------------------------------------------
Registered Nurse
NC 17.6% 7% 5.5% 3.5%
National 12.2% 6.6% 8.7% N/A
----------------------------------------------------------------------------------------------------------------
Nurse Faculty
NC 15.3% 3.4% 2% .9%
National 7% 3% 2% .6%
----------------------------------------------------------------------------------------------------------------
Nurse Practitioner
NC 14.6% 6.1% 5.5% 2.7%
National 6.0% 3.0% 1.0% N/A
----------------------------------------------------------------------------------------------------------------
Question. The budget justification for the Scholarships for
Disadvantaged Students Program argues that students from disadvantaged
backgrounds could simply seek assistance from ``private and non-profit
scholarships and other Federal loan programs that support student
education.'' Such a justification seems to simply disregard the
significant institutional barriers that people of color and people from
disadvantaged backgrounds face as they seek to achieve success.
According to HHS's own data, 65 percent of students with SDS
scholarships during fiscal year 2015 were members of under-represented
minority groups. What proportion of the students currently served by
SDS do you believe would receive assistance by other means?
Answer. Grants and loans are the major forms of Federal financial
aid for degree/certificate-seeking undergraduate students, including
students from disadvantaged backgrounds. The largest Federal grant
program available to undergraduate students is the Pell Grant program.
In order to qualify for a Pell Grant, a student must demonstrate
financial need. Federal loans, on the other hand, are available to all
students. In addition to Federal financial aid, grants from State and
local governments, institutions, and private sources are available, as
are private loans. There are also Parent Loans for Undergraduate
Students (PLUS) and other loans made directly to parents. The
Department of Education offers assistance in finding and applying to
private and Federal scholarship and loan opportunities here: https://
studentaid.ed.gov/sa/types.
While the administration defers to Department of Education about
the specifics for under-represented minorities, 86 percent of first-
time, full-time degree/certificate-seeking undergraduate students were
awarded financial aid in academic year 2014-2015 at 4-year degree-
granting postsecondary institutions.\10\
---------------------------------------------------------------------------
\10\ See: https://nces.ed.gov/fastfacts/display.asp?id=31.
---------------------------------------------------------------------------
children's health insurance program
Question. The FY18 proposed budget makes several changes to the
Children's Health Insurance Program that stand to increase costs to
States and put health-care coverage for some of our most vulnerable
citizens--our children--at risk. These proposals include ending the 23
percentage point increase in the enhanced Federal match rate for CHIP
funding, ending the maintenance of effort provision that requires
States to maintain their eligibility levels and prevents States from
imposing more restrictive standards for eligibility or enrollment, and
for the first time imposing a cap on the enhanced Federal match rate at
250 percent of the Federal poverty level.
New Jersey currently allows for enrollment in CHIP for children in
families whose income does not exceed 355 percent of the Federal
poverty level. Analysis by New Jersey Policy Perspective suggests that
a cap on the enhanced Federal match rate would threaten the health-care
coverage of 35,000 children in New Jersey. The Department's proposal
would weaken the flexibility that high-cost States like New Jersey have
used to increase eligibility levels to fit their State's needs. How
does the Department expect high-cost States like New Jersey to continue
to provide care to those that it has decided should be eligible for it?
Should the maintenance of effort provision, which does not expire
until the end of fiscal year 2019, be ended early by congressional
action, which States do you expect will enact policies that will
restrict eligibility levels for CHIP or create new burdens to
enrollment in CHIP?
Answer. The 2-year extension included in the budget provides
budgetary stability and additional flexibility to States while focusing
the program on lower-income families. The budget would allow States the
flexibility to set eligibility levels and features of their CHIP
programs that reflect individual State needs and populations. This 2-
year extension would provide stability during the period of health
system reforms, including the implementation of the Medicaid reforms
and new flexibilities for States.
centers for disease control and prevention
Question. The FY18 proposed budget makes deep cuts to a variety of
programs at the CDC, at a time when our Nation continues to face
significant public health challenges. This includes the elimination of
several vital programs that have made a positive contribution to public
health.
The FY18 budget request reduces funding for Public Health
Preparedness and Response by $136.3 million. The budget justification
States that resources will be directed to the States with the
``greatest need.'' In FY16, New Jersey received more than $20 million
in funding through the Public Health Emergency Preparedness, Public
Health Preparedness and Response, and Hospital Preparedness Programs,
including funding for the public health response to the Zika virus. In
FY15, New Jersey received more than $25 million through these programs
to assist in the response to the Ebola virus. How do you define
``greatest need?'' How would the Department determine what States are
prioritized at the expense of others?
Answer. The FY 2018 President's budget restructures HHS
preparedness grants to direct resources to States with the greatest
need and to provide more innovative approaches. As outlined in the
proposed FY 2018 budget, the Public Health Emergency Preparedness
(PHEP) cooperative agreement will gain efficiencies, address gaps, and
incentivize innovation by incorporating a competitive and risk-based
component.
The PHEP program works to protect the health and safety of the
population during a public health event or emergency. Therefore, the
historical risk component is a population-based formula and is intended
to direct more resources to those jurisdictions with higher
populations. The proposed new funding formula is not yet final;
however, all current 62 PHEP award recipients will continue to receive
funding to ensure some level of sustainability and maintenance of
public health preparedness and response capacity and capability.
maternal, infant, and early childhood home visiting program
Question. The Maternal, Infant, and Early Childhood Home Visiting
(MIECHV) program has been incredibly successful since I successfully
incorporated it as part of the Affordable Care Act in 2010. Through
this program, nurses, social workers, or other professionals visit at-
risk families in their homes to evaluate their living situation and
provide information on resources available to improve the health,
educational, and economic opportunities for at-risk children. These
resources include services such as health care, early education,
parenting skills, child abuse prevention, and nutrition education or
assistance. Nearly 1 million home visits were made to over 160,000
program participants as a result of this program in FY16.
I am pleased that the Department supports the continuation of this
program, which is set to expire at the end of the current fiscal year.
However, I am concerned that the Department's budget request asks only
for funding to continue through fiscal year 2019. Is it the stated
policy of the Department to allow the MIECHV program to expire at the
end of fiscal year 2019?
Answer. The Maternal, Infant, and Early Childhood Home Visiting
program is one of five HRSA programs that is funded through FY 2017
under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
The FY 2018 President's budget requests 2-year funding for Fiscal Years
2018 and 2019 for Home Visiting and the other four MACRA-funded
programs--Health Centers, the National Health Service Corps, Teaching
Health Center Graduate Medical Education, and Family-to-Family Health
Information Centers. Funding decisions for resources beyond FY 2019
will be decided in future year budgets.
______
Questions Submitted by Hon. Thomas R. Carper
Question. I understand that reducing childhood obesity and opioid
addiction are two of your top priorities as the Secretary of the Health
and Human Services Department. Is that right? Can you discuss your
efforts to address these two critical challenges facing our country?
What is your strategy for reducing obesity among our youngest children
when the budget eliminated $4 million for the early child care obesity
program, which has reduced childhood obesity rates in 10 States?
Answer. Reducing childhood obesity and opioid addiction are
critical priorities for HHS, along with addressing serious mental
illness.
The FY 2018 President's budget calls for $811 million in support of
the five-pronged strategy guiding the Department's efforts to reduce
opioid misuse and abuse:
Improving access to prevention, treatment, and recovery
services, including the full range of medication-assisted treatment;
Promoting targeted availability and distribution of overdose-
reversing drugs;
Strengthening our understanding of the epidemic through better
public health surveillance;
Providing support for cutting edge research on pain and
addiction; and
Advancing better practices for pain management.
This funding increase will expand grants to Health Resources
Services Administration (HRSA) Community Health Centers targeting
substance abuse treatment services from $94 million to $144 million.
Also within this total is $500 million for State Targeted Response to
the Opioid Crisis Grants that were authorized in the 21st Century Cures
Act, which expand access to treatment for opioid addiction. Using
evidence-based interventions, these grants will help to address the
primary barriers preventing individuals from seeking and successfully
completing treatment and achieving and sustaining recovery.
CDC's activities are focused on equipping States with resources and
scientific expertise to address opioid overdose. Some examples of State
activities include maximizing the use of prescription drug monitoring
programs (PDMPs), linking across sectors including public health,
public safety, and treatment, and the analysis of State-level policies
to evaluate efficacy and inform strategies that can be scaled up across
States. CDC is also working to improve opioid overdose data, by making
it more timely and higher quality. The better we understand the opioids
problem, the better we can respond to it--on the national, State, and
local levels.
With respect to childhood obesity, approximately 12 million
children in the United States are obese, putting them at increased risk
for serious and costly health and social consequences. A two-pronged
approach is needed to: (1) prevent obesity for children by achieving
and maintaining a healthy weight, and (2) treat the millions of
children struggling with obesity.
Preventing obesity requires addressing a number of specific risk
factors including poor nutrition, low levels of physical activity,
inadequate sleep, and sedentary behaviors. The National Academies
recommend that nutrition and physical activity interventions occur in
the places where children spend their time. HHS grantees, therefore,
address these risk factors through supporting providers and families in
key community settings where children learn, live, and play through
data, resources, and training including: community settings, schools,
and early care and education settings.
Question. I believe we both share the goal of ensuring that
Medicare is an efficient and effective payer and that it derives the
greatest value that it can for both patients and taxpayers. I have
heard from various parties that outcomes-based contracts can help drive
our system from fee-for-service to value-based. However, I understand
that there are several regulatory barriers in place, including Medicaid
Best Price, that are serving as deterrents to our fully being able to
realize the potential of these types of value-based arrangements. Can I
count on you and others in the administration to seek to address these
regulatory barriers?
Answer. (See response below.)
Question. Today, we stand on the cusp of very exciting developments
in biomedical science, including but not limited to cell and gene
therapies. However, as we have seen great advances in science, Medicare
and Medicaid have lagged in appropriately reimbursing these
technologies. What changes to our public payer systems would you
suggest to ensure that this innovation continue and that these
technologies are both recognized and appropriately reimbursed?
Answer. HHS is committed to achieving the President's goal of
eliminating barriers to innovation, whether through regulatory relief
or other actions to spur innovation on behalf of patients. The
administration has included as part of this budget a set of actions to
provide regulatory relief to the industry and speed the development of
safe and effective medical products.
Question. I have heard from insurers that the continuous coverage
requirement in the American Health Care Act will not be an adequate
replacement for the individual mandate. Some of my Republican
colleagues have pointed to the auto-
enrollment individuals into health insurance plans as another way to
ensure that insurers have adequate risk pools to spread risk and
restrain premiums. From your perspective, what are the pros and cons of
continuous coverage and auto-enrollment?
Answer. The individual mandate has not worked and millions of
Americans are not buying into the notion of Washington-controlled
health care. In January 2017, the IRS reported that around 6.5 million
Americans paid $3 billion in penalties to the IRS rather than buy
unaffordable Obamacare plans in 2015. Americans should have the freedom
to make the decisions that are right for them and their families, and
should have more choices and access to the health care they want and
deserve.
Obamacare is failing the American people, delivering high costs,
few options, and broken promises. The administration has supported
legislation including the House-passed AHCA that replaced the failing
individual mandate with policies that encouraged continuous coverage.
The devastating effects of Obamacare go beyond the flawed individual
mandate. If we do not act, many more Americans could lose access to
care.
The administration is taking steps to increase patient choice and
provide greater flexibility for issuers to help attract healthy
consumers, with the aim of improving the risk pool and bringing
stability to the individual and small group markets. On April 13, 2017,
CMS finalized the Market Stabilization rule, which includes policies to
ease issuer burden and provide States with greater flexibility.
Question. Last year, 60,000 Americans died from a drug overdose.
Drug addictions are now the leading cause of death among Americans
under 50. As you have held listening sessions on the opioid epidemic
around the country, what are the most important recommendations that
Congress and the Federal Government should heed? Last month, Senator
Portman and I held a hearing on the opioid and drug addiction crisis
ravaging our country. Our second panel included a police chief and a
medical examiner from Ohio, a physician from Delaware, and Michael
Botticelli, the drug czar in the Obama administration. Every one of
them expressed concerns that the AHCA's $800 billion dollar cut to
Medicaid would decimate their efforts to stem the opioid addiction
epidemic. How many of the experts and patients that you have heard from
have encouraged you to reduce Medicaid coverage or to eliminate private
health insurance protections that guarantee coverage for drug addiction
treatment? If you have received those types of recommendations, please
share those suggestions with me and the other members of this committee
in writing.
Answer. The U.S. Department of Health and Human Services (HHS) is
keenly aware of the devastating impact that opioid addiction is having
on our families and communities. The administration is committed to
doing all that we can to end the scourge of opioids that is sweeping
across this Nation.
The administration is committed to bringing everything the Federal
Government has to bear to address the health crisis opioids pose. The
budget calls for $811 million in support of the five-pronged strategy
guiding our Department's efforts to fight this scourge:
1. Improving access to prevention, treatment, and recovery
services, including the full range of medication-assisted treatments;
2. Targeting availability and distribution of overdose-reversing
drugs;
3. Strengthening our understanding of the crisis through better
public health surveillance data and reporting;
4. Providing support for cutting edge research on pain and
addiction; and
5. Advancing better practices for pain management.
This funding increase will expand grants to Health Resources
Services Administration (HRSA) Community Health Centers targeting
substance abuse treatment services from $94 million to $144 million.
Also within this total is $500 million for State Targeted Response to
the Opioid Crisis Grants that were authorized in the 21st Century Cures
Act, which expand access to treatment for opioid addiction. Using
evidence-based interventions, these grants will help to address the
primary barriers preventing individuals from seeking and successfully
completing treatment and achieving and sustaining recovery.
One of the key pillars of our approach is improving access to
treatment and recovery services, including medication-assisted
treatment (MAT) with naltrexone, buprenorphine, or methadone. As
mentioned above, through the State Targeted Response to the Opioid
Crisis grants authorized in the 21st Century Cures Act, HHS is
expanding access to opioid addiction treatment through evidence-based
interventions, including MAT. We are targeting the primary barriers to
seeking and successfully completing treatment and achieving and
sustaining recovery. This funding is critical to reversing the opioid
epidemic.
We will continue to explore additional opportunities for States to
provide a full continuum of care for people struggling with addiction
and develop a more streamlined approach for section 1115 substance
abuse treatment demonstrations. We look forward to building upon
initial efforts, including previous collaborations, amongst the States.
Question. Our Republican colleagues are working behind closed doors
with no public hearings, discussion, or transparency to pass a health-
care bill that, according to the Congressional Budget Office, cuts
funding to Medicaid by more than $800 billion over 10 years and
requires seniors to endure an 800 percent increase in their health
insurance premiums. CBO found that the House Republicans' health-care
bill would create unstable health insurance markets in a sixth of the
country where sicker Americans would be priced out of insurance
coverage. Maternity care and substance abuse treatment would become
unaffordable for many lower-income Americans. President Trump has said
that his health-care plan will result in ``insurance for everybody''
with ``much better health care . . . at much less money.'' Can you
explain how unaffordable maternity care and substance abuse treatment
meets the standard of ``much better health care'' for ``less money''?
Answer. President Trump is committed to signing a bill into law
that will provide all Americans access to quality, affordable health-
care coverage, and will provide individuals and families tools to
choose the coverage that best meets their needs.
Question. You rightly noted when we first met that the cost-sharing
reduction payments are the most important issue for health insurers
deciding whether to remain on the health insurance marketplaces. Do you
think that cost-sharing reduction payments will remain in place through
2018? What have you recommended to President Trump regarding the cost-
sharing reduction payments?
Answer. (See response below.)
Question. Does the President understand that his threats to
discontinue the cost-sharing reduction payments has forced insurers to
exit some insurance marketplaces or increased premiums by as much as 20
percent? What was the President's response to your recommendations?
Answer. The administration has emphasized the importance of
reforming our health-care system to one that works better for patients
and their providers. Our budget calls for Congress to repeal and
replace the Affordable Care Act. In the interim, we are evaluating
policy options to relieve American's from Obamacare's burdensome
mandates and to restore choice and competition to the individual and
small group markets, increasing availability of health insurance
options so that all Americans can purchase coverage that meets their
needs.
Question. The President has said repeatedly he wants to force
Democrats to the table on health-care reform. That's a ridiculous
statement. I, and every Democrat I know, have been at the table since
before the ACA was passed, getting stood up for the last 8 years. To
your knowledge, has the President ever called or spoken to a Democratic
member of Congress, on the House or the Senate, about a bipartisan path
forward to improve our health-care system? Since your confirmation, how
many substantive conversations have you had with a Democrat in Congress
about improving the individual health insurance market and Medicaid?
Answer. Obamacare is failing the American people, and it's
devastating effects are more apparent every day. The administration is
eager to work with Congress--Republicans and Democrats--to rescue
Americans from the failures of the Obamacare.
______
Questions Submitted by Hon. Sherrod Brown
national institutes of health (nih) total budget
Question. In your recent testimony before the House Energy and
Commerce Committee, you praised the ``incredibly important'' work of
the NIH. As a physician, you can appreciate the value of basic
biomedical research leading to the development of novel medications and
discovery of new medical procedures, both with the support of NIH
funding, which lead to advances in patient outcomes and survival.
On June 6th, President Trump publically announced that he planned
to keep Dr. Francis Collins as the director of the NIH. Just last year,
Dr. Collins asked for $33.136 billion for FY17, and in fact, the
Presidential budget request for NIH has not been below the President
Trumps FY18 ask of $26.92 billion since FY 2002. That is almost two
decades.
Based on your supportive stance on the NIH and the history of the
NIH budget request, can you please explain why you think a 22 percent
cut in the NIH budget from FY17 to FY18 is even feasible?
Answer. The FY 2018 budget presents an opportunity for HHS and NIH
to reexamine how to optimize Federal investment in a way that best
serves the American people. This policy will enhance the stewardship of
taxpayer dollars by focusing our resources on innovative scientific
research. The Department assessed opportunities within the NIH to
determine where greater efficiencies may be possible.
Additionally, the administration will propose a package of reforms
to streamline Federal compliance requirements and reduce burden on NIH
grantees. These targeted policies will reduce the time and expenses
that grantees must currently spend to comply with overly burdensome
Federal grant requirements, thus lowering grantees' administrative
costs and mitigating the impact of lower reimbursements. The approach
will also seek to develop a uniform indirect cost rate to all grants
that mitigates the risk for fraud and abuse by simplifying and
uniformly applying the rate for grantees.
Question. A cut of this magnitude will greatly impact the United
States' seniority and leadership in biomedical and clinical research. I
have heard repeatedly from constituents who remind me that research
projects are not conducted in just a few months; clinical trials are
not completed within one calendar year. The extreme fluctuations in
funding levels suggested by this budget will drive American research
progress to a halt. But the impact of such a cut goes beyond the
research. NIH funding supports nearly 17,000 jobs in Ohio. At a recent
House Energy and Commerce hearing, Representative Nita Lowey cited that
the proposed NIH cuts would result in up to 8,000 fewer grants awarded,
and decimate the economy by eliminating 90,000 jobs at medical
institutions across the country.
Do you envision that adoption of the President's budget will have
no economic impact?
How do you envision such a dramatic budget cut to the NIH will not
yield wide-spread scientific and economic impacts across this country?
Answer. Thank you for recognizing both the long arc of research and
the economic value of NIH investments. The Department supports the
administration's agenda of creating a more effective and efficient
government and to support economic growth. The FY 2018 budget presents
an opportunity for HHS and NIH to reexamine how to optimize Federal
investment in a way that best serves the American people. These changes
will enhance the stewardship of taxpayer dollars by focusing our
resources on innovative scientific research rather than administrative
and overhead costs.
indirect costs
Question. In your March testimony before the House Energy and
Commerce Committee, you commented that the facilities and
administration, or indirect costs, covered by NIH grants are
``inefficiencies.'' These ``inefficiencies'' include essentials like
the facilities where research is conducted, utilities that keep
freezers and incubators on, and the staff that manage the grants and
keep the research enterprise running. Currently, research grants
awarded to your former employer, Emory University, put aside
approximately 35 percent towards these indirect costs.
One argument I have heard is that many private foundations offer
research grants with only 10 percent set aside to cover indirect costs.
NIH Director Dr. Collins commented on this in his recent testimony
before the House Appropriations Labor, HHS-Education Subcommittee,
noting that universities are only able to accept grants with these
lower indirect cost rates because of the support they already receive
from the NIH. He stated that even NIH grants are not sufficient for
covering all indirect costs associated with research projects. Dr.
Collins warned that if NIH grants dropped indirect cost rates to 10
percent, many small- to mid-sized universities, especially State
schools, would no longer be able to afford NIH-funded research.
If you reduce indirect costs to a cap of 10 percent, how do you
expect a medical institution of any size to pick up the slack
overnight? Will it be in decreasing the number of staff? Number of
medical and graduate students? Number of patients the hospital can
take? Increasing tuition?
Answer. The effect on grantees will vary by institution, depending
on the current indirect cost rate and a variety of other factors. The
impact will likely be greater on institutions that have a higher
percentage of NIH funding compared to total funding, or a lower ability
to cover indirect costs from other sources (e.g., donations, endowment
income, State government, tuition). The Department continues to work on
specific details of the NIH indirect cost policy for FY 2018 and will
assess the impact on grantees once the policy is finalized.
the public-private partnership
Question. Secretary Price, in your nomination hearing QFR
responses, you stated that the ``NIH plays a leading role in so many
public-private initiatives'' and that you are ``. . . keenly aware of
the progress that has been made and still to be made through important
research initiatives that are fully or partially funded by the Federal
Government.''
I agree that partnerships between academia and the private sector
are important, especially for the efficient translation of new research
into cures and treatments for patients. I also want to enforce that
relying on private funding to cover differences imposed by NIH budget
cuts is not a feasible option. In that same House Appropriations Labor,
HHS-Education Subcommittee hearing last month, Dr. Collins commented on
a recent meeting in the White House, involving biotech CEOs and
academic scientists and their descriptions of public-private
partnerships. Dr. Collins reflected that the biotech leaders ``were
quite clear . . . that their stockholders would not necessarily
appreciate their putting money into things that are not directly
connected to a product.''
What are concrete examples that you can offer to medical schools on
how they can ``cut corners'' when they lose 20+ percent of an NIH grant
based on this proposed budget?
How do you expect the United States to maintain its role as a
leader in innovation in biomedical research and patient care under
these proposed cuts?
Answer. Working with industry is a powerful tool to improving the
health of our Nation and our economy. Officials from across the U.S.
Department of Health and Human Services (HHS), including leadership of
the NIH and FDA, have begun discussions with pharmaceutical companies
about developing non-addictive pain medications and new formulations of
opioid antidotes. The United States is a leader in biomedical research
due, in no small part, to our ability to marshal the strengths of the
public and private sectors to address the health-care needs of America.
HHS is not currently involved in the budgetary decisions made by
medical schools and will continue to defer to medical schools to
determine future investment strategies.
Additionally, the FY 2018 President's budget presents an
opportunity for HHS and NIH to reexamine how to optimize Federal
investments in a way that best serves the American people. The FY 2018
request changes the reimbursement of indirect costs for NIH grants,
which will be capped as a percentage of total research, in order to
better target available funding toward high priority research. In
addition, Federal research requirements for grantees will be
streamlined to reduce grantee burden through targeted approaches as
proposed by NIH. HHS is working with NIH to identify strategies to
streamline processes and increase efficiencies, including reforming
policies to release grantees from the costly and time-consuming
indirect rate setting process and reporting requirements. These
targeted policies will reduce the time and expenses that grantees must
currently spend to comply with overly burdensome Federal grant
requirements, thus lowering grantees' indirect costs and mitigating the
impact of lower reimbursements.
low-income heating assistance program (liheap)
Question. During your nomination process, I submitted two QFRs
about the Low-Income Heating Assistance Program (LIHEAP). I want to
share my questions and your answers with you again in light of the new
FY18 budget proposal, and then re-phrase my question to you.
As you may know, the LIHEAP program plays a key role in helping
low-income families stay warm in the winter and avoid dangerous heat in
the summer. It is a program that is critical to nearly 450,000
households in Ohio that otherwise would be forced to choose between
keeping warm or going hungry.
If confirmed, will you commit to maintaining the program as
currently structured?
Answer. If I am confirmed, I will implement the program dutifully
in as effective and efficient manner as possible.
Question. Nationwide, nearly 7 million of our Nation's poorest and
most vulnerable households rely on the program. Will you commit to
maintaining and possibly even supporting an increase in the program's
annual appropriation?
Answer. If I am confirmed, I will implement the program dutifully
in as effective and efficient manner as possible. Should circumstances
on the ground change, and current resources are found to be
insufficient, I will inform Congress and work with them on finding
solutions.
Question. The President's budget calls for no funding for LIHEAP in
FY18. How do you intend to ``implement the program dutifully in as
effective and efficient manner as possible'' without any funding?
Answer. At the time of the confirmation hearing, the administration
was in the process of reviewing programs and formulating the
administration's budget. LIHEAP has been unable to demonstrate strong
performance outcomes. In addition, we reviewed programs and policies of
utility companies and State and local governments and found that they
provide significant heating and cooling assistance and the majority of
States prohibit utilities from discontinuing heating during the winter
months. With our limited resources and based on that review, we
determined that continued funding of the LIHEAP program is not the best
use of taxpayer dollars and have proposed eliminating future funding
for this program. However, as long as there continues to be an
appropriation of resources for this program, the U.S. Department of
Health and Human Services (HHS) will continue to implement the program
in as effective and efficient manner as possible.
public health emergency preparedness
Question. Secretary Price, in your testimony you touted HHS's
successful history of responding to and protecting Americans from
public health emergencies. You talked about your recent trip to Liberia
and the incredible work of the Centers for Disease Control and
Prevention in the region combatting Ebola. In this increasingly
globalized world, serious public health threats are just a plane ride
away, as you alluded to in your comments about Ebola.
Given the cuts in the President's budget to public health emergency
preparedness and the hospital preparedness program, how will the
administration make sure that communities and health systems are
prepared to respond to increasingly frequent public health emergencies?
Answer. Public Health Emergency Preparedness: HHS, through the CDC,
will continue to support States, cities, and territories through PHEP
cooperative agreements. CDC will award PHEP cooperative agreement funds
to all current 62 recipients to ensure some level of sustainability and
maintenance of public health preparedness and response capacity and
capability. The FY 2018 budget proposal achieves program efficiencies
by modifying the PHEP funding formula to prioritize funding to areas
with greatest risk and by adding a competitive component. The proposed
new funding formula is not yet final; however, formula changes will
allow PHEP awardees to address capability gaps, identify opportunities,
and incentivize innovation. Through PHEP, CDC will continue to provide
expertise and support to State and local health departments' efforts to
prepare for and respond to more localized emergencies, including those
requiring coordinated healthcare and public health responses.
Through increasing efficiencies and streamlining processes, CDC
will continue to support critical infrastructure and research to
facilitate preventing, and responding to, public health emergencies.
Key ongoing activities will include:
Regulating and monitoring ownership, use, and transfer of
dangerous biological agents and toxins;
Activating CDC's Emergency Operations Center to ensure effective
and efficient response operations;
Developing standard Laboratory Response Network protocols and
providing training and quality assurance for testing biological and
chemical threat agents;
Advancing the development of a surveillance system for the
timely exchange of syndromic data; and
Developing and expanding partnerships with other Federal
agencies, national organizations, and the private sector to identify
opportunities to leverage resources to accomplish common goals.
At the proposed funding level, CDC would be able to replace most
expiring Strategic National Stockpile countermeasures in FY 2018. CDC
will provide training and exercise support in FY 2018 to sustain State
and local capabilities critical to effectively distribute and dispense
stockpiled medical countermeasures to ensure access for individuals
exposed to public health threats.
In addition to PHEP funding and maintaining the Strategic National
Stockpile, CDC will continue to provide rapid epidemiological and
laboratory assistance to States during public health emergencies. CDC's
unique scientific expertise includes the ability to detect and track a
broad range of microbes and respond to disease threats from many
different pathogens, including emerging and resistant infections like
Candida Auris. In FY 2018, CDC will also continue to invest in the
Epidemiology and Laboratory Capacity for Infectious Diseases platform,
a nationwide cooperative agreement focusing on building the essential
epidemiology and laboratory capabilities in all grantees.
Hospital Preparedness Program: The Hospital Preparedness Program
(HPP), administered by ASPR, intends to create a lean and effective
program in FY 2018 by focusing on those States and jurisdictions with
the greatest risk. For health-care preparedness, ``risk'' will be
determined through evidence and science-based tools that consider
population, national security issues, and the potential for natural
disasters.
Under the Department's proposal, those States and jurisdictions
with the greatest risk will be prioritized to receive health-care
preparedness and response funding. ASPR strives to assist all
jurisdictions with preparing for, responding to, and recovering from
emergencies and disasters. When disaster strikes, ASPR provides
critical services to protect public health and help communities recover
faster. For example, ASPR provides substantive preparedness and
response technical assistance to jurisdictions and systems by
connecting them with resources and subject matter experts (SMEs)
through ASPR's Technical Resources Assistance Center and Information
Exchange (TRACIE).
TRACIE provides evidence-based applications, technology, and proven
best practices to help States and communities build enhanced capacity
and improve their knowledge and effectiveness. TRACIE also provides
surge assistance and resources during and after incidents.
With a reduced level of funding, HPP will, through its FY 2018
budget proposal, direct Federal funds to those jurisdictions at
greatest risk. Meanwhile, HPP will continue to provide all
jurisdictions with technical assistance to inform their preparedness
and response efforts.
cdc and vaccinations
Question. The CDC plays an important role in infectious disease
control by releasing guidelines and recommendations for vaccinations,
reducing health disparities by ensuring vaccine access to all Americans
regardless of insurance status, and conducts research to inform
policies and practices involving immunizations. With Minnesota's recent
measles outbreak, now totaling more cases in that one State by June
than the entire country recorded in all of 2016, it is clear that
promoting vaccine education and access is still essential.
Given the deep cut to Immunization and Respiratory Disease in the
CDC budget, does the administration support widespread adoption of
vaccines as a method of infectious disease prevention?
Answer. Vaccines are one of the greatest success stories in public
health and are among the most cost-effective ways to prevent disease.
For each dollar invested in the U.S. childhood immunization program,
there are over $10 of societal savings and $3 in direct medical
savings. Childhood immunizations over the past 20 years have prevented
322 million illnesses, 732,000 deaths, and nearly $1.4 trillion in
societal costs.\11\
---------------------------------------------------------------------------
\11\ ``Benefits from Immunization During the Vaccines for Children
Program Era--United States, 1994-2013,'' Centers for Disease Control
and Prevention, Morbidity and Mortality Weekly Report, April 25, 2014/
63(16);352-355.
Question. How will the administration ensure people have access to
vaccines in light of this financial cut to State and local public
---------------------------------------------------------------------------
health department capacity?
Answer. The discretionary Immunization Program plays a fundamental
role in achieving national immunization goals and sustaining high
vaccination coverage rates to prevent death and disability from
vaccine-preventable diseases. It is the backbone of our Nation's public
health immunization system that supports the science that informs our
national immunization policy and programs; provides a safety net of
vaccines for uninsured, poor adults and use in outbreak response;
monitors the safety and effectiveness of vaccines; educates providers
and the public about the benefits of vaccines and the diseases they
prevent; and conducts surveillance, laboratory testing, and
epidemiology to respond to disease outbreaks.
The CDC Immunization Program provides funding to all 50 States, the
District of Columbia, 5 major cities and 8 territories. In FY17,
Congress appropriated $607 million for this important program. At the
funding level proposed in the FY 2018 President's budget request, CDC
will continue to provide vaccines and funding for immunization
infrastructure to the 64 awardees at a reduced level. CDC will also
continue providing technical assistance and laboratory support to
States and local communities responding to vaccine-preventable disease
investigations, including outbreaks, at a reduced level.
individual marketplace and the affordable care act
Question. At your confirmation hearing earlier this year, you
repeated to members of this committee over and over again, that every
American should have access to health insurance. However, the actions
your agency is taking and the proposals in this budget do not live up
to that promise.
As you know, earlier this week we learned that Anthem will not be
participating in the individual insurance market in Ohio next year.
Here's what Anthem said when asked about why they made this decision:
``The lack of certainty of funding for cost sharing reduction
subsidies, the restoration of taxes on fully insured coverage, and an
increasing lack of overall predictability simply does not provide a
sustainable path forward to provide affordable plan choices for
consumers.''
This decision affects more than 66,000 Ohioans, and leaves up to 20
counties in Ohio with no insurer for next year. What's worse, is it
leaves more than 10,000 people in my State without ANY access to
insurance next year.
You are in charge of the Department of Health and Human Services.
Your party is in charge of the House and the Senate and the White
House. Your President, who you advise on health-care issues, has the
power to help ensure certainty and create a sustainable path forward
for insurers in the marketplaces by guaranteeing cost-sharing reduction
(CSR) payments, and by pushing regulations that provide consistency and
stability as opposed to Executive orders that direct sabotage.
You have the power to fix this and to ensure that the individuals
in my State that currently have coverage do not lose it next year.
Why did you let this happen, and what are you going to do to fix it
and provide certainty to these Ohio families?
Answer. (See response below.)
Question. What are you going to do to fulfill your promise that the
10,000 Ohioans without any choices next year have access to insurance?
Answer. Obamacare is a disaster, delivering high costs, few
options, and broken promises. Americans across the country have seen
their health insurance choices disappear and premiums spiral out of
control, increasing by double and triple digits. This administration is
committed to empowering consumers with providing more choices and
access to the health care they want and deserve.
The administration recognizes that States are the primary
regulators of health insurance, and it remains imperative for the
executive branch to empower States with more flexibility and control.
The Department finalized a Market Stability Rule in April, which
tightened special enrollment periods, made it more difficult for
enrollees to skip premium payments, adjusted the open enrollment period
to align with other health-care markets, lifted one-size-fits-all
requirements regarding network access, and widened the actuarial value
bands within which insurers can offer plans to patients.
Our budget calls for Congress to repeal and replace the Affordable
Care Act. In the interim, we are evaluating policy options to relieve
American's from Obamacare's burdensome mandates and to restore choice
and competition to the individual and small group markets, increasing
availability of health insurance options so that all Americans can
purchase coverage that meets their needs.
children's health insurance program (chip)
Question. The Children's Health Insurance Program, or CHIP, is a
bipartisan success story. Thanks to the leadership of Senator Hatch and
former Senator Kennedy, more than 6 million kids across the country--
including approximately 100,000 in Ohio--have access to quality,
affordable health care. The program will celebrate its 20th anniversary
this August.
Throughout its history, Congress has acted to reauthorize and
improve the program several times. Most recently, we extended funding
for CHIP for 2 years when we passed MACRA, which passed the Senate by
an overwhelming vote of 92-8. Thanks to these efforts, fewer children
remain uninsured than ever before.
During your confirmation hearing, I was pleased to hear your
enthusiasm for the CHIP program, and I was thrilled when I asked if you
would support a 5-year extension of the program and you instead
suggested Congress act to extend funding for the program for 8 years.
Much to my disappointment, however, the President's budget only
proposes a 2-year extension of the program and compromises the CHIP
program by eliminating a provision that helps kids get covered and
lowers administrative costs, while cutting support to States. During
your recent testimony, you mentioned a meeting with the National
Governor's Association. On May 11th, NGA sent a letter to Congress
requesting a fast, clean 5-year extension to CHIP. Though you clearly
value the Governors' input and have, in the past, spoken out for
States' rights, the FY18 budget does not reflect the recommendations of
the Nation's Governors regarding CHIP.
If an 8-year extension is better than 5, as you said earlier this
year, isn't 8 years also better than the FY18 proposed budget's 2-year
extension?
Does the President disagree with your policy recommendation of an
8-year CHIP extension?
Do you agree with his proposal, which could hurt kids and working
families, as well as State budgets?
Answer. CHIP funding will expire at the end of FY 2017, and without
an extension of funding, children could lose health-care coverage. This
proposal would extend CHIP funding for 2 years through FY 2019. The
administration remains committed to working with Congress to provide
budgetary stability and additional flexibility to States while
providing additional help to lower income families.
Question. Despite the recommendations of the National Governors
Association and MACPAC, you recommend just a 2-year extension of CHIP
in the budget proposal. But you go even beyond that, in making
substantial cuts to CHIP and shifting about $3.5 billion in CHIP costs
to States through eliminating the enhanced matching rate. You also
propose to repeal the Maintenance of Eligibility requirement that runs
through 2019 that requires States to maintain their existing Medicaid
and CHIP eligibility levels for children and not make it harder for
eligible children to enroll.
Do you think it's a good idea to undermine everything we and the
States have accomplished on a strongly bipartisan basis since the
enactment of CHIP in 1997?
Answer. This proposal would extend CHIP funding for 2 years to
guarantee that the most vulnerable children will continue to have
coverage. CHIP has made substantial progress in making health-care
coverage available to children, but there is more work to do. Extending
CHIP funding for 2 years provides stability to States and families
while the future of the program is addressed alongside other health
reforms.
Question. The budget proposal ends the 23 percent enhanced matching
rate effective almost immediately. This is a significant cut to States,
which have planned CHIP implementation based on this matching rate,
which was to extend through FY 2019.
Do you expect States to call special sessions for their State
legislatures in order to develop an emergency contingency plan if this
significant cut is approved and implemented as proposed, by the end of
the fiscal year?
Answer. CMS plans to work with States to achieve flexibility in
their CHIP programs.
medicaid savings in chip
Question. Your proposed budget assumes over $16 billion in savings
to the Medicaid program through reducing Medicaid payments in a 2 year
extension of CHIP. This is a huge cost to States and leaves their hands
tied with what services they can offer with a drastically reduced
budget.
Can you walk me through the policy proposals you considered to
arrive at this level of savings? Please be specific; a policy is not
just a number, though it is the way that your staff attempted to
explain the cuts to Senate health staff at a budget overview briefing
in May.
Answer. (See response below.)
Question. The President's budget proposes capping coverage for
children on CHIP at 250 percent of the Federal Poverty Level. That's a
single mom with two kids trying to support her family on $50,000 a
year. That's a married couple with three kids, working hourly jobs for
a combined income of $70,000 a year.
How will you ensure that these families won't face any higher cost-
sharing or any cuts to the benefits that they rely on today if States
are given complete control over what they will provide, with no Federal
guidance for minimum standards of care?
Answer. (See response below.)
Question. In 2009, the CHIP reauthorization bill included the
Express Lane Eligibility tool in order to effectively and efficiently
enroll or renew CHIP-eligible children in the program. This tool helps
kids get covered while also lowers the administrative cost of running
enrollment processes.
Do you not support the effective, cost-saving mechanisms provided
through Express Lane Eligibility?
Answer. It is important that every child has access to high-quality
health coverage, particularly children in lower income families. This
proposal would extend CHIP funding for 2 years to guarantee that the
most vulnerable children will continue to have coverage. CMS plans to
work with States to achieve flexibility in their CHIP programs, while
focusing resources on lower-income families.
The budget proposes a 2-year extension of CHIP through fiscal year
2019, with reforms to rebalance the Federal-State partnership. The
score of the CHIP proposal reflects the cost of an extension to the
CHIP program ($13.9 billion). However, because children would move to
Medicaid or other Federal programs in the absence of extending CHIP,
this proposal results in savings to Medicaid of $16.7 billion and
savings to other Federal programs and accounts of $3.0 billion.
Therefore, this proposal results in net Federal savings over 10 years a
result of children remaining on CHIP and not migrating to Medicaid or
other Federal programs.
syringe exchange programs or syringe services programs (seps and ssps)
Question. You recently conducted a listening tour in States most
affected by the opioid epidemic, including a stop in Wilmington, OH.
One strategy I did not see you mention in your op-eds following your
tour is the use of syringe exchange programs (SEPs) to stop the spread
of infectious diseases associated with the opioid epidemic.
I know you conducted a diverse tour geographically and in terms of
affected individuals that you met with. Were SEPs discussed as an
effective method for decreasing devastating clinical side-effects of
opioid abuse?
Answer. Please see answer below.
Question. I asked a few questions of you regarding SEPs following
your nomination hearing, and your answers did not convince me that you
understood the value of these programs, and would help States most
affected by the opioid epidemic to find ways to fund these successful
programs. Cuyahoga County in Ohio was awarded a ``determination of
need'' request by CDC in 2016 due to high rates of Hepatitis and HIV
resulting from injection drug use. Because of the current limitations
on Federal dollars, the HHS funds going to Cuyahoga County cannot be
used to purchase needles or syringes to replace used ones.
You have been the Director of HHS for approximately 4 months now.
Your clinical knowledge should allow you to assess SEP program
effectiveness without bias. Furthermore, you have the authority to make
suggestions to the President and to Congress about effective measures
to protect the public health of all Americans, including those with
devastating addictions.
Will you urge the President and Congress to consider lifting the
funding ban on clean needles and syringes through federally funded
SEPs?
Answer. The rising rates of Hepatitis C and other health
consequences associated with injection drug use are of great concern.
The administration is committed to bringing everything the Federal
Government has to bear to address the health crisis opioids pose, and
HHS is deploying a comprehensive strategy to address the opioid abuse
crisis and opioid-related harms. HHS has identified five specific
strategies that we can bring to the fight: improving access to
prevention, treatment, and recovery services, including the full range
of medication-assisted treatments; targeting availability and
distribution of overdose-reversing drugs; strengthening our
understanding of the crisis through better public health surveillance;
providing support for cutting-edge research on pain and addiction; and
advancing better practices for pain management. In recent years,
Congress has provided HHS limited authority to support components of
syringe exchange programs. HHS looks forward to continuing to work with
Congress on this issue and will implement the law as directed.
advisory role of cabinet members
Question. I am frustrated by many of your answers to your
nomination QFRs when discussing your role as a Cabinet member. You
often commented that you would be an administrator and not a
legislator, implying your limited influence on policy changes. However,
as a chosen Cabinet member, the President relies on you as a trusted
adviser to inform his decisions regarding your areas of expertise; I
fully expect that you are indeed serving as a policy adviser and not
just waiting in the wings for congressional action.
In developing the FY18 budget, what was your role in informing the
President regarding his suggested changes to the HHS budget?
Answer. Anyone who has worked on the President's budget knows it is
second only to passing legislation in terms of the compromise,
collaboration, and commitment required. Director Mulvaney and the U.S.
Department of Health and Human Services (HHS) maintained open lines of
communication during the budget process. The President's FY 2018 budget
reflects difficult decisions made across the Federal agencies,
including at HHS. Implementing this budget is step one in the
President's plan to improve our Nation's fiscal stability and HHS
supports the President's goals.
Question. During the hearing, I spoke about the huge financial
impact that the Medicaid program has on Ohio's ability to fight the
opioid epidemic. You have spoken about your recent visit to Ohio, and
it seems an unnecessary trip if you are not using that interaction as a
way to inform policy changes that the President may suggest. According
to the FY18 proposed budget, that ``policy change'' is a cut of $618
million from the Medicaid program.
What was your thought process, as an adviser to the President, in
arriving at such a drastic cut to the Medicaid program? What is the
justification for the cuts, and what are your actual policy suggestions
that States can functionally use to absorb these deep cuts and continue
to serve their residents?
Answer. The budget provides additional flexibility to States and
reforms the fiscal structure of Medicaid, allowing a choice between a
per capita cap or a block grant beginning in FY 2020. Rigid and
outdated Federal rules and requirements prevent States from
prioritizing Federal resources to their most vulnerable populations and
from innovating and testing new ideas that will improve access to care
and health outcomes. This proposal will free States to advance
solutions that best serve their unique populations--for example,
encouraging work, promoting personal responsibility, and meeting the
spectrum of diverse needs of their Medicaid populations. States, as
administrators of the program, are in the best position to assess the
unique needs of their populations. The administration is determined to
work with Congress to put in place a plan to give States the
flexibility they need to achieve better health outcomes for patients
while putting Medicaid on a more sustainable fiscal trajectory.
tobacco cessation
Question. In the QFRs for your nomination, I asked a few questions
about tobacco cessation programs and services. In one answer, you noted
that the ``availability of cessation programs is important.'' I agree,
as tobacco is the number one cause of preventable deaths in the United
States and sees exceptionally high use in Ohio.
The President's FY18 budget eliminates the CDC's Office on Smoking
and Health, which plays an important role in tobacco use reduction
through a variety of cessation campaigns and programs, as well as
research initiatives to develop innovative ways to curb tobacco use in
the country. The proposed block grant does not sufficiently replace a
proven program.
How do you justify the elimination of funding for a program with
proven success against the number one cause of preventable death in the
United States?
Answer. The President's FY 2018 budget does not eliminate funding
for tobacco control. Instead, it frees CDC and the States to address
tobacco use within a holistic chronic disease prevention portfolio and
funding structure.
Question. Do you disagree that tobacco cessation programs should be
available in every State through a Federal program with funding
dedicated to assistance for those fighting tobacco addiction?
Answer. Seven in 10 adult smokers want to quit, and quitting
smoking is beneficial at any age. Efforts that combine media campaigns,
quitlines, barrier-free tobacco cessation treatments, and environmental
and policy approaches are most effective. This includes (1) high-impact
tobacco education campaigns such as CDC's Tips From Former Smokers,
which has helped an estimated half a million Americans quit for good;
(2) State tobacco quitlines, which have broad reach and are effective
with diverse populations; (3) counseling and FDA-approved cessation
medications, which are effective for treating tobacco dependence,
especially when used together; and (4) smoke-free indoor environments
that reduce tobacco consumption and support quitting.
The proposed block grant would allow every State to dedicate
Federal funding to tobacco cessation efforts, which are important for
preventing and reducing tobacco-related death and disease.
domestic tuberculosis (tb)
Question. The proposed HHS Budget in Brief, the description for
HIV/AIDS, Viral Hepatitis, STIs and TB Prevention funding only mentions
suggested changes for HIV programs, but funds for domestic TB programs
through the CDC is decreased by $11.986 million. TB is the number one
infectious disease killer in the world, and increasing globalization
threatens to continue the spread of new TB infections in the United
States. There is still much work to be done into research for new
treatments, especially for multi-drug-resistant TB, as well as better
preventive measures including surveillance and other public health
methods.
TB is far from eradication, and funding that goes towards better
treatments for existing infections and methods to prevent new
infections is greatly needed. How do you justify cutting the CDC budget
for domestic TB by 10 percent?
Answer. The FY 2018 President's budget request describes that CDC
will continue to focus efforts on maintaining TB control within the
United States. CDC will also continue to support States to conduct TB
surveillance and contact tracing, focusing on States with the highest
prevalence of TB.
Preliminary 2016 TB surveillance data indicate a 2.7 percent
decline in reported cases and a 3.4 percent decline in case rate per
100,000 from 2015. Although declines have occurred, progress has
stalled, with TB rates remaining at levels 29 times higher than the
Nation's goal of eliminating this disease in the foreseeable future.
CDC has made advances in developing a new short-course therapy for
latent TB infection (LTBI) which will provide opportunities to improve
efficiency. Randomized controlled trials led by CDC have shown that a
new combination regimen of isoniazid and rifapentine administered
weekly for 12 weeks is as effective for preventing TB as other regimens
and is more likely to be completed than the previous U.S. standard
regimen of 9 months of INH daily. Preventing TB by treating LTBI is a
cornerstone of the U.S. strategy for TB elimination, so this new
regimen offers many advantages.
Over the last 20 years, TB control efforts have prevented as many
as 300,000 TB cases across the U.S., averting over $6 billion in
costs.\12\ Eliminating TB will require both strengthening systems to
diagnose and treat active TB disease and intensifying efforts to
identify and treat latent TB infection (LTBI) among Americans infected
with TB bacteria who are not yet sick. CDC estimates that up to 13
million Americans have LTBI, which develops in some people exposed to
an active case of TB disease; about 5-10 percent of them will develop
TB disease later in life without treatment.
---------------------------------------------------------------------------
\12\ Castro, K.G., Marks, S.M., Chen, M.P., Hill, A.N., Becerra,
J.E., Miramontes, R., Winston, C.A., Navin, T.R., Pratt, R.H., Young,
K.H., and LoBue, P.A., ``Estimating tuberculosis cases and their
economic costs averted in the United States over the past two
decades.'' International Journal of Tuberculosis and Lung Disease.
2016; 20(7):926-933.
---------------------------------------------------------------------------
cdc staffing
Question. In your response to my nominations hearing QFR question
about domestic tuberculosis, you commented that you look forward to
working with the CDC on combating this disease. I want to remind you of
a letter my colleagues and I sent to you last week, highlighting the
vacancies of nearly 700 positions at the CDC.
The CDC is a vital agency for protecting the public health of all
Americans, including through the prevention of the spread of TB. How do
you envision the CDC can continue its programs to combat diverse public
health issues by decreasing the budget by 17 percent and allowing the
continuation of extensive vacancies?
Answer. The FY 2018 budget request includes a number of
programmatic reductions and eliminations, while maintaining key
priorities that will allow CDC to advance its core public health
mission.
Question. Is it your plan to continue the hiring freeze and
continue to stifle the important work of the CDC?
Answer. HHS continues to follow guidance provided by the Office of
Management and Budget (OMB) relating to its April Memorandum,
Comprehensive Plan for Reforming the Federal Government and Reducing
the Federal Civilian Workforce, to ensure efficient and effective
delivery of services while continuing its critical health and safety
responsibilities.
refugee programs
Question. Several Ohio refugee resettlement agencies have had to
close their doors or lay off staff as a result of the President's
Executive order targeting refugees. The President has also proposed
drastic cuts to HHS's refugee assistance programs in the FY18 budget.
In what ways is HHS continuing to support resettlement
organizations in light of the President's executive actions and
proposed 30 percent budget cut to HHS Refugee Programs?
Answer. HHS continues to support the resettlement of refugees
through funding in significant program areas. We continue to issue
grant funding to States and nonprofit agencies that provide health
coverage, cash assistance, medical screenings, and employment services
to refugees and other eligible populations. Through grants administered
by participating States, we also provide specialized foster care for
refugees and other populations of youth, as authorized by law. The
proposed cuts to these benefits and services in the President's budget
are partially a result of the decrease in projected arrivals.
Additionally, we continue to provide funding to ethnic community-
based organizations, non-profit agencies, and resettlement agencies for
additional specialized programs, such as services for survivors of
torture.
When changes in the program affect our partners, we communicate
through Dear Colleague Letters, such as the letter announcing the
change in the Cuban and Haitian social services set-aside program, and
through in-person meetings and phone calls.
Question. How will you ensure refugee resettlement remains a
priority at the Department?
Answer. HHS is increasing efforts to engage receiving communities,
and we are working to improve the program. Successful resettlement
requires positive collaboration between refugees and receiving
communities in multiple environments, including workplaces, schools,
neighborhoods, and places of worship. We work to facilitate and enhance
this collaboration, particularly within the private sector. As part of
this community outreach, the Director of the Office of Refugee
Resettlement (ORR) visited several agencies that serve refugees in
northern California in May, and has visited resettlement agencies in
Charlottesville, VA, and Boston, MA, in July.
The ORR Director and staff will continue to participate in meetings
with government representatives and NGO participants, like the United
Nations' Annual Tripartite Consultations on Resettlement, which the ORR
Director attended in June.
prescription drug prices
Question. President Trump has been outspoken both as a nominee and
in his current role about the high costs of prescription drugs, yet
there is no indication of this being a priority through the notable
absence of funds to address the issue in the proposed FY18 budget. In
your budget hearing, you stated that the President has charged your
department with developing policy suggestions to combat this issue, and
that you have begun holding roundtable discussions with certain
stakeholders. You also mentioned that you would like to engage with
others interested in lowering drug prices; I am interested in doing so,
and have already worked with Senate colleagues to introduce multiple
bills this year to combat this issue.
Is there a reason that prescription drug costs did not make it into
the President's FY18 proposed budget?
Please share with me the stakeholders who you are including in your
discussions to work on this issue, and a timeline of your plan to share
your policy suggestions with the President and Members of Congress.
Answer. High drug prices and costs are an issue of major concern
for HHS and for the American people. This includes the millions of
seniors who rely on Medicare for their drug coverage, and the taxpayers
who have to foot the bill for government spending on this program. As
you know, the President has made prescription drug prices an absolute
priority and has charged the U.S. Department of Health and Human
Services (HHS) with making recommendations to his office on reducing
drug prices. HHS has been meeting with stakeholder groups from across
the health-care spectrum over the past several months in order to
understand where there are areas of consensus.
It is important that we move forward quickly, but also carefully,
so that our policies do not have unintended consequences. We need to
balance the goal of ensuring affordability and access with the mandate
to continue supporting development of lifesaving innovations.
______
Questions Submitted by Hon. Robert P. Casey, Jr. and Hon. Rob Portman
complex rehab
Question. Complex Rehab wheelchairs and accessories are used by a
small population of people with high levels of disabilities such as
ALS, cerebral palsy, multiple sclerosis, muscular dystrophy, spinal
cord injury and traumatic brain injury. For this reason, Congress
exempted Complex Rehab Technology from the competitive bidding program
established in the Medicare Improvements for Patients and Providers Act
(MIPPA) of 2008.
Unfortunately, in 2014 CMS announced it intended to apply Medicare
competitive bidding program pricing to Complex Rehab wheelchair
accessories effective January 1, 2016. We expressed our concern to CMS
at the time but the agency chose to move forward. Congress has delayed
these reductions through legislation twice; however, the cuts are
scheduled to take effect July 1, 2017.
Mr. Secretary, we remain concerned with CMS's interpretation of the
competitive bidding program which will reduce access to CRT accessories
when provided on complex rehab wheelchairs for people with
disabilities. We urge you to use your administrative authority to stop
these cuts prior to June 30 and ask what plans you have to provide
assistance in this area.
Answer. CMS is committed to providing beneficiaries with access to
the services and medical devices they need. On June 23, 2017, CMS
issued a new policy on how adjustments to the fee schedule based on
information from competitive bidding programs apply to wheelchair
accessories and back and seat cushions used with group 3 complex
rehabilitative power wheelchairs. As a result, retroactive to July 1,
2017, payment for these items are based on the standard unadjusted fee
schedule amounts through December 31, 2018. By continuing these higher
payments, this new action will help to protect access to complex
rehabilitative power wheelchair accessories on which people with
significant disabilities depend.
aging
Question. Secretary Price, on February 24th, after having traveled
across Pennsylvania, I sent you a letter regarding administration
proposals that threaten the financial and health security of older
Americans and their families, questions that you failed to answer
during the confirmation process. On April 4th, I sent you a letter
regarding the administration's efforts to undermine the Affordable Care
Act through executive action. In that letter, I requested you provide a
letter reportedly presented to House Republicans from President Trump
outlining the ACA regulations the administration could repeal on its
own. On May 8th, I sent you, Treasury Secretary Mnuchin, and OMB
Director Mulvaney a letter regarding the administration's efforts to
sabotage the ACA. That letter called on the administration to commit to
making cost-sharing reduction payments and requested documents and
communications. You have not responded to any of these letters.
Do you commit to providing responses to each of these letters in
writing as well as producing the documents requested in the letters?
Answer. I have provided responses to all of the letters listed
above.
cost-sharing reductions
Question. Secretary Price, you and other members of this
administration have repeatedly stated that the ACA marketplaces are
failing, yet Pennsylvania's Insurance Commissioner Teresa Miller
recently announced aggregate rates for the 2018 plan year, and these
increases were in the single digits. Her statement also noted that if
the administration eliminated cost-sharing reduction payments, premiums
would increase by over 20 percent. She further noted that if
Republicans repealed the individual mandate, premiums would increase by
over 23 percent. If both of those changes happened, premiums would go
up over 36 percent. On May 8th, I, along with Ranking Member Wyden and
11 other Senators, sent you a letter calling on the administration to
halt its efforts to undermine the Affordable Care Act and permanently
commit to continuing to make cost-sharing reduction payments. The
administration has failed to do so. It's clear that Pennsylvania's
market would be on path to stability if the administration and
Republicans would just stop their sabotage of the ACA. Health insurers,
medical providers, and business leaders have all said that continuing
cost-sharing reduction payments is key to the success of the health
insurance marketplaces and is the ``most critical action'' the
administration could take regarding the ACA.
Will you commit today to permanently funding cost-sharing
reductions payments?
Answer. The administration has emphasized the importance of
reforming our health-care system to one that works better for patients
and their providers. Our budget calls for Congress to repeal and
replace the Affordable Care Act. In the interim, we are evaluating
policy options to relieve American's from Obamacare's burdensome
mandates and to restore choice and competition to the individual and
small group markets, increasing availability of health insurance
options so that all Americans can purchase coverage that meets their
needs.
______
Questions Submitted by Hon. Claire McCaskill
Question. On February 17, 2017, I sent a letter to Acting
Commissioner Stephen Ostroff asking a number of question regarding the
Food and Drug Administration's role in overseeing the dietary
supplement industry. To date I have not received a reply. Please
provide the date on which I will receive a complete response, including
all documents and other requested materials.
Answer. HHS, and all of our component agencies, are committed to
providing meaningful responses to correspondence from Members of
Congress. FDA is working to provide you with a complete response and
they will keep you updated on their progress.
Question. The administration's budget cuts funding for rural health
outreach funding. In Missouri, this funding has been used to expand
access to services. Will these cuts result in reduced access to care,
if enacted? If not, what steps will the administration take to preserve
the expanded access to services?
Answer. The FY 2018 President's budget provides $51 million to
target funding for the Rural Health Network and Quality Improvement
Grants Outreach. These investments will support the existing awards and
fund new awards to improve access to quality healthcare services in
rural and underserved areas.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
This administration, from day one, has preferred ``alternative
facts'' and convenient spin to the truth. One of the most recent
examples was its budget proposal, which double-counted $2 trillion to
maintain some whiff of fiscal responsibility while it slashed health
programs and protections for basic living standards.
The budget math is fake, but the extreme agenda that would deprive
millions of Americans of access to health care and wipe out living
standards is not.
Unfortunately, this morning I have to split time between the
Finance Committee and the Intelligence Committee, so I'll keep my
remarks brief. But there are a few issues in the President's budget and
the administration's agenda I'd like to address.
First is Medicaid. Secretary Price is the captain of the
President's health-care team. He's been the top advocate for Trumpcare,
a bill that cuts Medicaid by $834 billion to pay for massive tax breaks
for the wealthy.
Fourteen million Americans would lose coverage, and millions more
would see caps on their care. As if that wasn't enough of a cut, the
budget proposal that came out a few weeks ago goes even further,
slashing hundreds of billions more from Medicaid. In a program that
covers nearly half of all births, 37 million kids, millions of working
families and people with disabilities and two out of three nursing home
beds in America, that would be an enormous blow to people across the
generations.
These facts and figures have been met by a wave of the hand from
Secretary Price. When asked if his proposed cuts would result in
millions of Americans losing access to Medicaid, he responded,
``Absolutely not.'' He went further, claiming ``there are no cuts to
the Medicaid program,'' and he also said, ``nobody will be worse off
financially.'' I've heard Secretary Price and others make the baffling
argument that people are actually worse off on Medicaid--that their
health doesn't improve as a result of gaining coverage. Often this
argument is based on a brief, old study performed in my home State.
Here's the bottom line on Medicaid. Seventy-four million Americans
rely on this program for health coverage--parents with sick kids,
people with disabilities, seniors in nursing homes who have nobody to
turn to for help if their benefits disappear, and thousands of
Oregonians who are healthier under my home State's model. It would be a
tough sell to convince those people that they're worse off being
enrolled in Medicaid, or that the program needs more than a trillion
dollars in cuts.
And public opinion is clear: two out of three enrollees are happy
with the program. Seven out of 10 Americans say Congress should leave
it as is--no block grants, no per-capita caps.
Fortunately, the budget proposal hit the wall here in Congress and
there's a lot of debate left to be had on Trumpcare. But right now, the
administration is causing turmoil in insurance markets, and it's
already having disastrous effects for millions of families. The
President issued a day-one Executive order undermining the Affordable
Care Act. And nobody on the Trump team can give a straight answer about
whether the administration will continue making cost-sharing reduction
payments that are key to making insurance affordable for working
families. And because of that sabotage, insurers are pulling out of
markets, and people are left without plans to choose from.
You don't have to take my word for it. The insurers are quite clear
about why they're making these decisions.
Furthermore, on the campaign trail, the President said he wouldn't
cut Medicare. But the Trumpcare bill shrinks the life of the program,
and the budget proposal extends the mandatory cuts under the sequester
by more than $30 billion. The Food and Drug Administration, the Centers
for Disease Control and the National Institutes of Health--all slashed
in the budget. The same is true in programs aimed at basic living
standards--programs that fund Meals on Wheels, child care, and foster
care.
This is the budget you write if you think seniors and working
families have it too easy.
I want to thank Secretary Price for joining the committee today.
This is never any easy appointment for a Cabinet Secretary, and I'm
sure there will be some rigorous debate this morning. As I mentioned,
I'm double-booked with the Intelligence Committee, so I want to thank
Senator Stabenow for generously offering her time to fill in for me
today. Thank you, Chairman Hatch.
______
Communications
----------
American Academy of Family Physicians (AAFP)
AAFP Headquarters
11400 Tomahawk Creek Parkway
Leawood, KS 66211-2680
800-274-2237 913-906-6000
[email protected]
AAFP Washington Office
1133 Connecticut Avenue, NW, Suite 1100
Washington, DC 20036-1011
202-232-9033 Fax: 202-232-9044
[email protected]
On behalf of the American Academy of Family Physicians (AAFP), which
represents 129,000 family physicians and medical students across the
country, thank you for the opportunity to submit a statement for the
record to the Committee on Finance regarding the Trump Administration's
Fiscal Year 2018 Budget Request.
On the whole, the AAFP is deeply troubled by the Administration's FY
2018 budget, and its implications for patient health, safety, and
access to care. The AAFP believes that if implemented, the spending
reductions and policy changes requested in the budget would create a
domino effect of damage that ultimately will harm the health of America
on both an individual and community-wide basis. Below, the AAFP sets
forth its principal concerns with the budget, as well as qualified
support for selected policies.
1. The Committee Should Reject the Administration's Position on
Repeal and Replace of the Affordable Care Act
The AAFP supports health care coverage for all, consistent with the
public-health mission of the specialty of family medicine. The AAFP
promotes this in the form of ``a primary care benefit design featuring
the patient-centered medical home, and a payment system to support
it,'' for everyone in the United States.\1\ AAFP believes that all
Americans should have access to primary-care services without patient
cost sharing. This primary care benefit is especially important today
in high-deductible health plans. The AAFP believes that universal
health care also should include services outside the medical home
(e.g., hospitalizations) with reasonable and appropriate cost sharing
allowed, but with protections from financial hardship. Supporting
access to primary care is also consistent with the ``triple aim'' of
improving patient experience, improving population health, and lowering
the total cost of health care in the United States. Research supports
the AAFP's view that having both health insurance and a usual source of
care (e.g., through an ongoing relationship with a family physician)
contributes to better health outcomes, reduced disparities along
socioeconomic lines, and reduced costs.\2\
---------------------------------------------------------------------------
\1\ AAFP, ``Health Care for All'' (2014), available at http://
www.aafp.org/about/policies/all/health-care-for-all.html.
\2\ See, e.g., The Robert Graham Center, ``The Importance of Having
Health Insurance and a Usual Source of Care,'' Am. Fam. Physician
(September 15, 2004), available at http://www.aafp.org/afp/2004/0915/
p1035.html.
The AAFP applauded the passage of the Affordable Care Act (ACA) in 2010
as an incomplete yet important step toward the goal of universal
coverage. While the AAFP does not oppose repeal and replacement of the
Affordable Care Act per se, the AAFP has clearly articulated to
Congressional leaders its grave concerns with any approach to replacing
the ACA that would increase the number of uninsured, degrade the
health-care safety net, or eliminate important patient protections in
the health-insurance marketplace. After the Congressional Budget Office
(CBO) issued its report dated March 13, 2017, projecting that H.R. 1628
(the American Health Care Act or AHCA) would ``increase the number of
uninsured people relative to the number under current law . . . to 24
million in 2026,'' the AAFP expressed to House leaders its formal
opposition to that bill--based in large part on this projection about
insurance coverage. The AAFP subsequently expressed ``deep
disappointment'' when the House passed the current version of the AHCA
on May 3rd (a later CBO report dated May 24, 2017 projected that under
the modified version of the AHCA, the number of uninsured would
increase to 23 million, 9 million of whom would have been insured
---------------------------------------------------------------------------
through employer-based or private non-group coverage).
Although the Administration has never precisely articulated its vision
for repealing and replacing the ACA, it states in this FY 2018 budget
that it ``continues to support a repeal and replace approach'' to the
Affordable Care Act (see Budget in Brief at 2) that broadly tracks the
AHCA framework of tax credits, expanded health savings accounts, high-
risk pools, and changes to Medicaid financing. The Administration
proposal ``eliminates Obamacare's onerous taxes and mandates, provides
funding for states to stabilize markets and ensure a smooth transition
away from Obamacare, and helps Americans purchase the coverage they
want through the use of tax credits and expanded Health Savings
Accounts,'' all of which matches the AHCA. (Id.) The Administration has
also indicated (through a Statement of Administration Policy dated
March 22, as well as a public event held in the White House Rose Garden
on May 3rd) that it ``strongly supports'' the AHCA--both the version
approved by the House Budget Committee and the version that the House
passed on May 3rd.
Although the Administration has not made its own projection about
coverage losses under its repeal-and-replace proposal, it is clear that
the Administration's proposal is equivalent to the AHCA, and thus gives
rise to the same concerns about loss of insurance coverage. The AAFP
urges this Committee to reject the Trump Administration's vision for
repeal and replace, and instead adopt reforms that extend affordable
insurance to more Americans, strengthen the health-care safety net, and
lower the overall cost of health care by investing in a stronger
primary-care foundation.
2. The Committee Should Reject the Administration's Proposals to
Cap Medicaid Financing
The AAFP and its members are committed to ensuring that all
individuals, regardless of their socio-economic status, have access to
health care coverage. This commitment is focused on individuals and
families who do not have access to employer-based health insurance and/
or are economically unable to secure health care coverage through the
individual market. Our commitment to low-income individuals and
families is reflected in family physicians' participation in the
Medicaid program. More than two-thirds (68%) of AAFP's members accept
new Medicaid patients into their practices. Participation in Medicaid
by family physicians is at its highest level since the AAFP began
monitoring the issue in 2004.
The Administration's budget proposal ``reforms Medicaid funding to
States starting in FY 2020 through either a per capita cap or a block
grant'' (see Budget in Brief at 3). The Administration projects that
these changes will reduce federal Medicaid spending by $610 billion
over 10 years. Amazingly, the budget also contemplates ``additional
savings to Medicaid as a result of the Administration's plan to repeal
and replace Obamacare with solutions that focus Medicaid on the most
vulnerable Americans--the elderly people, with disabilities, children,
and pregnant women--those Medicaid was intended to serve'' (see Budget
in Brief at 61). Office of Management and Budget (OMB) Director Mick
Mulvaney confirmed \3\ that the Medicaid reductions in the budget
proposal are to be added to those found in the AHCA ($834 billion per
the CBO report dated May 24, 2017), yielding a potential total of more
than $1.4 trillion in federal funds removed from Medicaid over 10
years. This strongly suggests that the CBO's estimate that 14 million
Medicaid beneficiaries would lose their health coverage by 2026 is a
floor, not a ceiling. President Trump's proposal would likely
significantly reduce support to states, causing even more low-income
Americans to lose Medicaid coverage--an unacceptable result to
America's family physicians.
---------------------------------------------------------------------------
\3\ See White House, off-camera briefing of the FY18 budget by
Office of Management and Budget Director Mick Mulvaney (May 22, 2017):
``We assume the Affordable Health Care Act that passed out of the House
passes. That has some Medicaid changes into it. We wrap that into our
budget proposals. We go another half a step further and ratchet down
some of the growth rates that are assumed in the AHCA. So if you assume
growth rates--I can't remember what the exact measure is--it's a CPI-
plus measure. We take a measure that we think is closer to what the
actual growth rates look like.''
The AAFP has consistently stated opposition to the means by which the
Administration achieves its budgetary goals in Medicaid (by shifting
costs onto states, localities, providers, and patients). Rather, the
AAFP supports maintaining the current financing structure of Medicaid:
the federal medical assistance percentage (FMAP) system. Capping
federal financial participation in Medicaid by definition shifts risk
of medical loss to states, localities, and ultimately to patients
themselves. Eventually, under the fixed federal contributions with the
growth rate set forth in the AHCA, states will be unable to fill
funding shortfalls, and will be forced to reduce payments to providers
and managed-care organizations (MCOs). Many more providers will drop
out of Medicaid, and many MCOs will shrink their provider networks,
providing still fewer choices for Medicaid patients, and rendering
states unable to fulfill the equal-access mandate of the Medicaid
program. As federal contributions cover less and less of the total cost
of care over time, some state Medicaid programs may ultimately create
waiting lists for patients, and other forms of rationing for non-
emergent services. And of course, for the 14 million or more who will
lose coverage altogether, they will have no access to care at all save
for charity and uncompensated care. The AAFP strenuously opposes such a
fundamental undermining of the Medicaid entitlement and the damage that
---------------------------------------------------------------------------
it would do to Americans' public health.
3. Congress Should Provide Long-Term Support for the Teaching
Health Center Graduate Medical Education Program
The budget proposal ``maintains funding for the Teaching Health Center
Graduate Medical Education Program and requests $60 million in new
mandatory funding in both FY 2018 and FY 2019'' (see Budget in Brief at
22). The AAFP commends the Administration for its recognition of the
importance of the THCGME program, which will expire on September 30,
2017, absent Congressional intervention.
The THCGME currently provides training for 742 medical and dental
residents. Residents in the THCGME program train exclusively in
primary-care medical specialties and dentistry--two thirds of whom are
training in family medicine and pediatrics.\4\ Residents in the program
train in community health centers (including federally qualified health
centers), and tend to be concentrated in rural and other underserved
areas that need access to more providers, particularly primary-care
physicians.
---------------------------------------------------------------------------
\4\ Health Resources and Services Administration, ``Teaching Health
Center Graduate Medical Education Program, Academic Year 2014-2015,''
available at https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/
teaching-health-center-graduate-highlights.pdf.
THCGME, which funded its first class of residents in 2011, is already
achieving Congress's intent to get more doctors practicing in rural and
underserved areas. The most effective way to get family and other
primary-care physicians into rural and underserved areas is to train
them in these underserved areas. American Medical Association Physician
Masterfile data confirms that a majority of family medicine residents
practice within 100 miles of their residency training location.\5\ By
comparison, fewer than 5 percent of physicians who complete training in
hospital-based GME programs provide direct patient care in rural
areas.\6\
---------------------------------------------------------------------------
\5\ E. Blake Fagan, M.D., et al., ``Family Medicine Graduate
Proximity to Their Site of Training,'' Family Medicine, Vol. 47, No. 2,
at 126 (February 2015).
\6\ Candice Chen, M.D., MPH, et al., ``Toward Graduate Medical
Education (GME) Accountability: Measuring the Outcomes of GME
Institutions,'' Academic Medicine, Vol. 88, No. 9, p. 1269 (September
2013).
The AAFP stresses to Congress that the Administration's proposal to
fund the program at $60 million per year is not enough to continue
financing the program at its current size. The Health Resources and
Services Administration (HRSA) has completed a study documenting that
``the median overall cost of training a resident in a THC in FY 2017 is
estimated to be $157,602.'' \7\ Therefore, the annual cost to maintain
the current size of the THCGME program is at least $117 million per
year. The AAFP views this as the bare minimum that the program should
receive in order to prevent reductions in existing levels of primary-
care training. However, given that Congress devotes some $15 billion
per year to training residents, Congress could fund the THCGME program
at $150 million per year and still account for only one percent of the
overall spending on GME. The AAFP urges Congress in the strongest
possible terms to dramatically expand and make permanent this highly
successful and bipartisan GME program.
---------------------------------------------------------------------------
\7\ Health Resources and Services Administration, ``Cost Estimates
for Training Residents in a Teaching Health Center,'' available at
https://bhw.hrsa.gov/sites/default/files/bhw/grants/thc-costing-fact-
sheet.pdf.
4. The Committee Should Swiftly Approve a ``Clean'' Long-Term
---------------------------------------------------------------------------
Extension of CHIP Funding
The AAFP urges the Committee to swiftly approve a bipartisan long-
term extension of CHIP, in order to promote stability and health
security for 8.9 million low-income children \8\ and their families.
Time is of the essence in completing this work in order to ensure
continuous access to primary and preventive services for this
vulnerable population, protect progress in public health and allow
States to adequately plan. Although the Administration's budget
``proposes to extend funding for CHIP for two additional years through
FY 2019'' (see Budget in Brief at 66), the AAFP believes that Secretary
Price articulated a better position during his January 24th
confirmation hearing in this Committee when he suggested that an 8-year
extension would be preferable.\9\
---------------------------------------------------------------------------
\8\ Centers for Medicare and Medicaid Services, 2016 Enrollment
Report, available at https://www.medicaid.gov/chip/downloads/fy-2016-
childrens-enrollment-report.pdf.
\9\ During his testimony, then-Representative Price stated about
CHIP (in response to Senator Brown): ``Well, if we could extend it for
8 [years] it would probably be better than 5 [years].''
The AAFP has supported CHIP since its inception in 1997, and during
each subsequent reauthorization and extension of funding (2007, 2009,
and 2015), as a way to extend health coverage to uninsured children
whose families do not meet eligibility requirements for Medicaid. Since
the enactment of the Medicare Access and CHIP Reauthorization Act of
2015 (MACRA), the AAFP has reiterated support for CHIP funding beyond
the current end-date of September 30, 2017--through letters to this
Committee and to Congressional Leadership. Although the AAFP does not
collect member survey data on CHIP participation, we know (due to the
close connection between Medicaid and CHIP--including the fact that
some states operate combined Medicaid/CHIP programs--and the fact that
family physicians perform so many pediatric services) that family
physicians are helping to carry out Congress's intent behind CHIP:
treating low-income children, many of whom would be uninsured without
---------------------------------------------------------------------------
the program.
Family physicians play an important role in addressing the health needs
of American children. According to the AAFP's latest member census,
published December 31, 2016, over 80 percent of AAFP members care for
adolescents, and 73 percent care for infants and children.\10\ Other
AAFP member survey data reflect that about 20 percent of AAFP's members
deliver babies as part of their practice, with roughly 6 percent
delivering more than 30 babies in a recent calendar year.\11\ Of AAFP
active members with full hospital privileges, 70 percent provide
newborn care in the hospital, and 64 percent provide pediatric care in
the hospital.\12\ This is consistent with family medicine's traditional
role of practicing in the entire scope of the physician license, in
order to meet the needs of the community in which the family physician
practices. A family physician who serves a small rural community
without a pediatrician, for example, will often perform most or all
pediatric care for that community.
---------------------------------------------------------------------------
\10\ AAFP Member Census (December 31, 2016), available at http://
www.aafp.org/about/the-aafp/family-medicine-facts/table-13.html.
\11\ AAFP, 2015 Practice Profile Survey (July 15, 2016).
\12\ Id.
The AAFP urges the Committee to pass a ``clean'' extension of CHIP with
a minimum of unnecessary policy changes. Accordingly, the Committee
should extend the current enhanced federal medical assistance
percentage (FMAP), as well as the current maintenance of effort (MOE)
provisions, which are both in effect through September 30, 2019, in
order to align with an extension of CHIP funding. For example, if
Congress extends CHIP funding for 8 years, then it should extend the
enhanced FMAP and MOE provisions for 6 years. The Administration
proposal does quite the opposite--it ``ends the 23 percentage point
increase in the enhanced Federal match rate and the current law
maintenance of effort requirement after FY 2017'' (see Budget in Brief
at 66), which would terminate these important policies this year--two
years earlier than Congress had envisioned. The AAFP opposes scaling
back what our current bipartisan commitments to the nation's most
---------------------------------------------------------------------------
vulnerable children.
5. The AAFP Welcomes Efforts to Expand Direct Primary Care in
Medicaid
The Administration proposes to ``expand Medicaid Direct Primary Care
(DPC), which provides an enhanced focus on direct physician patient
relationships through enrolling Medicaid patients in DPC practices.
These practices enhance physicians' focus on patient care by
simplifying health care payments for patients and physicians'' (see
Budget in Brief at 62). The AAFP supports the physician and patient
choice to, respectively, provide and receive health care in any ethical
health care delivery system model, including the DPC practice setting.
Payments in all primary-care models should be appropriate to ensure an
adequate supply of participating family and other primary-care
physicians. Just as the fee-for-service payments in Medicaid should be
at least at Medicare levels, periodic payments in Medicaid DPC should
be comparable to payment levels from other third-party payers such as
employers and Medicare Advantage plans, in order to allow family
physicians to appropriately serve this patient population in this
unique model.
6. The Committee Should Work to Ensure That CMS is Adequately
Funded in Order to Implement the Many Programs Under the Committee's
Jurisdiction
The Administration proposes to reduce CMS program management by $379
million in FY 2018--a 13-percent reduction in the agency's FY 2017
budget (see Budget in Brief at 71). Given that CMS is responsible for
the administration of Medicare, Medicaid, CHIP, and the Affordable Care
Act federal marketplaces, as well as over one trillion dollars in
corresponding annual payments, the AAFP advises the Committee to work
with the Appropriators to resist such a large and unwarranted reduction
to the CMS operating budget in FY 2018. The vast majority of AAFP
members participate in one or more of Medicare, Medicaid, and CHIP, and
the millions of newly insured under the ACA have looked to America's
family physicians for primary care--many for the first time in their
lives. Accordingly, ensuring the smooth functioning of CMS is critical
to the ability of so many Americans--the elderly, the low-income, those
insured in the marketplaces, and others--to receive high-quality
primary care.
Moreover, the AAFP continues to invest significant resources preparing
its members for the Medicare Quality Payment Program (OPP), established
in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and
launched on January 1, 2017. AAFP members are now reorienting their
practices to prepare to report quality and other measures to CMS
through the Merit-Based Incentive Payment System (MIPS) or one of the
advanced alternative payment models (A-APMs) such as the Comprehensive
Primary Care Plus (CPC+) model, rolled out earlier this year by the
Centers for Medicare and Medicaid Innovation (CMMI). The AAFP has also
submitted an original primary-care advanced payment model proposal to
the Physician-Focused Payment Model Technical Advisory Committee
(PTAC)--an expert panel established in MACRA to help review and approve
new models for use under the OPP. These efforts to make the OPP a
success will be compromised unless CMS receives adequate funding to
implement them. The FY 2017 funding level of $2.82 billion already
represents less than one-half of one percent of the $1 trillion in
program payments flowing through the agency this year; the AAFP fails
to apprehend the rationale for such a steep cut to program management
in FY 2018 when it accounts for such a tiny fraction of the agency's
overall budget.
The AAFP commends the administration for its statement that it wants to
``work to reduce provider burden [under the OPP] while providing
incentives for providing high quality care'' (see Budget in Brief at
53). However, in the AAFP's experience, depriving CMS of resources to
implement the QPP and other programs is not conducive to implementing
bold initiatives like regulatory reform. Accordingly the AAFP urges
Congress to reject a draconian cut to CMS program management.
7. Title X Funding
The Administration's FY 2018 Budget Request ``provides $286 million-the
same level as the FY 2017 Continuing Resolution-to support low-income
individuals with comprehensive family planning and related preventive
health services through the Title X Family Planning Program'' (see
Budget in Brief at 24). The AAFP agrees that this important program
should, at a minimum, receive $286 million for the upcoming fiscal
year, in order to continue supporting existing Title X clinics, which
offer preventive services such as: screening for sexually transmissible
infections, cancer screenings, HIV testing, and contraceptive care.
______
National Family Planning and Reproductive
Health Association (NFPRHA)
1025 Vermont Avenue, NW, Suite 800
Washington, DC 20005
Testimony of Clare Coleman, President and CEO
My name is Clare Coleman; I am the President and CEO of the National
Family Planning and Reproductive Health Association (NFPRHA), a
national membership association representing providers and
administrators committed to helping people get the family planning
education and care they need to make the best choices for themselves
and their loved ones. Many of NFPRHA's members receive federal funding
from Medicaid and through Title X of the federal Public Health Service
Act, the only federally funded, dedicated family planning program for
low-income and uninsured people. These cornerstones of the nation's
public health safety net are essential resources for those providing
access to high-quality services in communities across the country. As a
result, NFPRHA respectfully disagrees with the administration's
priorities laid out in its fiscal year (FY) 2018 budget.
Publicly funded family planning services are provided through state,
county, and local health departments as well as hospitals, family
planning councils, Planned Parenthoods, federally qualified health
centers, and other private nonprofit organizations. For decades, these
diverse provider networks have helped ensure that millions of poor and
low-income individuals as well as those who are underinsured or
uninsured receive access to high-quality family planning and other
preventive health services in all 50 states, the District of Columbia,
and U.S. territories.
Oppose Cuts to Medicaid
The President's proposal advances congressional proposals that, if
enacted, would cut more than $627 billion from Medicaid, alter the
structure and financing of the program, and dismantle the provider
network, deepening a crisis in public health. NFPRHA opposes the end to
or rollback of Medicaid expansion, either of which would reduce the
number of people with access to Medicaid, thereby leading to fewer
people getting health care, even-greater increases in rates of sexually
transmitted diseases, and a reversal of the reduction in rates of
unintended pregnancy.
Furthermore, these proposed changes to the structure and financing of
Medicaid will compound the demands being place on the publicly funded
family planning safety net. NFPRHA opposes both per capita caps and
block grants. Both proposals would inevitably shift costs to states,
forcing them to make choices about program eligibility, benefits, and
provider payments in order to adapt to new funding constraints.
Medicaid beneficiaries would also likely face new barriers to coverage,
such as premiums and other cost-sharing requirements.
Increase Support for Title X
An analysis published in the American Journal of Public Health last
year found that, in order for publicly funded providers to meet the
needs of all low-income, uninsured women of reproductive age for family
planning services, the Title X program would need to be supported with
approximately $737 million annually. This estimate is based on the
presumption that the Medicaid expansion resulting from the Affordable
Care Act remains unchanged. The president's budget requests only level
funding ($286.5 million), a fraction of what is needed to serve low-
income, uninsured women across the country. It is also important to
note that the Title X program also supports men, so the resource needs
identified in the analysis are extremely conservative. Since FY 2010,
Title X has dropped from $317.5 million annually to $286.5 million
annually, leading to a loss of approximately 1.2 million patients from
the network.
The ongoing threat of the Zika virus has only increased demand on Title
X providers. The CDC confirmed causal linkage between babies born with
microcephaly and pregnant women infected with the Zika virus reinforced
the simple concept that in a time of public health emergency, women
will turn to Title X-funded providers for thorough counseling, risk
assessment, and access to family planning services. As summer returns
throughout the United States, public health experts expect the Zika
virus to continue to spread domestically and demand for education and
services to rise again.
Oppose Cuts to Other Safety Net Programs
NFPRHA is further troubled by proposals to eliminate several maternal-
child health programs, the Social Services Block Grant, and the Teen
Pregnancy Prevention Program. Each of these programs is a vital part of
the federal government's role in fostering healthy women, children, and
families. NFPRHA also opposes the harmful reductions to the National
Center for HIV/AIDS, Viral Hepatitis, STIs, and TB Prevention;
Temporary Assistance for Needy Families; Special Supplemental Nutrition
Program for Women, Infants, and Children; Ryan White HIVIAIDS program;
and rural health programs. Budgets for each of these programs are
already stretched thin, and these further reductions will harm the
patients our providers serve.
Oppose Harmful Budget Riders
NFPRHA is deeply concerned by the harms to the Title X network and
other health care programs that would be caused by the budget rider
that seeks to prohibit any funding in the Labor-HHS appropriations bill
from going to essential community providers that provide abortions or
contract with abortion providers and that received more than $23
million in Title X funding in FY 2016. The implicit intention of this
proposed rider is to exclude Planned Parenthood affiliates, which are
key networks within the publicly funded family planning safety net. A
recent analysis by the Guttmacher Institute found that Planned
Parenthood serves 32% of all safety-net contraceptive clients despite
having just 6% of the nation's safety-net family planning providers.
Our members, from federally qualified health centers to local public
health departments to universities and school-based programs to private
non-profits, rely on Planned Parenthood to offer patients high quality
services and share the patient load in communities with high levels of
need for publicly funded family planning.
Conclusion
Millions of low-income women and men depend on the safety-net programs
for affordable access to the family planning and preventive health
services that help them stay healthy. However, this budget would
jeopardize the capacity of our nation's public health infrastructure to
help these vulnerable individuals and families as well as the broader
social services and health care safety net. NFPRHA urges the Committee
to reject the President's budget proposal.
______
Oral Health America
180 N. Michigan Avenue, Suite 1150
Chicago, IL, 60601
www.oralhealthamerica.org
phone (312) 836-9900
fax (312) 836-9986
June 19, 2017
The Honorable Orrin Hatch The Honorable Ron Wyden
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Building
Washington, DC 20510 Washington, DC 20510
Re: CHIP Reauthorization is Essential to Children's Oral Health and
Well-being
Dear Chairman Hatch and Ranking Member Wyden:
On behalf of Oral Health America (OHA), a leading nationwide
organization dedicated to changing the lives by connecting communities
with resources to increase access to care, education, and advocacy for
all, especially those most vulnerable; I write to submit a statement
for the record following the Senate Committee on Finance's June 8, 2017
hearing on ``The President's Fiscal Year 2018 Budget.'' OHA requests
the importance of extending funding for the Children's Health Insurance
Program (CHIP) be taken into strong consideration by the Committee as
the September 30 deadline approaches. Specifically, OHA urges Congress
to support a five-year extension through to fiscal year 2022 as has
been widely-recommended. OHA is deeply concerned the president's FY
2018 budget cuts CHIP by an estimated $6 billion, or a 20% cut, despite
the program being extended through to 2019.
Since 1997, CHIP has helped children whose families have incomes too
high to qualify for Medicaid, but too low to afford private health
insurance. CHIP has reduced the number of uninsured children by more
than 50% while improving health outcomes and access to care for
children and pregnant women across the nation. Of direct interest to
the oral health community is the fact CHIP is the only insurance that
guarantees eight million children a dental health benefit that includes
coverage for screenings and exams, cleanings, fluoride, and sealants.
Untreated tooth decay can cause pain that may lead to difficulty
eating, sleeping, and concentrating in school, leading to poor school
attendance, and academic performance. Without CHIP, these children
would lose much needed medical and dental coverage. According to the
Medicaid and CHIP Payment and Access Commission (MACPAC), without CHIP
some families would be susceptible to additional premiums and cost
sharing to access dental services in marketplace plans and/or employer-
sponsored insurance. This is particularly concerning for low-income
families and children. Furthermore, CHIP contributes to overall cost-
savings to the system by decreasing the number of emergency room visits
that are 10-times more expensive than routine, preventative care.\1\
---------------------------------------------------------------------------
\1\ Health Policy Institute American Dental Association, Thomas
Wall, Marko Vujicic, ``Emergency Department Use for Dental Conditions
Continues to Increase,'' April 2015.
Historically, CHIP has had bipartisan support. It gives states
flexibility in designing their programs, allowing them to implement the
program by expanding Medicaid, creating a separate program, or a
combination of both approaches.\2\ With that flexibility, states can
design a program that works best for their state and its children.
Simply stated, CHIP provides states needed ``certainty'' in planning
their budgets. MACPAC estimates all states would exhaust federal CHIP
funding at some point in FY18, with four states and the District of
Columbia running out of federal funds as early as December 2017.\3\
Therefore, time is of the essence. OHA urges Congress to act soon with
a five-year CHIP funding extension.
---------------------------------------------------------------------------
\2\ https://www.hhs.gov/about/budget/fy2017/budget-in-brief/cms/
chip/Index.html.
\3\ https://www.macpac.gov/topics/chip/.
---------------------------------------------------------------------------
Respectfully submitted,
Beth Truett
CEO and President
[all]