it always seems that when we do we get the coldest window in the washington whether that is available in the last three visits there is no and ice storms in a cold snap at the present time. no one should understand the arguments that we are making better than the americans. those of us that wants to leave the european union wants to regain control of our own wall making. we want to control our own borders and our own money. and those arguments for sovereignty off to resignation after here than anywhere else. but instead, we seem to be getting into an argument about none of those things, simply asking what is europe's phone number. we have to get the debate going for reasons i will come to in a moment. no one in the united kingdom has

had an opportunity to tell whether we stay in the european union or not. it's changed since my father voted to join in the market and against it it still never made up from about one and the european union has changed fundamentally from what was originally going to be the economic organization into an organization that moved ever closer to the political union. and union. and that is at the heart of the debates that we have and then we will come back to this but a lot of people in britain have voted for a loose arrangement or economic arrangement in the reformed european union but this isn't on the table in the referendum. it's clear that the european union is not fundamental and is continuing its path towards the union. i don't want to live in a country whose identity is being

consumed into a greater political identity because i think that the super nationalism is not a happy one and it's not happy in the continent at the present time. so, the three reasons that i gave, getting control of the wall and the border and the money. since 1996 at the european council where the big decisions are taking the direction of the policy, when on 72 occasions the united kingdom government either let labour government government or the concept of government have objected to the policy being made on the basis that it was against britain's national interest on 72 occasions we lost on the attempts to block what was happening there. and it has resulted in a whole range to the united kingdom some something very trivial. i know we had everything from the european applied laws on the uk sales of the minerals in the

uk to the seal of pics between the farms to our lifeboat becoming brussels-based maritime safety and we've had the drivers allowed to not drive on british roads with european permits default well below the standards we would have allowed in the uk but nonetheless, irrespective of the concerns we had the wall applied to us and went you look at the way in which they have applied, they tend to be regulations of the market and interference and constitutional issues. and the european parliament level increasingly following the lisbon treaty, more power has been invested between 2009 to 2014. we oppose a number of measures against on 86% of the occasions where the majority of the british proposed legislation were defeated.

so, there is a path and emerging with more of the law is being made overseas and it's difficult to put an exact number on it at but about 13% of the legislation in about 15% of the legislation is not made outside the united kingdom and i find that from the question of sovereignty quite unacceptable. then we come to the issue of the borders and this was probably the most explosive issue in this referendum in the uk for the largest number of voters. in the last ten years we've had 1.162 million citizens settled in the united kingdom. and as long as we are members of the european union, we have no ability to restrict the migration into the united kingdom. and that for a relatively small country geographically has put huge pressure on school places, housing, healthcare in

particular areas where that density is being held very high, and it is resulting in the sort of backlash that is not in my view conducive to good social stability. and the irony perhaps of all of this is that many of those that are supporting, britain remaining in the european union the goldman sachs commission funded establishments supported the campaign of the people least likely to worry about whether they required a public school place or access to a doctor or public housing so there is something of an element developed in this referendum where it is perceived as a well-funded, extremely pro- eu establishment and we've all seen

what the antiestablishment movement can look like politically and i think that we are seeing when developing the uk at the present time. the second issue about the order is that we have seen 1.5 million plus migrants moving into the european union from syria, afghanistan, pakistan in the last year. the question is where do they ultimately end up in for us, the point is this. when those million plus million we are expecting this year, when they get citizenship of any country whether it be hungary, germany, australia, they will automatically have the right to come and settle in the united kingdom whose economy is growing much faster than any other in europe we were introducing a higher minimum wage in a very short time which will act as a magnet for those coming.

and the authorities don't know if those coming to germany whether they are economic migrants, genuine refugees or sympathizers with some of the heart of mining groups were in fact may be an infiltration into that migrant population of some of the groups themselves and neither will we know and i think that is a security risk so far that we are taking. into all of this makes we are not talking about president obama coming to the united kingdom. i understand to take part in a rally in support of britain remaining in the united kingdom. let me put this as gently as i can. we have a strong critical of noninterference in the domestic issues of our friends and partners and believe me, that is a massive domestic interference if the president wouldn't come to speak in the united kingdom before the general election.

i might put it this way the president is entitled to his views and entitled to express them when the un has the open border with mexico that is able to overrule the supreme court. now in terms of money this is an area that is controversial in the uk. we have a next -- net some into the problem with this is the budget is largely dependent upon the success versus the success of the continental european economy and that is largely the euro zone.

it was a political project that had an unsigned architecture that a lot of the wrong countries to join in with a solid fiscal policy and come to diverge from the criteria and we have seen the results today with millions of young europeans being sacrificed with single currency. when it grows faster the budgetary constitution goes up. we've actually been forced to subsidize the failure of the project but we stayed out of because it was doomed to failure. they would get a good deal out of that.

we have to look at all of these elements and the political element that's the biggest friction in all of this that is the renamed campaign and the british government and that is the project here. it's however much they might like. it would be a leap into the blackness the day after we would leave the european union and we would be called isolated. the day after we leave the european union we still have a permanent seat on the un security council. we still have one of the top ten economies with the fifth biggest defense budget and the center of nato and the center of the commonwealth.

it doesn't sound like a grand isolationism to me. but they can only cope with the era of globalization, one in which i -- if we have the european union holding our hands with your hands in our our hands in our pockets at the same time i think it's for the both. it's time for people of britain to regain the right to determine their own destiny and that is a decision for us to take. and i hope all of those that believe in the values that i mentioned this morning of sovereignty, our ability to make our own law and held our own finances respect the right to do so and will not interfere in something that is frankly none of their business. [applause] you have given us plenty to talk about this morning. thank you so much.

we will have a bit of a discussion ourselves and then we will let the audience jump in with it. i know there's a lot of questions. i would like to start with the politics surrounding the referendum and what some are calling the eyes of march. the now forming secretary of work and pensions. the politics around the referendum seem to be getting more difficult for the conservative party and the government, not better. and in some ways this whole referendum as a way to put back the schism as well as the popularity of the united kingdom and the independent party. describe to us what the politics are. did mr. smith's resignation -- was it about the budget, was it about europe were a leadership challenge, help the americans understand what is going on in

the government right now. >> as a concerned member of parliament, there are times we should probably paid double. we have no effective opposition to speak of in the uk at the present time is of the labour party and they almost got wiped out at the general election. there is and always has been a strong division in the party largely based on the issue of sovereignty which is much more an issue to conservatives than to other parties. but coming in here is quite a big about, we know that this runs right through the british public at least they've pretty much neck and neck. i think that the current leadership in britain was totally taken aback by the strength of the parliament reappointed whereby half of the members of the parliament are signed up to believe be leave the campaign in one form or another much bigger than the

government predicted. and i think that's because the strength and the feeling of that isn't necessarily shared by those at the top of the government. succumbing you've got the parliament parliament report economy is that the party in the country that is even more in favor of leaving, only about 70% and you can see the political difficulties began to come from. the decision to have a referendum was largely in response to the european party and when i said we were going to win the general election there were a number of my colleagues that were not sure they were going to win and we discussed last time one of the consequences of winning the election would be that we were transported very quickly into the environment of the referendum which is where we find ourselves and i'm not sure that everyone was exactly prepared perhaps emotionally for

what i was going to bring. and as i kept telling my colleagues, friendships with the cast and enormous passions would be aroused that was absolutely inevitable that we would get to this point. the only thing that i'm surprised about is if anyone is surprised. we would simply have to take this through june 23. it would be impossible to get any legislation through. it would be impossible i think for them to get any legislation that originates in europe during this period because for people like myself to issue to see if we leave the european union but vote for the legislation that's coming our way as a result of that so it makes it for very very difficult legislative period as well. and the message that i get to my colleagues is we have a parliament we can't have an election until may, 2020 and we

will have to govern as a majority party in a time and how difficult and how easy that is going to be depends on how nice we are to one another in the run-up to and during that referendum. so, a little bit of respect for one another's views. a little less personalization wouldn't go amiss. and i really regret that some of my colleagues have spoken about one another and just watching it there's a chance of increasing the bitterness in this dispute personalizing it and we are making it difficult to put humpty dumpty back together again. >> you talk about preparing for this referendum. and your comments on the economy after the referendum we've already seen the markets respond quite negatively after the

minister secured his deal and brought it back. it's like the market will have to say my gosh, this thing is going to happen. looking at the polling saying that it's getting tighter. it seems to me that the government is not preparing for the potential of the decision. it wants to focus on and remain, yet i'm not sure where i don't see the campaign helping me understand what happens the next day if markets, this is a global shock, you have the cbi and others coming out saying there could be a pretty dramatic decrease in the gep.

anyone who says there is a risk free option is not telling the truth. there are huge risks, the euro zone will integrate more as a result of the problems it has got and the architecture will change anyway so we don't know what we would be seeing, one thing we can do is on the ballot paper. you can't vote for what it is today. it will change one way or another and we will go into closer economic and political union, that will take two european unions, the euro zone and non-euro zone countries. i felt the european union was leaving us. irrespective of what we did. very interesting question about the role of appointment. the problem at the moment is the conflation between government acting in the national interest and leaders of the government acting in the interest of the remaining campaign because in british politics before we have

a general election, we sit down with the opposition party and they walk their legislative program and there is contingency planning for a change of government but the current government refuses to allow them to do contingency planning, that seems to me irresponsible. it is being done because the government is acting in the interest of the remaining campaign to do contingency planning except there may be a lead vote so there is a conflict between the government and the national interest and the government acting as the remaining campaign which needs to be resolved and the government a few times in parliament over the nature of the question, the referendum and government's ability to exempt itself from existing legislation of government referendums in the country so there is a risk to

leaving because there is no actual plan the way it works, we would probably -- go to our european partners and say we decided to leave and not getting notice we are triggering the two year period of negotiating but there are constraints on the reality of what happens because i saw the report this morning, if you actually read the subtext of the reported is very unlike the headlines of the report, when they commission these reports looking for a specific answer, one of those is the nature of our trade with europe and we have a huge trade imbalance in the european union as a country. back in the mists of time twee

10 years ago in 2005, 55% of our trade was with the european union. it just dropped below 40%. so we are increasing trade with the rest of the world, our number one trading partner being the us and our trade at which europe is shrinking as it stagnates, you will never get a trade deal with europe, that would be odd because they expert 60 billion tons worth of goods to us that we export to them. are we expected to believe don't sell bmws to britain as a punishment or president holland will doom himself with french wine or get italian furniture in britain as a punishment for having that outside the e.u.? with a french presidential election next year and german general election do you think they will tell their people you must have lower profits and higher unemployment to punish the british?

it doesn't chime with reality, countries don't trade with companies, countries sell to consumers, goods and services, the right policy people once. lots of fluctuations in the global economy, currency being one of them. you have to be rational about all of this was all this nonsense that we lose 1 million jobs, if you look at worst-case scenario you would create numb 1 million jobs fewer than you might create in the best case scenario between now and 2030. >> how is the campaign addressing the economic consequences, this could potentially give us a shock to the global economy at a time

when china's global demand is questionable, europe is stagnating, the us is doing okay, no one needs a shock. what is the campaign's response to that? >> guest: it is not risk-free but the so-called shock is not necessarily their. we won't stop trading with our trading partners, britain is an upward looking trading nation. we won't stop importing from other countries. we have the fastest growing economy, least likely to suffer the shocks currently being undertaken in europe. i would have thought the european union is more dependent on selling to britain, to get the free trade agreement as quickly as possible to prevent a shock to the european continental economy diminishing our risk. it is almost inconceivable they are not pricing and already.

some of the risk we have seen, fluctuations in currency, tend to self-correct recently. in any case for us it is about our ability to prepare for a better future. i don't view this is about leaving the e.u. but rejoining the rest of the world. >> the us ambassador said the us would not initiate a free-trade agreement with the uk should you decide to leave the e.u.. your response? >> next year, one way or the other, the dying embers of the current democratic administration increasingly of little importance. >> check that. >> guest: again, let's leave politics aside and i will come back to the concept of bullying.

given the uk is such a market for american exports and vice versa what would be the point of introducing friction into that relationship? it doesn't make sense economically unless you are willing to say we will punish our manufacturers and consumers for something as abstract as a british decision to be members of the european union. this whole involvement in trying to threaten the british public of what is perceived as threats by the british public does not go down well. two weeks ago, at the beginning of the week our european allies, britain would stay in the european union, they would miss us, within two days president holland told us there would be unknown consequences if we left. we were told we would be economically targeted from the

euro zone, and we went from being best friends when you are with a protection racket if we didn't pay our $10 million of debt every year bad things would happen. the organization that promises your punishment beating, unless you give them the money, we agree to give them up to this point. it will not go down well from a us perspective trying to tell the british people that they have to do something when it is their national free will being tested. in europe, a couple weeks ago, the european union going to visit -- but the reason we have that is continental europe

contains its extremism in the 20th century going for fascism and in the cold war of communism. because britain is free and independent we helped europe diminish the impact twice in the 20th century, rewriting history, in this way, many of us find offensive. let's stick to arguments about trade and the politics and those who want britain to remain in the e.u. make the case for supernationalism and submerge our identities in a new european political identity. i don't think supernationalism has a great track record. the last example was the soviet union which did not end that well. what happened at europe at the present time is nationalist tendencies, and i think britain

is better outside that. >> host: let me pull on unity. the decision to leave the uk, implications for scotland with a second referendum and some have argued this is not even about the e.u. but the unanimity of the united kingdom itself and you have strong connections and understanding of the politics. >> being scottish, i do. when people ask me to describe my politics i describe myself as reconstructed free-market unionist eurosceptic atlanta cyst. at least it has the benefit of clarity. we had the referendum in scotland and the people of scotland voted to remain part of

the union. i don't know which bit of that scottish nationalists didn't understand, lost the referendum and people of scotland voted to be part of the union and in a referendum, both kinds from the north of scotland, equally weighted in a referendum. scottish nationalists made it clear whether we are in the e.u. or not, try to have another referendum we can win it. it is bizarre that people say i don't mind being in the e.u. but i will vote to stay because scottish nationalists might call another referendum. the possibility of the worst of both worlds, you end up in the e.u. you don't life and scotland has a referendum anyway. we should look at the merits of the european decision and leave the internal evidence aside. frankly, i am in that kind of mood this morning, we don't hear english politicians saying it is a narrow vote in england but it is outweighed by a vote in

northern ireland, and break up a country because they didn't like the results people gave them. it is a unionist decision and we have to accept whatever it turns out to be. none of us can tell. very evenly balanced, when you look at voters willingness to go to the polls. those who want to leave have a very high probability of moving and much lower. as the remaining campaign continues, the current campaign which is to say it is not very good, move inside rather than outside. for voters to get a high turnout. >> host: let's talk about the

security dimension of this. uk will not leave the manage security council and instruments. and the uk for two years solely focused on difficult negotiation, and strong role in nato, international organizations, and a strong uk. what is your response to that and how can we, through this period, the turmoil, how do we ensure that the uk plays a strong role in the world. >> people make this case we end up leaving, so preoccupied we won't do anything else. we can walk and chew gum.

we are able to do more than one thing at a time. there are important elements, consequences on the security side. if you look at the nato budget, how much is contributed by the e.u. countries who remember nato, it is a frighteningly small some. it is quite interesting to ask british audiences how big you think that proportion is, usually 14% or 15%, when you tell them 24%, you reach 17%, we are at 74% around that to the nato budget. just ridiculous. we have this myth that the e.u. is an important part of security. nato has kept the peace since world war ii, not the european

union. not to say anything about the european union is bad from a political perspective, but nato is the cornerstone of our defense. the trouble is in recent years it has forgotten its political role. the us has been too happy to hand it over to the european union which has a different global perspective from the us. if britain were to be outside the european union, first of all, european defense in france at that point removes pretension from the e.u. that it is something global, a defense force, potentially for the future, that would force the uk to put stronger focus which is sorely lacking in recent times. i see no evidence in the nato

summit. i don't see the downside in that, much needed shock therapy to remaining countries of the european union, better start thinking about their own security because there won't be the pretense of the uk umbrella. >> host: in the atlantic, the uk and other allies have not paid their fair share? has the uk not paid its fair share? >> guest: one of only four country that has not met that on -- the former defense secretary, at a higher level. at the fiscal hawk, budgetary consolidation, european countries, many of them -- whose contributions verged on

laughable in terms of why european security, i used to sit with bob gates, used to do part 1 of the lecture, you can't complain they are influenced by security policy. to develop a voice of your own, if you don't agree to say there is a greater pay. you can't expect to have a free ride on the back of american taxpayers. there was a bit of irritation in the uk that we are lumped along with other countries who have not been pulling their weight. particularly the way the uk alongside the us and it ran and afghanistan to be lectured that we didn't play our part in

security relationship. didn't go down well. >> host: one person celebrating the decision will be vladimir putin. your comment on the strategic implications? >> i don't think his invasion of georgia or annexation of crimea or incursions into the ukraine were put off by membership of the european union, this idea that this is one of the great calculations that was made in westminster is not one of the guiding factors. we have the strength of vladimir putin because of serial appeasement, cyberattack on estonia, did nothing, and he

still got troops there, and asked crimea with sanctions and it is serial weakness to respond. this idea that one of the key factors is britain's membership of the european union is fanciful at best. >> host: let's turn to the referendum. there is a lawsuit being put forward by british patriots who have lived outside britain for 15 years. we are pretty confident the referendum will be held on june 23rd or a chance the lawsuit will come up. >> it will be held on june 23rd. a lot of people wanted to be held later. this is a complication you don't need to know about, we have elections in london, scottish elections and local elections and a lot of whistling parties don't want referendums at these

elections because for a lot of these, they are not actively finding local elections because they are finding referendums so that has been another little threesome on that. it will be june 23rd and it is a very big day. pollsters, academics tell us that actually for all the passion being arise to buy this we expect relatively low poll. >> host: this is a historic vote. >> i think europe energizes people who care about europe, but for a lot of voters they see it as abstract. at the polling is telling us if you are looking at the scale, very high proportion want to

leave. a small proportion of those who want to remain between 8 and 10, looks like differential turn out so my guess would be high turnout favors romain, low turnout is where we are going. it will be june 23rd. we wake up june 24th whatever happens things won't be the same. >> the may 5th election, london, mayoral race, a couple other elections, will they tell us anything? >> nothing about the referendum. what is interesting in scotland compared to other parts of the uk, my suspicion is a lot of that i won't say rather than don't know giving the pressure from all the major parties in scotland. they are unwilling to tell the pollsters but in the last few weeks, one other movement you

alluded to at the beginning, a much better guide than where people are putting their opinions and that is where they are putting their money, movement from what was a very heavy romain vote with bookies to a shift that is beginning to mirror the opinions, no doubt the real change going on, how far do they come in? >> host: a recent survey of the top three issues on voters minds, migration number one, and hs and europe or economy and the impact of the referendum. some suggested external events may shape the outcome of this referendum as much as internal

deliberations of it. you alluded to migration, something about you, migration, its implication for the syrian migration crisis you are experiencing now, any thoughts as you look at migration questions as we go towards june 23rd? >> one of the remaining's was the alternative date, they didn't want migrant pictures across that. it is too late. the public has that firmly in their mind it does look like europe on the southern border, that will be very controversial in the uk. events in paris, widely covered in the uk media. the implication being if we don't have proper control of our borders we are much more porous

to threats that might come in. i always wanted to have a point system for the uk, immigration can bring economic benefits if the right immigration, and the trouble with that, what we have seen in europe, it has not been an attempt to say fine, there is big potential migration, the people who will be best served whether they are refugees and so on and britain has a different policy from the rest of the e.u. we said we would take syrian refugees but only take them from you and camps so we know who they are. what she said was those who run fastest and farthest will take them and that left potential for children in particular being stranded on the other side of that equation.

you have a lot of single young men who could get to germany quickly before the germans put up the gates. that is the worry and a lot of people's minds, who are the migrants coming into europe and what will that impact have? when you look at the uk, clearly the european economy at the present time, the euro zone well behind, just to put that in context we are constantly told membership of the european union is key to our economic success which does bag the question, why is it that 20 countries with the highest unemployment, 16 are in the european union and why the top ten countries, only one of them is not in the european union and that is turkey? if it is so great for economic

performance why is it not working for almost everybody else? the governor of the bank of england told us britain gets the lie and's share of investment in the uk which must be because of membership of the e.u.. think of the logic of that. if we were getting inward investment because of our membership in the e.u. we would expect a proportionate share not the lie and's share so getting the lion's share it is because we are doing something different so it is the utter lack of a lot of these assertions which i think is driving people into the leave camp saying we believe what we are being told, deal with turkey or migration or anything else. >> let's welcome the audience into this discussion. if you can state your name and affiliation, for ease of purpose we collect a few questions and let you weigh in and at the very

end, we are going to get your predictions. we will go over there. >> i want to frame the question differently. perhaps it does go through, do you see potential rebalancing of britain towards the commonwealth specifically canada, australia and other countries? historically prior to the european union, that was the focus of british trade and investment? >> so many microphones. >> i am director for western european affairs and one thing you mentioned is there would be this rally the president is participating in. i am in the process of putting

together the visit and i knew nothing about the rally. a bilateral meeting with prime minister cameron, a press conference follows that and if there are questions about breakfast, he will also do a public event as he does wherever he goes but the major theme is not breakfast. i think this rally idea is a rumor that has been started because some people are afraid, we recognize completely that this is a question for british voters to decide. they will vote, we will not. you mention, it may be none of our business. we think it is our business because it has to do with the strength of the relationship with the us and the uk.

as british voters go on the 23rd and drop their ballot in the box, we would like to consider what their cousins across the ocean have to say though we are not telling people how to vote but my question for you is can you give me examples how it would be in the best interest of america to let the uk leave the e.u.? >> there is an emotional attachment to the uk, but our relations have to be based on national interest and that will be economics and trade, we want to be able to exploit markets the best we can, free ourselves of as much european regulation as possible to give ourselves the actual freedom to operate in a global market with each opportunity and if you look at britain's trading performance

and the countries where they are growing, countries in china and india, in turkey, south africa, australia, and none of the countries in the european union at the present time. it is a huge economic opportunity, it requires us to rebuild our diplomatic surfaces which are decreasingly swallowed up into the european union and that would be a good thing because that would be free to project our values as widely as possible. that is more possible in some countries than others because of historic links with the uk and others don't face. it is probably the best news i heard today, not because i think it would help the campaign anyway, but it would have in a

terrible breach of protocol and going back to the point i made, the arrangements for the european union in terms of loss of sovereignty, voter control, arrangements the united states would never tolerate for the united states. being told we should stay in an arrangement that is not optimal for the uk because it might suit the us will not go down well. we need to make decisions that are good for us and our allies need to live with those decisions whatever they turn out to be. i think it will give new impetus to political elements of nato because we will not be tied into concepts of european security policy. hugely overblown and i think it will be a britain that develops

as an exporting and importing market and economy in ways we can't do when being lumbered with european interference in market performance. when you look at some of the laws of the european union stacking up behind the referendum, impediments to the concept of free market, i am a free-market liberal. i am not a social democrat. i don't want to live in a social democratically oriented european economy which i think is clearly failing, and the direction of travel will continue to do so. we want to be free from those restrictions and one of the reasons that will benefit the us is it will apply shock therapy to the european union and say to them unless you want to lose other free-market members you better start reforming yourself.

they need to -- anecdote as to why that is, an event -- more than a third of european voters vote for parties that want to leave the european union or destroy the european union. does this not worry you? the answer was typically a euro craddick view which was one third want to destroy that means two thirds are happy and we should continue the direction going in the present time. that logic says until 50.01 want to destroy the entity you won't listen to the voices being raised in opposition. that seems to me utterly crazy but that is the direction they are going in. that is a british exit that would provide a shock to the body politics in europe to show

what happens when members become disillusioned. i see that as being a huge benefit to the european union, what the prime minister and others say, there is no reform in this referendum. >> does it matter to the british people what the united states think or what the american president thinks it should or shouldn't do? for me, how president obama will frame this, strong e.u. we know that platform does it matter what americans think? in some ways people have suggested transatlantic like you, how the us and uk special

relationship, don't think you can lean on us, we want you with europe. how does that reaction reverberate into british publication on what the president says. >> host: >> guest: it is of enormous importance. those of us, interested in american opinion, and the opinion of the administration to think of. american export opinion is something. a strong britain and is a strong e.u. we don't have a strong e.u.. and unless it reforms it will

continue down that path. and at the present time, in any case i want britain to be a free and independent country because the best thing we have done in country's history, free to do them and it is britain's destiny, when they voted for us to join the e.u. and got involved in the union my view is they sold out our birthright. i am not willing to do that to the next generation. >> host: the witching hour, time to throw down, what do you think will happen at the close of the day on june 23rd? >> any turnout above 60% will remain, any turnout 50% we leave. >> host: you heard it here

first, thank you, this has been a stimulating discussion, a series we enjoy producing on the road to june 23rd and we will have other voices from the remaining campaign but we are so delighted that you kicked us off in an important decision. the british people think of the american presidential election, they have no say but it has an impact. i feel the same about the uk referendum. i have no say but it will have a big impact on my work. we look forward to watching the outcome. [applause] [inaudible conversations]

[inaudible conversations] [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations] [inaudible conversations]

[inaudible conversations] >> hillary clinton today issued a statement on the terror attacks in brussels that have killed 31 people and wounded dozens saying, quote, today's attacks only strengthen our resolve to stand together as allies and defeat terrorism and radical jihadist him around the world. a statement from mitch mcconnell, quote, our nation stand in solidarity with the people of belgium and we will renew our determination to prevent more senseless violence against the innocent. >> when i tune in on the weekends usually it is authors

sharing new releases. >> watching nonfiction authors on booktv is the best television for serious readers. >> on c-span they can have a longer conversation delving into their subjects. >> they bring you arthur after author after author. the work of fascinating people. >> i love booktv and i am a c-span fan. >> with the senate in recess this week booktv in prime time, tonight's books on george washington starting at 8:00 pm eastern, edward larson on the return of george washington 1783-1789.

booktv in prime time starting at 8:00 eastern. president obama this week became the first us president to visit cuba in 88 years. he spoke to the cuban people saying he made the visit to, quote, barry the last remnants of the cold war in the americas. you can see the speech at 8:00 pm eastern on c-span. three states hold presidential nominating contests today for the primary in arizona, caucus es in idaho and utah and tonight c-span will have results from those contests and candidate speech as well. the president's budget request for the national institutes of health totals $33 billion for the next year and includes money for what the white house calls a moonshot initiative to try to cure cancer. doctor francis collins testified before a house appropriations subcommittee about his agency's budget.

[inaudible conversations] >> good morning. it is my pleasure to welcome you to the subcommittee on labor, health and human services and education to discuss fiscal year 2017 national institute of health budget request. looking forward to hearing the testimony of doctor collins and his colleagues, brought in for questions along the way. i would like to publicly thank doctor collins and staff at the

nih for hosting me and other subcommittee members for a briefing and a tour of the nih campus a few weeks ago. the second of what i hope becomes an annual track to nih by this committee. we all left nih with an appreciation for exciting work the staff does every day to find ways to save lives. i am proud last year this congress was increasing funding by $2 billion. i am confident through these efforts we will find cures for cancer and alzheimer's. i was there -- i was disappointed to see the proposed budget cuts to the national institutes of health this year and by the administration, proposals of $1 million of biomedical research funds to the mandatory side of the budget level and relied on unlikely authorizations to continue the advances we have made in increasing research funding is disheartening. i do not plan to let the $1 billion cuts stand.

we need to ensure a specific biomedical research base sustained to pave the way for these long-term advancements, proposing one time mandatory spending that may never materialize is not the path to do this. i look forward to discussing the effects of the president's proposed discretionary budget cuts and also want to stress how important it is to ensure we focus on next generation of investigators. we know how long it takes a new drug or treatment to make it from the lab to patients. without a young pipeline of surgeons committed to following the process we won't find the cures we seek. i will be asking some questions this morning about a variety of issues like institutional development awards, alzheimer's disease, the cancer moonshot. i hope to learn more on how the increases we provided are being used to move us forward toward

cures of these diseases that cause so much suffering in our nation. without further a do i want to welcome doctor francis collins, nih director, of the subcommittee, accompanied by four institute directors to assist in answering specific member questions. doctor anthony fauci, director of the national institute of infectious diseases, doctor richard hodges of the national institute of aging, doctor douglas lowy, acting director of the national cancer institute, the director of the institute for drug abuse. as a reminder to the subcommittee and our witness hes will abide by the 5 minute rule but before we begin we are joined by the big chairman as we like to call him and our ranking member. i will defer to the chairman for any remarks he would like to move and then i will move to ranking member mister lowy. mister chairman.

>> the five minute clock does not apply to you. >> that means i got to keep it under one minute. welcome. all of you, to this hearing. thank you, mister chairman, for the courtesy. throughout our work together, you have exhibited the highest level of professionalism and dedication and during a time of so much groundbreaking research, nih has the right man at the helm to meet the challenges we face. the emergence of the zika virus, one of those challenges underscores the importance of the mission to gain and apply knowledge to enhance health, lengthen life and reduce illness

and disability. since most of the recent emergence in brazil, it is spread to dozens of countries and although the cdc does not anticipate widespread outbreak in the us, we had the travel associated cases, the chairman and i and others returned from south america the night before last, we met leaders, health officials talking about the virus. we are interested to hear your thoughts on the role nih can play to develop vaccines and therapeutics based on existing and future research, to limit americans exposure going forward. we met with various officials on that trip particularly in

brazil. it explored what they are doing to tap out the exposure and others in the region. given the importance of nih research, i am proud that we were able to work in a bipartisan fashion to increase your budget and fiscal $162 billion to fund more groundbreaking medical research. this year the nih budget request prioritizes basic foundational research, precision medicine, applying big data to approved health outcomes. in addition to the public health benefits that accompany your work, the economic impact of medical research should not be underestimated. nih research dollars not only impact research facilities and researchers, but they also

helped get new drugs and devices to the marketplace. through these funds, we have established a strong relationship between nih and kentucky. national cancer institute designated cancer center at the university of kentucky and the uk center for clinical and translational science continue to perform transformative research benefiting the entire region and country. we look forward to continuing our work to bring an end to these devastating diseases. that being said, funding towards that goal must come through regular, discretionary channels that allow us to respond to leads as they arise. disappointed to see their request cuts nih discretionary funding by numb $1 billion including $57 million from

national institutes on drug abuse and over 1 $.8 billion in mandatory, i look forward to meeting your requirements through the regular appropriations process. we don't like mandatory spending. it is completely out of control. we had to cut discretionary spending the last five years by almost $200 million in real cuts. the mandatory entitlement side of the budget is soaring out of control. when i came to congress we appropriated two thirds of federal spending, now it is one third. now they are two thirds and growing. unless we deal with it we can't even pay the interest on the debt with discretionary funds. that is why we are dead set

against mandatory increases. we need to keep control of spending that takes place, the honorable -- only accountable way under the constitution. a champion for advancing the science of drug abuse and addiction as director of national institutes of drug abuse for 15 years now. beyond her personal expertise and cutting-edge brain imaging she has been with us since the beginning of the battle against drug abuse in middle eastern kentucky where it got its start. i am anxious to hear about your recent efforts regarding the abuse of prescription medications. this epidemic now runs rampant across our nation. i hope you will update the committee on your work with pharmaceutical companies to evaluate the risks associated with long-term use of opioids and what nih is doing for that,

and opioid alternatives. i am pleased you have committed to sharing these insights at the national prescription summit in atlanta in a few weeks and we are excited about your being there for this one. and we are hopeful the chairman and others on the subcommittee will be able to make that fifth annual summit as well. secondly i look forward to hearing from you today about your pursuit of the adolescent brain cognitive development study. collecting extensive data on the effects of marijuana and other drugs on a young person's brain will help us finally appreciate the harm these substances can do over time. the law is clear yet states continue to rush to decriminalize or legalize marijuana despite lack of scientific data about its use.

this study will help close that gap and hopefully shift public perception back to reality. we appreciate this very esteemed panel being with us today, we look forward to working with you during the years to make sure you are doing what the country expects of us. >> thank you. we will move next to ranking member of the full committee, distinguished member from new york, miss lloyd. >> thank you for holding this important hearing him a pleasure to be with you and ranking member delauro. this is one of the most exciting hearings. i attend every appropriation session. i would like to welcome doctor lowy, doctor fauci, doctor collins, i would like to thank each of you for your service and it is because of your vision and

dedication the national institutes of health are providing bright future for millions of americans suffering from illness and disease. i am pleased to discuss important investments in biomedical research and the health of our nation. i must say i was thrilled as i always am to meet with many of you at the nih two weeks ago. i saw firsthand the life-saving breakthroughs including gene therapy, advanced cancer, ultrahigh field mri machines to get the clearest look at an aging brain, allowing advances in alzheimer's and other diseases and clinical studies that are improving mental health and reducing suicide and so much more. these breakthroughs and the need for additional research into

hundreds of other diseases is why this committee thought to increase funding of the nih by $2 billion in fiscal year 2016 omnibus spending bill. nih has the world's best physicians, research, technology at our disposal. and i worry that even $2 billion investment will not go far enough to ensure that the nih can compete against foreign research initiatives. it does not serve our national interests if there are not enough grants to support young researchers or researcher lured away to foreign countries to develop medical breakthroughs abroad. that is why last year, although i was pleased with the $2 billion increase, i called on this committee to once again commit to doubling funding for the nih.

i was here when that bipartisan effort was made and i do call on my colleagues, both sides of the aisle to double the funding that the nih -- we cannot afford to let some of these brilliant researchers not get the support they need. fiscal 2017 budget request would be a positive step toward that end, your budget increase targeting investments such as the cancer moonshot, increases in precision medicine initiative, the brain initiative. in addition it would result in 600 additional research project grants. these investments not only fund research that is suffering but greatly reduce ballooning costs associated with treatments down the line. i must say i have the

opportunity to visit watson, the ibm research center in my district, just last week. in fact, i am not sure i understood everything but what i paid particular attention to is the effort between watson and other research facilities and your precision initiative. it is so amazing to me that precision medicine and the research being done at the nih is coordinating with many facilities. i understand in my follow-up watson isn't the only place. doctor collins, i would love if you touch on that, the coordination that is going on and the amazing work to think that someone could get there

cancer analyzed at the nih and all the facilities out there. that could certainly help lead us to new discoveries and new cures. ..

i know you're doing additional research. still not satisfied only pregnant women can suffer from zika. so i know we touched on that in our discussions. but the bottom line is, we are already behind. we must act. i urge this committee and congress as a whole to meet this need without delay and thank you, mr. chairman. >> we now go to my good friend the ranking member of the subcommittee. >> thank you very much, mr. chairman. if there are any yankee fans in this audience you will know the

term murderers row which is babe ruth, lou gehrig and others. i want to look at this group this morning as survivors row. you are indeed allowing people to survive as i've said many times in the past did he give the gift of life and we are so honored really to have you here this morning and to listen to you and i the opportunity to have a discussion. so thank you i want to welcome everyone and as we discussed the budget, the nih is the leading biomedical research entity in the world. and with the scientific discovery each medical breakthrough, it's research advance of human knowledge improve the quality of our life and save lives. funding this research has the power to do more good for more people than almost anything else within the purview of our government. last year we were able to provide a significant increase

of $2 billion to the nih. want to say thank you to chairman cole and all the members of the subcommittee for the bipartisan work to support nih research. the additional funds are helping nih accelerate research to fight cancer, alzheimer's, and hope to move forward with exciting new programs like the precision medicine initiative and the brain initiative. however, i was disappointed to learn that funding for hiv/aids research is not increasing. in its 2016 budget request and a age proposed an additional $100 million for hiv/aids research in order to advance its work on universal vaccine to prevent hiv infection. i think it's a mistake to change course and i hope to see nih supported research this year editor something i will advocate for. and h. plays an integral role in responding to emergency public health threats.

2014 as ebola raged in west africa, nih accelerate its work to create an ebola vaccine. more recently nih has been working to develop a vaccine to address the looming zika crisis which poses an urgent and serious threat that my colleague mrs. lowey said to pregnant women and their babies. to take a look in yesterday's "new york times," pregnancies shadowed eyes fears of zika. this is real in the minds of men and women, and women particularly. i look forward to hearing from dr. fauci about the current status of ebola vaccine candidates as well as progress on moving a vaccine candidates towards clinical trials. some of my colleagues have expressed a desire to shift an obligate funds that congress provided for ebola to respond to zika. i strongly oppose that idea. i would be anxious to do what activities would have to forgo if we shift funds away from ebola to zika.

we need to be able to respond to multiple public health threats at the same time. which is why in this congress and the last congress by proposed funding a public health emergency fund that mirrors a disaster relief fund which would enable the federal government to immediately respond to public health threats. i would also urge the nih to use its statutory authority to respond to the rising cost of prescription drugs. as you know when taxpayer funded the research results in a truck packed in an age may require a patent holder to license the resulting intellectual property to third parties. resulting in competition that drives down drug prices. it is outrageous that drugs invented under taxpayer-funded grants can cost six americans hundreds of thousands of dollars over the course of a year. the public paste it to fund and they pay of the backend.

in the snow while nih is no funded at 32 port $1 billion thanks to the $2 billion increase, that has not kept pace with the rising cost of biomedical research. nih's fy 16 funding level remains $7.5 billion below the 2003 level adjusted for biomedical inflation. 15 years ago nih funded about one in three meritorious research grants. today the rate has fallen to about 15. a slight improvement over recent years but still low by historical standards. we are missing opportunities to work towards cures for life altering diseases affecting far too many people. brings us to today's topic in today's discussion at 2017 budget request. so much good in the proposal and i applaud the ambitious proposal to increase cancer research by $680 million in 2017. as a 30 year survivor of ovarian

cancer, you've heard me say before, i am alive because of the grace of god and biomedical research. i am pleased to see proposed increases of $100 million, $45 million for the prescription medicine initiative in the brain initiative. these have conjured to revolutionize our understanding of the disease as was our understanding of long-term physical and mental health. i think we can do better. this budget is constrained by sequestration and arbitrarily low budget caps. as i said i think we need to boost funding for hiv/aids research and not relent until we have developed a universal vaccine. this would save countless lives as well as save billions in treatment costs in future years. we need to continue to develop new antibiotics or risk devastating consequences of antibiotic resistant bacteria to our public health and our entire public health care system. i want to note my concern over

mandatory funding for nih in this budget. it is the responsibility of this committee to fund the nih. and increased to the subcommittee's allocation is the straightforward and responsible way to support nih research rather than to rely on mandatory funding that will not materialize. we should also continue to uphold the long-standing tradition of scientific independence incenting federal research agendas rather than override scientific judgment with congressional practices. that ability to allow the scientific independence has been a hallmark of this subcommittee. i had the opportunity reduce the bill laughter that would enable our committee to increase nih funding by 50% over five years, by providing a cap adjustment. just like what we do in a cap adjustment for program integrity funding, we have a model, we do

it there. we opted able to do this to the nih. that would insure proper funding for research without robbing other vital programs to do so. thank you again for everything that you do. biomedical research is one of the most important investments that we can make as a nation. as i said it gives the gift of life. thank you, look forward to your testimony into our discussion. >> thank you. announced dr. collins, we will go to your opening statement. >> good morning chairman cole, ranking member delauro, chairman from the full committee rogers and ranking member of the full committee, ms. louis. my colleagues and are delighted to appear before you today and we were on a very much to host you at nih with several other committee members by all means let's do it again next year. i think i was asked and healthful for us to have you on our campus. in this hearing on the last budget proposal of this administration i plan to reflect

more broadly in my opening statement you than usual on nih contribution to the nation's health. i will break with tradition and make some predictions. 10 areas to which i believe we can expect to see major progress 10 years from now, given a sustained commitment of resources for nih. so this is 10 for 10. here we go. first the long arc of scientific discovery must begin with babies osha basics of experiments that are going on right now and labs across this nation contained the seeds of breakthrough discoveries that will transform medicine. let's fast-forward to 2026 in the first of these 10 breakthroughs. i think i will be advances in analysis of individual human cells. also the unit of life. biology like adams or for chemistry. and yet during the long history of medical research we have not have the technical ability to study individual cells. we've had to deal with millions

of cells, maybe billions. the new technologies just in the last couple of years, that's all changing. that's just one example. we cannot decode the process by which individual onion cells attack and destroy healthy tissue and autoimmune disorders, transform the way we approach lupus, rheumatoid arthritis, notable sclerosis and many other diseases. on to breakthrough never too. in 10 years time tools developed to the brain initiative will have identified hundreds of different types of brain cells and major circuits responsible for motor function, vision, memory, and emotional functioning at the speed of thought. as a result we will be able to diagnose conditions earlier and more precise and we love you targets to explore for prevention and treatment as conditions like autism, prescription drug addition, traumatic brain injury, schizophrenia, parkinson's disease. number three, aided by the brain initiative new imaging decades and discoveries made with our

private sector collaborators, i believe we will be able to identify individuals at high risk for alzheimer's disease even before any symptoms appear that provides them with effective therapies aimed at slowing or preventing the disease. personal and family tragedies will be delayed or diverted pick the economic savings on this album will add up to hundreds of billions of dollars. number four, i predict 10 years from now we will have developed an effective treatment for spinal cord injuries are already groundbreaking nih research has allowed for young man paralyzed from the waist down to walk the use of electrical stimulation that bypasses the severed court. resources are available to follow up this study. we can give freedom of movement back to victims of car accidents, sports injuries and other spinal trauma. number five, we will see the introduction of a safe and effective artificial pancreas. for those with diabetes such as

device will continually track changes in blood glucose levels and provide precise doses of insulin significant probing the management of their disease and preventing countless complications. number six, hope is on the horizon for heart failure, major cause of death in this country. the development of induced pluripotent tombstones derived from -- stem cells, has opened up new experts suggest a patient's heart could even be rebuilt using his or her own ips cells. this personalized rebuild part with the transplant waiting list and anti-rejection drugs obsolete. number seven, new vaccines will be readily available, universal flu vaccines will protect against all strains of the virus preventing a worldwide pandemic saving millions of lives and eliminating the need for an annual flu shot. arlie clinical trials are

already underway and we're in active collaboration with industry. i'm optimistic that an effective vaccine for hiv/aids will be available by 2026 giving us the opportunity to at long last bring and to this most frightening and costly global epidemic. number eight, genomics, structural biology will unveil entirely new targets for the treatment of pain. allowing the public and private sector to develop highly effective nonaddictive medications for pain management. turning around the current alarming trend of massive numbers of america's becoming addicted to opioids. number nine, we will have new approach is that it does not all people are the same. thanks in large part to the precision medicine initiative and the more than 1 million volunteers in the national research cohort of him to enroll by 2019. the willingness of these participants to share wide variety of the health related information will ensure that major new insights emerged and americans from all walks of life

will be healthier than ever 10 years from now. and last but survey not least, i predict a decade from now hundreds of thousands of individuals will be friday who without nih research efforts would have succumbed to cancer. powerful new prevention strategy that targeted therapies will arise from research et cetera by the vice president cancer moonshot proposal. if that sounds bold, consider what's happening right now. several months after jimmy carter revealed melanoma spread to his brain is beginning a course of therapy to boost his immune system's ability to destroy his cancer cells, last week he announced he is cancer free and no longer needs treatment. our nation needs a lot more stories like this. the sustained efforts of the subcommittee i think is possible. with strong stable trajectory for support of nih research the world can afford to a healthier and happier future whether 10, 50 or even 100 years from now. thank you, mr. chairman.

i colleagues and i welcome your questions. >> thank you very much, dr. collins. just for informational purposes ongoing ask the question and then will go to the chairman of the full committee and the ranking member of the full committee and to my good friend the regimen of the subcommittee and then we will proceed with questions in order of arrival. as i mentioned in my opening statement, although the administration budget appears to requesrequest an increase that increase is thought to mandatory side of the budget which is of course outside our jurisdiction as a committee. the administration's request before this committee proposes $1 billion cut in the very we actually have jurisdiction over. discretionary spending. if we were to appropriate exactly what the administration requested into budget on the discretionary side, again $1 billion cut below current levels, what would the impact on biomedical research in general be and on research and diseases like alzheimer's and cancer specifically?

>> a very sobering scenarios that you portray them on the we very much hope will not happen. certainly the impact woul woulde severe but it would be felt across every aspect of what nih supports, all of my colleagues and the other 23 institute and center directors would have to cut severely backed, initiatives not deal to get started and was utah got cancer or diabetes or heart disease or alzheimer's. this would represent a very significant slogan. again i am just a simple doctor to the country so the idea of how you divide up appropriations between discretion and mandatory is a little over my head. certainly please in the president's budget is a proposal for the increase and gratified by your words and by others of the intention of this committee to figure out how to maintain the trajectory you started this year with a $2 billion increase. i can't say what a shot in the arm that has been for our

biomedical research community. the morale, enthusiasm to take risks and start new projects which have been pretty much in a slowdown for about a decade is back. we want to see that continue, and appreciate your support. >> let me ask you a sunnier, more upside of a question. i can assure you, i've talked to the chairman of the full committee and the ranking member certainly make our feelings known. this committee is not going to cut $1 billion of discretion funding from the nih. it's not going to happen. so in essence you don't need to worry about that in front of you. but let's say last year the president proposed $1 billion increase which was very welcomed. this committee working in a bipartisan fashion was able to double out. let's assume you're able to go be on what the president asked for, beyond the 32.8 alien dollars roughly. if are able to give you extra money, where which you directed. what you think the most

promising use of additional funds might be if we were able to give it? >> what a wonderful question. certainly in my professional judgment or a lot of areas that provide for expansion and the opportunity be able to go even faster on those would be welcome indeed. as you know of great deal of the research we support is ideas that come to us from investors all over the country. it is their bright brains to push for the envelope and we would want to be sure to do something to encourage more of those grants to be fundable. we are still under 20% for the t successfully. that would have affects across the board. antimicrobial resistance would have more resources, alzheimer's could go faster with additional resources. cancer research even beyond the moonshot, so many things are possible now. opioid abuse and other issues of drug abuse. and i could go on, diabetes, autism, all these conditions which might are scientifically poised for rapid advances, all of them would have opportunities lifted by this kind of wonderful

scenario that you portray. >> that's wonderful. let me move to another area of particular interest to the committee and certainty me. so a recent article that highlights some of the early stage clinical trust a somewhat understand to be nih supported basic research. i visited nih if you still. -- a few weeks ago. if you could comment as a public good to try for osha right away, i don't have a lot of time but tell us where you're at and what you see the prospects are on alzheimer's and other dimensions speak with thank you for the question. thank you very much for the increase funding this year which is made an enormous difference. fortunately the biggest is the opportunities will but only by the brain in alzheimer's disease

have expanded enormously so that resources are really applicable to research that is well-thought-out, well prioritized or in preparation of a particular for the budget that we submit for the first time last year, we underwent a very extensive planning process in which national international experts can go to identify priorities. is that translate into milestones. but we had to achieve to accelerate those such as thousand of effective intervention in the nearest possible terms. this meant with the additional funds we were poised to act on this full spectrum of well defined priorities and milestones. for example, the initiative issue we were able to work upon include expectable look at the most basic biology genetics to understand new targets for intervention. new clinical trials take advantage of those most promising interventions. waste into being -- health disparities, epidemiology at

center. across this broad spectrum we've seen a huge increase of applications, scientists who have been inspired by the available resources and, of course, his trajectory we see a bright future accelerated process -- progress. >> i want to move next intimate to the chairman of the full committee for whatever questions he cares to ask. >> thank you, mr. chairman. dr. collins, dr. volkow, thank you both for actively engaging the issue of prescription drug abuse. we lose 100 americans a day from overdoses of prescription medicine and heroin. we need a holistic multi-pronged approach to the epidemic that cdc says we have. before we get to the pills themselves let me explore a sizable part of the problem. oversupply of opioids. as you know over 250 million prescriptions are written each year for opioids.

many of which need not be written at all. and thanks in part to deceptive marketing practices and reckless overprescribing, these drugs have become a default solution it seems for anything, rather than the severe pain for which they were intended. doctors should properly targeting with appropriate and proportionate medicines or moderate measures for moderate pain, more powerful opioids for those who really need them. what are we doing to address the lack of effective non-opioid treatment for chronic pain? >> mr. chairman, of what you thank you for your leadership in this area over these years and again i think many of us looking forward to the summit you are bringing us together for a couple of weeks. i'm going to ask dr. volkow to

explain other areas of pain management. >> thank you for your leadership in this will area that has been very devastating. research on paint access across multiple institute of the and eight institute of the and eight and is a pain consortium that actually aims to integrate this effort. as it relates to the developer of new strategies for the management of pain, the are several approaches. one of them is the one helping develop the tier four -- that cannot be tampered with. that's one of the approaches. another approach to development of analgesics that are not based on oprah to do for going to be a reward their effort approach that aims for the use of simulation technology that will affect the impulses in nerve and in the brain to control and regulate them. that relates to tools like magnetic stimulation our electrical erect current that allows you to either inhibit certain areas of the brain are

stimulated them. there's also research in terms of evaluating behavior and cognitive intervention that can improve the outcome in patients. suffered from chronic pain. there's a wide variety of approaches who tried to address the lack of effective interventions that are safe for management of chronic pain. >> yesterday that cdc announced new prescribing guidelines for opioids. there are 12 recommendations but i think here's the bottom line. doctors should avoid using powerful opioids as the first line of defense against pain. saying the risks from such drugs outweigh the benefits for most people. with respect to the dosage, cdc says start low and go slow. do you think doctors are likely to follow the recommendations that the cdc has put forward?

what steps can take to get medical committee more engaged in the problem? >> yeah, and, indeed, the cdc can't let her actually a step forward in helping to improve the prescription practices as it relates to the use of medications dramatically for the management of chronic pain. and get that cdc guidelines were excluding patients that leads to cancer pain or hospice care pain. the guidance put out a frame of reference that is based on the current dollars but also experience in there is no sufficient scientific evidence on how to properly use opioids. and as a result about and added with the fact that there is an increased awareness, that kurt prescription practices of opioids cannot confuse the way they are doing right now. is unacceptable. that education o on the health care system and also on the public, along with guidelines like the one of cdc, will

facilitate the changing of practices of how we prescribe these medications for the management of chronic pain while at the same time i think because that's the other aspect of it, providing adequate care for those patients that suffer from chronic pain which can be very devastating. >> we thought for years, you and the congress and others have fought for years to get the pharmaceutical companies to develop abuse deterrent formulations to make opioids so they could not be crushed and take away the time release of the drug, to just a split second. and no we've got i think five abuse deterrent opioid pills on the market. doctors are no are not prescrib. i don't know what they don't know about it or don't care about them or whatever, but the bottom line is they are not using what we have developed as an abuse deterrent strategy.

what do you think about that? >> it's likely there are different reasons why doctors may not be using them but one thathat is but for us to be awae of is that we have to be certain because there's different formulations recorded over, they tend to be more expensive than the old opioid medication. we want to be mindful that the our insurance is that when physician prescribe it, physician will be reimbursed for costs associated with the. went to create a system that incentivizes the utilization of these formulations that by default will be in general more expensive. >> insurance companies are reluctant to pay the increased cost because they say the regular opioids are cheaper and, therefore, we are only going to cover the lower cost. how can we deal with the insurance companies, not paying

for the abuse deterrent feature? >> i'm going to -- i am just a pure scientist, and that's above my pay grade. >> i am way over time here. but can you answer that one prickly? >> it's a complicated ecosystem you're talking about in terms of what we need to do to educate physicians about the role, and i think most physicians, the people at this table also our focus on trying to deliver the right care to patients. things take some time to filter down and we need to speed up the process of translating. what we know anything to cdc guidelines are attended to achieve that. in terms of economics, however, that comes down to whether insurance companies can't in fact be talked into this kind of reimbursement if they are given a strong reason. i think we have a stronger case yet that needs to be made about moving where we have been from drugs that are so abuse prone to things that are safer. >> if there's any insurance

companies listening, they would be very wise to two of our coverage of these abuse deterrent drugs because they don't want to know what would happen if they don't. >> thank you, mr. chairman. and with that we will go to my good friend the ranking member of the full committee, the gentlelady from new york. >> thank you very much, mr. chairman. and i want to say with our big chairman on this issue. i want to get back to the cancer been shot, because when you look at the numbers and to think of a number of people i'm sure in this room whose lives have been touched with a loved one who is suffering from cancer, i am thrilled that we are focusing on this issue. in 2015 there were nearly 1.7 million cases of cancer diagnosed in the united states

your so i am very pleased to see this focus of the president and the nih. dr. lurie, could you provide specific examples about the cancer moonshot hopes to achieve that current research from the precision medicine initiative, not address and how is the cancer moonshot target cancers that to date have been difficult to detect and treat such as any cancer and pancreatic cancer of? >> thank you, congresswoman. we really appreciate your strong support, the support of the subcommittee and the support of the congress, not just for 2016 but also the long-term support that has gotten us to this point where incidence and mortality rates from cancer are going do down. but as you point out not only is the incidence high, but in addition close to 600,000 people in the united states will die

this year from cancer. the moonshot is designed to look at many different aspects of cancer, and to take advantage of the enormous opportunities that we have in this area. two areas of focus are not just areas of treatment but also for prevention and screening. in prevention looking to develop vaccines, not just against targeted material from infectious diseases but also abnormalities in cancer. and then in addition for screening, taking advantage of new technology such as dr. collins mentioned for single cell analysis and peripheral blood. we can make these changes looking at the blood and other fluids to try to screen for early detection of cancer and cancer. these are just two of the highlights in the moonshot. >> thank you.

i have a little time left. estimates, and i've been very concerned with the numbers in my own district, that one in 68 children will have an autism spectrum disorder. this is one of the reasons i am such a strong supporter of the brain initiative which could provide a deeper understanding of how the brain works and unlock treatment for autism as well as a host of other disorders. i think all of us here appreciate the work that you do it on alzheimer's disease as well. if you could tell us, what has the research told us to date about the cause of autism, both in genetics and environmental factors, and have with the fy 2017 budget request bolster these research initiatives both under the brain initiatives as well as other institutes throughout the nih?

>> thank you for that question because we are a normal six sided about what's possible now in terms of research on the human brain come to probably most challenging frontier in all of biomedical research, the most complicated structure in the known universe. they are are 86 billion neurons in the brain to each of those have about 1000 connections and we are just bold enough to think we might be able to understand how those circuits work to do the amazing things they do over the course of the next 10 years in a very well-developed blueprint for the research which is guiding the brain initiative which is not in its third year. and take it tohe congress for supporting it. and we hope they'll continue to bgive to rip up to its full funding. autism is clearly a complex heterogeneous collection but if anybody thought that going to come up with just one simple molecular explanation, that chance has long gone by. it does now seem that with careful analysis of dna, which at the genome information, that

something in the neighborhood of 20-25% of those with autism, it tends to be in the more severe end of the spectrum, do in fact have genetic changes that happened for the first time in that child, not in the parents but it was a mutation that arose during the course of spermatic unit or -- does have an interesting set of features we hope to see what genes are involved with their mostly jeans that come from proteins that are active at the synapse, the plae where neurons talk to each other. that make sense to autism is a circumstance where the medication systems in the brain are not functioning in the normal way. that gives us hope that we could begin with the unifying theory of what's happening in autism, begin to develop better ways of introducing new therapeutics. this will be one of the many consequences i think of the investment in the brain initiative which is itself a basic science effort to understand the brain but it builds a foundation upon which

we can do all kinds of other kinds of research to understand autism, alzheimer's disease, parkinson's disease, traumatic brain injury, drug addiction, all of which have of course roots in the brain circuits that sometimes don't function the way they should. it's an enormous exciting time for us to push this forward. it has resulted in the recruitment of a really fascinating array of people coming from different in this primary perspectives. the brain initiative has lots of technology and engineering and loss of neuroscience and nanotechnology, all those things folded together. >> thank you very much and thank you, mr. chairman. >> will next go to my good friend the ranking member of the subcommittee. >> thank you very much, mr. chairman. last year we talked about nih's relatively new policy to require applicants to report their plans for the balance of male and female cells in animals in preclinical studies in all future applications. this is an issue that we've been

working on since we first came to the congress. in our discussion last year you noted that institute directors were in the process of finalizing their guidelines for all grantees. let me note a recent analysis in nature magazine. march 3 article which showed as we sleep house 2014 only 53% of research papers recorded both the sex and age of the animals used in the study. i realize the analysis looked at research papers that predate the implementation of nih policy about sex ballots in pre-clinical research. can you provide an update on in the pages efforts to ensure that research include both male and female animals in preclinical studies, and can you update us on nih efforts to ensure that preclinical research includes both male and female tissues and

primary cells? >> well thank you for the question. as you can see in the visual output of this is something nih has gotten very interested in committed to, and this article that we wrote in nature about a year and half ago very much going out from nih's perspective that you are right, and ms. low-income you are right, and all those who have made this case are right, that we have not been taking enough attention as we should give bouncing mails casinos in preclinical research. and in the process because many animal experts particularly with ms. have focused solely on mails we've been missing out on the important differences, biological significance of my very well be things we need to know for human medicine. we are determined to change all of that. i saw the article you mentioned in nature and happy to say i don't think you would see that article being written in another year or so. we did, in fact, put out a notice back in june but it went

into effect on gender 25th. from now on if you're a nih funded committee into doing estimates involving animals you need to include males and females. if you some idea that you're not going to do that you have to justify it if you're studied prostate cancer. you can probably get away with just taking to the male. but for most of the things they will be dashed that it would be a condition that is reviewed. >> that is true -- >> i think that's been a real wakeup call as well. people thought i felt this just to sell. but it has a sex also and we are losing out information if we don't take account of that and that has also now they come work of the norm of the wicked witch we want to fund research. >> thank you very much. let me talk about, taxpayers provide more than $30 billion annually for nih's research. dr. collins, you said nih conducts basic science fosters innovation that leads effective ways to treat complex medical

conditions. and yet in so many cases taxpayer funded research leads to drugs that are sold back to the taxpayers at exorbitant prices. example, ucla led to a patent for a drug to treat prostate cancer that the drug now cause patients $129,000. the same cost of the patients in the country about a third of that amount. i realize the pharmaceutical companies invest their resources, they bring new drugs to market, they should profit from that innovation. but what i want to do is want taxpayers are getting gouged for drugs that would not exist without the significant investment of u.s. taxpayers. can you better explain why u.s. taxpayers are paying for biomedical research at the front end and paying exorbitant prices at the back into?

and i will just say 50 of my colleagues and myself sent a letter to you and to secretary burwell requesting a nih at hhs assert march in rights on taxpayer-funded research leads to a patented product that is not available to the public under reasonable turn. what are reasonable terms? a drug shouldn't cost $129,000 for people to get access to get. >> i know this is a topic of great interest and while it should be, my heart goes out as all of us do to patients or in need of a therapeutic which is outside of their financial means to be able to get access to. that really ought to be the thing that drives us time to come up with better solutions. i would say with regard to march in rights we read the letter carefully. you saw the response from secretary burwell. nih does, in fact, have the ability to march in a reachable terms are not to be met and if we have intellectual property that is attached to the product. >> what is a reasonable term?

>> that's where it gets down to the nitty-gritty. we have look at that situation several times in the past, have not felt we have reached regional terms but we are totally open to considering that on a case-by-case basis and will be glad to do that with other products that are brought forward for our consideration. we get it that this is a serious issue. >> let's have further conversations. i have gone over my time. spent next operating on the order of arrival, mr. harris you are recognized. >> thank you. thank you very much. good to see all of you again. it was a great visit just last month to see what's going on. meeting with doctor rosenberg and the patients just reminded me of why i went into medicine. what am i doing in politics? anyway, let me ask a couple questions. first of all with regards to the strategic plan, you know, dr. collins you mention one of