the senate finance committee is gathered on capitol hill this morning to hear testimony from health and human services secretary, alex azar. he'll be testifying on prescription drug prices. we expect him to arrive shortly here, and then it will get under way. live coverage on c-span3. letting you know about some of the other programs coming up today. a senate judiciary subcommittee will hear testimony on the influence of shell companies and virtual currencies on elections. that starts live here on c-span3 at 2:30 eastern. and housing and urban development secretary, ben carson, will be testifying tomorrow before the house financial services committee. live coverage of that starting

at 10:00 eastern on c-span3. also online at c-span.org. and you can listen with the free c-span radio app. hhs secretary alex azar arriving here in the hearing room, so this hearing should begin momentarily. [ banging gavel ] i'd like to welcome everyone to today's hearing on prescription drug affordability. and innovation. we're pleased to have our secretary here, secretary azar, who i think is doing a great job before the committee. i know members on both sides of the aisle are eager to hear from him on the trump administration's plan to lower prescription drug costs. i was in the rose garden when the president announced his plan to put patients first by lowering prescription drug and

out-of-pocket costs to consumers. and i commend the president and the secretary for their focus in this area and for releasing this comprehensivelu. i also appreciate that hhs is seeking feedback from the public on the policy ideas on the blueprint. the administration is prudent to work through options by property consulting those affected by these policies first. as we continue to develop policy options, it is imperative to understand the impact on patient access, affordability and innovation before taking any specific action. to that end today, in my opinion, is a golden opportunity for members to discuss policy proposals and ideas in the blueprint, which contemplates many issues that would seriously change the current way of doing things. and on that note, i believe that those who have criticized the blueprint as insufficient are either responding from a lack of knowledge or purely for

political gain. now i bring to the table decades of experience of working on drug pricing. that's why we've titled today's hearing in a way that clearly explains the heart of these issues. quote, prescription drug affordability and innovation, unquote. this hearing title references a concept that has been very important. to me throughout my time in the senate. after all, the goal is to help consumers and the best way to do that is to balance both affordability and innovation. over three decades ago, i championed the drug price competition and patent term restoration act, which has since become known as hatch waxman. as i noted in an editorial that ran in roll call yesterday, the hatch waxman law established a system for regulating drugs that rewards new products while encouraging generic competitors. around that same time, i sponsored the orphan drug act,

and i'm proud to say that law has resulted in new treatment options that have enhanced care and drastically improved the quality of life for hundreds of thousands, if not millions of people that live with rare diseases. at the time, we thought we were just taking care of some rare diseases. but it's become a very important law. those two bills are just the tip of the iceberg. i have since spearheaded numerous other legislative initiatives to address shortcomings in the system, and to capitalize on opportunities for improvement. i brokered the agreement that allowed physician-administered biologics to flourish, providing effective treatment for many cancers and other serious medical conditions. more recently, i've successfully advocated policies to promote development of bio similars, as a way to foster competition and lower costs. now i don't bring up this history to boast, but to point out that the pursuit of the

balance of affordability and innovation has served us well. now nearly 90% of prescription drugs dispensed to patients are generics. yet we also have realized life-altering breakthroughs in treatment. maintaining this balance must be a part of the conversation here today, and as we move forward. i want to keep it that way. any lasting solution must continue to be market-driven. the medicare part d prescription drug program is built on a system of private entities competing on price and service. this private sector approach is ingrained in the design of the part d program, which wisely forbids the government from interfering with the negotiations between these private entities. for part b drugs and biologics, medicare pays based on the average price that the manufacturer charges to other payers. this if effectively represents a

rate negotiated in the private sector. now don't take this to mean the way medicare pays for prescription drugs is perfect. there is certainly room for improvement. but the fact that the united states continues to be a pharmaceutical research and development powerhouse is in large part because we have long preserved the market-based approach. it is vastly superio to the alternative of direct government involvement and price-setting. after all, the price sector has proven time and again that it is far better suited at identifying challenges and turning them into opportunities. one persistent challenge is that certain key drugs and items are in such short supply that hospitals and other providers simply can't even purchase them in sufficient quantity. these drug shortages, which include generic medications, threaten patient care and demonstrate a weakness in our

system. i'm pleased to say that my home state of utah is taking a leadership role by creating a market-based response. utah-based intermountain health care has joined with other like-minded systems across the country to form a generic drug company. this new venture will fill a market need by producing and distributing drugs that are in shortage. this new company will also provide more competition that will improve prices and opportunities for consumers. there are others, too, like some commercial health plans, that have responded to market demand by offering prescription drug coverage options that pass along the need -- negotiated discounts and rebates to their enrollees at the point of sale, rather than only through a lower premium. turning back to the psent blueprint, it contains policy ideas related to medicare and medicaid that merits serious

consideration. take, for example, the idea of paying for a drug based on its success in achieving the intended patient benefit holds promise, especially for breakthrough therapies that do not yet have competition. we should explore how these value-based arrangements can work within our federal health programs. we should also assess how we can modernize the popular part d program, because it is now more than ten years old. and a review of the part d program should involve action to mitigate the change in the bipartisan budget deal enacted earlier this year that increased the discount that manufacturers are required to provide on drugs in the coverage gap. this misguided change has only dampened some of the competitor forces that have made the program so successful. we will soon hear from secretary azar on the policy ideas and the blueprint. it will be important to

understand how the policies in the blueprint would impact not only the list price, but patient access beneficiary premiums and other cost-sharing as well as innovation. as the vast majority of this blueprint -- of the blueprints policies are in the jurisdiction of the finance committee, this engagement with the secretary will inform how we move forward. before i conclude my opening remarks, i must say that i suspect that some of my colleagues may want to talk about other pressing issues that touch on hhs' jurisdiction. to head off just one such issue, i've made my position on the situation at our southern border known. we must keep families together as we work to avoid illegal border crossings. we also need to ensure that children who have been separated from their parents are reunited. and i know the secretary is working aggressively to do so.

however, my experience tells me that our time at this hearing will be best spent discussing the issues we all have prepared for weeks to talk about with secretary azar. after all, the cost, innovation and availability of prescription drugs is a deeply important and often life or death issue for millions of our constituents each day. my hope is that we can all take advantage of the opportunity before us today and stay focused on the agreed upon subject matter of this hearing. with that i'm going to turn to our ranking member, my good friend and partner, senator wyden, for his opening statement. >> thank you very much, mr. chairman. and mr. chairman, thank you for holding this hearing. i'm going to get to rescuing americans who are getting mugged by their prescription drug bills, as well as the administration gutting safeguards for those with preexisting conditions. first, the american people are

owed an answer about what is going to be done to protect the thousands of children the trump administration separated from their mothers and fathers and put in the custody of today's witness. as of this morning, health and human services, homeland security and the justice department seem to be doing more to add to the bedlam and deflect blame than they're doing to tell parents where their kids are. according to new reports, the government is ransoming these children by telling their parents they can have their kids back if they agree to leave the country. the president tweeted that the u.s. should forget about due process rights for immigrants, essentially an endorsement of judging people by the color of their skin. the white house chief of staff floated this family-shredding

policy in the press more than a year ago. it wasn't conjured out of thin air this spring. but with news reports that the department is scrambling to collect resumes of individuals with experience in child care, it's clear that the department was woefully unprepared. this committee has oversight of the child welfare system. members here have worked hard on bipartisan child welfare policies that keep families together whenever it's safe. that's because unnecessarily ripping kids from their families and putting them in institutions is harmful to them. it's harmful to their health. 's scarring to their emotional well-being. it's detrimental to their growth. that's a fact, and the department of health and human services knows it. secretary azar, you're certainly going to get questions about this today. an administration that has

traumatized thousands of child refugees, dehumanized these kids and their parents and tried to normalize this behavr through deception has a lot to answer for. now i'm going to shift to discussing americans getting hit with those enormous bills when they go up to the pharmacy window. when the president said in early 2017 that drug companies were getting away with murder, he offered his diagnosis of the prescription drug cost problem. a year-and-a-half later, it sure looks like he's decided not to treat the problem. the president made prescription drug costs a key part of his pitch to the american people on health care. but the party in power hasn't done any legislating on it. they put out a so-called blueprint, essentially a collection of the same questions that have been asked on these issues for a decade or more.

to me, this so-called administration blueprint looks less like a blueprint than it does like blue smoke and mirrors. and a lot of what the president and his team have said is just head-scratching. for example, the administration says that european countries are free loaders. he said that if drugs got more expensive overseas, in effect fattening the wallets of the pharmaceutical companies, prices fall at home. that is just fantasy land. i don't know what magic wand the administration plans on using to hike drug prices in it other countries, but i don't know of having the power today exists. second, even if drug companies did come into a windfall from overseas, it's laughable to expect that they take that as a reason to slash prices in america. look at the trump tax law.

huge amounts of cash were showered on these multinational drug companies. what did they do with it? they put it into stock buybacks that benefit shareholders, not consumers. one other trip to pharmaceutica consumers. on may 30th the president said in two weeks drug companies would be announcing voluntary massive drops in prices. two weeks went by. three weeks went by. it's been a month. no massive drops in prescription drug bills. as long as americans are getting mugged at pharmacy counters from sea to shining sea, this issue demands bipartisan action. so begin that, i am releasing a comprehensive report that looks exactly at what makes this industry complicated and why those policies do so much to make sure that prices just go up

and up and up. and it's not just a look at the drug manufacturers. there are a lot of pieces to the puzzle. middlemen, distributors, broken out of date policies. so the report is a comprehensive look under the hood of the entire pharmaceutical industry for the first time. otherwise, what americans get from the trump administration and the president in particular, when you look at the record is talk. the fact is their blueprint has raised issues that have been raised for quite some time. the administration needs to stop pretending that asking the same questions that have already been asked is the equivalent to getting results. the fact is there is a big gap between the headlines the trump administration tries to grab on prescription drugs and the lack of serious proposals put forward. so today i hope we'll see that

gap getting closed. one last issue. the trump administration said recently it was going to get out of the business of defending protections for americans who have pre-existing health conditions. these protections have millions americans at the law of the land. there are more than $150 million americans who get insurance through their employers. i bet they're going to be very surprised to learn that this trump decision can hurt them, too. if you don't have a pre-existing condition, i guarantee you know somebody who does. and the trump administration decided it just isn't interested in protecting them. so we have a lot to do this morning, mr. chairman. as always, since we have done so often in the past, i look

forward to working with you in a bipartisan way. >> thank you. thank you very much. once again, i would like to thank secretary azar for coming here today. we appreciate you today. secretary was sworn in on january 29th, 2018. because there is a lot of ground to cover, we all have to come to know -- have come to know secretary azar quite well. so i'd like to move right along. as such, secretary azar, please proceed with your opening statement. >> thank you, mr. chairman and ranking member widen and members of the committee. i appreciate the opportunity to appear before you today to discuss an important issue, why american prescription drug prices are too high and what we're doing about it. drug pricing was one of the very first topics that i mentioned before this committee during my confirmation process earlier this year. i know members of this committee

are serious about taking on this challenge, and i appreciate your efforts in this area. from day one, president trump has directed hhs to make drug pricing a top priority. earlier this year, the president's 2019 budget laid out a range of proposals on the issue, including reforms to medicare and medicaid, topics that i received ant when presenting the president's budget earlier this year before this committee. in may building on the budget, the president released a blueprint to put american patients first. this is a plan for bringing down drug prices while keeping our country the world's leader in innovation and access. it lays out dozens of possible ways that hhs and congress working together can address this vital issue. we face four significant problems in the pharmaceutical market. high list prices set by manufacture manufacturers. seniors and government programs overpaying for drugs due to the lack of the latest negotiation tools, rising out-of-pocket

costs and foreign governments free riding off of american investment. the president's blueprint lays out four strategies for tackling these problems. first, we need to create the right incentives for list prices. everybody in today's system makes money as a percentage of list prices, including benefit list manager who is are supposed to keep prices down. everybody wins when list prices rise except for the patient, whose out-of-pocket cost is typically calculated based on that price. one of hhs's initial actions is working to require drug companies to include their list price in advertisements. for example, americans deserve to know the price of a wonderful new drug they hear about on tv before going to ask their doctor about a product they may find unaffordable. more fundamentally, we may need to move to a system without rebated where pbms and drug companies negotiate fixed price

contracts. such a systems incentives detached from artificial list prices would likely serve patients far better. second, we need better negotiatio drugs within medicare. that is what president trump has promised, and it is what we are going to deliver. in medicare part d, hhs will work to give private plans the market based tools they need to negotiate better deals with drug companies. part d is a tremendously successful program, but it has not kept pace with innovations in the private marketplace. for instance, well intended patient protections may be preventing plans from appropriately managing utilization. while everybody agrees on the importance of the drugs in the protected classes, manufacturers often use that list as a protection from paying rebated. we also want to dribring negotiation to medicare part b.

right now hhs just gets the bill and we pay it. the system may be driving doctors to prescribe more expensive drugs while tempting manufacturers to develop drugs that fit into part b rather than part d. we will look at ways to merge them and leverage existing private sector options. third, we need a more competitive pharmaceutical marketplace. thanks to the reforms that congress passed in the 1980s, america has the strongest generic drug market in the world. but there are many ways that manufacturers unfairly block competition. since the rollout of the president's blueprint, they have publyized the names and issued new guidance to help lessen the effects these actions may he on access. finally, we need to bring out out-of-pocket costs for american patients. it is unacceptable to have gag clauses barring pharmacists from

working with patients to lower -- to identify lower cost options. more broadly, we're going to work to ensure patients know how much a drug costs, how much it is going to cost them and whether there are cheaper options long before they get to the pharmacy counter. these are just some of the elements of an aggressive, long-term plan to solve this problem we all care deeply about. thank you again for having me here today, and i look forward to taking your questions and discussing how together we can help american patients. >> mr. chairman. >> well, thank you, mr. secretary. one of the ideas both mentioned in the blueprint and that you have discussed publically since its release is doing away with rebated in medicare part d through changes to anti-kick back statue safe harbors. you have stated the rebated could be replaced with something called a, quote, fixed price

discount, unquote. the terms fixed and price in the same phrase does make me a little bit nervous. i'm sure it doesn't mean setting a price, but can you explain what that term means, how it would be different from a rebate and how it would limit list price increases from year to year or over a longer period of time. >> right now the problem is that the pharmacy benefit managers make theironey often on getting a high list pric negotiating a big rebate off of that and then keeping a percent of that rebate that they don't necessarily pass to the patient or to the insurance companies they work for. that's just the business model. it is not saying they're doing anything wrong. it is just the business model. what we are thinking about proposing and have been asking for comment out of the request for information that we have is moving to a system where instead of encouraging a very high list price with a rebate that gets administered after the fact,

what if our contracts that the pbms have instead just say here is the price. here is what we will pay. you have market power as a pharmacy benefit manager. you control a form lair and you are going to get this level of discount. an that actually gets administered at the point of sale. so you take list price out of the equation. the pharmacy benefit manager has no incentive for a higher list price. it is just administered right there. it is an actual discount. the money flows with it. and we just take list price off the table. >> well, states continue to e vav wait the concept of a closed form lair in medicaid with the recent examples of massachusetts and arizona. and other states with the bipartisan mix of governors considering the idea, there is growing interest in the outcomes of imposing a closed form in medicare. how would the drug rebate

program interact with such a proposal and do you envision carve in protections for certain drugs or classes of drugs or required coverage of medically necessary treatments for which there is no alternative? >> so, as you mentioned, mr. chairman, the president's 2019 budget does propose having five states have the opportunity to see if they can do better than the medicaid statutory rebate program in negotiating. so right now the system we have is that all drugs are available in medicaid, but in return for that, there is a statutory rebate that the drug manufacturers have to pay. some have suggested that the states, if they could run their formulary or the way any of us with our commercial insurance manage, that they could get a better deal. we would like to give them that chance to try and see if they can, in fact, do so. now, there would still be patient protections there would still be medical appeals,

clinical necessity, everything you mentioned, mr. chairman, would be there, just as it is for your insurance, my insurance, anybody else's insurance to protect you from unreasonable or nonclin care based management. absolutely. >> thank you. i'm pleased that this administration reversed an obama era payment policy that sent the wrong signal. that is not a recipe for the development of a new -- you know, new bio sims. what else can be done as a way to increase competition and lower spending? >> so, mr. chairman, we want to do for that market exactly what

you did for the agagenerics mar. we want to ensure there is adequate market. since we made that change, we saw one enter the market at significantly below what analysts thought the pricing would be. we believe at the fda that we can get rid of these abuses by drug companies that are preventing access to their products for the companies to be able to do the clinical trials needed to bring products to market. we also are going to be building the scientific and evidence base that would allow the development of that generic market as you did. >> thank you so much. >> mr. secretary, your agency plays a crucial role in child safety. so i have a few questions that i think are pretty brief, and i want to see if you can give me

specific answers. how many kids who were in your custody because of the zero tolerance policy have been reunified with a parent or a relative? >> so i believe we have had a high of over 2,300 children that were separated from their parents as a result of enforcement policy. we now have 2,047. >> how many have been unified. >> so they would be unified with their parents or other relatives under our policy. if the parent remains in detention, unfortunately, under rules that are set by congress and the courts, they can't be reunified while they are in detention. >> so is the answer zero? >> no. we've had hundreds of children who are now with -- for instance, if there was another parent here in the country they go with that parent. >> i want to know about the children in your department's custody. how many of them have been reunify snd. >> well, that's exactly what i'm saying. they had been placed with a parent or other relative who is

here in the united states. >> how many? how many? >> several hundred. >> of the 2,300 plus that came into our care. >> how many parents have been told where their kids are? >> every parent has access to know where their child is. >> that's an 800 number. >> the 800 number would be the backup on that. but that should be the fail safe. every parent should know. >> but how many -- how many parents -- >> answer the question. >> mr. chairman, the time is short. >> i'll give you more time. >> the american people have been getting lots of deception, lots of rosy answers, not many facts. how many parents not have access -- how many parents have been told where their kids are? >> that information is available for every parent, and we have actually deployed public health service officers to work with the ice case managers to meet with all of those parents to

help them fill out the reunification paperwork they need for the background check and to confirm parentage, as well as they make contact, get them on the phone, get them on skype if that's available. we want every child and every parent connected and in regular communication. >> i asked twice how many parents were actually told where their kids are. you said they have access. and this is just in my view part of the rosy responses the american people have been getting, and it sure doesn't line up with the first-hand accounts of parents that i hear from who desperately want to know where their kids are. >> there is no reason why any parent would not know where their child is located. i could at the stroke of -- at key strokes, i sat on the orr portal with just basic key strokes and within seconds could find any child in our care for

any parent available. >> mr. secretary, suffice it to say, portals are not part of the daily existence. >> that's why we have case managers and the 800 nuer. >> i would like to hold the record open so you can tell me specifically as of today how many parents are told where their kids are. now, on drug prices, not less than 14 days after the president's speech on prescription drugs, bear announced the price of two of its cancer drugs going up $1,000 per month. that was the second price hike in six months. so it sure doesn't look like the drug makers are taking your blueprint particularly seriously. we have 42 million persons that get their drugs through part d of medicare. they are getting price hikes every day. after a year and a half in office, i don't see any evidence of this administration taking re action until possibly january 1, 2020, a thousand days

after the president said drug companies were getting away with murder. so are there any policies in your so-called blueprint that have actually taken effect and will hold drug prices down? >> so patients have aeady saved $8.8 billion from added generics. they have saved $320 million a year from the change to part b medicare reimbursement. we have already listed the 150 branded companies that are hiding behind the recommends program to provide access to their product for generic or similar testing. we have put a dashboard out that shows the price increases. we have already told the part b plans we find the gag clauses to be unacceptable. i'm disappointed by those price increases and i want to put the drug companies on notice. we're hitting july 1st. i hope they will exercise restraint as we come across this

period. we have seen fewer increases than we historically do, lower increases as we historically do. >> my time is up. you didn't answer the question. i asked about part d changes, and we haven't seen for those 42 million americans who get their drugs through part d, we haven't seen any change. i'll hold the record open for this, as well as the other matters that you didn't ask -- didn't respond to. and tell us specifically what medicare part d changes are being made and when they're going to be made. they are going to help those 42 million people. >> senator stavenau. >> thank you. let me first speak to the issue of the children separated from the border. this is obviously appalling what had happened. it is an american tragedy. it is a tragedy for these

parents and these children, and i want to start by calling you to make sure the over 2,000 children in your custody at hhs are able to get back to their parents as quickly as possible and that you make this a priority. as i indicated to you we have over 60 children in michigan right now. they are in loving, safe foster homes, but that is not the point. as of my last contact with the agencies, they did not know -- they were not given any information up to this point about where the parents are. and there was not communication going on in terms of what's happening for these children. so every single day in a child's life -- you know, the kids keep growing up no matter what we do, how bureaucratic we are. every day these children are growing and changes and experiencing trauma and pain. and, so, i just want to go on

record as saying that this needs to get fixed and needs to be the top priority for what you are focussed on in terms of children and families right now. this is on your watch and we will hold you accountable. so let me go on to the question and the topic of the day. and speak specifically about what's happening with the outrageous prices. we have an opoid crisis. we talked about this before. and let me just speak again about the history of pricing on an overdose reversal drug that has saved countless lives, as you know. it was first approved by the fda in 1971, long off patent. generic versions have been available since 1985. as of 2005, a generic vile was

available for about $1, about $1 in 2005. but by 2013, now that we have a crisis, the generic companies are selling the drug for 15 times as much and an auto injector now sells for $4,000. $4,000 for a two pack. it was 1 in 2005. and narcan is sold for about $150 for a two pack. so at your confirmation hearing i raised this issue and i raised the fact that the president's commission on the crisis, opoid crisis recommended negotiating the best price. at the time you said i want to look at that, learn more about this situation, but if the government is the purchaser,

there is absolutely nothing -- nothing wrong with the government negotiating that. i followed up with a letter, with colleagues. you spent response that didn't even include the word negotiation. so is it price negotiation in the drug pricing blueprint? >> so the blueprint doesn't address any specific drugprice. narcan tends to be a preferred formulation for first responders. that's actually available. i looked into this. that is available under the federal supply schedule at $78 a package and our other first responders, state and locals have access to that same kind of pricing there. we're also working at fda to bring over the counter to the market and also ways to increase more generic competition.

there are of course different formulations. >> i understand. in the interest of time, mr. secretary, the answer is no. >> well, the supply schedule is that's $78. >> $78. was $1. now $78. such a deal. >> well, it wasn't nasal. >> all right. so it was something slightly different. >> nasal is the preferred administration vehicle. >> it was administered in a different way. now with this particular way of administering it it is $78. i want to share with you that southwest michigan behavioral health is planning to spend $366,100 next year on this particular discounted price that you are talking about. $366,100 that they could be spending on treatment for people in michigan who have an opoid addiction. and instead they are paying, even at this discounted rate,

78% -- 78 times more than what was available in 2005. i just have to say, mr. chairman, if we want to talk about weak systems, there is not a more weak system than the way prescription drugs are priced. >> thank you, senator. >> thank you, mr. chairman. mr. azar, i appreciate your service. i can't think of anybody better qualified to serve in the position you are serving in, so i appreciate the expertise and experience you bring to this role. i wanted to just raise the issue because in addition to the blueprint that you rolled out to try to control prescription drug costs, there are other cost drivers that we see in the health care system that the administration has tried to address. one is the department of labor has now issued regulations to make possible for more people to get access to association health care plans so they could take

advantage, not of the individual market, but of the employer provided insurance market and find their premiums substantially lower. i would note that people in the individual market, the 9 million people in the individual market, do not have any subsidies, and they seen their costs rise by 105% since 2013, which is unaffordable by any measure. the second thing i just wanted to raise with you, i'm sure you are aware of, is the good work being done by senator collins and senator alexander, repres t representing walden and costello to make sure people get access to lower premiums for their health care coverage. again, the problem is the affordable obama care model, which has all the mandates and provides spotty subsidies, particularly to people below

250% of poverty. that would result, if embraced by congress, the alexander-collins, wall wald walden-costello bilo bill. in addition to the good work you are doing on prescription drugs, which i applaud and ask and encourage you to continue, these are two other areas i want to highlight. one add administration by the

department of labor and the other legiative, but which has been rejected pending the outcome of the mid- elections by our democratic colleagues. but since i was in brownsville on friday and our colleagues across the aisle want to talk about this issue and not prescription drug costs so much, i had the chance to visit two facilities in brownsville and was enormously impressed with the quality of care being provided to these young people who were brought across the border without their parents and some with their parents. isn't it true that 83% of the individual children in care were brought -- or were sent without a parent. does that figure sound about right to you? >> it is. most came here unaccompanied, sent by their parents and they find themselves in our custody,

question. >> i haven't heard a word about those 83% of the children who were sent here by their parents, voluntarily separated by their parents because of the conditions in the country in which they live in the hope for a better life here in the united states, which certainly we all understand. but it seems to me what is being advocated is not zero tolerance, but zero enforcement. indeed, our senator has persuaded all the democrats in the congress in the senate, i would say, to sign on a bill that basically provides a no enforcement zone for violation of immigration zones within 100 miles of the border. you have probably seen where some democrats in the house have introduced bills that would literally abolish immigrations

customs enforcement. if you go on twitter or any of the social media sites you will find a hash abolishice that wants to do away with any enforcement of our immigration laws. we ought to agree these children ought to be joined together with their parents where possible and indeed there is legislation that would do that. i hope we can pass that this week. >> senator, your time is up. we'll go to senator nelson. >> thank you, mr. chairman. mr. secretary, i'd like to seek some answers respectfully to have a civil discourse. you are a friend of a close friend of mine, and i respect that. on saturday, i was not allowed in the detention facility in homestead florida to speak with

the 70 children that i was told that were there that had been separated from their parents. do you know what has changed since saturday with those 70? >> so, senator, and we are very happy to arrange visits for senators and members of congress to these facilities. we need to do so in a way that's orderly. the first priority is the safety of these children. you should have been and would have been able to interact with them but not, of course, interview them. these are minor children. they will not there to be deposed or interviewed, so i do want to be careful about that. that's not acceptable. we have to protect these children. they're in care. they're in shelter. it is a difficult situation for all of them, and we just -- we all -- i'm sure you share that

deshare that we are doing our best and utmost to be respectful of those children. >> mr. secretary, i didn't ask that. i asked what has happened since saturday to those 70 children. >> well, i don't know which 70 children you met with. >> no, no. no, no. i didn't meet with any of them. i was not allowed to, as you just stated. >> you were allowed to be in their presence, but you can't depose them, and that's -- >> i understand. so my question, please, i'm going to be respectful. my question is the 70 children that i was told were in that facility that had been separated from their parents, what has happened to them. >> so they would either continue to be in our care or if they have reached a point where a sponsor who was in the united states who is a parent or a relative has been vetted and has been approved for sponsorship, they would have been released as

quickly as possible to those sponsors. >> how many of those children have been able to be in contact by telephone with their parents from whom they were separated? >> so for any of them who have been separated from their parent at the time of the parents detention by the customs and border patrol, within 24 hours of arriving at an orr shelter, we even cover to put them in touch, get on the phone with their parents. sometimes that can't happen. for instance f the parent has been located for criminal prosecution and placed by the bu bureau to stay within the county jail, we are deploying officers out there to facilitate that. we want every child and every parent to be in communication at least twice a week so they are talking by skype or by phone available. we want this to happen. i can't say as to those 70.

but all should have been within 24 hours of arriving made in touch if possible with the parent if the parent was accessible where the parent was being kept. >> okay. now i ask that question. the lady who is overseeing the facility of getting the children in touch said that the handful of the children had not been able to be on the telephone. so i said, well, what is your plan for reuniting these children? and she said there is a lady named barbra flotis who doesn't work, except on the weekdays, and i said, well, i will try to reach her to tell me what is the plan. i was prevented from speaking

with barbara flotis yesterday, monday. can you help arrange that so that i can know what the plan is to reunite the children? >> so we will be happy to work with you to arrange. she is not an employee of my department. >> through the grantee. >> it would be their decision if they want to make her available to you. we will continue to work with your staff. >> you will not hinder me talking? >> no. >> well, yesterday that occurred. so what is the plan to reunite 2,300 children. >> absolutely. >> so the first thing we need to do is for any of the parents we have to confirm parentage. that's part of the problem with any child in our care. we have to ensure there are traffickers, smugglers. we have tone sure that the parentage is confirm. we have to vet those parents to make sure there is no criminality or violent history on them.

that's part of the regular process for any placement with an individual. at that point they will be ready to be reconnected with our parents. this is where our broken immigration laws come into play. we are not allowed to have a child be with a parent for more than 20 days. until we can get congress to change that law, the forcible separation there of the family units, we'll hold them or place them with another family relative in the united states. but we are working to get all these kids ready to be placed with their parents, get that all cleared up as soon as if congress passes a change or if those parents complete their immigration proceedings we can then reunify. we want to be ready. the president assures we do not want any children separated from their parents longer than necessary under the law. and we want to effectuate that and make that happen.

>> senator menendez. >> thank you, mr. chairman. mr. secretary, back to the subject at hand, you have talked at length about the goal of lowering drug prices as part of the administration's plan. if manufacturers were to announce a reduction in list prices, has the administration considered what that would mean throughout the supply chain in the part d program? and particularly if an announcement came mid year, h would it impact plans and pbms. what would the beneficiary experience be in the way of changes and premiums and copays at the pharmacy counter. >> i'll answer the second first, which is if list prices go down, the patient benefits. that's why list prices matter.

most patients whether in part b, part d or just in commercial plans pay less at the pharmacy when the list price is lower. now to your first question. we have had many major drug companies with major products who want to make substantial and material price decreases. this has shown just how broken our system of drug pricing and drug distribution is in the united states because they are all dependent on getting a percent of list price. and the reaction to some has been if you were to decrease your price, you will actually be harmed in terms of form status and patient access versus your competitor. i would encourage the senate and congress to inquire of pharmacy benefit managers as to which they have received suggestions or approaches for lower list prices and what has the reaction been? i believe still that this will be solved.

these are adults. this is so absurd it will be fixed. but this is what is keeping the individual companies so far removed. the prices are their prices, okay? but the channel is definitely not making it easier. >> okay. well, i just think the concern in all of this is how does it get passed on in the form of savings to the ultimate consumer, to the beneficiary. a follow up question would be how could that reduction in list prices be sustained over time? >> so there -- so we're of course not counting on just voluntary reductions in price. that would be -- it would be nice if that happens based on them seeing this is the northbound train. this is where it's going. we are going to lower list prices, better negotiations, lower net prices in this country, get on the train, get a competitive advantage by moving there first. that's the idea. but our plan will be reversing the incentives to ever increasing list prices.

i mentioned that means getting after this whole rebate system. it means asking congress to overturn the obama care gift to the pharma companies of capping rebated in the medicare program at 100% as they increase their list price. it used to be your rebate would keep going up. obama care capped that at 100%. that would create a major financial disincentive and would sustain any lower prices that we would see. >> okay. let me ask you asking, just switching gears for just a minute. i have shared with you how aren't the 340b program is in my state and it's probably a view shared by most of the folks on this panel and the congress. but could you talk a little bit about what you foresee happens in terms of proposed changes to the drug rebate program and how it might impact the 340b program perhaps what you see happening

in terms of the 340b program, realizing there is litigation and regulatory action underway at the moment. >> so as we have seen the 340b program expand, it has in some respects perhaps gotten untethered from its purpose of helping those hospitals and uninsured individuals. we want to keep working with continue to make sure it is delivering on that promise and is not being used for abuse and expanded beyond anything resembling its actual intent. now as more and more drugs go through that and as the flow of money comes out of that, it can lead to a cross problem where more money might be paid elsewhere in the system. it might actually be an incentive towards higher list prices. we want to ensure it is there. it's healthy. it has integrity and it is tied

to the purpose of helping these hospitals and these patients. >> most of the players on the field that i work with, that i'm familiar with in my state are folks who operate those programs with great integrity and it is important to their bottom lines, which i why i think you hear us raise this issue so often to you and other members of your team. we will continue to do that. and i hope you h continue to work with us and be responsive and try to work with the affected hospitals to come up with a good path forward. >> your time subpoena. senator? >> thank you for coming today. before i start my questions, i want to urge your staff at cms to carefully consider the requests of the entire bipartisan new jersey delegation to extend the imputed rule. this is critical to new jersey hospitals. i hope that you will have your staff pay some critical attention to it. cms predicts prescription drug

price growth in 2018 will be double what it was in 2017, contrary to the president's pronouncement that there would be a, quote, voluntarily massive drop in prices in early june. one of the reasons that we are not seeing reduced prescription drug prices is because some bad actors continue to game the system to prevent cheaper drugs from coming to market. in fact, the fda recently named and shamed some of the worst actors. congress is working to pass the creates act, which is a bipartisan bill that would go after the abuse of some companies that are preventing cheaper drugs from coming from market. does the administration support the act? >> we don't have a formal administration support on it, but what's in the act resonates completely with what we have been staying and what the fda has been doing to prevent the abuses that you have correctly laid out there. >> well, i hope that the

administration can come to a formal position. it is bipartisan legislation. it does exactly what the president's blueprint said he sought to do by ending bad actors in the prma world. and, so, i'd ask that -- let me ask you. after the fda named and shamed, has there been any behavioral changes by these companies? >> i don't know if there has been any change? let me check on that and get back to you. we put out two guidances as a follow up to that also making clear that they should not be able to hide behind our regulatory processes and protect safety. if i could get back to you. >> okay. appreciate that. would you commit to working with me and my colleagues in a bipartisan way to even shurs customers see generics come to the market as quickly and safely as possible. >> absolutely. i would love to hear from you as you hear from abuses or entities

manipulating patent processes. consider an open door. >> i appreciate that. are you familiar with the reducing drug waste act of 2017? >> i am not, senator. >> okay. i'd like to call it to your attention, including members of this committee who have joined together because the hhs office of inspector general found millions of dollars in waste due to drug packages. >> yes. you did mention this to me. i'm sorry. but i have not learned enough of the detail on this. >> okay. this is a bipartisan legislation. the senator from iowa and many others on a bipartisan basis are looking at this as a way to stop the basically waste of drugs as a result of drug packaging. so i'd ask you to look at that as well. let me just turn to the question

of the children who are being stripped away from their parents at the border. i have to differ with you. the reason we have a crisis is that the administration has decided that even those who come to a border crossing, present themselves, ask for asylum are turned away at a legitimate border crossing. they come back the second day. they're turned away again. they come back a third day. they're turn aid way again. after traveling thousands of miles, obviously fleeing horrific violence, they are not about to have an opportunity for asylum. children have been sent thousands of miles. primarily it seems to be in blue states. but we don't want to have them stripped away that their parents. let me ask you this. will those parents that have been deported and whose children

are here, are they going to be reunified? and if so how. and secondly, my understanding is there are still 2,000 minors separated from their parents and have not been reunited? what is the time frame that you estimate that that will take place? >> so as to any parent who is deported, of course, the child has independent rights. we find they ask the child to remain separated and remain in this country. that happens in normal proceedings. i don't know in the last couple months. >> the child is a minor, can't make that case for themselves. >> they have counsel and sometimes they actually decide to remain or the parent actually asks that we have them remain in the country. we keep them in touch, though, as long as the child is in our care. we keep them in touch even if the parent is outside the country. so in terms of times, again, we're working rapidly to confirm parentage and do the vetting and proper criminal background

checks, et cetera, on any parents in custody so that we're ready to go as soon as either the parent is -- their immigration proceedings are complete and we can reunify at the time of deportation or if they entered into the country, we could connect them then. or we have alternatives if they have a parent already in the country. we would put them with that parent or with other relatives here in the country. we have to get children out of our care and custody -- >> but you don't have a time frame. >> it is dependant. right now i would gladly put these children back with their parents in ice or border parole. but i legally can't. we need congress to change this 20 day limit on parent reunification. >> senator, your time is up. >> i look forward to talking about drug pricing in a second. but let me comment briefly on

this. as you know, we spent a couple of years studying the issue of unaccompanies kids. and hhs has in my view a very difficult job to do, which is to help with regard to kids who come without their parents. these are unaccompanied kids. i commend the president for the executive order which changes that approach. we now have to deal with the kids already in the system. but even though you have a very tough job to do, as you know, in the obama administration and in the trump administration, i have not felt as though hhs has done a very good job in a tough situation because they have not come up with that agreement between department of homeland security and hhs. there is a memorandum of understanding and a commitment to come up an operating agreement so we can understand how the hand off occurs, who is in charge. but as recently as april of this

year we had a hearing on this and hhs said that they're willing to take a fresh look at the question of who has responsibility for these kids once they leave hhs detention facility or are placed with the sponsor. my concern is that nobody's responsible. and, you know, i got involved in this because children landed up in an egg farm in ohio because they were given to their traffickers rather than a family that was going to take care of them. so my question to you today is, and again i'll get to drug pricing in a second, but, one, you are taking a fresh look at this, as i understand it. you have a july deadline to come up with this operations agreement. i don't know if you follow this closely. but are you on track on the operations agreement with dhs? and who is going to be accountable or responsible for these children? once they leave --

>> we ensure adequate and full vetting of any potential sponsor. these are relatives, either parents or aunts, uncles, adult relatives. >> in the case of the farm, they were drug traffickers. better screening is a good thing. >> exactly. once they are placed with a sponsor, they are no longer subject to our jurisdiction. we cannot pull a child back from a relative. we don't have the legal authority. they are then under the state and local child welfare laws as well as of course they're subject to any immigration proceedings that they may have. but we don't have any authority to go out and pull a child back from a sponsor once they're in that sponsors. we learn about it. we would let --

>> again, i want to get on to the drug pricing in a second here. but one of the concerns -- and this goes back to the obama administration again and the first half of the trump adstti, not even telling the states the kid was in their jurisdiction. and again there is an issue of getting these kids to their hearing. that's the idea. more than half of them we think are not showing up for the hearing, which is the whole idea, to get them with a family pending their hearing on their immigration status. we have work to do still. i want to make sure you knew we were going back and forth with your team and we expect to have this operations agreement in place by july as was committed to during our april hearing. on drug pricing for a second. i know the senator talked about one of the issues that is a big deal to me, which is how you deal with the opoid crisis. and specifically the cost

increases, $575 for an auto injector in 2014 just for four years ago today. over $4,000 for one of these things. you go on your dashboard. you have a dashboard now where you can see drug pricing information more transparently. but it is very confusing because it shows part d spending per unit. this is for medicare increased from $739 to $4,500, and the list price was actually below both of these. when we push on this, we're told this doesn't include some other information like the manufacturers rebated more other price concessions, which seems to run the other way. but anyway, we have been pushing on this and trying to get hhs to give us an answer. why can't all that information be on the dashboard? why can't we also include what's going on with regard to the rebated where other price concessions?

>> well, taking it beyond that particular drug instance, disclosing publically negotiating rebate rates is disclosing highly confidential information. let's say we took just any other regular drug and we started publically disclosing negotiating discounts, there could be very serious anti-competitive issues with that, as there would be if walmart were forced to disclose their tide discounts. their competitors would love to have that information more than anything. so we have to be careful here. we're happy to get you whatever information we have. but that's just an initial reaction on that issue of disclosing whatever the discounted rate would be on a particular product. >> i would think that -- >> isn't that right, your time is up. >> these drugs were bought by the taxpayer and not tide. it's a different issue. so one with regard to us getting a transparency and consumers on medicare and medicaid, i would think we will end up there. we have to figure out a way to provide that information.

>> thank you, mr. chairman. thank you, mr. secretary for coming back to the hearing and an y for your service. just along the lines of the original question, did hhs have a role in participating in the desi of the administration's zero tolerance policy at the border? we deal with the children once they're given to us if they're unaccompanied. so we are not the experts on immigration. >> you weren't involved in planning meetings? >> it wouldn't be appropriate for me to discuss interactions within the administration. our role is in receiving the children. >> and to that, to that end, mr. secretary, is the process you describe today a special process for reuniting the 2,300 kids with their family, or is this the existing process that orr uses for unaccompanied minors?

>> this would be the process we use to procure safe placement because it may seem like, oh, their parents came across the border with them. they were separated. just reunite them automaticalla. unfortunate unfortunately, that journey through mexico is a horrific journey and often the -- not often. but we do see traffickers and very evil people sometimes claiming to be the parent of children. so the same protections we have for any unaccompanied children are vitally important here. >> so i can appreciate why you can't answer precisely when every single child will be reunited with their parents. but could you give the committee a sense of whether you are talking about days or weeks or months? what is your -- what direction have you given hhs employees or

contractors to do the work that i'm sure you feel as urgently about as we do. >> i cannot reunite them, though, while the parents are in custody because of the court order that doesn't allow the kids to be with their participants for more than 20 days. i find it hard to imagine, but we need congress to fix that. what i have ordered our team to do, i want the kids ready. i want the parents confirmed and vetted so that we can place them as soon as it would be either congress changes the law or the parents through their immigration proceedings and ready to be deported or released so we are ready to reconnect them. i have a separate legal obligation to keep working to expedite if there are other sponsors in the country, a different parent or other relatives i can place them with because i can't have them with us any longer than necessary. >> so do you imagine that this will be -- that we'll be having this conversation weeks from

now. or do you think this will be resolved weeks from now. >> if congress doesn't change the 20 day limit on family reunification, then it depends on the process for any individual parent going through the immigration proceedings. as long as they are in detention they can't be together for more than 20 days, absurdly, but it is the case. >> what is the age of the youngest child that is in hhs' care. >> we have infants in our care. as shocking as it sounds, we have always had infants in our care, even just straight unaccompanied children left on the border as infants. >> what is the youngest? >> zero, infants. we have always had from parents or smugglers or traffickers who leave or have lost a child at the border and they're placed in our care. so we have always -- the program has always had -- has devastatingly tragic as that sounds. >> what happens if the child has

already completed expedited removal proceedings and has been deported? how long does the child have to wait to be reunified under those circumstances? >> so if the parent wishes to have the child reunified, we will work to, of course, because we have to confirm the parentage and the vetting to ensure. even in a foreign country tone sure the parent doesn't have any information, that we don't have any conversation suggesting that we're placing the child in jeopardy. we work then of course with the home country for the transfer of the child there, if that's the parents wish. there are instances where a child may assert their own right to pursue asylum or other claims they have independent of their parents and may seek to remain in the country and remain in our care. >> and are children, mr. secretary, from certain countries treated differently from children from other countries or is everybody treated the same? >> even is treated the same within our care.

immigration laws are different. there are provisions that the department of homeland security would be expert in that are different on immigration laws and the processes there around -- around deportation that i'm not the expert in. children in our care, we treat all of these children the same and attempt to reconnect them, get them to sponsorship as quickly as possible and it might be dependents on cooperation with home countries, getting birth certificates or other confirmation information. >> thank you, mr. azar. >> thank you. >> senator carper. >> thank you. welcome, good to see you. thank you for your being here today and responding to our questions. i want to just follow up briefly on the issue of children. at our borders and families on our borders. we are paying a lot of attention to the symptoms of problems, we should, serious and it needs to be dealt with, not easy issue to

deal with. i spent part of yesterday in new york city, with jay soeh johnso previous homeland security, and one of the things we discussed was as important as it is to get right what's going on at the border and spirit of matthew 25, when i was a stranger in your land did you welcome me. it's important for us to focus on that and treating the kids the way we would want our kids to be treated. the other thing is, it's important for us to focus on the root cause for why these kids and families are coming to our border. i would remind my colleagues about 20 years ago, in colombia, a bunch of gunmen rounded up the colombian supreme court members took them into the room and shot them to death. shot them to death. and you had the drug lords, you had the farq, leftist gorillas,

but almost working in concert to bring down the government of colombia. desperate times, some leaders of the country stood up and said we're not going to let this happen to colombia and those were supported by bill clinton, president, joe biden, the chairman of foreign relations committee, dick lugar, senior republican on foreign relations to come up with something called planned colombia, you can do it we can help, security for your country, economic opportunity in your country. they had to do the left heavy lefting, but we helped. [ inaudible ] those are -- i call it it's a planned colombia for those countries. and it does many of the same things that plan colombia has done. we're in the third year on this program and we need to continue to fund it, continue to do

oversight on that. and the reason why these people coming to our countries because they live horrific lives, lives of desperation, dangerous, high homicide rates, lack of econoc opportunity. we are complicit in their misery. that's why we have a moral obligation to help them and trying to do that. so that's -- i would just leave that at your feet. and my colleagues' feet really. i want to talk about value based pricing. we talked about this before. i would like to say everything i do, i know i can do better and true of all of us and true in the delivery of health care and a big piece of that are pharmaceuticals. as we've discussed before, transitioning to value based reimbursements for drugs is top priority to not just reduce drug prices seniors and might be in medicare, but for our government and taxpayers and regular, ordinary people. what are stakeholders and your policy experts telling you about

value based contracting of prescription drugs and how this policy could improve affordability for consumers and our government programs and ultimately for taxpayers? >> senator, thank you for your leadership in the area of value based payment. we are already moving forward on that. commissioner gottlieb has just recently couple weeks ago put guidance out to create a better pathway for sharing of information and discussions between pharmaceutical manufacturers and insurers around economic information and to plan on new product launches so they can collaborate and build the value-based arrangements as quickly as possible. we're working on guidance around government price reporting and anti-kickback statute rules that can, again, create a greater pathway around how we can help private actors and set up the value-based arrangements there. we all believe it's the future of how we need to pay for drugs, pay for outcomes, pay for health care. frankly i would love to see it if they could be more

incorporated into the overall wholistic health of the patient, more of a bundled notion. i think that's probably long term the future of value-based, more than just the payment on the drug itself. >> what actions do you need from us on this side to enable you to implement value-based pricing and ensure spending for health care services and products are lined to lower overall health care costs? >> i believe we have the authority to create these pathways around the value-based reimbursement models directly on -- with through the anti-kickback statute and government price reporting. if i find our regulatory authority is limited i will come back to you and ask you for that authority because it is so critical. >> your time is up. >> mr. chairman, i just want to commend you and the ranking member for holding this hearing. i think this is terrific. the proposal from the administration, broad proposal, it's like a baseball team that hits a lot of singles and

doubles. i don't know there are a lot of home runs. i hope we can work together and score some points on the board for taxpayers and foritens. this is great we're here doing this. appreciate the secretary being here. >> sounds like a tripple to me. senator cassidy. >> mr. secretary, thank you for being here. let me start off with a specific drug and then we'll build from that into a line of questioning. you and i have in the past spoken of glevic, released in 2001 used to be probably a couple thousand dollars a year, now i'm told that it costs $8800 a year in canada, and it costs $144,000 here in the united states. now, as you and i both know, the way that the catastrophic coverage works, is that once somebody moves into the catastrophic portion, the beneficiary is responsible for

5% of the list price, not the net price. and so i have a former patient, i'm only former because i'm no longer practicing, she's paying 5% of $144,000 for a drug which has been released since 2001. now my staff tells me that the company that has glevic has extended the patent protection if you will with an agreement with the generic competition. now, senator asked, what do we do about this and you responded we need competition. i would say what do we do about glevic, available since 2001, canadians spend less than $9,000 and we spend $144,000. that is egregious and my 5% of the list price patient cannot afford. what do we do about that? >> so, senator, i may be misinformed here, and i would want to get back to you on this, i do believe that generic glevic is actually available.

>> so then let's say that we're back in 2015 or 2016 in which this would apply and which, again, a drug 15 years after release is $144,000 here because there will be another glevic, if now there is a generic, there will be another glevic. how do we address that? >> one of the items in terms of affordability that we have is in the president's budget, which i would love the chance to work with the congress and this committee on, would t reform the part d drug benefit to actually create several changed, one of which would be a genuine, for the first time ever, i think ranking member widen has a separate piece of legislation to this effect, a genuine, out-of-pocket, catastrophic -- >> let me pause on that. so one of the -- as we both know, just for context, one of the protected the taxpayers on

the hook, so i'm looking here at a cms report which says that federal taxpayer outlays to pbms has increased from roughly $11 billion in 2010, to $33 billion in 2015. and so the taxpayer is getting hosed because of this reliance. even if we protect the patient with her 5%, how do we pro teshts the taxpayer? >> you are actually correct and i'm glad you raised that, that is one of the five-point changes to part d we proposed in our budget to reverse that incentive structure in the catastrophic benefit to ensure that pharmacy benefit manager is bearing 80% of the cost, taxpayers only 20%, so that pbms have more skin in the game to get that list price controlled -- >> so would we change, so that it's only the net price that counts moving the patient into

the catastrophic as opposed to the list price. >> >> it would be total expenditure, but that would be because the list would do that. the pbms would have more incentive to get that list price controlled not just the net, because they're going to be bearing 80% of that in the catastrophic. >> okay. then i see one of the proposals is that currently, maybe one proposal to get rid of rebate structure altogether but another proposal is that a third, at least a third of the rebate would be returned to the patient at point of sale, why not 100%? why should the patient be forfeiting two-thirds of that rebate amount? as we get after the issue of where rebates are allowed at all that may be where we end up at the point of sale completely. in the budget proposal we proposed a third. there, obviously, is significant debate about the issue of rebates. we think it's the right thing, patients should get the ben fit of the rebates. >> i don't mean to cut you off. limited time. one more thing, if d does not come in -- excuse me if part b

does not come into d, imagine another glevic within the part b space, in which we're paying that, the u.s. taxpayer is paying this, basically a price taker as you said, but overseas they're paying far less. why not reference pricing? why not say, okay, let's take our five biggest developed countries, germany, japan, australia, canada, britain, france, you name them, pick up five or six of those, and we're going to have a price, some multiple, might be 1.6, might be 1.2, but it won't be 14 times such as was the case with glevic, and so just imagining again within the part b space, why not reference pricing? >> it's something we could look at. i would rather use the tools of competitive marketplace than price fixing at the national level to keep patient choice -- >> i will point out that did not work with glevic. >> your time is up. senator cantwell. >> thank you m chair. i'm sorry, i had to step out but i did hear your opening

statement and i wanted to -- because you mentioned four things. list price, negotiating tools, cost share and the foreign outlook. on plans for negotiating, one of the best negotiating tools that i think is out thes the provision of the basic health plan or essential plan now operating in a few states where families can have affordable -- basically the state ends up negotiating. the state negotiates on behalf of a large group of individuals, those who may not belong to a large employer or employer who doesn't have insurance, so those can see as little as a $6 co-pay for generic drugs, $15 co-pay for brand drug form larrys or $30 co-pay for drugs off the for mu larry. in my mind that's a great model because it's a negotiating tool

by creating market leverage by a large group of individuals who wouldn't have market power, you know, i call it the costco model, buy in bulk you should get a discount. the state, in this case new york or minnesota buying in bulk, is getting a discount. why shouldn't we continue to look at that as a model? >> so i want to learn more about how the basic health plans are doing that. as long as it's done in a competitive framework of competitive insurance as opposed to with any preferential thumb on the scale that hinders other private insurance actors and choice in the system, i mean, any kind of -- those kinds of collective aggregation to negotiate is what we do in part d with the negotiating, why we get such good deals in part d through our private plans. >> i think unfortunateyou'll fi york, 13 different insuresers bidding into the market, they like they're bidding on 650,000 people and willing to give a

discount. >> sure. >> i'm looking for market power for individuals who aren't finding it in other ways and i'm. >> i'm happy to look at that with you. yeah. >> great. i'm sure a more thorny question, i have in our state, a woman, miss guzman calindres held in washington state, from honduras, and was seeking asylum and now is separated from her child. so i want to know, i know you've had a bunch of questions here already, but what beyond confirming the relationship between child and parent, and the criminal check background, what else needs to happen for her to be processed? >> okay. in terms of reunifying her with her child? >> yes. >> first off i want to ensure she knows where her child is, in touch and able to communicate. if that's not happening off line let me know and as we are with

all of the children and parents make sure that is happening. >> she has not been able toalk to her child. >> we want to make sure that happens. we want to -- we are working with every parent and child, want them in regular touch and communication. let me know off line and we will get on that and make sure that's happening. in terms of reunification, once she's cleared from a background check perspective at that point, it's really if she completes her immigration proegs, granted asylum into the united states she could be reunified. if she has a deportation order, reunify at that point, only thing i can't do is send the child back with her in a detention facility because of a court order allowing a max of 20 days. congress can change that and we hope they will. >> mr. azar, i think what you need to hear is that this problem in her case, miss guzman's case, didn't exist prior to this administration changing the law. in that case, miss guzman seeking asylum would have come

to our border asked for asylum and would have been processed in a way she was either being able to stay in the community with her child and not seen as a threat. this administration is turning her into a threat. we want due process, we want people to be understood. but people seeking asylum should not be treated as the same way as some criminal that the president is now talking about incessantly. we want people with criminal background to be stopped before they get in the united states. we want people seeking asylum not to end up in a detention center not to be heard from again or brought up in a hearing to get attention to their case. >> i don't want to speak about her case, but if they present at a lawful bder crossing, as opposed to coming illegally into the country, they will not be separated, they will not be arrested, they are not violating the law. so the challenge here is she came in the country illegally and we have laws and we're enforcing the sflus and i will

want to find out besides doing that background check and the parenting, how long is it going to take her to have that process? what are the other steps she will have to take? >> those would be the steps we have to take, but she has to be able to receive t child and if she is in custody i cannot legally because of the 20 day limit reunite her with her child. >> i'm asking how long it's going to take you to do both of those things? . we're going to get back to you. >> no deadline on it. >> i think that's what we want. >> the problem is one can't -- one has to confirm parentage, if she's from honduras i have to get a birth certificate perhaps. >> i'm going to talk about that too because i think there's technology to help speed up this process. >> we will be happy to. >> senator casey. >> mr. chairman, and mr. secretary, thank you for being here. i wanted to ask you about the issue of preexisting conditions. we're told this affects 130 million americans. so a lot of people affected by it. i know that when you were here

last, or i'm sorry, here when you were at the help committee, senator hassan asked you a question about it, and you said, regarding the issue of preexisting conditions and the attorney general's legal position, you said, quote, we share the view of working to ensure that individuals with preexisting conditions can have access to affordable health insurance, unquote, and that you also look forward to working with congress, quote, under all circumstances. unquote. to achieve that shared goal. because it does affect that many tens of millions of americans, there is, to say there's uncertainty with regard to this because of what the administration said in a legal proceeding in a case and what you said here as secretary, there's a lot of uncertainty and if there is one aspect of our

health care policy that needs absolute certainty it's that both parties, both houses, with the administration is going to guarantee that no one who has coverage now, that has a preexisting condition will lose it and no one in the future will have that uncertainty. i guess one of the first questions i have for you is, what have been your recommendations to the president regarding how you and the administration generally are going to maintain those protections for people with preexisting conditions? >> so, of course, my discussions with the president are not asking i'm at liberty to discuss, but the administration's position is we support, of course, graham cassidy, the proposal that's in the budget in the 2019 budget, and as part of that would provide for states to have alternative mechanisms to say an individual mandate as a means of going -- protecting preexisting conditions. in terms of litigation, the

litigation that you're referring to, in that litigation, there is a legal position, first a constitutional matter, regardi the impact of the removal of the tax provision, and then the impact on the mandate and follow the obama administration's views of statutory construction other provisions must fall if that provision falls. we are operating the 2019 program under existing authority existing interpretations as if everything is remaining as it is so we're doing everything to keep stability in the program and operate the program as it is. >> why -- mr. secretary, why not take the uncertainty off the table? just say we will support this policy no matter what? you're not forced as a legal matter to take a position. the administration has chosen to take that position. there's no mandate that you take

that position in a court of law or otherwise. why not just -- why not just say, we're going to make sure by way of policy, by way of any other action the administration takes that everyone who has a preexisting condition will have coverage and treatment no matter what. why not just make that the position of the administration? you don't have to tell me what you told the president. but it ought to be clear to the american people with the administration's policies on preexisting conditions. 130 million people. why not make it very clear that that's a, in essence, a broad statement of administration policy or whatever the hell we call it these days, just be clear about it. to say that there's no question that this administration, hhs, the white house, the department of justice, no one, no institution, no entity in this administration, has a position other than we will guarantee. not have access to coverage,

guarantee. because that's what the law provides today. why not say we're going to uphold existing law. you can have your debates with us about a lot of other issues, but my god, why is this -- why is there uncertainty at all? >> of course we are upholding existing law and the position of the attorney general is the position as to what the existing law is in the statute and before the courts, but the policy position of the administration is, that in whatever framework we have around the individual markets we support solutions to prevent, to ensure people with preexisting conditions have access to affordable insurance. we will work with congress. if the affordable care act those provisions found to be invalid we will work with congress to continue the efforts to find alternative ways to provide affordable insurance including those with preexisting conditions. >> that sound likes a legal mumbo jumbo. just make it clear that the policy -- >> we are a country of laws. we follow the law. >> this isn't following the law. >> my policy preference doesn't become law. >> you can get to the same

policy outcome by saying we will ensure the people will have this protection. >> senator mccaskill. >> thank you, i'm going to follow up with the same topic senator casey was on. on saturday, the president of the united states said at a very public rally he was being critical of senator mccain who voted no on the republican plan to replace, repeal and replace the aca, and then he said, i'm quoting, it's all right because we've essentially gutted it anyway. do you agree with the president's statement? >> the -- what the president -- >> it's a simple yes or no. either you agree with the -- >> without the individual -- without the individual mandate, individuals now are free, they are liberated from having to pay a tax to buy insurance they do not want and cannot afford and that is what i believe the president was referring to.

>> and haven't there been other steps that have been taken that he has -- that have gutted it, that are resulting in much higher premiums on the market this year. >> the ste we're taking to provide affordable, the 28 million locked out of this unaffordable insurance and the individual market. we continue to try to find affordable options for them in the system. we've tried to work on a bipartisan basis to get congress to appropriate csrs to stabilize that market there for this year. >> so do you support csrs being paid? >> we did support what was at the time bipartisan legislation to fund csrs and create reinsurance. there was not at the end of the day bipartisan support to on the alexander collins pact, nelson package. >> i think there is bipartisan support. >> if there were it would have passed. the president personally pushed for its passage. >> secretary that bill hasn't been brought to the floor. mitch mcconnell has decided

we're not allowed to vote on that bill. you all are in charge of health care. you control the white house, you control congress, and this bipartisan bill you speak of, first of all, the president went back and forth as to whether csrs would ever be paid, you know that, yes, we got together in a bipartisan way and i think the chairman will not argue with me about this, those bills are sitting there and i think they've got 60 votes, inexplicably to me, the republican party, i've not seen the president at a rally saying let's pass the csrs. i've not heard him saying let's stabilize with reinsurance, i've heard him say we gutted it. so to sit there -- >> if i can interrupt for a second. i have to say that mcconnell, the leader, would have included this in the omni, but the democrats objected to that. >> mr. chairman, i will guarantee you this, if mitch mcconnell will put on the floor the bipartisan pieces of legislation that have been

negotiated to stabilize the markets, you will pass that by -- i can't imagine there's any democrat that would vote against that. i don't know what the negotiations are in these magic rooms, that none of us get to see, the same place the tax bill was done, the same place the appropriation bills are done, we don't get to see what's going on, i don't know what is going on in those rooms. >> that's what happened. >> well i'm not sure what happened, mr. chairman, we aren't allowed to be told or we don't see, but i know this, that the president is proud that they have gutted this and i want to offer into the record a very important document which is a document that was received and it's not been made public before back in 2010, when the house was investigating the way preexisting conditions were handled before the aca protections. mr. chairman, i would ask unanimous consent to enter into the record the humana agent eligibility and underwriting guide. >> without objection. >> this document goes through and by the way, all the companies have this, i want people to remember what it was

like, because the administration has gone to court to do away with preexisting conditions. the attorney general in my state has gone to court to do away with preexisting -- the attorney general in my state has gone to court to do away with preexisting conditions protections in the united states. there were 400 things listed including high blood pressure and what it says in this document, the low conditions are permanent declines unless otherwise indicated. everything from autism to diabetes to pregnancy, to high blood pressure, denying air traffic controllers and minors and steel workers the ability to get insurance, they were told they're not supposed to write insurance for them. it is stunning to me that we find ourselves in this place, that this administration and

what they do is more important than what they say and what they're doing right now is going to court and saying, do away with all of the consumer to prevent the people in -- the that are -- millions of people that have the 400 different conditions, that said don't write insurance for these people, we don't want them, so i -- i understand that you can say that somehow it's our fault that this legislation is not getting passed, but i think the american people are going to make an independent judgment on that. thank you, mr. chairman. >> thank you, senator. senator brown. >> thank you, mr. chairman. chairman hatch mentioned during his opening remarks that over a month ago president trump hosted many of my colleagues in the rose garden to tout his drug pricing blueprint promising, quote, these are our chairman quoting our president massive cuts to drug droig.

-- prices. i would like to point out that now a month later we were stale waiting for these quote/unquote massive cuts that the president promised. my guess is we'll see dozens more prices increase before we see any massive cuts. mr. secretary, do you agree, if you would answer yes or no, do you agree there are scenarios where pharmaceutical companies increase the list price of their product in price gouge consumers for no reason other than to increase their profit margin? >> of course. we've seen examples of that, yes. >> thank you. the fact that there's absolutely no repercussion for a company that engages in this type of predatory behavior is a problem, surely that contributes to our broken drug pricing system. let me read -- don't take my word for it, read briefly from a letter i received from an ohioan whose husband had parkinson's disease. my husband takes numerous medications some of which are expensive but one in particular gets my attention.

i noticed last year when i was preparing our tax returns the retail price of this generic drug fluctuated between $1,000 and $3,000 for a 90 day period. 90 day supply. she said i thought this is exorbitant and asking why the price was so high though i didn't get a satisfactory answer. i was doubly shocked when we last refilled our prescription for a 90 day supply and price over $6,000. it's getting so generic brands of drugs are costing more than that those that haven't gotten off patent because medicare can't negotiate drug price it seems some unscrupulous companies see that as an open door to gouge the government and gouge all the rest of us too. unquote. the incentives included in the administration's drug pricing blueprint to lower along the su chain are not enough to fix this broken system. there's nothing in your proposal that would prohibit or penalize the actions that are gouging

ohioans. the government needs tools to prevent these companies from jacking up the price of life-saving drugs like epipennar locksen and make millions off the backs of hard-working americans whose lives depend on these medicines. my stop price gouging act would give the government the tools they need to hold bad actors accountable imposing penalties on corporations proportionate to the severity of their price gouging. proportionate to the severity of their price gouging, would hold bad actors accountable, something we rarely do around here. my question mr. secretary, will you commit to reviewing this legislation which i introduced last year and will you commit to working with me on finding a way to prevent pharmaceutical companies from the price gouging consumers as you acknowledged they sometimes do? >> absolutely. happy to work with you on that. there are elements -- we agree the price gouging by sole source generics in our plan actually

does address that. we want to give part d plans the ability even mid-year if there is any price increase on a sole source generic to allow the form larry to be reopened immediately rather than waiting until the end of the year and want to open up medicaid rebates for those drugs so that there would be uncapped liability based on that kind of a price increase. if there's a part b drug we have as part of our budget proposal an inflation penalty there for any drug increased above the price of -- above the rate of medical inflation as you have suggested also. >> okay. i mean that's just part d, not everyone. that's not everyone we need to protect. work with us on that. last thing, mr. chairman, my last minute or so, i know many of my colleagues have raised our collective concern over the administration's actions to separate children from their parents. something that our government, something that is shameful and embarrasses as members of this government. while i understand policies at

dhs and remain influx the situation tns, of course, to be extremely troubles to anyone paying attention. last wk in response to reports of facilities under your purview were preventing children from comforting one another, i sent a letter to you and secretary nielsen concerning the care provided for traumatized children at hhs facilities. regardless of the topic i've had trouble getting written answers to my letters in this administration, so the interest of getting a timely response i would like to ask you to please commit by getting me a response to that letter by the end of this week. >> i haven't seen that particular letter. i will get you a response. i responded this morning, it may have been including your questions. i can tell you in terms of comforting there are no or restrictions on comforting of tender age children or any other provision other than, of course, state child protection laws around that. there was some media story, i have no idea, i've asked about this, no basis for what that individual recorded. these are normal child care

facilities subject to state law. we -- these grantees, these charities, i cannot tell you how seriously they take their mission to care for these children. it is inspiring to see their work. >> i wish the administration of which you're a part took equal care in caring for our children. >> thank you. jur time is up. senator whitehouse. >> thank you, chairman. mr. secretary, welcome. i want to begin by echoing senator menendez comments about the imputed rural floor problem. unless that is corrected you will be creating a market shifting reimbursement cliff around rhode island differentiating it from massachusetts and from connecticut. we are not a very big state. so it really does not make any sense to undue what has been the status quo for years and we'll continue to try to work to make sure we don't create that

anomaly. i thk we've h thi conversation before, but as you know, i think one can generally divide the pharmaceuticals market into three categories. one category is where there is a functioning competitive marketplace, the other category is where there is a legally approved monopoly, protected under patent law, for instance, and the third is where a company enjoys a de facto monopoly, there is not real competition, and it's in that sector of the pharmaceutical industry that i think we have seen the worst misbehavior. and my concern is that you get these companies that come in that buy up a drug manufacturer, add no value, invest in no

research, but simply crank up the price for speculative purposes. first of all do you agree with me these de facto monopolies exist in the prescription drug market? >> i do. we have seen that in these -- with some of these sole source generics that senator brown and i were just talking about. >> not a generic, just a pharmaceutical outside of its patent could have a monopoly. >> you could if you see a branded company abusing the patent system, the rems programs or other things we want to get after. >> or after expiration of their pat. >> exactly. anything that prevents -- >> so the concern that i have is that we are not seemingly addressing that problem. i know that you've proposed reopening a for mu larry, but if you have a situation in which a

drug manufacturer has a de facto monopoly, they were able to succeed at the original low price that the speculator then came in, bought the company, and bid up, it is always going to be within their capability should a competitor emerge to drop back to their original price and price out the competitor. so you can play the market in that way and the threat that somebody might reopen a form larry isn't helpful in that case because a wise speculator will happily bet that nobody will come into that marketplace because they can drop their price back again and price them back out. it seems to me that we have tools that go back to the age of grain silos and railroads and ma bell for dealing with

monopolistic behavior, why not just use those time-tested tools once a particular entity has been determined to be a de facto monopoly and many cases not even a member of the pharmaceutical industry you a speculator in trying to squeeze money out of the system? >> i think that's -- senator, that's a fair question to look at anti-trust policies and competition law there in those circumstances to see if monopoly power is being abused. i don't report to be an expert in anti-trust policies but that's a fair question. i will follow up on that. i think that's a fair thing to look into. we need to increase competition, though. i think -- >> i think we all agree on that. we need a strong, robust, generic marketp we may be driving those prices so low we're creating manufacturing

anomalies that lead to sole source products with others exiting. we need to be open minded about whether we've made it too low even. >> i think in the area of de facto know nop ply it would be hard to identify an agency of government in that area. so i think that's part of the problem right there. i will ask you a question for the record, related to what i'm hearing are very significant problems getting drugs in emergency rooms and so just to flag that between us now, so that when you see the qfr you know this was a question i was concerned about. mr. chairman, thank you. >> senator warner. >> thank you, mr. chairman. good to see you again. i know this is a question about drug pricing today and i will come back, but i, like a number of my colleagues have questions about the ongoing crisis of the children at the border.

the department of health and human servi has contracted facilities to house thousands of unaccompanied minors including one in my state in the shenandoah valley the juvenile center near stanton, virginia, where there have been very disturbing reports of abuse and lawsuits filed as a result of those accusations. i sent your -- the administration multiple letters on the need for us to get information back and senator kaine and i have, and my hope would be that we can get those responses and be anxious to know if you would be able or willing to comment on any of the accusations made about the center in stanton? >> sure. so without regard to the particular individuals involved, it's important to know that when we get these children into our care, they're immediately evaluated with a mental health and behavioral evaluation. as with any children, with 1200 children in our care, 60,000 per year, there are going to be some children who need

extra care, some mental health or may present a risk to themselves or others. we have contracted with some facilities that specialize in juvenile care of a special need for those who may be a risk to themselves or others. our children are kept separate from the rest of the juvenile population. these are -- it's a separate grant provision. they are required to fully comply with all state licensure, state licenses around medication, et cetera. we oversee that, the state licensing authorities oversee that. we take any allegations very seriously here. weant proper and appropriate care for these children. any allegations are quite disturbing. i have seen nothing to confirm the nature of those allegations, but we will certainly respond to and work with you on that. >> i hope the reports have come up of minors being kept in solitary confinement for 23 to 24 hours, to being strapped to a

chair, to being strapped to a chair without any clothing, to have bags put over their head. all practices that both seem inhumane and wore this of a great deal of review. now the -- i just wonder without understanding you may not be able to speak to the specifics of what happened in stanton, what level of training does the orr put for guards in these type of facilities as in -- if it shows these actions took place, i would hope we would put training regimes in place that would not sanction such behavior. >> without in any way knowing to be able to confirm the validity of any of those types of allegations, this would be subject to state requirements and licensure around the care of children in any kind of custodial arrangement and so there would be whatever the state, whatever the state, commonwealth of virginia

licensure are in addition to orr oversight i do not know we have separate training in addition to state licensure requirements around the care in those juvenile detention facilities. i will be happy to get back to you on that because i do not know the answer. >> we have sent a couple letters, the sooner you can get me a response on those, the better. >> thank you. >> let me move a moment to an area senator whitehouse was talking about, that is around the pricing of generic drugs. we saw a great deal of relief 15 years ago, but as you have indicated, generics then trying to price right below the price point or sometimes margins were so thin that companies would not continue to produce, particularly older patented drugs and the ability to keep competition in the generic marketplace has dramatically declined. many areas we maybe only have one generic. what tools has the administration proposed or can you or cmmi use to try to

increase more generic competition and actually build enough of a market here in addition to the brand, three or four generics to provide the price competition we need to bring drug prices down? >> i absolutely agree with you and if you have any suggestions, i would welcome them. we are working at the -- the commissioner is working if we have any product approaching sole source status we're making clear to other manufacturers that that's a market opportunity, make expedited pathways for generic approval, streamlining any process as we have to get products to market there to compete and bring them in. we need to look on the reimbursement side. that's where the request of information asked for insight there. any help you can provide, ideas, open book please. >> i would love to work with you on that because i think pricing transparency and again more knowledge within the marketplace of possible opportunities. we can actually see whether the

market will perform or not or whethere need, as senator whitehouse and i agree, other things to spur this type of competition. >> thank you, senator. my partner would like to ask a question or so. >> thank you, mr. chairman. one last pharmaceutical question and then a matter that we have to clear up and i'll do that as part of my closing remarks. now, mr. secretary, earlier i asked you what you were doing to help the 42 million seniors on medicare part d with their skyrocketing prescription drug bills. you deflected the question by talking about other matters and after asking you again, what you were going to do to help the seniors on part d, i have your exact quote here, you said this morning, you hope that the big

drug companies will exercise pricing restraint. as we begin to wrap this up, mr. secretary, i have to tell you, to get real pricing relief for those millions of seniors i've been asking about on part d, it's going to take a whole lot more than your hopes that you former ceo pharmacy colleagues are just going to step in and help those seniors. so my last pharmaceutical question is going to deal with another matter that will determine whether we're actually going to get some results here or just continue to make these vague promises. press reports indicate you and your office are negotiating directly with drugmakers to lower the price of drugs like insulin for patients who pay

cash for their drugs. is that correct? >> that story was a mystery to everybody that i have spoken to at my department. we have no idea what that was in reference to. >> so it is not correct? >> i am not aware of negotiating that cms is doing around cash pay, on any product, that was -- we are having discussions, of course, with drug companies that are thinking about decreasing their list prices to see if we can help clear barriers, do anything in the channel, as i've mentioned to you privately, working to see how that can be facilitated to drive prices down, but that story was a mystery to everyone i asked about that. >> then let's make sure we understand what these conversations are all about. you don't see them as negotiating about anything? >> no. this is -- if companies are seeking to lower their prices and they're facing barriers from wholesalers or pharmacy benefit managers we're attempting to see can we clear any barriers that

we have regulatory, political or otherwise, around that to help facilitate that. i also, you know, anything that we do, senator, you made a statement about my previous answer and i think you sort of cabined it as if it didn't relate to part d. anything that we do to lower list prices will help our patients in part d because of their cost sharing. our five-point plan in our president's budget would decrease patient out-of-pocket cost sharing by tens of billions of dollars if only congress will pass the five-point plan we have. we want to fix the stars system and protected class system to allow genuine negotiation against the drug companies in part d where now they're not paying commercial level rebates in part d. we will empower greater -- >> you are a smart fella and good at this. but that's not what you said. you said -- >> i've said it now. >> well great, but you earlier said, you hope, i'm just reading it to you, you hope they will

exercise restraint. >> that's one we can -- listen, i would love it if drug companies cut their drug prices just on their now. it would be great also if there were no price increases. that is not our plan. our plan is that we create a regulatory and financial incentives, competition, negotiation, out-of-pocket payment, incentives to lower list price, that is our plan. those would simply be ancillary benefits. our plan is to get that to happen by our actions. that's what i meant. >> well, mr. secretary, i just want to wrap up with one other very disturbing aspect of the hearing. you told me a little bit ago that the department has 2,047 kids in its custody. >> that are separated. we have about 12,000 uncompanied minors in our program. >> a little bit after you made that statement, you said that the department has 2,053 kids. and that was the same number

reported six days ago. >> that was t number in a press release yesterday by the evening it was down to 2,047. it's a fluid situation but by evening it's just the press release shows the 2053, but as of the -- as of last night the last information is 2047. we have them. they're in the system. it's not like there's a mystery here. as we outplace the kids to parents or to their relatives that number will change. >> mr. secretary, the point is, in both of these areas that we have talked about today, and with respect to prescription drugs, i don't think you're going to fix the problem of skyrocketing prescription drug bills if your former industry colleagues get off the hook by your signaling at a hearing like this that you hope that something might happen, and i don't think we are going to solve this calamity of kids being separated from their

parents at this kind of pace. i mean, no matter whether we're talking about 2,053 or 2,047, it's going to take you months and months and months to bring these kids back to their parents and back to safety. on both counts, i sure hope and you're a smart guy, there's no question about that, i sure hope we're going to see action rather than this continued effort to offer us rosy projections and happy thoughts that for seniors aren't going to help them when they get mugged at the pharmacy window and for the kids, it's not going to help them get to safety any time soon. thank you, mr. chairman. >> okay. >> mr. chairman -- may i ask unanimous consent before we conclude. >> you want to ask unanimous consent, go ahead. >> relating to the imputed rural

floor issue. >> sure. >> i have a letter from the hospital association of rhode island expressing its concern about the boundary effects that this will crte, also a letter from our governor, governor romado expressing her concern and a gel dellgation letter from the entire rhode island delegation to administrator verma. this is important to us. it's not like -- >> make that all part of the record. >> thank you. >> okay. thank you. >> mr. chairman? >> yes. >> i know we're -- we went to a second round. >> we're not going to a second round. i think -- we've got to respect -- >> what? >> senator casey asked one question. >> sure you can ask one question, but i'm not going to a second round. >> okay. >> i think the secretary -- secretary has been more than gracio. he's answered every question and he's answered them well as far as i'm concerned. >> mr. chairman, thank you. i know the secretary has been here a while.

just very briefly, this -- the issue of children at the border and the separation policy, i've said it's a policy straight from the pit of hell. i think most people agree with that. i know the executive order is in place. the problem is, zero tolerance led to the problem of separation, zero tolerance will continue to separate children. unless you change and have alternatives to that policy. here's my question, y have read, i know, mr. secretary, all of the statements made by medical professionals all across the country. one from "the washington post," "c" charles nelson, pediatrics professor at harvard, quote, the effect onhildren would be, quote, catastrophic. you heard from the academy of pediatrics, we read the statements about the adverse and long-term permanent damage it does to children. some of the damages being inflicted as well even if they're with the parent in detention. so one question i have for you

is, what, if any, of these organizations that live their lives to give us information about the effect of a policy like this on children, whether it's the academy of pediatrics, the american psychiatric association, for folks with children and individuals with disabilities, the association of university center on disabilities, has hhs or did hhs in the lead up to this policy or once the attorney general announced zero tolerance, did you or anyone at hhs and if you're aware, did anyone at the justice department ever consult with the american academy of pediatrics? >> so first, i want to share your concern, none of us -- none of us want impacts on these children. none of us want the separation. we do everything we can to mitiga any impact on these children with mental health

care, medical care, dental, vision, education, activities athletics. we try to ensure as happy as safe as good an environment for these children through people who exercise real compassion on them. i'm not aware of engagement with any of those particular groups. i believe the doctor's -- the administrator has been working with orr with her expertise, her psychiatric expertise. i believe that's the case. certainly our grantees are trained in and are expert in and have clinician care. every child goes through mental health evaluation and mental health care when they're there, but it's not a desirable situation to have children separated from their parents. listen, if the parents didn't bring them across illegally this would never happen. we are where we are in terms of once they're separated, we want to reunite them. if congress will get rid of the 20 day ban on family unification we will act so quickly to get the kids back together with

their parents. as long as i have a court order not allowing that integration with the family it blocks pe. we want that to happen. we want the reunification. we want the kids well cared for. >> we have to go, mr. secretary, will submit you some questions in writing for you to answer as part of the record with regard to kids with a disability, kids with down syndrome, how they're cared for, how many kids you have under your care. so i'll be submitting those for the record. thank you for the extra time. >> thank you, senator. and i just want to say, you know, i've only been here 42 years, and i've seen a lot of witnesses in my time and certainly a lot of them on health care and a lot of witnesses who have been in your position, i've never seen a better witness than you. you're clearly very competent, you're clearly doing a really good job, you've clearly been saddled with some really, really tough problems, and i have

confidence that unfortunately handle them expeditiously and well. i'm really proud of you and to be honest with you, i think everybody in america ought to be proud of you and glad that you're in this position. finally to add further clarity to what occurred on the alexander collins stability package, i want to note that when senator collins asked for a unanimous consent agreement to call up and pass the amendment, senator murray objected. democrats seem to have no interest in working with us to stabilize the individual market. so it's nice to pretend otherwise, but that's really what happened. it was pretty disturbing to me. mr. azar, i've been around a lot of secretaries in my day and i've chaired three major committees.

you've had some of the worst problems i've seen in the history of my 42 years. i want to personally extend my congratulations for -- and compliment you for the efforts you've put forth for the work that you've done, for the care that you've and for the kindness that i've seen. keep it up. these are tough times. these are tough issues. these families are all suffering. these kids are in danger. and i'm just glad you're there. i think people ought to be thanking you, rather than criticizing you. i would like to thank everybody for their attendance here at this -- and participation today in this particular hearing. again, thank you. again, secretary azar, for your excellent testimony. i ask that any member wishes to submit questions for the record, do so by the close of business on tuesday, july 10th.

and with that then, this hearing is adjourned.

>> this senate finance committee hearing will reair tonight at 8:00 eastern on c-span2. it's also online at c-span.org, as is secretary azar's testimony on june 12th before the senate health committee. later today, a senate judiciary subcommittee will hear testimony on the influence of shell companies and virtual currencies on elections. live coverage starts at 2:30

eastern here on c-span3, also on c-span.org, and you can listen with the free c-span radio app. housing and urban development secretary ben carson will testify tomorrow before the house financial services committee. live coverage begins at 10:00 eastern here on c-span3, online at c-span.org, and you can listen with the free c-span radio app. also coming up tomorrow, president trump's pick to lead the veterans affairs department will go before the senate veterans affairs committee. his confirmation hearing starts live at 2:30 eastern. it's also available online and with the c-span radio app. thursday, the house judiciary committee holds a hearing on oversight of fbi and doj actions surrounding the 2016 election. deputy attorney general rod rosenstein and fbi director christopher wray testify about the findings contained in the partjusticnt's inspector general's report. watch live at 1:00 p.m. eastern on c-span3, c-span.org, or

listen on the free c-span radio app. this past week with the help of our cable partners gci, the c-span bus travelled to juneau and haynes, alaska. as part of our 50 capitals tour, the bus continues the trip across alaska to our next stop in fairbanks. >> for most of us, it's the only way to see our delegation hard at work in washington. gci is proud to carry c-span for a number of reasons, especially for their emphasis on education. from lesson plans and handouts to timely teachable videos and educator conferences, the c-span classroom program offers so many resources to teachers and adds a great deal of value to today's classrooms. >> thank you for being part of it, bringing your awesome bus to fairbanks. the tour of that was just incredible. i heard stories of driving up

from the folks who brought the bus. the things they saw on the way coming to alaska, it was a nice trip from what i heard. i've driven it a few times myself. it is an awesome trip. we're so glad that your bus came here. using it as a tool to b fairbanks nationwide. >> what i appreciate about c-span, it's 40 years old, much older than me, but what i appreciate -- that's a joke, by the way. you can laugh. what i appreciate about c-span is that it's not partisan. you watch the sparring that takes place. you watch your delegations talk back and forth. it's extremely informative and very educational. one of the best things on the bus, and i'm a tech geek so i hope they take me with them on their tour because i would just spend hours on that bus, but if you go in and look at the video screens, people can learn and kids can learn about government.

i mean, government doesn't have to be a bad word. >> be sure to join us july 21st and 22nd when wll feature our visit to alaska. watch "alaska weekend" on c-span, c-span.org, or listen with the free c-span radio app. former secretary of state madeline albright spoke at the u.s. global leadership coalition conference. she talked about president trump's meeting with north korean leader kim jong-un and secretary of state mike pompeo's leadership of the state department. after that, a panel reflected on the president's emergency plan for a.i.d.s. relief 15 years after its creation during the bush administration. [ applause ] >> thank you. good morning. as liz said, i'm sarah thorne, senior director for global government affairs at walmart and a pr