[Senate Hearing 115-390]
[From the U.S. Government Publishing Office]
S. Hrg. 115-390
NOMINATION HEARING
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
ON
NOMINATIONS OF LANCE ROBERTSON, BRETT GIROIR, M.D., ROBERT KADLEC,
M.D., ELINORE F. McCANCE-KATZ, M.D. AND JEROME ADAMS, M.D.
__________
AUGUST 1, 2017
__________
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Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming PATTY MURRAY, Washington
RICHARD BURR, North Carolina BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia BERNARD SANDERS (I), Vermont
RAND PAUL, Kentucky ROBERT P. CASEY, JR., Pennsylvania
SUSAN COLLINS, Maine AL FRANKEN, Minnesota
LISA MURKOWSKI, Alaska MICHAEL F. BENNET, Colorado
SUSAN M. COLLINS, Maine SHELDON WHITEHOUSE, Rhode Island
BILL CASSIDY, M.D., Louisiana TAMMY BALDWIN, Wisconsin
TODD YOUNG, Indiana CHRISTOPHER S. MURPHY, Connecticut
ORRIN G. HATCH, Utah ELIZABETH WARREN, Massachusetts
PAT ROBERTS, Kansas TIM KAINE, Virginia
LISA MURKOWSKI, Alaska MAGGIE HASSAN, New Hampshire
TIM SCOTT, South Carolina
David P. Cleary, Republican Staff Director
Lindsey Ward Seidman, Republican Deputy Staff Director
Evan Schatz, Minority Staff Director
John Righter, Minority Deputy Staff Director
(ii)
C O N T E N T S
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STATEMENTS
TUESDAY, AUGUST 1, 2017
Page
Committee Members
Alexander, Hon. Lamar, Chairman, Committee on Health, Education,
Labor, and Pensions, opening statement......................... 1
Murray, Hon. Patty, a U.S. Senator from the State of Washington,
opening statement.............................................. 5
Young, Hon. Todd, a U.S. Senator from the State of Indiana....... 7
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode
Island......................................................... 7
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana... 23
Collins, Hon. Susan M., a U.S. Senator from the State of Maine... 27
Murphy, Hon. Christopher, a U.S. Senator from the State of
Connecticut.................................................... 28
Warren, Hon. Elizabeth, a U.S. Senator from the State of
Massachusetts.................................................. 32
Hassan, Hon. Margaret Wood, a U.S. Senator from the State of New
Hampshire...................................................... 34
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of
Pennsylvania................................................... 37
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin.. 39
Witnesses
Robertson, Lance, Nominated to be Assistant Secretary for Aging,
Edmond, OK..................................................... 8
Prepared statement........................................... 10
Giroir, Brett, M.D., Nominated to be Assistant Secretary for
Health, College Station, TX.................................... 11
Prepared statement........................................... 13
Kadlec, Robert, M.D., Nominated to be Assistant Secretary for
Preparedness and Response, Alexandria, VA...................... 14
Prepared statement........................................... 15
McCance-Katz, Elinore F., M.D., Nominated to be Assistant
Secretary for Mental Health and Substance Use, Cranston, RI.... 17
Prepared statement........................................... 18
Adams, Jerome, M.D., Nominated to be Surgeon General of the
Public Health Service, Fisher, IN.............................. 19
Prepared statement........................................... 21
Additional Material
Statements, articles, publications, letters, etc.
Burr, Hon. Richard, a U.S. Senator from the State of North
Carolina, prepared statement............................... 50
Letters of support for:
Lance Robertson.......................................... 52
Brett Giroir, M.D........................................ 110
Robert P. Kadlec, M.D.................................... 124
Elinore McCance-Katz, M.D................................ 128
Jerome Adams, M.D........................................ 163
(III)
Response by Lance Robertson to questions of:
Senator Murray........................................... 177
Senator Sanders.......................................... 179
Senator Casey............................................ 180
Senator Franken.......................................... 182
Senator Bennet........................................... 183
Senator Whitehouse....................................... 183
Senator Baldwin.......................................... 184
Senator Murphy........................................... 184
Senator Warren........................................... 185
Senator Hassan........................................... 188
Response by Brett Giroir, M.D. to questions of:
Senator Murray........................................... 189
Senator Sanders.......................................... 190
Senator Franken.......................................... 191
Senator Bennet........................................... 191
Senator Whitehouse....................................... 192
Senator Baldwin.......................................... 192
Senator Warren........................................... 193
Response by Robert Kadlec, M.D. to questions of:
Senator Murray........................................... 197
Senator Sanders.......................................... 200
Senator Casey............................................ 200
Senator Franken.......................................... 201
Senator Whitehouse....................................... 202
Senator Baldwin.......................................... 204
Senator Murphy........................................... 205
Senator Warren........................................... 205
Response by Elinore F. McCance-Katz, M.D. to questions of:
Senator Murray........................................... 211
Senator Sanders.......................................... 212
Senator Casey............................................ 212
Senator Franken.......................................... 214
Senator Bennet........................................... 214
Senator Whitehouse....................................... 215
Senator Baldwin.......................................... 217
Senator Murphy........................................... 217
Senator Warren........................................... 220
Response by Jerome Adams, M.D. to questions of:
Senator Murray........................................... 223
Senator Sanders.......................................... 226
Senator Casey............................................ 227
Senator Franken.......................................... 227
Senator Bennet........................................... 227
Senator Whitehouse....................................... 228
Senator Warren........................................... 229
NOMINATION HEARING
----------
TUESDAY, AUGUST 1, 2017
U.S. Senate,
Committee on Health, Education, Labor,
and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 2:30 p.m., in
room SD-430, Dirksen Senate Office Building, Hon. Lamar
Alexander, chairman of the committee, presiding.
Present: Senators Alexander, Murray, Collins, Cassidy,
Young, Casey, Bennet, Whitehouse, Baldwin, Murphy, Warren,
Kaine, and Hassan.
Opening Statement of Senator Alexander
The Chairman. The Senate Committee on Health, Education,
Labor, and Pensions will please come to order.
Before we get down to today's business, which is to
consider five of the President's nominees, I want to begin the
hearing by saying that while we have not always had hearings on
nominees for these positions that I especially appreciate
Senator Murray's agreeing that we will mark-up these nominees,
or we will consider them for mark-up, tomorrow. I appreciate
that very much.
I wanted to say a few words first about healthcare, and
then give Senator Murray a chance to say a word about that, if
she wishes. Then we will go on to the business at hand, which
is the hearing for these five nominees.
This committee, which is the Senate's health committee,
will hold hearings beginning the week of September 4, 2017 on
the actions Congress should take to stabilize and strengthen
the individual health insurance market so that Americans will
be able to buy insurance at affordable prices in the year 2018.
We will hear from State insurance commissioners, from
patients, from Governors, healthcare experts, and insurance
companies. Committee staff will begin work this week working
with all committee members to prepare for these hearings and
discussions.
The reason for these hearings is that unless Congress acts
by September 27--when insurance companies must sign contracts
with the Federal Government to sell insurance on the Federal
exchange next year--millions of Americans with Government
subsidies in up to half our States may find themselves with
zero options for buying health insurance on the exchanges in
2018. Many others, without Government subsidies, will find
themselves unable to afford health insurance because of rising
premiums, co-pays, and deductibles.
There are a number of issues with the American healthcare
system, but if your house is on fire, you want to put out the
fire, and the fire in this case is the individual health
insurance market. Both Republicans and Democrats agree on this.
Our committee had one hearing on this subject on February
1, and we will work intensively between now and the end of
September in order to finish our work in time to have an effect
on the health insurance policies that will be sold next year in
2018.
I am consulting with Senator Murray to make these hearings
bipartisan and to involve as many members of the committee as
is possible; all who want to be involved. I will be consulting
with Senator Hatch and Senator Wyden so that the Finance
Committee is aware of any matters we discuss that might be
within its jurisdiction.
In these discussions, we are dealing with a small segment
of the total health insurance market. Only about 6 percent of
insured Americans buy their insurance in the individual market.
Only about 4 percent of insured Americans buy their insurance
on the exchanges. While these percentages are small, they
represent large numbers of Americans including many of our most
vulnerable Americans.
We are talking about the roughly 18 million Americans in
the individual market. About 11 million of them buy their
insurance on the Affordable Care Act exchanges. About 9 million
of those 11 million Americans have Affordable Care Act
subsidies. Unless we act, many of them may not have policies
available to buy in 2018 because insurance companies will pull
out of collapsing markets.
Just as important, unless we act, costs could rise once
again making healthcare unaffordable for the additional 9
million Americans in the individual market who receive no
Government support. Roughly 2 million of them buy their health
insurance on the Affordable Care Act exchanges, but do not
qualify for a Government subsidy and roughly 7 million buy
their insurance outside of the exchanges. This means they have
no Government help paying for their premiums, co-pays, and
deductibles.
As we prepare for these discussions, I have also urged the
President to temporarily continue the cost-sharing reduction
payments through September so that Congress can work on a
short-term solution for stabilizing the individual market in
2018.
Cost-sharing reduction subsidies reduce co-pays, and
deductibles, and other out-of-pocket costs to help low-income
Americans who buy their health insurance on the exchanges. That
would be those who make under 250 percent of the Federal
poverty level, or roughly $30,000 for an individual or $60,000
for a family of four.
Without payment of these cost-sharing reductions, Americans
will be hurt. Up to half of the States will likely have bare
counties with zero insurance providers offering insurance on
the exchanges, and insurance premiums will increase by roughly
20 percent, according to America's Health Insurance Plans.
In my opinion, any solution that Congress passes for a 2018
stabilization package would need to be small, bipartisan, and
balanced. It should include funding for the cost-sharing
reductions, but it also should include greater flexibility for
States in approving health insurance policies.
It is reasonable to expect that if the President were to
approve continuation of cost-sharing subsidies for August and
September--and if Congress in September should pass a
stabilization plan that includes cost-sharing for 1 year--it is
reasonable to expect that the insurance companies in 2018 would
then lower their rates. They have told us. In fact Oliver
Wyman, an independent observer of healthcare, has told us that
lack of funding for the cost-sharing reductions would add 11 to
20 percent to premiums in 2018.
If the President over the next 2 months, and Congress over
the next year, takes steps to provide certainty that there will
be cost-sharing subsidies, that should allow insurance
companies to lower the premiums that they have projected. In
fact, many insurance companies have priced their rates for 2018
at two different levels; one with cost-sharing and one without
cost-sharing.
It is important not only that the President approve
temporary cost-sharing for August and September, but that we,
in a bipartisan way, find a way to approve it at least for 1
year so we can keep premiums down.
This is only step one in what we may want to do about
health insurance and the larger question of healthcare costs.
We will proceed step by step.
A subsequent step would be to try to find a way to create a
long term, more robust individual insurance market. For the
short term, our proposal is that by mid-September see if we can
agree on a way to stabilize the individual insurance market to
keep premiums down and to make affordable insurance available
to all Americans.
We need to put out the fire in these collapsing markets
wherever these markets are. I think it is reasonable for the
President to do that for 2 months and then for us to act during
the month of September.
Senator Murray, if you have any comments on our hearings, I
would welcome them, and then we will go to the business at
hand.
Senator Murray. Thank you very much, Chairman Alexander.
I think it is really clear that the path to improving
healthcare, lowering premiums, and increasing access and
quality has to be through working across the aisle, and
bringing patients and families into the process, and coming
together to find common ground. There is a lot of work we need
to do for patients and families we represent, especially when
it comes to the uncertainty in the markets and threats from the
Administration, and the potential for significant premium
increases if we do not act.
Chairman Alexander, I want to say I really appreciate your
work with me on this and your commitment to getting a result
for all of our constituents, particularly when it comes to the
cost-sharing subsidies and that we do not cutoff premiums and
spike those for patients and families.
I think I speak for all of us on this side that we look
forward to bipartisan hearings, and hearing from patients and
stakeholders, and working with colleagues both on this
committee and off to work together in a bipartisan manner to
stabilize the healthcare market and reduce premiums for our
families.
Thank you very much for your work on this.
The Chairman. Thank you, Senator Murray.
This committee has proved it works best when it works that
way. She made an important point I did not make.
A number of Senators have approached us who are not Members
of the committee who want to be a part of what is happening. We
are going to find ways, both this month and next month, to make
sure that they have an opportunity to be updated on and
participate in our discussions as much as possible.
The first nominee we will hear from today is Mr. Lance
Robertson, the nominee to be Assistant Secretary for Aging.
In this role, he will oversee grants to States to support
Meals on Wheels and provide Medicaid recipients homecare and
financial management. He is currently State Director of
Oklahoma's Aging Services, a position he has held for the past
decade. He has received broad support from national and State
groups.
We received his ethics paperwork on June 30, concluding he
is in compliance with applicable laws and regulations governing
conflicts of interest. The committee received his committee
paperwork on July 10.
Welcome, Mr. Robertson.
Next, we will hear from Dr. Brett Giroir, who has been
nominated to be the Assistant Secretary for Health.
He will oversee many public health programs including
promoting biomedical research regulation and integrity;
encouraging vaccinations to protect Americans against outbreaks
of vaccine-preventable diseases, something this committee in a
bipartisan way has strongly supported; and helping respond to
the opioid abuse crisis. Last year, Congress provided $1
billion over 2 years in State grants to address that crisis in
the 21st Century Cures bill that came out of this committee.
He is the founder and CEO of Health Science and Biosecurity
Partners, and an Adjunct Professor of Pediatrics at Baylor
College of Medicine in Houston.
He was nominated on May 25. We received his paperwork on
May 30, and his Office of Government Ethics paperwork on June
5. The Office of Government Ethics has approved his nomination.
Then, we have Dr. Robert Kadlec, who has been nominated to
serve as Assistant Secretary for Preparedness and Response.
This role was created under the Pandemic and All-Hazards
Preparedness Act to lead the Nation in emergency preparedness
and response to protect Americans in the event of public health
emergencies and disasters. It is vital in ensuring that we are
prepared at the Federal, State, and local levels for the next
public health threat, whether natural, such as Ebola or Zika,
or a bioterror attack. He served as Deputy Staff Director for
Senator Burr on the Intelligence Committee.
President Trump nominated him on July 11. We received his
ethics paperwork on July 19 and his committee paperwork July
25.
The next nomination is Dr. Elinore McCance-Katz to be
Assistant Secretary for Mental Health and Substance Use.
In 1992, the Substance Abuse and Mental Health Services
Administration was established within the Department of Health
and Human Services to, ``Reduce the impact of substance abuse
and mental illness on American communities.''
The 21st Century Cures Act last year, which Senator Murphy
and Senator Cassidy played such a large role in, made some
significant changes to the agency. It directs the Assistant
Secretary to focus on evidence-based practices, ensure the
agency's grants are used effectively, improve the recruitment
of mental health and substance abuse professionals, and
collaborate with the criminal justice system to improve
services.
She is currently the chief medical officer for the Rhode
Island Department of Behavioral Healthcare, Developmental
Disabilities, and Hospitals.
She was nominated on June 15. The committee received her
completed paperwork on June 26. OGE concluded she is in
compliance with the conflicts of interest.
Finally, we will hear from Dr. Jerome Adams, the nominee
for Surgeon General. He will also serve as medical director in
the Regular Corps of the Public Health Service.
The Surgeon General is often called the Nation's doctor and
in the past, Surgeons General have addressed important issues
such as preventing chronic diseases, supporting breast feeding,
nutrition and exercise, and mental health. Today, he is
Indiana's State Health Commissioner.
He was nominated June 29. We received his ethics paperwork
July 7 and his committee paperwork July 24.
We are holding the hearing today because our democratic
members requested it, even though many of these nominees for
these positions have not had hearings over the last several
years. Having said that, I want to thank Senator Murray for
agreeing to mark-up the nominees tomorrow.
I am going to call on Senator Young and Senator Whitehouse
when I introduce the witnesses before they speak, because they
want to also introduce you.
Senator Murray.
Opening Statement of Senator Murray
Senator Murray. Thank you very much, Chairman Alexander.
Thank you to all of our nominees for joining us today. I am
looking forward to discussing your vision for the roles you
have been asked to fill.
As my colleagues know well, I have repeatedly stressed the
importance of a thorough and complete vetting process for
nominees, and this naturally includes ample time to examine
nominees' qualifications, and experience, and record of
previous statements or decisions.
I am also very interested in whether a nominee has
demonstrated a commitment to putting everyday people first. I
want to know if they are going to put science and facts ahead
of politics and ideology. Critically, I want to know if they
will truly be independent and will do the right thing no matter
how much pressure is put on them by their bosses. I am going to
have several questions on this today as well as questions to
submit for the record.
I do want to take just a minute to address some initial
concerns, because I am deeply troubled by actions President
Trump and Secretary Price have taken on the issue areas for
which every one of these nominees will be responsible, if
confirmed. One thing I am going to want to understand today is
how they will address these issues.
Dr. Kadlec, if confirmed, you would hold a critical job
overseeing our Nation's efforts to prevent, prepare for, and
respond to public health emergencies and natural disasters. So
far, the Trump administration has failed to prioritize
preparedness efforts, which I believe has left us vulnerable to
public health threats.
I will want to hear from you how much you would stand up to
the Administration on this, given you have been an outspoken
voice on the need to increase investments in our preparedness
efforts at HHS.
Dr. McCance-Katz, I am concerned this Administration has
delayed some very critical steps that could help provide
immediate relief for families suffering from the opioid
epidemic.
The role to which you have been nominated for was created
by this committee, as Chairman Alexander mentioned, thanks to
Senators Murphy and Cassidy. It reflects a bipartisan
commitment to this issue, as well as larger priorities
regarding mental health and substance abuse.
If confirmed, you would be the first person to ever serve
in this role, so I will want to hear from you how much you
would put patients and families first in that role.
Mr. Robertson, we are in desperate need of a strong
advocate for older Americans and for people with disabilities
in this Administration. I know you have been an outspoken
advocate for older Americans back in your home State of
Oklahoma.
I will want to hear more about your commitment to protect
and defend the rights of people with disabilities and advocate
for investments for all of ACL's programs including the
disability programs.
Dr. Adams, President Trump's firing of the previous Surgeon
General just halfway into his term shows to me a lack of
respect for that office and for the independence of science.
You and I have talked about this.
I have made my concerns known, but I want to make clear
today the next Surgeon General must be an advocate for science
and facts, and must be able to stand up and correct
misinformation coming out of this Administration.
Dr. Giroir, I am deeply concerned with many actions that
have been taken this year by the office you have been nominated
to lead and this is particularly true with regards to attacks
on women's health and the rights of women.
First and foremost, President Trump has proposed
underfunding the Title X Family Planning Program and signed it
into law. That law states to block Planned Parenthood and other
qualified women's health providers from receiving title X
funds. We know he has appointed radical anti-choice individuals
throughout the Administration, including within the office you
will be charged to lead and just recently, he proposed gutting
the Teen Pregnancy Prevention Program.
I want to be clear from the outset, it would be
unacceptable to confirm someone who would seek to continue
those actions and be unwilling to stand up to ideological
attacks on women. I have some varied concerns here. I will be
asking you direct questions about that today.
We have a lot to cover, Mr. Chairman. I appreciate you
doing this hearing and working with you to move nominations
tomorrow.
I really want to say I appreciate you being willing to work
with us on healthcare. I think we have shown time and again
that we can work through some tough problems and comprise. I am
ready to get to work and I know our side is as well.
Thank you.
The Chairman. Thanks, Senator Murray.
I think we are too.
I am going to turn to Senator Young and then to Senator
Whitehouse. Senator Young to make some comments about Dr.
Adams, Senator Whitehouse about Dr. McCance-Katz, and then we
will hear from the nominees.
Senator Young.
Statement of Senator Young
Senator Young. Thank you, Chairman, for this opportunity to
say a few words of support of my very good friend, Dr. Jerome
Adams.
Dr. Adams, congratulations on your nomination to be the
next Surgeon General of the United States. Congratulations to
your family, who is here to support you along the way.
In the past few years, Dr. Adams has served us Hoosiers
well as the Indiana State Health Commissioner. I, along with
Senator Donnelly, believe he has the experience and
demonstrated leadership to promote public health nationwide and
bring awareness to some of our most pressing public health
challenges as our Nation's top physician.
I want to submit for the record a letter of support from
Senator Donnelly and I, as well as statements of support from
our Governor, Eric Holcomb, the Indiana Black Legislative
Caucus, the American Medical Association, the Association of
State and Territorial Health Officials, and Ascension.
The Chairman. Without objection.
Senator Young. Without objection.
[The information referred to may be found in Additional
Material.]
Senator Young. I look forward to hearing Dr. Adams'
testimony and I yield back.
The Chairman. Senator Whitehouse.
Statement of Senator Whitehouse
Senator Whitehouse. Thank you, Chairman, for the
opportunity to join you in welcoming Dr. Elinore McCance-Katz
to the committee.
As you mentioned, Dr. McCance-Katz is an addiction
psychiatrist. She currently serves as the chief medical officer
at Rhode Island's Department of Behavioral Healthcare,
Developmental Disabilities and Hospitals affectionately known
in Rhode Island as BHDDH. She is also a professor of Psychiatry
and Human Behavior and Behavioral and Social Sciences at Brown
University in Providence.
I have spoken to a number of Rhode Islanders who have been
impressed by Dr. McCance-Katz's work in our State. She has
helped expand access to medication-assisted treatment,
stabilized psychiatric services at Eleanor Slater Hospital,
served as an expert advisor to the Governor's Opioid Overdose
Prevention and Intervention Task Force, and much more.
Thank you, doctor, for your willingness to take on this new
and important role. I look forward to hearing your testimony.
If I may take a moment also to welcome Dr. Kadlec, who we
know from Senator Burr's staff, and whose interest in and
passion for bioterror preparedness and protection is well-
established and most welcome. To Dr. Adams, who comes extremely
well-recommended by our director of health in Rhode Island,
Nicole Alexander-Scott.
Thank you, Chairman.
The Chairman. Thank you, Senator Whitehouse.
We will have testimony from the five nominees. We welcome
you. We welcome your families, some of whom are here, and you
are welcomed to acknowledge them, if you would like to.
If you could keep your remarks to about 5 minutes, we would
appreciate it because that will leave more time for Senators to
ask you questions.
Mr. Robertson, let us start with you.
STATEMENT OF LANCE ROBERTSON, NOMINATED TO BE ASSISTANT
SECRETARY FOR AGING, EDMOND, OK
Mr. Robertson. Good afternoon.
Thank you, Mr. Chairman, Ranking Member Murray, and members
of the Senate Health, Education, Labor, and Pensions Committee
for allowing me to appear before you today.
I am honored to be here with my fellow nominees and I am
grateful for your consideration of my nomination to serve as
the Assistant Secretary on Aging and the Administrator of the
Administration for Community Living or ACL.
I look forward to discussing how we can advance that
organization's ongoing successful work in serving seniors and
individuals living with a physical and/or intellectual and
developmental disability. I appreciate the wisdom many of you
and your staff members shared with me in advance of this
hearing.
I would like to thank so many family members, friends, and
colleagues who have supported me through this nomination. As
the Chairman allowed us to do, I would like to recognize and
especially thank my wife of 23 years, who is with me today,
Lori and then also the tremendous support from our daughters
Brooke and Kaitlyn.
ACL's mission, and I quote, is to,
``Maximize the independence, well-being, and health
of older adults, people with disabilities across the
lifespan, and their families and caregivers,''
and that is timely and critical. ACL represents populations
that number more than 140 million Americans and these
populations continue to grow. Ensuring choice, independence,
and meaningful community inclusion is the hallmark of ACL's
work and my life's mission.
As Assistant Secretary, my vision would involve a four-
pronged strategy, an overarching strategy that positively
impacts all populations.
The first strategy is to improve access to information
about long-term services and supports. Many Americans are
unsure where to turn when confronted with an illness, a
disability, service need, or when they stumble into the role of
caregiver.
The next strategy focuses on supporting caregivers. The
informal caregiver, and the service he or she provides, is the
epicenter of the long-term services and support system. Our
Nation must recognize how critically important it is that we
help these 44 million unpaid family caregivers whose work to
the care system is valued at $470 billion a year.
Under my leadership we will continue to bolster evidence-
based solutions and build support systems that work. We will
continue to seek ways to meet caregivers where they are and
equip them with the tools needed to be successful in their
roles.
The third strategy is dedicated to strengthening elder
justice. Far too many Americans are exploited and abused, and
we must continue to aggressively fight this growing epidemic.
Strong momentum can be seen through the work of the multiagency
Elder Justice Coordinating Committee, the recent release of
innovation grants funded through ACL, and the bipartisan
congressional caucus focused on this important issue.
The final strategy is increasing our network's business
acumen. Nonprofit aging and disability community-based
organizations work hard every day to feed, support, transport,
and assist individuals. These organizations are the backbone of
our effort to promote independence, well-being, and quality of
life for older adults and people living with disabilities.
If confirmed, I look forward to working with the great team
at ACL. As a collective body, ACL boasts a cadre of
intelligent, committed, and impressive individuals. I look
forward to listening, learning, and working together, if
confirmed.
As you fulfill your important role of confirming nominees,
I am certain you look for individuals who not only have the
requisite experience and skills, but preferably convince you
that their commitment is unmatched and possibly even galvanized
by personal experience.
I humbly submit to you that I meet such criteria with
nearly a quarter century of public service experience, a
graduate degree in public administration, holding national
leadership roles, and comprehensive experience in directing
aging and disability network programs.
I am humbled and appreciative of the endorsements that I
have received from organizations across the aging and
disability networks. It is my hope that when you review these
letters of support, it will assure you of the abilities I will
bring to this position, if I am confirmed.
Having been partially raised by my grandparents, served as
a caregiver, and having a niece living with significant
disability affords me a personal view of ACL's important work.
Never does a day go by that I am not impressed with the
resiliency of those we serve. In most cases, particularly
through programs offered by ACL, these individuals just need a
little help: a meal, assistance with employment, transportation
to the doctor, a referral to a community organization, a bit of
respite, et cetera. We help by supporting the least expensive
and preferred home and community-based care where it is
desired.
I believe wholeheartedly in our work to offer choices,
empower people, and support families across the care spectrum.
We help Americans live healthy, productive, and independent
lives in their community. Our work is vital.
In closing, I wish to thank President Trump for his
nomination, support, and confidence and I am excited to work
under Secretary Price's leadership, if confirmed.
Thanks to each of you for the outstanding leadership and
passion you provide each day on behalf of our great country. If
confirmed, I look forward to working with you and your staff.
Mr. Chairman, thank you for the opportunity to be with you
today.
[The prepared statement of Mr. Robertson follows:]
Prepared Statement of Lance Robertson
Thank you Chairman Alexander, Ranking Member Murray, and members of
the Senate Health, Education, Labor, and Pensions (HELP) Committee for
allowing me to appear before you today. I am honored to be here with my
fellow nominees and am grateful for your consideration of my nomination
to serve as the Assistant Secretary on Aging and Administrator of the
Administration for Community Living (ACL). I look forward to discussing
how we can advance that organization's ongoing successful work in
serving seniors and individuals living with a physical and/or
intellectual and developmental disability. I appreciate the wisdom many
of you and your staff members shared with me in advance of this
hearing.
I would also like to thank so many family members, friends, and
colleagues who have supported me through this nomination. I wish to
especially thank my wife of 23 years, Lori, who joins me here today. I
am grateful beyond words for her unwavering love and support and that
of our daughters Brooke and Kaitlyn.
ACL's mission of maximizing ``the independence, well-being, and
health of older adults, people with disabilities across the lifespan,
and their families and caregivers'' is critical. ACL currently serves
more than 140 million Americans and this population continues to grow.
Ensuring choice, independence, and meaningful community inclusion is
the hallmark of ACL's work and my life's mission.
As Assistant Secretary, my vision would involve a four-pronged,
overarching strategy that positively impacts all populations.
1. The first strategy is to improve access to information about
long-term services and supports that are available both with publicly
funded and private-sector resources. Many Americans are unsure where to
turn when confronted with an illness, disability, service need, or when
they stumble into the role of a caregiver.
2. The next strategy focuses on supporting caregivers. The informal
caregiver and the service he or she provides is the epicenter of the
long-term services and supports system. Our Nation must recognize how
critically important it is that we help the 44 million unpaid family
caregivers whose work to the care system is estimated at $470 billion a
year. Under my leadership we will continue to bolster respite vouchers,
promote evidence-based solutions, and build support systems that work.
We will continue to seek ways to meet caregivers where they are and
equip them with the tools needed to be successful in their roles.
3. The third strategy is dedicated to strengthening elder justice.
Far too many older adults are exploited and abused, and we must
continue to aggressively fight this growing epidemic. Strong momentum
can be seen, however, through the work of the multi-agency Elder
Justice Coordinating Committee, the recent release of innovation grants
funded through ACL, and the new bipartisan congressional caucus focused
on this issue.
4. The final strategy is increasing our network's business acumen.
Non-profit aging and disability community-based organizations work hard
every day to feed, support, transport and assist individuals. These
organizations are the backbone of our effort to promote independence,
well-being and quality of life for older adults and people living with
disabilities.
If confirmed, I look forward to working with the great team at ACL.
As a collective body, ACL boasts a cadre of intelligent, committed and
impressive individuals.
As you fulfill your important role of confirming nominees, I am
certain you look for individuals who not only have the requisite
experience and skills but preferably convince you that their commitment
is unmatched and possibly even galvanized by personal experience. I
humbly submit to you that I meet such criteria with nearly a quarter
century of public service experience, a graduate degree in public
administration, holding national leadership roles, and comprehensive
experience in directing aging and disability network programs. I am
humbled and appreciative of the endorsements that I have received from
organizations across the aging and disability networks. It is my hope
that when you review the letters of support it will assure you of the
abilities that I would bring to this position if I am confirmed. Having
been partially raised by my grandparents, served as a caregiver, and
having a niece living with significant disability affords me a personal
view of ACL's important work.
Never does a day go by that I'm not impressed with the resiliency
of those we serve. In most cases, particularly through programs offered
by ACL, these individuals just need a little help--a meal, assistance
with employment, transportation to the doctor, a referral to a
community organization, a bit of respite, etc. We help by supporting
the least expensive and preferred home and community-based care where
it is desired. I believe whole-heartedly in our work to offer choices,
empower people, and support families across the care spectrum. We help
Americans live healthy, productive and independent lives in their
community. Our work is vital.
I wish to thank President Trump for his nomination, support and
confidence and I am excited to work under Secretary Price's leadership
if confirmed. Thanks to each of you for the outstanding leadership and
passion you provide each day on behalf our great country. If confirmed,
I look forward to working with you and your staff. Mr. Chairman, I
thank you for the opportunity to be with you today.
The Chairman. Thank you, Mr. Robertson.
Dr. Giroir.
STATEMENT OF BRETT GIROIR, M.D., NOMINATED TO BE ASSISTANT
SECRETARY FOR HEALTH, COLLEGE STATION, TX
Dr. Giroir. Chairman Alexander, Ranking Member Murray,
members of the committee.
Thank you for the invitation to testify before you here
today.
I am especially grateful to the many committee members who
spent time meeting with me individually to engage in truly
substantive discussions about important health issues facing
our Nation.
I am honored to appear before you as the President's
nominee to be the Assistant Secretary for Health, and I am very
pleased to be joined here today by my wife, Jill, of 32 years;
my mother Freida, a retired police officer and cancer survivor;
and our younger daughter Madeline. Not here today is our older
daughter Jacqueline, who just recently delivered our first
grandchild, Isabel; her husband Erik, an Iraq veteran; and my
late father Frank, also a police officer and a veteran, who
would have been truly honored to be here today.
As this committee well knows, the Assistant Secretary for
Health is the senior advisor to the Secretary of Health and
Human Services on issues of public health and science.
Component offices--including the Office of the Surgeon General,
the National Vaccine Program Office, the Office of Disease
Prevention and Health Promotion, the President's Council on
Fitness, Sports and Nutrition, and the Offices of Adolescent
Health, Minority Health, Women's Health, Population Affairs,
and HIV/AIDS and Infectious Disease Policy--provide leadership
and coordination across the U.S. Government for a vast array of
science and public health issues that touch nearly every single
American.
Should I be fortunate enough to gain your confidence and be
confirmed, I will be a passionate advocate for policies,
programs, research, and innovative solutions to enhance the
health of all Americans, and especially support initiatives
that reduce our current disparities in mortality and suffering.
There are no silver bullets, but I believe the pathway is
clear, emphasize prevention and early detection by empowering
individuals and groups; embrace science and data; welcome new
data; listen to all stakeholders, especially those with diverse
viewpoints; foster an innovative environment that maximizes the
creativity of academia and the private sector; remain humble;
and as a physician, I always focus on patients and their
families.
Because of my parents' emphasis on education, I became the
first member of my family to attend college and graduated from
Harvard University. I chose to attend medical school in Dallas
at the University of Texas Southwestern Medical Center, not
only for their renowned faculty, but for the opportunity to
provide compassionate care to patients at one of our Nation's
preeminent safety net public hospitals, that is, Parkland
Memorial Hospital.
I completed a residency and chief residency in pediatrics
and then a fellowship in pediatric critical care medicine. I
remained on the faculty at UT Southwestern for 10 years,
becoming a tenured professor, associate dean, and chief medical
officer at Children's Medical Center where I was privileged to
care for thousands of critically ill children and their
families.
My career then took an unexpected turn when I was recruited
by the Defense Advanced Research Projects Agency, also known
commonly as DARPA. I joined a science and technology assessment
committee, and ultimately DARPA itself as the Deputy Director,
and then the Director of the Science Office. I learned very
quickly that when the Government can effectively collaborate
with academic and industry partners, there can be unimagined
advances in medicine and human health.
In this regard, one of the most meaningful accomplishments
of our DARPA team was the development of a revolutionary
prosthetic upper limb that restored near-normal human
capabilities, and could be controlled by muscles, by nerves, or
even directly by the brain.
Following my assignment at DARPA, I have remained dedicated
to disease prevention, patient empowerment, and the development
of new vaccines and treatments for infectious diseases and
cancer.
I am called to the Assistant Secretary for Health position
for one reason, and that is to do whatever I can to enhance the
health of our Nation. To do so will require broad
collaboration, public engagement, and bold initiatives.
I will do everything also in my authority and ability to
support, advance, and advocate for the Commissioned Corps of
the U.S. Public Health Service, which for more than 200 years
has been America's warriors against disease with the enduring
mission to protect, promote, and advance the health and safety
of our Nation.
I thank you again for the opportunity to appear before you
and welcome your questions.
[The prepared statement of Dr. Giroir follows:]
Prepared Statement of Brett Giroir, M.D.
Chairman Alexander, Ranking Member Murray, members of the
committee, thank you for the invitation to testify before you today. I
am especially grateful to the many committee members who spent time
meeting with me individually to engage in substantive discussions about
important public health issues facing our Nation.
I am honored to appear before you as the President's nominee to be
Assistant Secretary for Health, and am pleased to be joined here by my
wife of 32 years, Jill, my mother Freida--a retired police officer and
cancer survivor--and our younger daughter Madeline. Not here today is
our older daughter Jacqueline, who just recently delivered our first
grandchild, her husband Erik--an Iraq veteran--and my late father
Frank, also a police officer and a veteran, who would have been truly
honored to attend this hearing.
As this committee well knows, the Assistant Secretary for Health is
the senior advisor to the Secretary of Health and Human Services on
issues of public health and science. Component offices--including the
Office of the Surgeon General, the National Vaccine Program Office, the
Office of Disease Prevention and Health Promotion, the President's
Council on Fitness, Sports and Nutrition, and the Offices of Adolescent
Health , Minority Health, Women's Health, Population Affairs, and HIV/
AIDS and Infectious Disease Policy--provide leadership and coordination
across the U.S. government for a vast array of science and public
health issues that touch nearly every single American.
Should I be fortunate enough to gain your confidence and be
confirmed, I will be a passionate advocate for policies, programs,
research, and innovative solutions to enhance the health of all
Americans, and especially support initiatives that reduce our current
disparities in mortality and human suffering. There are no silver
bullets, but the pathway is clear: elevate prevention and early
detection by empowering individuals and groups; embrace science and
welcome new data; listen to all stakeholders especially those with
diverse viewpoints; foster an innovative environment that maximizes the
creativity of academia and the private sector; remain humble; and
always focus on patients and their families.
Because of my parent's emphasis on education, I became the first
member of my family to attend college, and graduated from Harvard
University. I chose to attend medical school in Dallas at the
University of Texas Southwestern Medical Center in Dallas, not only for
their renowned faculty, but mainly for the opportunity to provide
compassionate care to patients at one of our Nation's preeminent safety
net public hospital--Parkland Memorial Hospital. I completed a
residency and chief residency in pediatrics and then a fellowship in
pediatric critical care medicine. I remained on the faculty at UT
Southwestern for 10 years, becoming a tenured professor, associate
dean, and chief medical officer at Children's Medical Center where I
was privileged to care for thousands of critically ill children and
their families.
My career then took an unexpected turn, when I was recruited by the
Defense Advanced Research Projects Agency, commonly known as DARPA. I
joined a science and technology assessment committee, and ultimately
DARPA itself as the Deputy Director, and then Director, of the Science
Office. I rapidly realized that when the government collaborates with
academic and industry partners, there can be unimagined advances in
medicine and human health. In this regard, one of the most meaningful
accomplishments of our DARPA team was the development of a
revolutionary prosthetic upper limb that restored near-normal human
capabilities, and could be controlled by muscles, nerves, or even
directly by the brain.
Following my assignment at DARPA, I have remained dedicated to
improving disease prevention, patient empowerment, and the development
of new vaccines and treatments for infectious diseases and cancer. I
truly feel called to the Assistant Secretary for Health position for
one reason, and that is, to do whatever I can to enhance the health of
our Nation. To do so will require broad collaboration, public
engagement, and bold initiatives. I will also do everything in my power
and abilities to support and advance the Commissioned Corps of the U.S.
Public Health Service, which for more than 200 years, has been
America's warriors against disease, with the mission to protect,
promote, and advance the health and safety of our Nation.
I thank you again for the opportunity to appear before you and
welcome your questions.
The Chairman. Thank you. Is it Giroir?
Dr. Giroir. Yes, sir.
The Chairman. I said it right. Good. Thank you. I did not
want to say it wrong. Thank you very much.
Dr. Kadlec.
STATEMENT OF ROBERT KADLEC, M.D., NOMINATED TO BE ASSISTANT
SECRETARY FOR PREPAREDNESS AND RESPONSE, ALEXANDRIA, VA
Dr. Kadlec. Thank you, Chairman Alexander, and Ranking
Member Murray, members of the Senate HELP Committee.
It is a privilege to appear before you today as you
consider my nomination for the position of Assistant Secretary
for Preparedness and Response.
Mr. Chairman, there are many I need to thank for this
opportunity; President Trump and Secretary Price for their
confidence in my abilities and nominating me for this position.
The many who have encouraged, and supported, and assisted me
through this process, and my family--my wife Ann, daughters
Margaret and Samantha, who are rising high school seniors and
who are currently on the Bataan Death March of college tours.
They have supported me and will enable me to take on this
responsibility, should I be confirmed.
I would also like to acknowledge classmates, colleagues,
friends, and fellow committee staff who are here or watching
from their offices. I want to specifically recognize my
colleagues at the Senate Intelligence Committee who, like many
congressional staff, get far too little recognition for their
dedicated, selfless, and important service to our Nation.
The prospect of becoming the ASPR is both exciting and
daunting. Having been a HELP Committee staffer who assisted
drafting the original position description under the great
leadership of Senator Richard Burr and the late Senator Ted
Kennedy, I have firsthand insight into the rationale of why HHS
and the Nation needed someone to be in charge of coordinating
medical and public health preparedness and response.
A decade ago, incidents like September 11, the anthrax
letters, Hurricane Katrina, and the potential for a deadly
influenza all demanded that we improve the Federal Government's
ability to assist State and local health authorities, and
mobilize the private sector in responding to future events. The
need now is as real and urgent as it was then.
The mission of ASPR can be distilled in just a couple of
words, and that is, to save lives. I can conceive of no greater
duty or higher calling than this.
If confirmed, I will fully accept the responsibility to do
everything reasonable and appropriate to prepare for and
respond to the spectrum of threats that endanger Americans, our
national security, and our way of life.
If confirmed, I pledge to you my all in pursuit of this
mission and will work 24-7-365 to fulfill the ASPR's duties.
Having spent the last 2\1/2\ years on the Senate
Intelligence Committee, I have had the unique privilege to
learn in exquisite detail the many threats and challenges that
confront our country, in particular those emerging as clear and
present dangers today. The threat landscape before us is more
diverse and more lethal than the one after September 11.
When I last sat in this hearing room in 2006 as a HELP
staffer, ISIL did not exist; North Korea did not possess both
the nuclear weapons, and the missiles and means to attack our
homeland; the use of chemical weapons by terrorists and by the
Syrian government on defenseless citizens was a concern, not a
routine occurrence; and the risks of cyber warfare were still
largely hypothetical. Today, all these and other challenges
exist in a way that makes the mission of ASPR more important.
If confirmed, there are five priority issues that I will
pursue.
First, provide strong leadership. Lead the capable and
dedicated men and women of ASPR, provide them clear policy
direction, improve their threat and situational awareness,
advocate for, and secure, adequate resources for the ASPR
mission.
Second, create a national contingency healthcare system
that better organizes, trains, and equips our State and local
healthcare systems, facilities, and providers to ensure that
they cannot only better respond to routine emergencies, but to
extraordinary events that are likely to occur.
Here we have an opportunity to better integrate Emergency
Medical Services, the tip of the spear of our national medical
response, into these efforts, and to increase effective
coordination across HHS and the Federal departments, such as
the Department of Defense and the Department of Veterans
Affairs, to support State and local responders.
Third, support CDC and the sustainment of robust and
reliable public health security capabilities that include an
improved ability to detect and diagnose infectious diseases and
other threats, as well as the capacity to rapidly characterize
and attribute them.
Fourth, reinvigorate and advance an innovative medical
countermeasure enterprise. We must capitalize on advances in
biotechnology and science to develop and maintain a robust
stockpile of safe and efficacious vaccines, medicines, and
supplies to respond to emerging disease outbreaks, pandemics,
and chemical, biological, radiological, and nuclear incidents
or attacks.
Finally, work with you and your staff on the
reauthorization of the Pandemic and All-Hazards Preparedness
Act in 2018 to further strengthen our Nation's readiness and
response for 21st century threats.
I would like to close by simply thanking you for your
consideration and the prospect of continuing to serve our great
Nation, if confirmed.
[The prepared statement of Dr. Kadlec follows:]
Prepared Statement of Robert Kadlec, M.D.
Chairman Alexander and Ranking Member Murray, members of the Senate
HELP Committee, it is both a privilege and special opportunity to
appear before you today as you consider my nomination for the important
position of Assistant Secretary for Preparedness and Response (ASPR) at
the U.S. Department of Health and Human Services (HHS).
Mr. Chairman there are many I need to thank for this opportunity:
President Trump and Secretary Price for their confidence in my
abilities and nominating me for this position; the many who have
encouraged and assisted me through this process; and my family--my wife
Ann, daughters Margaret and Samantha--who have supported me and will
enable me to take on this responsibility should I be confirmed.
I would also like to acknowledge classmates, colleagues, friends
and fellow committee staff who are here or watching from their offices.
I want to specifically recognize my colleagues at the Senate
Intelligence Committee who, like many congressional staff, get far too
little recognition for their dedicated, selfless and important service
to our Nation.
As I sit here, the prospect of becoming the ASPR is both exciting
and daunting. Having been a HELP Committee staffer who assisted
drafting the original position description under the great leadership
of Senator Richard Burr and the late Senator Ted Kennedy, I have
firsthand insight into the rationale why HHS and the Nation needed a
single leader to be responsible for coordinating medical and public
health preparedness and response.
Ten years ago, incidents like the September 11, 2001 attacks on our
country, the deadly anthrax letters, Hurricane Katrina, and the
potential for an influenza pandemic all demanded that we improve the
Federal Government's ability to assist State and local health
authorities and mobilize the private sector in responding to future
events. The need now is as real and urgent as it was then.
To distill the ASPR mission to just a couple of words, it is to
``save lives.'' As a physician, I can conceive of no greater honorable
duty or higher calling than this. If confirmed, I fully accept the
responsibility to ensure that we do everything reasonable and
appropriate to prepare for and respond to a spectrum of 21st century
threats that endanger Americans, our national security, and our way of
life. If confirmed, I pledge to you my all in pursuit of this mission
and will work 24-7-365 days a year to fulfill the ASPR's duties.
Having spent the last 2\1/2\ years working on the Senate
Intelligence Committee, I have had the unique privilege to learn in
exquisite detail the many threats and challenges that confront our
country, in particular those emerging as clear and present dangers
today. The threat landscape before us is more diverse and more lethal
than the one that we confronted after September 11.
When I last sat in this hearing room in 2006 as a HELP staffer ISIS
did not exist; North Korea did not possess both nuclear weapons and the
missiles to attack our homeland; the use of chemical weapons by
terrorists and by the Syrian Government on defenseless citizens was a
concern, not a routine occurrence; and the risks of cyber warfare were
still largely hypothetical. Today, all these and other challenges exist
in a way that makes the mission of ASPR more important and urgent. We
must redouble our readiness efforts and improve capabilities for these
and other threats.
There are five priority issues that I will pursue if confirmed.
First, provide strong leadership, including clear policy direction,
improving threat and situational awareness, advocating for and securing
adequate resources.
Second, seek the creation of a ``national contingency health care''
system. There is an urgent need to better organize, train and equip our
State and local healthcare systems, facilities and providers to ensure
that they cannot only better respond to routine emergencies but to
extraordinary events that are likely to occur. Here we have an
opportunity to better integrate Emergency Medical Services, the ``tip
of the spear'' of our national medical response into these efforts and
to increase effective coordination across HHS and the Federal
departments, such as the Department of Defense and the Department of
Veterans Affairs, to support State and local responders.
Third, support the sustainment of robust and reliable public health
security capabilities that include an improved ability to detect and
diagnose infectious diseases and other threats, as well as the capacity
to rapidly characterize and attribute them.
Fourth, re-invigorate and advance an innovative medical
countermeasures enterprise. We must capitalize on advances in
biotechnology and science to develop and maintain a robust stockpile of
safe and efficacious vaccines, medicines and supplies to respond to
emerging disease outbreaks, pandemics, and chemical, biological,
nuclear and radiological incidents and attacks.
Finally, work with you and your staff on the reauthorization of the
Pandemic and All-Hazards Preparedness Act in 2018 to strengthen our
Nation's readiness and response for 21st century threats.
Last, I simply wish to thank you all for your consideration and the
prospect of continuing to serve our great Nation.
The Chairman. Thank you, Dr. Kadlec.
Dr. McCance-Katz, welcome.
STATEMENT OF ELINORE F. McCANCE-KATZ, M.D., NOMINATED TO BE
ASSISTANT SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE,
CRANSTON, RI
Dr. McCance-Katz. Chairman Alexander, Ranking Member
Murray, and members of the committee.
I am honored to be here today. I want to thank you for
inviting me here today to consider my nomination as Assistant
Secretary for Mental Health and Substance Use.
I come from a family that has placed service to our country
as their highest calling, starting with my late grandfather,
William J. McCance, who served in World War II and participated
in both the North African and the D-Day invasions. My father,
William Thomas McCance, is a career Navy submarine force
veteran who rose to the highest enlisted ranks as Master Chief
Hospital Corpsman. My mother, Anna McCance, as the wife of a
navy chief of the boat, comforted and cared for the families of
sailors on the submarines on which my father served, faithfully
demonstrating that spouses also share in the defense of our
Nation.
I am happy to have my husband, Michael Katz, sitting behind
me, here with me today, as well as my daughters, Anna and
Heather. Our son, Josh, could not be here today, but they have
all been a source of support and joy to me. Service to our
country was modeled to me in my family, and I look forward to
continuing this tradition, if I am confirmed.
I am a psychiatrist, and I am sub-specialized in addiction
psychiatry. From my 30 years of caring for patients, I have had
the opportunity to learn a significant amount about mental and
substance use disorders.
I have also had the opportunity to work in both State and
Federal Government, so I have unique insight into the
challenges the current regulatory regime poses for assisting
people with these illnesses; experiences that I believe have
helped prepare me to implement the statutes enacted by Congress
and signed into law by the President.
Our country faces very serious challenges in mental health
and substance use, and the position for which I am being
considered heralds a new era in the treatment and care needs of
Americans through recent landmark legislation including the
21st Century Cures Act and the Comprehensive Addiction and
Recovery Act. These laws, in addition to other congressional
legislative guidance, will allow more effective use of Federal
funds at SAMHSA and coordination of funding initiatives at
other agencies to better serve Americans.
If confirmed, I would prioritize two areas, addressing the
opioid epidemic and focusing on those with serious mental
illness.
Our Nation is afflicted by a crisis of opioid addiction,
overdose, and death. Sadly, to a large extent, this is a crisis
that has grown out of ill-informed and misguided attempts to
address issues of pain.
Data from the National Survey on Drug Use and Health tell
us that 54 percent of mis-users obtained opioid medications
free from friends and relatives, while 34 percent admit to
misusing opioids prescribed by their doctor for pain
management.
The data teaches us important lessons about prevention and
treatment issues. We must educate Americans on safe and
appropriate use of pain medications. Innovative approaches to
healthcare practitioner training should address effective pain
management, identification, and treatment of substance use
disorders, as well as frequently co-occurring mental disorders.
Increasing access to care and recovery services is
critically important to addressing the opioid epidemic.
Evidence-based, medication-assisted treatment, peer
specialists, and a growing array of community supports are
essential underpinnings of recovery and form the basis of a
collaborative care model that can best serve Americans.
For too long, the care and treatment needs of the most
seriously mentally ill Americans have been neglected. SAMHSA
national survey data indicate that 35 percent of Americans with
the most serious mental illnesses receive no treatment
whatsoever. In addressing this, SAMHSA must assure that program
funding supports evidence-based early intervention, treatment,
and recovery services.
We are fortunate to have stakeholders from many
complementary disciplines who are ready and willing to
collaborate to help meet this goal. We must focus on evidence-
based services including psychiatric care, medication, and
psychotherapy treatments in collaboration with peer support and
other community-based services designed to provide the
resources needed to assure the best possible outcomes. We must
also work to include the families of those with serious mental
illness in the discussion of their loved one's needs.
If confirmed, I would look forward to working with Congress
and stakeholder groups on how to share information urgently
needed to assure care and safety of a person, while also paying
attention to their privacy needs and their rights.
If confirmed, I will be attentive to the concerns of
Congress. I look forward to your guidance and input, and I will
work very hard to implement Congress' vision informed by
stakeholders and enacted through legislation.
I look forward to answering your questions.
[The prepared statement of Dr. McCance-Katz follows:]
Prepared Statement of Elinore F. McCance-Katz, M.D.
Chairman Alexander, Ranking Member Murray, and members of the
committee, I am honored to be here today. I want to thank you for
inviting me here today to consider my nomination as Assistant Secretary
for Mental Health and Substance Use.
I come from a family that has placed service to our country as
their highest calling, starting with my late grandfather, William J.
McCance, who served in World War II and participated in both the North
African and the D-Day invasions. My father, William Thomas McCance, is
a career Navy submarine force veteran who rose to the highest enlisted
ranks as Master Chief Hospital Corpsman. My mother, Anna McCance, as
the wife of a Navy Chief of the Boat, comforted and cared for the
families of sailors on the submarines on which my father served--
faithfully demonstrating that spouses also share in the defense of our
Nation.
I am happy to have my husband, Michael Katz, here with me today as
well as my daughters, Anna and Heather. My son, Josh, could not be
here. They have all been a source of support and joy. Service to our
country was modeled to me in my family and I look forward to continuing
this tradition, if I am confirmed.
I am a psychiatrist, and I am subspecialized in Addiction
Psychiatry. From my 30 years caring for patients, I have had the
opportunity to learn a significant amount about mental and substance
use disorders. I have also had the opportunity to work in both State
and Federal Government, so I have unique insight into the challenges
the current regulatory regime poses for assisting people with these
illnesses--experiences that I believe have helped prepare me to
implement the statutes enacted by Congress and signed into law by the
President.
Our country faces very serious challenges in mental health and
substance use, and the position for which I am being considered heralds
a new era in the treatment and care needs of Americans through recent
landmark legislation including the 21st Century CURES Act and the
Comprehensive Addiction and Recovery Act. These laws, in addition to
other congressional legislative guidance, will allow more effective use
of Federal funds at SAMHSA and coordination of funding initiatives at
other agencies to better serve Americans. If confirmed, I would
prioritize two areas: addressing the opioid epidemic and focusing on
those with serious mental illness.
Our Nation is afflicted by a crisis of opioid addiction, overdose
and death. Sadly, to a large extent, this is a crisis that has grown
out of ill-informed and misguided attempts to address issues of pain.
Data from the National Survey on Drug Use and Health tell us that 54
percent of mis-users obtained opioid medications free from friends and
relatives while 34 percent admit to misusing opioids prescribed by
their doctor for pain management. The data teaches important lessons
about prevention and treatment issues. We must educate Americans on
safe and appropriate use of pain medications. Innovative approaches to
healthcare practitioner training should address effective pain
management, identification and treatment of substance use disorders as
well as frequently co-occurring mental disorders. Increasing access to
care and recovery services is critically important to addressing the
opioid epidemic. Evidence-based medication-assisted treatment, peer
specialists and a growing array of community supports are essential
underpinnings of recovery and form the basis of a collaborative care
model that can best serve Americans.
For too long, the care and treatment needs of the most seriously
mentally ill Americans have been neglected. SAMHSA national survey data
indicates that 35 percent of Americans with the most serious mental
illnesses receive no treatment whatsoever. In addressing this, SAMHSA
must assure that program funding supports evidence-based early
intervention, treatment and recovery services. We are fortunate to have
stakeholders from many complementary disciplines who are ready and
willing to collaborate and help meet this goal. We must focus on
evidence-based services including psychiatric care, medication and
psychotherapy treatments, in collaboration with peer support and other
community-based services designed to provide the resources needed to
assure the best possible outcomes. We must also work to include the
families of those with serious mental illness in the discussion of
their loved one's needs. If confirmed, I would look forward to working
with Congress and stakeholder groups on how to share information
urgently needed to assure care and safety of a person while also paying
attention to their privacy rights.
If confirmed, I will be attentive to the concerns of Congress. I
look forward to your guidance and input, and I will work very hard to
implement Congress's vision informed by stakeholders and enacted
through legislation. I look forward to answering your questions.
The Chairman. Thank you, Dr. McCance-Katz.
Dr. Adams.
STATEMENT OF JEROME ADAMS, M.D., NOMINATED TO BE SURGEON
GENERAL OF THE PUBLIC HEALTH SERVICE, FISHER, IN
Dr. Adams. Chairman Alexander, Senator Murray, members of
the committee.
Thank you for the invitation to testify today. I also wish
to thank President Trump, Vice President Pence, Governor
Holcomb, and the Indiana congressional delegation, friends, and
supporting organizations, and my family.
Especially my very well-dressed mother and father, who you
see behind me, and my beautiful little daughter, Millie. I had
to pay her a whole lot to do that.
[Laughter.]
I am taking her to your office afterwards to get Good
Humor, Chairman Alexander. He has a whole ice cream
refrigerator in his office, in case you all did not know.
[Laughter.]
And my wonderful wife, Lacey, without whose support I would
not be here today. Thank you, honey.
Both the position of Surgeon General, and the U.S. Public
Health Corps that the Surgeon General leads, are integral to
our national health education and response capabilities. The
U.S. Public Health Corps is an elite team of over 6,500 highly
qualified health professionals. The Corps serves as our
national health army, deploying whenever man-made or natural
crises place our public's health at risk.
Whether we are facing infectious diseases like Ebola and
Zika, or natural disasters like Hurricane Katrina, or human-
caused tragedies like the opioid epidemic, our country and
world deserve and need this ready to respond army of health
experts.
Many people call the U.S. Surgeon General the Nation's top
doctor. This title does not do justice to the professions
represented in the Health Corps: nurses and doctors, dentists
and therapists, scientists, and some of the country's best
doctors. The further suggestion that as a top doctor, I can be
all things to health does not give proper consideration to the
vital role partnerships play in the success of this position.
The position of Surgeon General carries with it a
tremendous power to convene and to facilitate important health
and wellness discussions. Therefore, the real power of the
position comes from the wide array of national health crusaders
that can be mobilized if the platform is used properly.
I would next like to share with you why I feel I can
uniquely contribute to the role of Surgeon General. Not only
have I earned a Master's Degree in Public Health with an
emphasis in chronic disease prevention from Berkeley, but I
have served as the Indiana State Health Commissioner, in
essence the Surgeon General for Indiana, for the past 2\1/2\
years.
In that role, I have personally overseen our State's
response to Ebola and Zika, and a rural HIV outbreak related to
injection drug use, and also overseen the State's Health and
Human Services and Tobacco Cessation Commissions, the State's
Public Health Laboratory, and its Health Care Quality and
Regulatory division.
I also continue to practice as a physician anesthesiologist
at Eskenazi Health, a Level One trauma center and a safety net
hospital, and serve as clinical associate professor of
anesthesia at Indiana University School of Medicine. In these
dual roles as both clinician and educator, I see the impact of
health policy decisions on both providers and patients each and
every day.
My final and toughest, but also my most important, job is
serving as father and mentor to my 7-, 11-, and 13-year-old
children. That means for every policy decision, I not only
sympathize, but empathize with all parents regarding the
potential impact.
With a bit more of your indulgence, I will briefly address
what I hope to be my priorities, if confirmed.
Our Nation is facing a crisis. The addictive properties of
opioids are a scourge on our country. Secretary Price has
declared the opioid epidemic and the untreated mental illness,
which lie at the root of much of the current situation, as top
priorities. I share his urgency, and feel I bring to this
discussion a unique perspective, and a proven track record of
partnering with various groups to address the problem.
If confirmed, I also hope to make wellness, and community,
and employer engagement centerpieces of my agenda. We will not
successfully tackle the opioid epidemic, or obesity, or
healthcare access and cost, if we continue to focus downstream.
Too much of our focus is on providing care after a person has
already developed a disease, but this frequently represents
many missed opportunities for prevention.
Our health starts in the communities where we live, learn,
work, play, and go to school. We need to partner with
communities and empower them to implement local solutions to
their toughest problems. I know it may sound like a cliche, but
if confirmed, I truly hope to make America healthier. Healthy
people and communities are more productive, and profitable, and
in turn attract more jobs and prosperity.
Unfortunately, however, American prosperity and
competitiveness are being compromised by America's poor health.
Major corporations know this, and in many ways, they are doing
better than our own health institutions to address the health
and wellness of their employees.
We must work with the business community to share best
practices and to reach beyond the workplace. Our goal should be
to truly develop and rebuild communities around wellness and
prosperity.
I would like to close my remarks by saying I cannot promise
you that we will be in agreement on all health and health
policy matters. The truth is we will not. I cannot promise you
that the office of the Surgeon General can fix all of the
health and healthcare problems plaguing our Nation.
What I can, in fact, promise you is my unwavering
commitment to finding the best, and presenting the best
scientific evidence, in both internal policy discussions and
external educational endeavors. I promise you I will continue
my strong and well-documented track record of reaching out to
everyone regardless of their politics, beliefs, culture, or
geography.
I promise you that, if confirmed, I will truly seek to be
the Surgeon General for all of our United States to the best of
my ability, a champion for everything our country aspires to be
in terms of health and wellness.
I look forward to your questions, and thank you for the
opportunity, Mr. Chairman and Madam Ranking Member.
[The prepared statement of Dr. Adams follows:]
Prepared Statement of Jerome Adams, M.D.
Chairman Alexander, Ranking Member Murray, members of the
committee: Thank you for the invitation to testify before you today. I
also wish to thank President Trump and Vice President Pence, Governor
Holcomb and the Indiana congressional delegation, my family, friends,
and supporting organizations.
It is a tremendous honor and opportunity to appear before you today
as the President's nominee to be our Nation's next Surgeon General. If
confirmed I would serve as our country's 20th Surgeon General,
representing 180 years of public health leadership from the position. I
assure you I do not take this legacy lightly.
Both the position of Surgeon General, and the U.S. Public Health
Corps that the Surgeon General leads, are an extremely important
component of our national health education and response capabilities.
The Commissioned Corps of the U.S. Public Health Service Corps is one
of the seven uniformed services, and is an elite team of over 6,500
highly qualified health professionals. The Health Service Corps serves
as our national health army, ready to deploy whenever a man-made or
natural crisis has placed our public's health at risk.
Whether we are facing infectious diseases like Ebola and Zika, or
natural disasters like earthquakes and Hurricane Katrina, or human-
caused tragedies like 9/11 and the opioid epidemic, our country and our
world deserve and need this ready-to-respond army of health experts.
This army deserves and needs a qualified leader--the U.S. Surgeon
General.
Many people call the U.S. Surgeon General the Nation's ``Top
Doctor.'' This moniker doesn't do justice to the diversity of
professions represented in the Health Corps--nurses, pharmacists,
therapists, scientists, and many others, in addition to some of the
country's best doctors. The further insinuation that one person can be
all things to health also doesn't give proper consideration to the
vital role partnerships play in the success of this position.
The position of Surgeon General carries with it a tremendous power
to convene supporters (as well as detractors), and to facilitate
important health and wellness discussions. The power of the position
comes not merely from the individual occupying it, but rather from the
even wider array of health crusaders that can be mobilized from a
multitude of sectors across our country, if the platform is used
properly.
Having shared a little of what I think the position of Surgeon
General represents, I'd next like to share with you why I feel I can
make a unique contribution in this role. The position of Surgeon
General must have ``specialized training or significant experience in
public health programs.'' Not only have I earned a Master's Degree in
Public Health with an emphasis in Chronic Disease Prevention from UC
Berkeley, but I have served as the Indiana State health commissioner--
in essence the surgeon general for Indiana--for the past 2\1/2\ years.
In that role, I have overseen our State's response to Ebola, Zika, and
a rural HIV outbreak related to injection drug use, and also overseen
Indiana's tobacco cessation efforts, the State's Public Laboratory, and
its Health Care Quality and Regulatory division.
In addition to serving as Health Commissioner, I continue to
practice as a physician anesthesiologist at Eskenazi Hospital--a level
one trauma center with a busy obstetrical service--and serve as
Clinical Associate Professor of Anesthesia at Indiana University School
of Medicine. In this dual role as both clinician and educator, I see
the impact of health policy decisions on both providers and the
patients we serve, and I have been honored to receive awards from my
institution and peers for my ability to educate, empower, and excite,
our next generation of health leaders.
My final and toughest, but also my most important, job is to serve
as father and mentor, to my 7-, 11-, and 13-year-old children. My
status as a father is significant as you consider my nomination,
because for every policy discussion I take part in, I not only
sympathize, but empathize, with parents regarding the potential impact.
When making decisions, I literally have no choice but to think about
both the immediate impact on our Nation's children--my own children
included--and the world I am leaving for future generations.
With a bit more of your indulgence, I will now briefly address what
I hope to be my priorities if I'm confirmed. Our Nation is facing a
drug crisis. The addictive properties of prescription opioids is a
scourge in America and it must be stopped. Secretary Price has declared
addressing the opioid epidemic, and untreated mental illness, which lie
at the root of much of the current situation, as among his top
priorities. I share the Secretary's urgency at addressing this crisis
and feel I bring to this discussion a unique perspective, and a proven
track record of bringing together various groups to address the
problem.
I also would make wellness and community and employer engagement a
centerpiece of my agenda, if confirmed. We will not successfully tackle
the opioid epidemic, or obesity, or healthcare access and cost, if we
continue to focus on how we handle these problems after they've taken
hold. Much of our national focus is on providing care after a person
has already developed a disease, but far too often this represents
multiple missed--and more cost-effective--opportunities to have
mitigated or even prevented the problem.
We also won't be able to solve these problems from Washington, DC.
Our health starts in the communities where we live, learn, work, play,
and go to school. We need to get out into those communities, learn
about their obstacles and successes, share best practices, and help
empower them to implement local solutions to their toughest problems. I
know it may sound like a cliche but if confirmed, I hope to make
America healthier. Healthy people and communities are more productive,
and profitable, and in turn attract more jobs and prosperity.
Poor health, however, is proving to be a drag on our country's
prosperity and worldwide competitiveness. Major corporations know this,
and in many ways are doing better than our own health institutions to
address the health and wellness of their employees. We need to work
with the business community in a reciprocal relationship, to share best
practices, and go beyond the workplace. Our goal should be to truly
develop and rebuild communities around wellness, and prosperity.
I'd like to close my remarks by saying that I can't promise you
that we will be in agreement on all health and health policy matters--
we won't. I can't promise you that the office of the Surgeon General
can fix all of the health and healthcare problems plaguing our Nation.
What I can in fact promise you is my unwavering commitment to finding
and presenting the best scientific evidence, in both internal policy
discussions, and external health education endeavors. I promise you
that I will continue my strong and well-documented track record of
reaching out to EVERYONE--regardless of their politics, beliefs,
culture, or geography. I promise you that, if confirmed, I will truly
seek to be the Surgeon General for all of our United States--to the
best of my ability a champion for everything our country aspires to and
can be in terms of health and wellness.
I look forward to your questions, and, if confirmed, I look forward
to working closely with all of you to improve our country's health.
The Chairman. Thank you, Dr. Adams. Thanks to each of you.
We will now go to a 5-minute round of questions for the
witnesses. We will begin with Senator Cassidy and then go to
Senator Murray.
Statement of Senator Cassidy
Senator Cassidy. Thank you all and I have had a chance to
speak with many of you.
Dr. Giroir, I actually know how to pronounce your name;
that comes from being from Louisiana. Dr. Adams, I enjoyed our
conversation.
Dr. McCance-Katz, of everybody, you are the one I am most
interested in because Senator Murphy and I heard from
stakeholders across the country that our Nation's response to
mental illness and addiction was failing. We spend billions of
dollars and it was failing.
You have a great pedigree and I know you have worked in
SAMHSA, but it is a big, dysfunctional organization. You cannot
throw them under the bus, but I will.
What would be your approach, if you can be just specific?
How are we going to make it better for the mentally ill person,
so that her one episode of psychosis becomes her only episode
of psychosis?
Dr. McCance-Katz. Thank you for that question, Senator
Cassidy.
There are a number of things that we need to do. One thing
that is really critical is that we need to increase the number
of healthcare providers, mental healthcare providers in this
country. We will probably never have enough psychiatrists or
addiction psychiatrists. There are just not that many being
produced every year.
Senator Cassidy. So, then? Just because I only have a
couple of minutes.
Dr. McCance-Katz. Yes.
Senator Cassidy. If that is the case, what do we do to
mitigate that? What do we do to expand the effectiveness of
those whom we have, knowing that the development of a workforce
takes years and we have a problem now?
Dr. McCance-Katz. Yes, and so we can train allied health
professionals much more rapidly than psychiatrists: nurse
practitioners, advanced practice registered nurses, physician
assistants.
Senator Cassidy. I accept that. Moving on from workforce
development, what next? I do not mean to be rude. I just have a
few minutes and he is about to rap me.
Dr. McCance-Katz. Yes. Also, innovative ways of delivering
care such as telemedicine where physicians can be extended
through those allied health professionals to lots of areas in
the country.
Senator Cassidy. Kind of a build out of manpower and woman
power shortage.
Dr. McCance-Katz. Yes.
Senator Cassidy. Moving beyond healthcare worker shortage,
what next?
Dr. McCance-Katz. To integrate mental health and substance
use disorder treatment into primary care settings.
Senator Cassidy. The 21st Century Cures, in our bill that
Senator Murphy and I had, had that provision to further
integrate addressing things such as same day rule, allowing
Medicaid to pay both.
May I ask, what next? Because all of that, I think we give
the tools and the license, if you will, through 21st Century
Cures. I think what we are just yearning for is leadership
within the Department that will begin to effect these changes.
We have given you these tools. Share further about your
approach, please.
Dr. McCance-Katz. I will just finish by saying that one of
the roles of SAMHSA is to disseminate all of this and to speak
to the medical community and to American communities about
these issues.
I think that in doing all of those things, focusing on all
of those things, we will be able to expand treatment.
Senator Cassidy. That sounds--I think I might have asked
the previous director, and he or she may have given the same
answer.
I do not mean to be harsh. It just is incredible
frustration about the lack of a coordinated, efficient,
effective response on the Federal bureaucracy side.
Particularly, perhaps, one thing we are asking is that you will
coordinate across all Federal agencies different services.
Any thoughts on how best to execute that?
Dr. McCance-Katz. That is one of the parts of the position
that was very important to me in reading about it.
I think that one of the first things I will be doing is
convening with the other Federal agencies that have funding in
substance use and mental disorders care, and determining what
they are doing, and whether these programs work. One of the
things we are going to have to do is look at metrics and
determine whether some of the programs we have really work.
These things take time to do, but we can do it, and we can
make use of the expertise within and also from our communities
to help us to do that. States also, they know their communities
best, and SAMHSA knows what is going on in States, and so can
help in that way as well to disseminate.
Senator Cassidy. In some cases, SAMHSA was apparently
giving grants to organizations which were skeptical of
medications. That would be counterproductive.
By the way, I hope I did not seem rude. You are going to
have no bigger advocate on this committee to support you except
maybe Senator Murphy because we are both incredibly invested in
your success. I hope I did not come across as brusque.
Dr. McCance-Katz. No.
Senator Cassidy. We just feel passionately about the need
to address this problem in our society. We thank you all for
taking your jobs and thank you in particular.
Thank you.
The Chairman. Thank you, Senator Cassidy. Thank you, again,
for the work that you and Senator Murphy did with Senator
Murray, and I, and others last year on the 21st Century Cures
bill.
A bill is not worth the paper it is written on unless it is
implemented properly. We will be watching.
Senator Murray.
Senator Murray. Thank you very much.
Dr. Giroir, let me start with you. If you are confirmed,
you are going to oversee both the Office of Population Affairs,
which administers Title X Family Planning grants, and the
Office of Adolescent Health, which manages the Teen Pregnancy
Prevention Program. As I said earlier, I am very concerned by
the actions taken by both of these under this Administration.
Recently, the Administration notified the grantees that run
Teen Pregnancy Prevention programs of plans to terminate their
grants 2 years early. These are competitive. They are evidence-
based programs. They have reached hundreds of thousands of
people nationwide and trained thousands of healthcare
professionals.
I, along with Senators Baldwin and Booker, led over 30
Senators in writing to Secretary Price to request information
on that decision. We have not gotten an answer yet.
I wanted to ask you, if you are confirmed, do you commit to
providing information to me and other concerned Senators about
why the Administration is trying to terminate these grants when
they are meant to continue for an additional 2 years? What do
you plan to do regarding the Teen Pregnancy Prevention Program?
Dr. Giroir. Thank you very much, Senator Murray, for that
question.
First of all as a pediatrician, I share your concern about
teen pregnancy. The good news is that since 2007, the rates of
teen pregnancy have been reduced by about 50 percent. The bad
news is that in 2015, we still had over 250,000 pregnancies of
teen mothers and there are long-term consequences both for the
young mother and also for the children.
To answer your first question, you have my commitment to
work with you and provide information. I think public health is
a common goal for all of us. We have to work together. Public
health is a team sport. You have, certainly, my commitment as
does everyone on the committee.
As part of the second part of the question, you certainly
have my commitment. The budgetary justification from the
Administration stated that the programs in the Teen Pregnancy
Program did not significantly influence the drop in teen
pregnancy rate. That is all I know about the rationale.
Senator Murray. Do you believe that?
Dr. Giroir. I have not been able to review the evidence or
the assessments that were made in order to achieve that
conclusion.
The only information I have is the public review, which was
very well done in 2015, that looked at the first 5 years of the
program. The program was evidence-based. It was community-
based. There were many programs that were successful. There
were many programs that could not be repeated, but even the
lack of repeatability of a program is information we need to
know. We need to know what works and does not work.
Once I have more information, I look forward to engaging in
this discussion vigorously. If fortunate enough to be
confirmed, this is certainly very high on my agenda.
Senator Murray. I appreciate that.
I just want to say for over 40 years, the title X program
has provided family planning services across the country. In
2015, the health centers under title X provided nearly 800,000
PAP tests, nearly 5 million tests for sexually transmitted
infections, and 1.1 million HIV tests. The Guttmacher Institute
estimates that for every dollar invested in family planning,
taxpayers save $7.
Supporting the title X programs, to me, is really common
sense and maintaining the funding for that is one of my top
priorities.
I wanted to ask you, do you believe that all providers who
qualify to provide the services should be considered for
inclusion in that program?
Dr. Giroir. Thank you for that question, and I know how
that is intended.
I will absolutely implement the laws as is passed by
Congress and given to me faithfully and as they are intended.
If there are restrictions that are passed down to me, I am
obliged to follow the laws as passed down to me.
It is my intent to assure that everyone who needs these
services, they are critically important services. They do
prevent disease. They prevent cancer. They provide early
detection, that those are allowed to be given to women across
the board in an affordable way and in an accessible way.
Senator Murray. OK. I just have a few seconds, so I am just
going to ask for yes or no answers.
Making sure that science is priority over politics is
important in every one of the offices that you hold. We have
seen under this Administration a Surgeon General who was fired
before the end of his term. We have seen promotion of theories
that have been disproven about immunizations. We have seen
hostile efforts to combat HIV and AIDS. Six members of the
Presidential Advisory Council on HIV/AIDS felt they had no
choice but to quit.
I want to make sure that each one of you understands that
picking science over politics is a critical part, and I just
want a yes or no from each of you.
Will you commit to publicly supporting and advocating for
science over politics and ideology? I will just go down the
row.
Dr. Adams.
Dr. Adams. An emphatic yes, Senator.
Senator Murray. Dr. McCance-Katz.
Dr. McCance-Katz. Yes. Absolutely.
Senator Murray. Dr. Kadlec.
Dr. Kadlec. Yes. Absolutely.
Senator Murray. Dr. Giroir.
Dr. Giroir. Absolutely, yes.
Senator Murray. Mr. Robertson.
Mr. Robertson. Yes, Senator Murray.
Senator Murray. OK. Thank you very much to all of you.
The Chairman. Thank you, Senator Murray.
Senator Collins.
Statement of Senator Collins
Senator Collins. Thank you, Mr. Chairman.
Dr. Kadlec, as a member of the Intelligence Committee, I
want to thank you for your service there on the staff and let
you know how much your expertise will be missed, but I feel
like we are giving you up for an even greater cause.
Congratulations to you.
To Dr. Adams, I want to say that I am certain that it was
your testimony before the Aging Committee last year, which I
Chair, that led to your appointment to be the next Surgeon
General.
Dr. Adams. I am absolutely certain of that too, Senator.
Senator Collins. That was the right answer.
[Laughter.]
Dr. McCance-Katz, we discussed in my office the terrible
opioid epidemic that my State is struggling with along with so
many others. The epidemic affects people of all ages, but it is
especially heartbreaking when it affects newborns.
According to the CDC, Maine has among the highest rate of
Neonatal Abstinence Syndrome in the country. We know that
hospital costs for newborns born to addicted mothers average
$66,700 nationally compared to $3,500 for those who are without
NAS, and most of those costs are paid by the Medicaid program.
Even more tragic, I always worry what happens to these
children after they go home, these babies who are born to
addicted mothers.
What special efforts should be undertaken to direct
programs toward helping pregnant women who are addicted?
Dr. McCance-Katz. There are programs across the country
that are for pregnant postpartum women. Those programs have
services coordinated for women with childcare issues, and with
addiction issues, and they have been very effective.
In terms of Neonatal Abstinence Syndrome, we are learning a
great deal about how best to treat that. We know that women who
have opioid addiction, who do not get medication-assisted
treatment, have much higher rates of obstetrical adverse events
up to, and including, miscarriage and fetal death.
If the standard of care is to give a pregnant woman, who is
opioid dependent, medication-assisted treatment, that would be
either methadone or buprenorphine. We are starting to learn
that not only is methadone effective, but buprenorphine is as
effective. There are studies that show that buprenorphine
treatment is associated with less severe symptoms of neonatal
abstinence, as well as fewer hospital days.
Recently, I will say in the last year, we have heard of a
new treatment called presumptive treatments, so we do not wait
until the infant shows symptoms of neonatal abstinence, which
can prolong and make the course more difficult, but start to
treat presumptively if we know the mom has been on opioids.
Making those kinds of best practices available across this
country will do a great deal to address neonatal abstinence
syndrome and to reduce the effects on these infants and their
families, their moms and their family members.
Senator Collins. Thank you.
Mr. Robertson, when there is a situation where there is an
opioid crisis within a family and the parents are unable to
care for the child, it is the grandparents who often come to
the rescue. I was listening to your testimony and learning
about your own experience in being raised by your grandparents.
The number of these kinship families is increasing across
the Nation. In Maine alone, the number of such families
increased by 24 percent between 2010 and 2015 due to the opioid
crisis.
We held a hearing in the Aging Committee, Senator Casey and
I, and a clear message from that hearing was the need for
kinship parents to have greater access to information about the
resources that are available to assist them.
Senator Casey and I have introduced the Supporting
Grandparent Raising Grandchildren Act. It creates a Federal
taskforce charged with the development and distribution of
information designed to help kinship parents. We think this
would help families navigate the school system, plan for their
family's financial future, address mental health issues, and
build support networks.
Do you think that such legislation would be helpful?
Mr. Robertson. Thank you, Senator Collins, for that
question, and certainly for your ongoing advocacy for
caregivers to include grandparents raising grandchildren.
I cannot thank you enough for, again, the opportunity to
expose an issue that often, in our communities, goes
unrecognized or unnoticed and that is that cadre of individuals
who offer that kinship care--many grandparents and others who
are raising children.
You are absolutely right. I think their biggest challenge
on Day One is to begin navigating the systems, whether that is
the school system, or the medical system, or many other systems
they must navigate to successfully raise those children.
I think our society depends on it and I know at ACL, we
have some programs dedicated to help kinship families and
grandparents who are raising grandchildren. Certainly, that
would be a priority for me, not just in a professional role,
but also with my personal experience as well, and I know that
Senator Casey feels the same way as well.
I cannot thank you both enough for your championing of
caregivers in general and know that I will be right there
alongside you doing all that I can.
Senator Collins. Thank you.
The Chairman. Thank you, Senator Collins.
Senator Murphy.
Statement of Senator Murphy
Senator Murphy. Thank you, Mr. Chairman.
I want to thank the Chairman and Senator Murray for their
work in helping to pass, at the end of last year, the
legislation which authorizes the position for which Dr.
McCance-Katz is being nominated for. I look forward to
supporting her through the process. The weight on your
shoulders will be great as the first Assistant Secretary for
Substance Use and Mental Health, but I know that you will be up
to the job.
I wanted to ask you a question about a subject that we
talked about in my office, and that is the sections of the bill
which authorizes your positions on the issue of parity, making
sure that the insurance companies are covering mental illness.
The President's Commission on Combating Drug Addiction and
the Opioid Crisis just released their interim report, and in it
are recommendations on increasing parity enforcement,
especially when it comes to these non-quantitative treatment
limitations.
I just wanted to ask you to talk for a moment about the
steps that your office and the steps that SAMHSA and HHS can
take to increase enforcement of the parity law, especially when
it comes to these non-quantitative treatment limitations. The
ways in which the bureaucracy is often used to restrict
someone's access to the mental health or substance abuse
system, especially now given that it is part of the President's
Commission's recommendations.
Dr. McCance-Katz. Thank you, Senator Murphy, for that
question.
The issue of parity for the treatment of mental and
substance use disorders has been an ongoing problem. We hear
frequently about families and their loved ones who cannot
access the care that they need for any number of reasons. The
inability to access payment for those services that they need
is certainly a very common theme that is, unfortunately, heard
too much.
One of the things that I would want to do is spend some
time with CMS around issues of how treatment is paid for at
this time, and various ways that we might look at facilitating
the care of individuals with mental and substance use disorder.
Often, there are not a lot of treatment options available.
When there are not a lot of treatment options available, there
tend to be limits placed that are not appropriate, but are
placed because insurers and payers are not as familiar with
those interventions.
By working collaboratively with CMS, I think that we can
come up with some different ways of paying for services and
different kinds of services.
What do I mean by that?
There are often two types of treatments: hospitalization or
community outpatient programs. What we need are levels of care
and those levels of care can be very difficult to get services
paid for. There are economies and efficiencies to be had, and
they can be less costly.
Senator Murphy. I just want to get another question. I
appreciate that.
I just would recommend to you that you have new enforcement
powers under this piece of legislation. Working collaboratively
with CMS is great, but you have new enforcement powers,
guidance that you can issue, audits that you can conduct along
with other partners named in the legislation. I look forward to
working with you on that.
Dr. McCance-Katz. Senator, I look forward to your guidance.
This would be something that would be very important for me to
be made aware of, and I will certainly do those things.
Senator Murphy. Thank you very much.
Dr. Adams, you have an impressive list of organizations
that have endorsed you. Two of them are the American Public
Health Association and the American Medical Association, both
of which have listed the epidemic of gun violence in this
country as a public health hazard. I appreciate our
conversation about that in which you noted that you, yourself,
are a gun owner.
I wanted to ask you about the ability of your office, the
ability of you as Surgeon General to address this issue as a
public health hazard, as it has been named by several of the
leading public health and medical organizations in the country.
Dr. Adams. Thank you very much for the question, Senator,
and I appreciated the opportunity to speak with you and your
staff.
As I did mention to you, the caveat is that I am a gun
owner and I have my lifetime gun permit. I also work in a Level
One trauma center, took care of a gentleman last week who was
shot six times. I see it each and every day.
I think what we have to do is separate the tool from the
perpetrator. Cars are not a public health problem. Car
accidents are a public health problem. Guns and gun owners are
not inherently a public health problem, but the violence that
results absolutely is.
There are evidence-based programs, some good ones out in
Colorado, where they are bringing law enforcement, gun owners,
and the public health community together to look at solutions
to lowering the violence. It is not just homicides; it is also
suicides. There are more suicides than there are homicides in
this country.
I think that there are lots of partners out there, if we
are just willing to stop demonizing each other and really work
together to look at evidence-based programs that help lower
violence in children and throughout the country.
Senator Murphy. I appreciate your answer.
The Chairman. We are running out of time.
Senator Murphy. Thank you, Mr. Chairman.
I hope you will just look at the evidence that suggests
that the propensity to commit a crime with a gun is directly
connected to the likelihood that a gun is in close proximity to
you. It is a little bit deeper than the problem that you
suggest.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Dr. Adams. I look forward to following up with you.
The Chairman. Thank you, Senator Murphy.
Senator Young.
Senator Young. Thank you, Mr. Chairman.
Dr. Adams, I commend you for the partnerships I have seen
you develop with law enforcement and other stakeholders, and
for the evidence-based programming that you catalyzed, that you
helped bring to bear as Indiana's State Health Commissioner.
I am speaking specifically about the opioid epidemic that
afflicted Austin, IN. I represented Scott County, IN when I was
a Member of Congress, so I spent a lot of time on the ground
there with you discussing this crisis. You helped educate me.
You led in a very big way.
This was one of the worst documented HIV outbreaks in the
entire country. Many here present, colleagues and others who
are watching, read about this crisis in the ``New York Times''.
The response to it, both by our Federal Government in
partnership with State authorities like yourself, is serving as
a national model in a positive way in so many ways as we look
to continue tackling this opioid epidemic.
What lessons, Doctor, were learned from your experience
with this HIV outbreak following the opioid crisis in Scott
County? What can we do to prevent crises like this working with
folks like you in the future?
Dr. Adams. I think the biggest lesson that I learned is
that the science and the evidence is necessary, but it is not
always sufficient to motivate change.
One of the things that was really successful for both me
and Vice President Pence, then Governor Pence, was to go down
to the community and to listen to the folks down there. Not
demonize them because of the beliefs that they had. Not to call
them bad people because of what was going on in their
community. Find out why they thought it was happening and how
they thought they could solve the problem.
I remember I had a beer and a sandwich with the sheriff,
and the sheriff shared with me his concern about the
possibility of starting a syringe exchange program, but also
his concern about the revolving door of his jail. I spoke with
him about how we can utilize a syringe exchange program as a
touch point to connect people to care.
We have connected over 100 people from that HIV outbreak in
Scott County to addiction and recovery services. We have given
Hepatitis C testing. We have provided HIV testing. We have
connected people with job training.
I always want to lead with the science and represent the
science, both as a physician and, if I am confirmed, as Surgeon
General. I also want to listen to what stakeholders are saying
and what my patients, if you will, the people of this country
are saying and speak to them in a way that resonates with what
their goals are. That is the lesson that I learned.
I think partnerships, again, are the key. One of the great
things about the Surgeon General position is you do get to go
out into communities. I hope that for everyone on this
committee, you all will invite me to your communities if you
feel, and I should be confirmed, and that we can talk about
this opioid epidemic because no one has the solution alone.
The solution is going to look different in each and every
community throughout the country. What worked in Scott County
is not the same thing that is going to work in different areas
of this country.
Thank you so much for the opportunity.
Senator Young. You always took great care, as you still do
today, to get a command of the details. You understand that
every context is different and every crisis has its unique
features.
In Scott County, IN and dealing with this opioid epidemic,
you were looking at the evidence base related to syringe
exchange programs.
Dr. Adams. Yes.
Senator Young. Right? This is an evidence-based practice,
but you understood, based on your consultation with various
stakeholders, that Scott County, IN was different than other
areas where this intervention had been used.
Could you speak to that uniqueness of Scott County and how
you adapted the syringe exchange model to these unique
circumstances?
Dr. Adams. Thank you for the opportunity there.
I grew up on the East Coast, trained at U.C. Berkley, and
now live in the Midwest. I was fortunate to grow up on a family
farm. Folks do not understand that a lot of the science is
developed in urban areas. Then when we try to apply it to rural
areas, we have to understand that there are different cultures,
different beliefs, and different barriers. There are not as
many physicians around.
We had to work with a lot of the folks from the Federal
Government and State Government to provide access to care in
Scott County, IN.
I think that understanding, again, that not all
environments are the same and that we cannot impose our
beliefs, even if they are based in science, on people without
first sitting down with them and having a conversation with
them. That is the key. That is the real key to success, whether
you are talking about HIV, or hepatitis, or opioids.
Senator Young. We are out of time here.
You had those conversations. You persuaded people of the
merits of the science and you improved health and saved lives
in the process. I commend you for that.
I am going to be voting affirmatively for your
confirmation. Thank you.
Dr. Adams. It all started with lunch with the sheriff.
Thank you.
The Chairman. Thank you, Senator Young.
Senator Warren.
Statement of Senator Warren
Senator Warren. Thank you, Mr. Chairman.
Thank you all for being with us today and your willingness
to serve.
I want to followup on where Senator Young started and that
is, I want to talk about another part, though, of tackling the
opioid crisis. That means making sure that people have access
to treatment.
As Senator Murphy noted, the law says that insurers must
cover treatment for mental health and for substance use
disorders on a par with the coverage provided for physical
health treatment.
Insurance policies are required to treat mental health
needs and addiction the same way they treat broken bones or a
busted knee. They are all medical conditions. They all get
covered. That is the law, but it does not always play out that
way on the ground.
A 2015 study found that nearly twice as many respondents
were denied coverage for mental health treatment as for other
medical treatment, and the numbers are not great on addiction
either. Let me start there.
Dr. McCance-Katz, you have been nominated as Assistant
Secretary for Mental Health and Substance Use. Is trouble
getting insurance coverage for mental health or addiction
treatment a problem in effectively treating these disorders?
Dr. McCance-Katz. Coverage is a problem for many. Access to
care is a problem perhaps, I would say, for most.
Senator Warren. For most. OK.
Dr. McCance-Katz. With these issues.
Senator Warren. I want to underline this because I think it
is really important that we do more to make sure that insurance
companies follow the law.
Right now, patients are often on their own trying to do
battle with insurance companies. We are not helping them out by
backing them up in these battles.
When I helped create the Consumer Financial Protection
Bureau, the CFPB, we had a problem with consumer financial
products like credit cards, and mortgages, and student loans
where lenders just did not follow the law.
CFPB set up a complaint system. We tracked those complaints
and it helped make sure that companies address those
complaints, and we made it all public. Anybody can go online at
CFPB.gov, and they can search and see what companies follow the
law and see what companies do not. Let me ask you this, Dr.
McCance-Katz.
Do you think that making sure that insurance companies
follow the law, when it comes to parity for mental health
conditions and addiction treatment, would help in our efforts
to tackle the opioid crisis?
Dr. McCance-Katz. I do. I do believe that. I believe that
there has been a history of--I think the word ``capricious'' is
not too strong--restrictions on the kinds of evidence-based
treatments that people should have access to.
You and I discussed this when we met and I believe that
people should have access to knowledge based on what their
peers and community members have experienced to help them to
make decisions. In doing that, that can bring a simple kind of
enlightenment, if you will, to insurers as to how they need to
do things in a way that better serves Americans and follows the
law.
Senator Warren. Good. I like that.
In fact, another way to say it is it helps make the market
work better because everybody can see right out there in
public. You had a place to file a complaint, what happened to
that complaint, which insurers are getting lots of complaints,
and which insurers are not, and trying to change their
behavior.
I think that is, at least, one way to try to take the
parity that is in the law and make it a reality for families
who are struggling with this.
Congressman Kennedy and I introduced a bill for this in the
last session and it had an online portal to be able to track
complaints about failure to cover mental health and addiction
coverage. I think we can go even further, making sure that
patients actually get responses to their complaints and making
the data public about which insurance companies are the worst
offenders.
Dr. McCance-Katz, if you are confirmed, I hope we can
continue to work together on this. I think we could do a lot of
good for a lot of families.
Thank you.
Dr. McCance-Katz. I would look forward to it, Senator.
Senator Warren. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Warren.
Senator Hassan.
Statement of Senator Hassan
Senator Hassan. Thank you, Mr. Chair and Ranking Member
Murray.
Good afternoon to all of the nominees. Congratulations on
your nominations and thank you to all the family members who
are here, too, for supporting your loved ones. We need all
hands on deck in this business and we appreciate you very much.
Dr. McCance-Katz, I wanted to just start with a couple of
more questions. New Hampshire has been terribly hard hit by the
opioid, fentanyl, and heroin epidemic. The science certainly
tells us, and I think your statements today have supported
this, that medication-assisted treatment like buprenorphine
plays an important role in recovery along with access to other
services and supports.
I have been concerned that Secretary Tom Price has been
critical about medication-assisted treatments suggesting it is
not very effective. Recently, during a trip to West Virginia,
Secretary Price said, ``If we are just substituting one opioid
for another, we are not moving the dial much.''
I know that you have been supportive of medication-assisted
treatment in the past and here today. You have called it an
effective form of care and you have argued that healthcare
providers should educate themselves on medication-assisted
treatment.
Do you agree with Secretary Price's sentiments? If not, how
would you address the concerns he has raised?
Dr. McCance-Katz. Yes, thank you for that question, Senator
Hassan.
I have not had the opportunity to speak with Secretary
Price about his comments, but here is what I thought when I
read--as I did in the paper--his comments.
Senator Hassan. Right.
Dr. McCance-Katz. Just giving an opioid is not treatment.
That is not going to solve the problem.
Senator Hassan. Right.
Dr. McCance-Katz. You have to have other psychosocial
services in place. They include individual counseling, family
therapy, group therapy, peer supports, community supports.
Those things need to be in place with those opioid therapies in
order for a person to be successfully treated.
If you look at the diagnostic criteria for opioid use
disorder, what you will see is that two of those criteria are
addressed by the opioid therapy, and that is tolerance and
withdrawal.
Senator Hassan. Right.
Dr. McCance-Katz. By addressing tolerance and withdrawal,
we then give people the ability to engage in the psychosocial
therapies that they need to then move on and get into
productive lives.
Senator Hassan. I thank you for that. Like all of us, I
have time constraints.
I also think it is fair to say, and I am hoping for a yes
or no answer here, that it is also really important that people
have access to an integrated healthcare system if they are
going to successfully control their substance use disorder.
Is that fair?
Dr. McCance-Katz. Yes, ma'am.
Senator Hassan. Thank you.
Dr. Giroir, welcome, and it was very nice to visit with
you.
Dr. Giroir. Thank you.
Senator Hassan. Some time ago, I think.
You have spoken about the value of vaccines, and in your
career, you have been successful in getting funding for mass
production of vaccines.
On the other hand, at least at one point in time, President
Trump has seemed to perpetuate a conspiracy theory around
vaccines, including saying that they were linked to autism.
Dozens of studies, following hundreds of thousands of
children around the world, have shown no connection between
vaccines and autism.
I am interested if you agree with President Trump on this
issue? Do you believe that vaccines can cause or contribute to
autism?
Dr. Giroir. Thank you, sincerely, for this question.
As a pediatrician, I want it to be very clear that vaccines
save lives. They are the most important public health advance
of our time, and they are not associated, with a high degree of
medical certainty, with any form of autism.
Senator Hassan. Thank you.
Dr. Giroir. That is done by epidemiological studies that
you referred to with hundreds of thousands of children being
followed. There have also been experimental studies with
nonhuman primates to show that the vaccine regimen, when given
to animals, do not induce behaviors of autism.
We are getting more and more evidence from research by the
NIH and NIH-funded investigators that the brain abnormalities
of autism start very early in fetal life. It is absolutely
incompatible with autism. I am a pediatric care physician.
Senator Hassan. Yes.
Dr. Giroir. I took care of children who suffered and died
of vaccine-preventable diseases including measles and whooping
cough. I have also seen diseases disappear because of vaccines
like H. influenzae B.
There will be no stronger advocate for vaccines than I will
be, but I also think we need to continue to support the FDA in
monitoring vaccine safety so we can give honest and transparent
assurance to the population that vaccines will remain safe in
the future.
Senator Hassan. I appreciate that very much.
To the other nominees, I do have some questions that I will
submit for the record.
Dr. Giroir, to your last answer, I am the granddaughter of
a pediatrician who started practicing in 1921. He could talk a
lot about what it was like before penicillin and vaccines. I am
very grateful for your work.
Thank you.
The Chairman. Thank you, Senator Hassan.
Senator Whitehouse.
Senator Whitehouse. Thank you, Chairman.
Welcome to all of you.
Dr. Kadlec, I particularly look forward to working with
you, and I want to thank you for the terrific work you have
already done to try to make sure our country is prepared for
bioterror threats. I want to recognize Senator Burr and Senator
Casey, who have been really good bipartisan leaders in that. I
know that there is work to be done. I look forward to working
with you on that.
Dr. McCance-Katz, welcome. Great to have a Rhode Islander
here.
We have recently passed the Comprehensive Addiction and
Recovery Act. We, shortly after the passage of that, agreed on
a billion dollars that would be put through to fund and support
for opioid treatment and intervention.
The first half billion went through already and the States
are in the process of distributing that. We hope very much that
the second half will move in September when we have our next
piece of funding legislation. When we do, I hope that you will
consider working within the Administration to see to it that
those funds are distributed in some manner consistent with the
new goals and principles of CARA.
I do not think we are going to be able to direct the
funding to be consistent with CARA through appropriations. But,
I do believe that HHS has the authority to say that grant
applications will be considered based on how well they align
with CARA's principles, and I hope that you would support an
Administration effort to align on that point.
Dr. McCance-Katz. Yes, I do.
Senator Whitehouse. Good.
Dr. Adams, welcome. We had a great conversation in my
office and I wanted to followup on it because I think one of
the areas where we have enormous bipartisan potential here is
in that very delicate, tender, and important period when a
person is nearing the end of their life and has to make
decisions about how much treatment they wish to undergo versus
how much time they want to spend with their families, and how
much comfort care versus intervention they will choose.
What many of us have seen as circumstances in which, like
getting your sleeve caught in the machinery, unintendedly you
are dragged off and before you know it, the healthcare system
is doing lots of things to you that you did not want.
Because the expression of your views was not either timely,
or complete, or filled every box, very often people are taken
on very unpleasant journeys at a time when, really as human to
human, the last thing we can do for people is to honor their
wishes on their way out. I think, by and large, we do a
terrible job of doing that.
To that end, Senator Collins has really showed a lot of
passion and leadership in the Aging Committee. Senator Isakson
has been outstanding on this. We have a huge group called C-
TAC, the Coalition to Transform Advanced Care, which is truly a
who's who of the American corporate and interest group power
structure.
Faith communities are gathering around this issue all
around the country. I want to particularly commend the Dioceses
in my home State. Everywhere you go, you hear from regular
folks who have come across this problem and remember tragedies
in their family.
There is a big opportunity here and I wanted to ask you to
consider having it be one of the ``bully pulpit sermons'' of
your tenure as Surgeon General to help catalyze that enormous
potential to help Americans get the care that they want. If it
is a lot of care, great; get a lot of it. If it is not, get the
care that you want and get your promises and your wishes
honored at that time.
I think we can help with that and I hope that you can help
us with that.
Dr. Adams. Thank you, Senator. I really appreciate you
saying that.
One of my priorities is prevention and I can tell you as a
physician, the absolutely worst and wrong time to be having a
discussion with someone about their end of life wishes is when
they have a tube in their mouth, and they are on a ventilator,
and they cannot communicate.
You are correct. We consistently fail our citizens in this
regard and there are best practices out there. In Indiana, we
led the way with physician orders for scope of treatment. You
all have similar forms in your States.
Senator Whitehouse. We have in Rhode Island and Gunderson
Lutheran does a great job up in Wisconsin. There is a lot of
good leadership.
Dr. Adams. Exactly. I think partnering with the faith-based
community is ever so important; the hospital associations in
our States and nationally; the medical associations, the AMA,
and the Indiana State Medical Association in our State.
In other States, I think we can bring together stakeholders
and go after some low hanging fruit here, and help people reach
the end of life with dignity. Ultimately die according to their
wishes and not according to a doctor or a medical professional
doing something that they would not otherwise want.
Senator Whitehouse. Thank you very much. My time is up.
The Chairman. Thanks, Senator Whitehouse.
Senator Casey.
Statement of Senator Casey
Senator Casey. Thank you, Mr. Chairman.
I want to start by saying how much we appreciate what
Chairman Alexander and Ranking Member Murray agreed to with
regard to bipartisan hearings before we started today. I was
not here for the announcement, but know of the substance of it,
and I think the country is grateful to hear that news, and we
are appreciative of that.
I want to thank Senator Collins for her reference to our
grand-families bill. Mr. Robertson, we are grateful for your
words about that as well.
Dr. Giroir, I wanted to start with a little known part of
the Affordable Care Act that I fought hard to make sure was
part of the law. It is called the Pregnancy Assistance Fund
which was both authorized and had an appropriation attached to
it in the bill for 10 years, $250 million over 10 years. To
provide support, in this case, in the form of competitive
grants to States and to tribes, a few tribes across the
country, in addition to States to provide a seamless network of
supportive services to young families.
Since 2010, the Office of Adolescent Health has awarded
these grants to 27 States and 4 Tribes to improve the
educational health, social, and economic outcomes for expectant
and parenting teens, young women, fathers, and their families.
It has been funded in a multiyear fashion in the three
previous times that the grantees have been awarded money. The
programs are already making a difference since the time it has
been implemented.
Folks who participate are more likely to complete high
school, even with a pregnancy. More likely go to higher
education and less likely to have a repeat unwanted pregnancy.
I was surprised to learn that this fund--the Pregnancy
Assistance Fund--which recently the announcement was for 15
States getting the grants and one tribal entity, but now it has
been proposed as a 1-year grant.
It is puzzling since Congress had provided funding through
fiscal year 2019 starting in 2010. The funding opportunity
announcement indicated that funding would be for 3 years.
I guess my question on this is, do you agree that it is
unusual to provide a 1-year grant when Congress has provided
funding through 2019 and the funding opportunity announcement
was listed as 3 years? Do you have any sense of that or do you
think that makes sense?
Dr. Giroir. Thank you for that question.
I am certainly aware of the Pregnancy Assistant Fund and I
think we can all agree that the goals of providing assistance
to pregnancy that could be troubled both physically or having
long-term effects is absolutely something critical that we need
to focus on.
I would certainly hope that aside from the very important,
but relatively limited scope of this program, that this type of
program would be available across the country because everyone
understands that the prevention of problems, as you have heard,
are much more important. I cannot comment on whether it is
usual or unusual because I have not been involved in this
specific decision. It is something I would certainly look at.
One thing of concern is that many research programs where
you are gathering data, may have multiple years in order to
have validity of the data independent of whether they are
servicing the patients or not.
It is something I know. I know the principles of the
program are very important and should be throughout the
healthcare system. It is something I would look at once, if I
were confirmed, because I do not have firsthand knowledge of
what was the decision tree to shorten that program and the
grants.
Senator Casey. I would also ask, Doctor, your commitment to
continuing the program and especially continuing it as a
multiyear program.
Dr. Giroir. At this point, because I have not been involved
in discussions, you certainly have my commitment that this area
is extremely important, and I understand the value of it, and
will argue for such programs to be scaled, and they should be
across the country.
I am not in a position to commit to support this program as
this program, in and of itself, until I really get within HHS
and have discussions. We have not been able to have those kinds
of discussions about the rationale, whether this is being moved
into a different program or under another auspice, but you have
my commitment to give it high priority.
As a pediatrician, this area of work is very high priority
for me and you also have my commitment that I understand the
importance of this type of program.
Senator Casey. Thank you, and we will followup.
Thank you, Mr. Chair.
Dr. Giroir. Thank you.
The Chairman. Thanks, Senator Casey, and thank you for your
comments.
Senator Baldwin.
Statement of Senator Baldwin
Senator Baldwin. Thank you, Mr. Chairman, and Ranking
Member Murray.
I also want to appreciate and recognize the opening
statements regarding our path forward on the things that we
need to do in our healthcare system. I welcome the opportunity
for hearings and input. I welcome the opportunity to work
across the party aisle.
I hope you will give us assignments before the end of the
week. I do not want to wait until the first week in September,
but I want you to know that I stand ready to do my part to work
with you to find solutions that stabilize our insurance
markets, that lower health costs, and improve coverage for our
constituents. Thank you both for setting that tone and
direction.
I am going to follow the suit of most of my colleagues in
talking about the opioid, and heroin, and now fentanyl epidemic
across this country and in my State.
I hosted a large number of roundtables and stakeholder
meetings across the State in urban, and suburban, and rural
settings to learn as much as I can. As we have discussed, there
are several measures and steps that Congress has taken that I
am proud of, and yet the crisis grows worse. I have several
questions on this.
I met recently with a constituent, Jesse Heffernan, of
Appleton, WI. He is in long-term substance use and mental
health recovery since 2001. His experience inspired him to
start something called the Recovery Corps Program. It is
modeled after AmeriCorps and the idea is to integrate recovery
coaches into the entire substance use disorder care spectrum.
He recently received some funding to pilot his program with a
Wisconsin health system.
I heard the exchange, Dr. McCance-Katz, with Senator
Cassidy about expansion of the very limited resources we have
and how we really need to do that. To improve clinical
treatment, we have to do more to break down silos also.
How would you expand and prioritize local efforts to
integrate peer support and recovery services into the substance
use disorder spectrum?
Dr. McCance-Katz. Thank you, Senator Baldwin, for that
question.
There are a number of programs now that train peers. They
are peer professionals and they are being integrated into
treatment programs across the country. There are many
demonstration programs of that at this point. What we can do at
a Federal level is to help disseminate what those programs look
like.
I believe that every State is different, every community is
different. States know best what their communities need. What
they need is access to the information as to how to establish
these kinds of programs.
I personally believe that peers are really an essential
part of recovery just as important as treatment.
Senator Baldwin. I was glad to hear you reference that in
your opening statement. We had a chance to talk about that.
Dr. McCance-Katz. Yes.
Senator Baldwin. I want to move onto a question for Dr.
Adams.
This past weekend, I had the opportunity to visit a V.A.
Medical center in my State at Tomah, WI. Sadly, a few years
back, Tomah had been an outlier with regard to over-prescribing
opioids. Working with colleagues in the Senate, I authored and
we passed the Jason Simcakoski Memorial Opioid Safety Act.
Actually, I toured and got reporting on the implementation
of this Act. The facility has significantly reduced its
reliance on opioids in treating pain and provided hopeful
alternatives to the veterans they serve.
It tells me that one of the keys to fighting our opioid
epidemic is the engagement of prescribers and health
professionals, retraining to the latest guidelines of the CDC.
Your role provides a real platform to do that, and I would
ask you how you would see your leadership in that regard?
Dr. Adams. Thank you, Senator, very much.
I want to, first of all, say thank you for your courage and
your leadership. As someone who has often been the only
minority in the room, I really sincerely appreciate what you
have accomplished and what you have done. For those who may be
watching and you do not know, Senator Baldwin is the first
openly gay Senator. Growing up as the only one in the room, I
know how it feels.
To your point, or to your question, I think the Surgeon
General's position has a tremendous opportunity to bring folks
together. I have done it, not just as surgeon general, not even
just as Indiana's State Health Commission, but as a physician.
As a leader in the American Medical Association partnering with
the Hospital Association, partnering with other entities to try
to bring the right folks together to make sure we are educating
people.
As an anesthesiologist, a physician anesthesiologist, I
teach people every day about proper prescribing and the dangers
of over-prescribing. One of my clinical focuses is on
alternatives to opioid pain management.
I think we need to look at how we are paying for different
modalities to make sure the easy choice is also the right
choice. Far too often, the easy choice is just to give out 60
Vicodin. We need to make the right choice the easy choice for
physicians.
I intend to go out to communities, to medical schools, to
dental schools, to nursing schools because we cannot forget the
prescribing community is more than just physicians and partner
with all the folks who are part of this chain. It is not just
one group that we want to point our finger at, but we all are
part of this problem.
I apologized, when I came before the committee on aging, to
all the committee for the part that I and my colleagues played
in the opioid epidemic. I go around telling folks, ``I do not
care if you are 1 percent responsible or 99 percent
responsible, what I care about is what you bring to the table
in terms of a solution.'' Hospitals, providers, legislators all
can play a part in this solution.
I look forward to the opportunity, if confirmed, to being a
convener, to bring those folks together.
Thank you.
The Chairman. Thank you, Senator Baldwin.
I think some Senators may have additional questions.
Senator Murray.
Senator Murray. I just have one additional, Dr. Kadlec. I
did not want you to get off free here.
Dr. Kadlec. Thanks for noticing, ma'am.
Senator Murray. As a staffer to Senator Burr, I know that
you played a key role in drafting the Pandemic and All-Hazards
Protections Act, which critically addressed both domestic and
international public health preparedness capacity and
capability. We have often seen this tested in recent years.
I was really concerned when I saw the President's 2018
budget request, which proposed significant cuts to CDC's public
health emergency preparedness grants to health departments and
to the Hospital Preparedness Program, which you would oversee
if you are confirmed.
The 2018 request proposes eliminating hospital preparedness
funding from 26 jurisdictions including my home State of
Washington.
Do you agree with the proposed cuts to those programs?
Dr. Kadlec. Ma'am, I was not part of those discussions or
deliberations, so I cannot give you color commentary to what
may have happened or what was represented there.
I can only assure you one thing, that I will be an advocate
for these programs and I will fight very hard to basically
represent them in the policy halls in HHS with Secretary Price
and the White House when the time comes.
I have done it before in OMB, and I have done it before in
the White House, and I certainly have not had the chance in HHS
yet, but I am looking forward to it, if confirmed.
I do have to tell you this, ma'am, is that we do have to do
some things, as raised by the Chairman, in terms of creating
certainty around funding for some of these programs. As is for
the health insurance programs, the same are required for
preparedness, whether it is for public health preparedness,
hospital preparedness, or for the development of
countermeasures.
That kind of certainty is required to ensure that the State
and local authorities--the private sector can do the things
that they need to do to ensure that, God forbid, when these
things happen, and they will as you know, ma'am, that we can do
that.
The only assurance I can give you right here, right now is
that if you support me, I am going to be a fighter for these
things. I know that States like yours have often led the way on
these issues, and I am certainly respectful of that. Also will
commit to the idea of, again, advocating for the programs and
for your constituents on these issues.
Senator Murray. Thank you. Thank you very much. I
appreciate that.
The Chairman. Senator Warren, did you have additional
comments?
Senator Warren. I do, but I yield to Senator Hassan?
The Chairman. Senator Hassan, do you have additional?
Senator Hassan. Thank you. Thank you, Senator Warren.
To the Chair and Ranking Member, also, count me in.
Obviously, I think all of us are eager to work on a bipartisan
process on healthcare and we are very, very grateful for your
leadership to both of you.
Dr. Kadlec, I do not have a question for you, but as a
former Governor, I can tell you I am right there with you on
the importance of preparedness, and certainty, and funding for
preparedness. You have an ally here and I look forward to that
work.
Dr. Kadlec. Thank you, ma'am.
Senator Hassan. Dr. Adams, I wanted to explore another area
with you.
Last year, the former Surgeon General issued a report
concluding that the use of electronic cigarettes, also called
e-cigarettes, pose a risk to Americans particularly to our
youth and our young adults.
The Surgeon General's report called for action to reduce e-
cigarette use among young people, including actions by Federal,
State, and local governments.
Just last week, though, the FDA announced it would delay
what is called the deeming rule to review products like e-
cigarettes that are on the market. Under the deeming rule, FDA
could take into account, for instance, the impact of e-
cigarette flavors like cotton candy and bubblegum on the
product's appeal to youth. It is an important tool that the FDA
has to protect children and the public health.
I am worried that delaying the deeming rule is
contradictory to what the 2016 Surgeon General's report called
for.
Do you agree?
Dr. Adams. I was not privy to the discussion within the
FDA, Senator, but I do thank you for the question. It is an
important one.
Decreasing the number of people who are consuming both
tobacco- and nicotine-related products is of utmost importance
from a public health point of view.
I think it is important that we distinguish between never
smokers and current smokers. There is actually a debate going
on in the public health community worldwide about the benefits
of e-cigarettes and vaping, and I think it is because people
are confusing the two.
Senator Hassan. Just because we are constrained for time, I
think this, though, is very specific. Because when you think
about it--while we can talk about the value or not of e-
cigarettes and vaping for somebody who might be trying to quit
the nicotine habit with regular cigarettes--this is about
flavoring e-cigarettes in a way that will get young people
hooked on the habit in one form or another to begin with.
Can we agree that that is harmful?
Dr. Adams. We can absolutely agree and I want to do
everything possible to prevent young people from starting down
the pathway of nicotine addiction. I commit to working with you
and, if confirmed, with the FDA to make sure we do that.
Senator Hassan. Thank you.
Here is a question for both Dr. Adams and Dr. Giroir. It
goes back to one of the other mentions of this that, I think,
Senator Murray made.
The Office of the Assistant Secretary for Health directs
the Presidential Advisory Council on HIV/AIDS. On June 16, 2017
six members of the Presidential Advisory Council on HIV/AIDS
announced their resignation in ``Newsweek''.
Here is what they said. Here are the quotes.
``The Trump Administration has no strategy to address
the ongoing HIV/AIDS epidemic, seeks zero input from
experts to formulate HIV policy. And most concerning,
pushes legislation that will harm people living with
HIV and halt or reverse important gains made in the
fight against this disease.''
They also said that they could not effectively fight HIV/
AIDS, and this is their quote, ``Within the confines of an
advisory body to a President who simply does not care.''
Further, there is also not yet a director of the White
House Office of National AIDS Policy.
Dr. Giroir and Dr. Adams, I am interested on your thoughts
about how you would address the concerns expressed by these
advisory council members and what you see as your role in
making sure that we are confronting and having a robust HIV/
AIDS policy and program in this country that can help people
living with the disease.
Why do I not start with Dr. Giroir?
Dr. Giroir. Thank you for that question.
I read that in the papers as well and I took it quite
personally. I took it personally because much of the complaint
was because of a lack of leadership in the office. This office
is under the office of the Assistant Secretary for Health.
Senator Hassan. Right.
Dr. Giroir. I remain in waiting, if confirmed, for that
position.
Senator Hassan. Sure.
Dr. Giroir. One of the first things I will do will be to
speak with those individuals to assure them that there is a
national HIV strategy. I have not discussed it within the
office, but it is a very robust one. There has been tremendous
gains.
I am absolutely committed to moving forward with those
gains, as well as the other important viral diseases that are
under that office's purview. Many of you have spoken to me
about Hepatitis C.
Senator Hassan. Sure.
Dr. Giroir. A very important disease with millions affected
and millions still left untreated, even though there is a
potential cure for it.
All I can say, if fortunate enough to be confirmed, is that
office will have all the attention that I can give it. We will
look very critically at the advisory committee to make sure
that it is appropriately staffed so that we get a diversity of
opinions grounded in science to move the successes we have had
with HIV even further.
Senator Hassan. Thank you.
I know I am out of time, but perhaps, Dr. Adams, if you
could just address it.
Dr. Adams. Mr. Chairman, if you do not mind.
Senator Hassan. I am out of time, but I would ask the
question of both Dr. Adams and Dr. Giroir.
The Chairman. If we do a third round, you can.
Senator Hassan. Perfect. Yes, that is fine.
The Chairman. Let us let the other Senators have their 5
minutes.
Senator Hassan. Thank you.
The Chairman. For Senators' knowledge, we have two votes at
5 p.m.
Senator Warren.
Senator Warren. Thank you, Mr. Chairman.
I want to continue our focus on the opioid. Last year, more
than 2,000 people died in Massachusetts alone. This is
powerfully important to me, and to the people I represent, and
to everybody who sits on this committee, and I think in the
United States Senate.
Dr. Adams, as Indiana Health Commissioner, you saw the
epidemic up close when you dealt with the HIV outbreak in Scott
County, IN. There has been a lot of discussion about that
today, several references to your work there.
You established a syringe exchange program, which was
illegal in Indiana at the time when you first recommended it.
The consequence is that you helped save lives and helped
contain that outbreak. I just want to ask you a question, Dr.
Adams.
Why did you press for such a program even though it was
controversial and, in some quarters, politically unpopular?
Dr. Adams. Thank you so much for the opportunity to answer
that question.
I pressed for it because it was the right thing to do. It
was the scientifically sound thing to do. It was what I felt
was necessary to save lives and stop disease transmission. As I
mentioned earlier, I also recognized that the knowledge base
oftentimes is not enough and that we had to partner.
The most important thing, as I mentioned earlier, that the
Governor and I did was to go down to Scott County and talk to
folks.
I do not want to take up your time, but I do want to say
very quickly. Ask yourself if I said to you, ``I am going to
open up a syringe exchange program across the street from where
you live.'' The first thing you are going to say is, ``Oh, no.
You are not.'' Then you are going to say, ``Come down and
explain to me why this is necessary.''
Senator Warren. Right.
Dr. Adams. Partnerships are critical. The science has to be
there, but it has to be given in a sympathetic and empathetic
way.
Senator Warren. The way I read this, your response, is you
said you are willing to do something that is innovative, data-
based even if it turns out to be politically controversial.
Dr. Adams. I feel a trap coming, Senator.
Senator Warren. No, no.
[Laughter.]
No, we can be friends here, Dr. Adams.
Dr. Adams. We are friends.
Senator Warren. Good, good.
Here is what I am going to ask you. Are you aware that the
American Medical Association recently endorsed developing pilot
facilities where people who use their own drugs can do so
safely under medical supervision?
Dr. Adams. I am. I was there when they debated it.
Senator Warren. What is your view on that?
Dr. Adams. My view on that is that the science is not quite
there to the extent that it is for syringe exchange programs,
but we have two natural pilot programs, one in Massachusetts
and, I believe, one in Seattle and I look forward to carefully
reviewing the data.
Even if we do have compelling data, just as I said with
syringe exchange programs, we still have to come back to local
control and local conversations.
Senator Warren. Reviewing the data, and studying it, and
perhaps expanding the studies of supervised injection
facilities as a public health tool in the fight against the
opioid epidemic.
Dr. Adams. I think it is one of many tools that should be
considered in the tool chest and communities need to be leading
that conversation about whether it is right for their
community.
Senator Warren. We need a Surgeon General who is also going
to lead that conversation.
Dr. Adams. I would love that conversation across the
country and quite frankly, across the world because of the
unfortunate HIV outbreak that occurred in Scott County.
Senator Warren. Thank you, Dr. Adams.
You were right. I hope that we very much are friends
because you are an evidence-based, committed physician even if
it is politically unpopular. I think that is what we need right
now in addressing the opioid crisis.
We truly do need all hands on deck whether they are
politically acceptable or not politically acceptable. We have
got to do what the evidence tells us may have an effect. We
study it, we find out, and then we follow through. I think that
is powerfully important and that is what I want to see in a
Surgeon General.
Thank you, Dr. Adams.
I will be submitting other questions for the record.
I am going to yield back my time, Mr. Chairman.
The Chairman. Senator Warren, that is the second time you
have done that today.
[Laughter.]
Senator Warren. Well, you know.
The Chairman. I commend you as a succinct professor, as a
terrific addition to the committee. I admire Dr. Adams for
seeing where you were going too.
I have a couple of questions.
Dr. Giroir, I talked with you earlier, and with Secretary
Price, and with Secretary Perry, and Seema Verma about using
the Government's super computers to identify waste, fraud, and
abuse which seemed like a no-brainer.
There was basically a pilot program done at CMS in the
Obama administration--which if we began to look for waste,
fraud, and abuse using the same techniques that we used to look
for terrorists in a needle in a haystack sort of search--that
we might get some good results.
According to ``The Economist,'' as much as $272 billion
across the entire health system is swindled each year and some,
``Criminals are switching from cocaine trafficking to
prescription drug fraud because the risk-adjusted
rewards are higher, the money is still good, the work
safer, and the penalties lighter.''
Are you willing to try to take another look at using our
super computers and our data at CMS to identify waste, fraud,
and abuse in the system?
Dr. Giroir. Mr. Chairman, thank you for that question.
I think it opens an even broader discussion--in that I was
in the Department of Defense for a period of time. We worked
very closely with DOE. We have to break down the silos between
the tremendous capabilities we have among our Government
agencies. The Department of Energy has super computers, not
only super computers but the world's best expertise on how to
program and ask questions.
What can be done by collaborating with the Department of
Energy for CMS, for the V.A. health system, for understanding
risk behaviors and outcomes cannot be understated. This is
something, certainly, I want to do and want to promote, which
is the work among the interagency.
I actually spent quite a period of time talking to national
leaders on the science side in the Department of Energy, and
what they told me was quite surprising to me. Not only do they
want to work on health problems, not just this problem of fraud
and abuse, but on health problems. The complexities of the
health problems that they have to deal with are making them
more capable of dealing with their primary missions of nuclear
security.
This is a win-win across the board.
The Chairman. Yes, I would hope.
I would imagine that the pushback from CMS will be, ``These
computer people do not know enough about healthcare.'' That is
true, but they can learn it. They can learn enough. To find
criminals in the haystack stealing money that could be better
spent caring for people, just as they have learned how to use
computers to catch terrorists who might be trying to blow us
up.
Dr. Giroir. I have not spoken to CMS, but I think you are
exactly correct.
The Chairman. Will you pursue this?
Dr. Giroir. I absolutely will pursue it.
The Chairman. You have at least two cabinet members and
Senator Blunt and I are very interested in this. Seema Verma
seems interested. She has had other things to do the last few
weeks.
Dr. Giroir. We have to understand that the tools of
mathematics and big data analysis cross all disciplines.
The Chairman. Good.
Dr. Kadlec, I want to give you a chance. We talked about
how the primary purpose of ASPR is to lead the public health
emergency preparedness and response. The question Senator Burr
often says here, ``who is in charge?''
What are you going to do about the ``who is in charge?''
question when it comes to a public health emergency?
Dr. Kadlec. Sir, I would just simply say, if confirmed, I
would be in charge for clarity, No. 1.
No. 2, it is really important to work with my colleagues.
The Chairman. Do you have an understanding with others, who
think they might be in charge, that you are in charge?
Dr. Kadlec. Sir, I think that is an issue that is set with
Secretary Price right from the get go.
The Chairman. Yes.
Dr. Kadlec. As I see it.
The Chairman. I agree with you about that.
Hyman Rickover, we have never had anyone die from a nuclear
reactor on a submarine or the ships since Rickover started it
in the 1950s, and it is because he told the captains in his
interview that, ``You have two responsibilities. One is the
ship, one is the reactor, and if anything happens with the
reactor, your career is over.'' There have been a lot of good
careers and there has never been a death as the result of a
reactor.
Who is on the flagpole makes a difference.
Dr. Kadlec. Yes, sir. It does. Sir, I would consider myself
to be that, but it takes more than one person to make this
work.
Clearly people like Dr. Fitzgerald at the CDC, folks at the
FDA, clearly these colleagues here are all going to have
something to add and collaborate with on these issues
particularly Dr. Giroir and Dr. Adams.
My interest is really building a team, or to help build a
team, under Secretary Price to kind of do the things 24-7-365
that nobody else really has the bandwidth to do honestly on a
day-to-day activity unless something bad happens.
My job is to think of those bad things and work with a
tremendous group of people at ASPR right now and kind of do the
arduous, predictive work that has to be done well in advance of
a crisis to ensure we have the means.
Sir, I will end my comments with a caution--which is one
that General Schoomaker, former Chief of Staff of the Army and
former Commander of Special Operations Command often used--
which was, ``Do not confuse enthusiasm with capability.''
The one thing I need, sir, to give you confidence in and
for Senator Murray as well, and your other members here, and
Secretary Price, is that we have the capabilities. Job one for
me--first, when I hit the ground--is really to evaluate, kick
the tires on the capabilities that we have and to see if they
are sufficient to deal with the likely crises we may encounter.
To Senator Murray's point, funding will always be
important. Right now, we spend about two-thirds of what we
spend on a single aircraft carrier for preparedness and
response. That imagery is kind of important to me because you
do not get very far on two-thirds of an aircraft carrier.
The Chairman. Thank you, Dr. Kadlec. I let the time run
over, but that is both my rounds of questions.
Dr. Kadlec. Thank you, sir.
The Chairman. I have remarks from Senator Burr who could
not be here today, expressing his support for Dr. Robert
Kadlec's nomination for Assistant Secretary for Preparedness
and Response.
I ask for consent for his remarks to be submitted for the
record, and they will be introduced.
[The information referred to may be found in Additional
Material.]
The Chairman. I also ask consent to introduce 43 letters of
support for Mr. Lance Robertson, 8 for Dr. Brett Giroir, 2 for
Dr. Kadlec, 25 for Dr. McCance-Katz, and 10 for Dr. Jerome
Adams into the record, and they will be introduced.
[The information referred to may be found in Additional
Material.]
Are there other questions before we conclude?
Senator Hassan.
Senator Hassan. Perhaps we could just let Dr. Adams speak
to the earlier question about HIV and AIDS policy and then I am
all set.
The Chairman. Sure. Dr. Adams.
Dr. Adams. Thank you for the question.
I very quickly and briefly will say, I oversaw the response
to the largest HIV outbreak related to injection drug use in
the history of the United States as declared by CDC Director
Tom Frieden. I am supported by the Damien Center, which is the
largest provider of HIV care in the State of Indiana. There is
a letter of endorsement from them.
The best thing that you can do to help improve what some
people perceive as a lack of direction in regards to HIV care
is to confirm this panel, including Dr. Giroir and I, so that
we can get to work.
Senator Hassan. Thank you very much.
Dr. Adams. Thank you.
The Chairman. Thank you, Senator Hassan.
Senator Murray. Mr. Chairman, could I----
The Chairman. Senator Murray.
Senator Murray [continuing]. Could I just say?
I know there may be some additional questions and due to
the uncertainty and timing on when we are voting on these, I
would just ask all the nominees to respond. If we could work
out a time that we could make sure that we get answers back to
those questions.
The Chairman. It might be hard to do it by tomorrow.
Senator Murray. I totally understand that.
The Chairman. We will work it out.
Senator Murray. We will work it out.
The Chairman. Yes, that is the way we will do that.
First, let me thank each of you for being here and
congratulate you on your nominations.
If you are confirmed, this will complete Senate approval of
all of the Assistant Secretary positions in the Department of
Health and Human Services in the Trump administration. There
will be a full team ready to go to work as far as we are
concerned.
We have talked a lot today about implementing laws. We have
been pretty busy the last couple of years in this committee on
mental health, on 21st Century Cures, on electronic healthcare
records, a whole variety of health-related issues.
We know the laws are not worth anything unless they are
implemented properly, so we hope and expect that if Senators
ask questions--I had a little discussion with Senator Warren
about this the other day involving another department--if
Senators ask questions, we would like for you to answer them.
If you feel you cannot, or the question is unreasonable,
well then, I would call the Senator and say, ``Look. I got this
from your office. Maybe somebody is writing letters under your
name,'' or something like that.
[Laughter.]
Do not ignore the question. It is perfectly understandable
if you cannot answer a question for some reason. Why, just call
the Senator and say, ``Here is my problem,'' and discuss it
with that person because it is important for us to be able to
communicate with you.
It fills all the Assistant Secretary positions under our
jurisdiction, maybe I did not say it that way, but that is what
I meant.
If there are any other Assistant Secretaries who are not
confirmed, it is not our fault.
[Laughter.]
Senator Murray has agreed that we can go ahead with the
mark up tomorrow, and then hopefully, you might be confirmed,
and in your jobs soon thereafter.
Senators who wish to ask additional questions of the
nominees, questions for the record, are due at a time that
Senator Murray and I will agree on.
For all other matters, the hearing record will remain open
for 10 days. Members may submit additional information for the
record within that time.
We will meet again, tomorrow, at a time convenient for
Senators for an executive session to consider these nominations
and additional nominations up for consideration.
Thank you for being here today.
The committee stands adjourned.
[Additional Material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Senator Burr
Mr. Chairman, when Senator Ted Kennedy and I designed the
role of the Assistant Secretary for Preparedness and Response
(ASPR) under the Pandemic and All-Hazards Preparedness Act, we
envisioned an official solely focused on the singular 24/7
mission of making sure we are prepared for the public health
threats we may face, whether naturally occurring like Ebola and
H1N1, or the result of a deliberate attack on our country. The
role of the ASPR was designed to answer the simple and critical
question: Who is in charge? It is critical for the individual
serving as the ASPR to recognize this singular focus, and
execute the role of the ASPR with a daily vigilance. We cannot
wait until a threat is upon us to respond, and the ASPR serves
to prepare for and respond to these threats in order to save
American lives. Put simply, Dr. Robert Kadlec is well-prepared
for and well-suited to fulfill every aspect of this role.
Dr. Kadlec brings with him a deep and thorough
understanding of the role served by the Assistant Secretary for
Preparedness and Response at the Department of Health and Human
Services. He has had the opportunity to serve in numerous
biosecurity, intelligence, and policy positions that will
inform his work as the ASPR. Notably, he has served under
President Bush as an advisor on the Homeland Security Council
and on my staff in the Senate Select Committee on Intelligence.
His years of honorable service show his dedication to country
and his work in the White House, military service, and
leadership of the Senate Select Committee on Intelligence have
helped to shape and grow his unique understanding of the
threats faced by our country. Each of the steps he has taken
throughout his noteworthy career will be valuable assets should
he be confirmed as the next ASPR, and each of the goals he
outlines in his statement are consistent with the vision
Senator Kennedy and I worked to get signed into law over a
decade ago.
The first goal Dr. Kadlec mentions is providing strong
leadership and clear direction. While the statute clearly
defines who is in charge during a public health emergency,
there have been multiple instances in recent public health
crises where the coordination and communication roles of the
ASPR were not operationalized effectively. I am pleased that
this is his first priority and goal, and I am confident that
Dr. Kadlec will bring to the role of ASPR the dedication,
vigilance, and urgency it requires.
Further, another critical role of the ASPR is to oversee
the Biomedical Advanced Research and Development Authority
(BARDA), which brings forward medical countermeasures to
prevent and respond to emerging infectious disease outbreaks
and other chemical, biological, radiological and nuclear
threats.
Bringing these medical countermeasures through the
research, development, approval, and procurement processes is a
long, difficult, and often risky task for manufacturers and
innovators in this space. In order to realize the full
potential of the medical countermeasure enterprise in our
country, we must ensure that the Federal Government is sending
a clear signal that we are a good-faith and willing partner in
this endeavor. Dr. Kadlec has the firsthand knowledge necessary
to achieve this goal, and will provide industry the confidence
needed to invest in much-needed medical countermeasures to
address the threats facing our Nation today and tomorrow.
Ultimately, the ASPR must properly coordinate and
communicate with other officials throughout the Administration
and manage all of the tools at our disposal to effectively and
efficiently prepare for and, if necessary, respond to a
chemical, biological, radiological, or nuclear attack. This
will only grow more challenging in the years to come and Dr.
Kadlec is uniquely prepared for this challenge. I urge each of
my colleagues to support Dr. Kadlec's nomination. He is the
right person to serve as the next Assistant Secretary for
Preparedness and Response. I thank the Chair.
Letters of Support
lance robertson
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Response by Lance Robertson to Questions of Senator Murray, Senator
Sanders, Senator Casey, Senator Franken, Senator Bennet, Senator
Whitehouse, Senator Baldwin, Senator Murphy, Senator Warren and Senator
Hassan
senator murray
Question 1. As the Assistant Secretary for Aging, you will also
serve as the Administrator for the Administration for Community Living
(ACL). This agency was created in 2012 by bringing together the
Administration on Aging, the Office on Disability, and the
Administration on Developmental Disabilities. The purpose of the
agency, therefore, is to address the full spectrum of community living,
health care, and long-term service and support needs for both the aging
and disability populations. However, your professional experience has
largely been established by administering aging service programs.
Describe your professional experience working with individuals with
disabilities and their families and the disability service providers
and programs in Oklahoma.
How have you bridged the silos that are often created between aging
and disability service programs in State government?
How will you ensure equity in resource allocation between programs
for people with disabilities and programs for older adults in ACL?
Answer 1. As I mentioned in my testimony, having a close family
member who lives with a significant disability and a mother who is a
career Intellectual and Developmental Disabilities case manager has
given me a personal view of the importance of ACL's work for people
with disabilities. Through my work as president of the National
Association of States United for Aging & Disability (NASUAD), we
decided to include a ``D'' in the organization's name to fully reflect
our work and commitment to the disability community.
Together, we are better able to leverage learnings and best
practices for meeting those similar needs. Further, the disability and
aging communities together have a larger voice than either community on
its own. Silos are not helpful within any organization, and I look
forward to working effectively at ACL to better unify our populations
and strengthen our programs.
Question 2. The President's 2018 budget proposal called for a
number of cuts to and restructuring of programs for individuals with
disabilities and their families. Specifically, the President's budget
recommended a cut of $23 million to the Independent Living program,
thereby eliminating funding for the Independent Living State Grants
program. The House Appropriations Committee fiscal year 2018 Labor,
Health, Human Services, and Education bill restores this funding to the
Independent Living program.
What efforts will you take to ensure the Centers for Independent
Living and the Statewide Independent Living Councils have the necessary
funding and administrative support to fulfill their responsibilities as
required by the Rehabilitation Act of 1973, and fully implement the new
core transition services required by the Workforce Innovation and
Opportunity Act (WIOA)?
Answer 2. The work of the Centers for Independent Living and the
Statewide Independent Living Councils is important. I look forward to
working with ACL team members, HHS leaders, and Congress to ensure
these programs are funded in the most responsible way.
Question 3. The President's 2018 budget proposal called for the
merging of several disparate disability programs, namely the State
Councils on Developmental Disabilities, the State Independent Living
Councils, and the State Advisory Boards on Traumatic Brain Injury into
the Partnership for Innovation, Inclusion, and Independence. The House
Appropriations Committee fiscal year 2018 Labor, Health, Human
Services, and Education bill does not consolidate these programs.
Do you agree that each of these programs plays a unique role in
facilitating the mission of ACL?
Would you support an effort to consolidate these programs to save
money?
Answer 3. The work of all three entities is important. The ultimate
goal is achieving the highest possible outcomes with the programs and
for the populations we serve. I look forward to being a part of the
coming conversation and working with all parties to deploy whatever is
decided and following the guidance given by the President and Congress.
Question 4. Older adults and people with disabilities experience
unique barriers during a crisis. As the director of the Aging Services
Division in Oklahoma, how did you engage individuals, service
providers, and communities in emergency preparedness? How will you
ensure emergency preparedness and response programs are accessible to
all individuals with disabilities?
Answer 4. Oklahoma ranks as one of the top States in disaster
declarations, giving me ample exposure to the importance of emergency
preparedness. For the past decade, I have served on several of our
State's top preparedness committees and many of my staff members are
directly tied to response plans. Building on the plans ACL already has
in place is critical, and my commitment to ensuring the safety of the
populations we serve during a time of crisis is very strong. I look
forward to working with the Assistant Secretary for Preparedness and
Response (ASPR) to make sure that programs are accessible to all
individuals.
Question 5. WIOA transferred the National Institute on Disability,
Independent Living, and Rehabilitation Research (NIDLIRR) from the
Department of Education's Office of Special Education and
Rehabilitative Services (OSERS) to ACL. NIDILRR's mission is to
generate new knowledge and promote its effective use to improve the
abilities of people with disabilities to perform activities of their
choice in the community.
What is your position on evidence-based programs and policy?
As director of the Aging Services Division in Oklahoma, how have
you used data to make program and policy decisions?
Answer 5. NIDLIRR has a commendable history of producing important
work, generating new knowledge, and contracting with partners to
provide assistance to people with disabilities for activities of their
choice in the community. Evidence-based programs and policies are
important to ACL, and I will certainly continue that focus.
Question 6. The President's 2018 budget proposal called for an
elimination of the Senior Community Service Employment Program (SCSEP).
The House Appropriations Committee 2018 Labor, Health, Human Services,
and Education bill transfers the program to ACL and also cuts $100
million in funding. The SCSEP is the only employment program targeted
for older adults and has been successful in assisting millions of low-
income job seekers find work.
Answer 6. If confirmed as the Assistant Secretary for Aging, will
you commit to protecting the SCSEP and advocate for robust funding to
ensure the program reaches all eligible older adults who experience
barriers to employment?
I am committed to removing barriers to employment, regardless of
age or disability. Ensuring that everyone who wants to work has as many
opportunities as possible to do so is a critical element of supporting
the ability of all people to live their lives as integrated members of
their communities. Increasing access and eliminating barriers to
employment has been part of ACL's mission since its creation, and I
look forward to continuing that important work.
Question 7. The Leadership Council of Aging Organizations (LCAO)
wrote a letter opposing ACL's proposal to eliminate LGBT older adults
from the National Survey of Older American Act Participants. Do you
agree with LCAO that,
``ACL must continue collecting data on whether the aging
network is reaching LGBT older adults in order to ensure the
maximum inclusion of LGBT older adults in programs funded under
the Older Americans Act?''
As the Assistant Secretary for Aging, would you stand up for LGBT
individuals and prevent any systematic effort by this Administration to
eliminate data necessary for the full inclusion of the LGBT community
in Federal programs?
Answer 7. Throughout its existence, ACL has been committed to
ensuring that all people touched by or eligible for our programs have
access to the high quality services and supports they need to be able
to live where they choose and with the people they choose, and to fully
participate in their communities, and I share that commitment. We will
continue to work with grantees and stakeholders in the aging and
disability networks to help them best serve older adults and people
with disabilities, particularly those with the greatest social and
economic needs.
Question 8. As you know, the Older Americans Act specifically
establishes the role of the Assistant Secretary for Aging with a direct
reporting relationship to the Secretary of the Department of Health and
Human Services (HHS). In the dual role for which you are nominated, how
do you anticipate being a leader and advocate on behalf of the Older
Americans Act and the Aging Services Network, while also providing
stewardship of the programs and services that both older adults and
individuals with disabilities rely upon?
Answer 8. I know from the State perspective that bringing together
aging and disability work at the Federal level has worked remarkably
well. The aging and disability networks have embraced the concept and
have committed to making it successful. There are a lot of similarities
in the services and supports older adults and people with disabilities
need to live independently. Together, we are better able to leverage
learnings and best practices for meeting similar needs. Further, the
disability and aging communities together have a larger voice than
either community on its own. At the same time, neither network loses
the unique elements of its individual mission.
When there are issues that affect both people with disabilities and
older adults, we can join forces to address them in a consistent and
holistic way. There also are issues that affect only older adults, or
only people with disabilities. I am committed to ensuring that ACL
continues to develop and manage programs that best serve each
population individually, as well.
Question 9. As a result of the Americans with Disabilities Act and
the U.S. Supreme Court's decision in Olmstead v. L.C., there has been a
national trend toward deinstitutionalization and community inclusion of
older adults and people with disabilities.
Do you agree with the Supreme Court's ruling that it is
discrimination to deny people with disabilities services in the most
integrated setting possible?
Do you agree that for older adults and people with disabilities,
having the option to live and receive services in their homes and
communities can be vital to their well-being?
If confirmed, will you defend and broaden access to home and
community-based services and supports for both older adults and people
with disabilities?
Answer 9. I am fully committed to implementing the laws passed by
Congress that provide ACL with tools to assist older and disabled
Americans to live where they choose and with the people they choose,
and to participate as they choose in their communities.
For this to be possible, home- and community-based services and
supports must be robust enough that individuals with even the most
complex medical and behavioral needs who desire to live in the
community can be appropriately and effectively supported in their own
home- or other community-based settings. While this has been
demonstrated in many communities, it is not reality everywhere.
ACL advocates for the expansion and coordination of home- and
community-based services and improvements in quality so that older
adults and people with disabilities have more and better options about
how and where to receive the long-term services and supports they need.
I look forward to continuing that work.
Question 10. The President's 2018 budget proposal called for a
number of cuts to programs for older adults and people with
disabilities under ACL, raising questions whether this Administration
values the programs ACL supports. If confirmed, will you be a vocal
advocate internally for funding for ACL and push back in future budget
cycles against cuts to programs that support these communities?
Answer 10. I have been an advocate for older adults and people with
disabilities throughout my career. I look forward to continuing that
role at the Federal level to help ensure the long-term sustainability
of the critical programs that support older adults and people with
disabilities and help them live independently.
senator sanders
Question 1. Mr. Robertson, this position plays a pivotal role in
assessing, planning and advocating for a variety of programs and
initiatives that are aimed at improving the health, health care,
wellness and lives of older individuals. As you know, as most Americans
age, they do so wanting to age in their own homes. Often times, this
means that they will require a variety of critically important support
services--like meal programs, community-based care, and assistance
provided to their care givers--many of which you strongly advocated for
in your previous positions. In fact, your past positions on the
importance of supporting and robustly funding these programs show that
you understand how vital they are to older people, especially to those
who are trying to age at home. Unfortunately, based on the budget he
proposed, President Trump seems far less supportive of these types of
very important programs. How do you plan to ensure that the very
programs that you have expressed strong support for in the past--
programs that make a very real difference to millions of older
Americans--do not get drastically cut or eliminated altogether in this
Administration? What are your plans to ensure that older Americans will
have the support services that they need to age with dignity in their
own homes?
Answer 1. ACL's work to help older adults and people with
disabilities live independently in their communities has never been
more important. There are 65 million people age 60 and older. All but a
tiny percentage of them live in non-institutional settings, as do
nearly 57 million people with disabilities.
Older Americans are one of the fastest-growing demographic groups
in the country. Maintaining service levels in the face of a growing
population is always a challenge. I believe that the use of innovation
and evidence-based practices will be critical to keeping these programs
vital, and to meeting the evolving needs of older Americans.
Question 2. In detail, please share the top three efforts or
initiatives that you plan to launch to address the unique and pressing
health and health care issues facing people with disabilities during
this time when the current health care system is being reformed?
Answer 2. I am looking forward to working with my colleagues at ACL
and throughout HHS to learn more about the programs and initiatives
already in place. The strategy I shared in my testimony applies to both
older adults and people with disabilities. For both populations,
navigating the systems of services and support, identifying what is
available, and understanding how to access those services, can be
overwhelming. We have to streamline that process and ensure the needs
of the person are kept at the forefront of our focus.
Families and friends play a critical role in supporting older
adults and people with disabilities alike. Supporting those people is
essential to helping older adults and people with disabilities continue
living independently in the community. It is imperative that we ensure
the community-based organizations, that form the aging and disability
networks, are able to survive in the increasingly complex health care
environment. ACL has been investing in helping the networks develop the
business acumen necessary to integrate the services they provide into
the overall health care spectrum. I believe that work is absolutely
critical.
senator casey
Question 1. During the campaign, President Trump said that he would
``do everything in [his] power to protect LGBT citizens.'' As we have
seen, the President and the Administration are failing to live up to
that promise. Last week, over Twitter, President Trump announced
transgender individuals would be banned from serving in the military.
Sadly, that is far from the only Administration action that would have
adverse consequences for LGBT Americans. In April, ACL eliminated
sexual orientation and gender identity questions on two important
surveys that are used to assess Older Americans Act and disabilities
programs. Mr. Robertson, if you are confirmed, will you ensure that ACL
programs meet the needs of the entire LGBT community and will you
commit to collecting data on both sexual orientation and gender
identity on ACL surveys that are used to assess the effectiveness of
ACL programs?
Answer 1. I am committed to working with the aging and disability
networks to help them best serve older adults and people with
disabilities, particularly those with the greatest social and economic
needs. I am committed to better understanding these issues and ensuring
that ACL's programs serve all people, including LGBT older adults and
people with disabilities.
Question 2. The President's budget included language that would
merge several disability programs, including the State councils on
independent living and the State developmental disabilities councils,
which are authorized under separate statutes and are currently
administered by ACL. At the same time, the administration has
significantly recommended cutting the funding for these programs. The
greater disability community is very concerned about this proposal. Do
you support this approach and how would you merge these programs while
ensuring congressional intent is maintained? Given that you do not have
extensive experience with the disability community, do you commit to
personally reaching out to them to obtain their input on this proposal?
Answer 2. I support the idea of delivering services that help to
achieve independence, productivity, integration, self-determination,
and inclusion in the community while eliminating silos that make it
harder for people to access the services they need. It is critical that
we work closely with the aging and disability networks to ensure we are
best meeting the needs of the people we serve. I look forward to
working with you to implement the law faithfully and to give full
consideration to the input from our partners across the disability
communities.
Question 3. While the number of older Americans is growing
exponentially daily, aging programs have been cut or flat lined in the
President's proposed budget. How are you going to ensure that vital
programs important to aging Americans are protected, are not subject to
arbitrary drastic cuts, and grow according to the needs of seniors
during your tenure in this Administration?
Answer 3. I have been an advocate for older adults and people with
disabilities throughout my career, and I look forward to continuing
that role at the Federal level to help ensure the long-term
sustainability of the critical programs that support older adults and
people with disabilities and help them live independently.
Maintaining service levels in the face of a growing population is
always a challenge. I believe that the use of innovation and evidence-
based practices, such as the flexibility Congress provided to allow up
to 1 percent of ACL's nutrition funding to explore innovative ways to
provide services, or the requirement that preventive health dollars be
used for evidenced-based approaches, will be critical to keeping these
programs vital and to meeting the evolving needs of older Americans.
Question 4. During your opening statement at the hearing on August
1 you stated that your goal is to provide services for those who are
aging and those with disabilities via the least expensive means
possible. You did not mention the quality of those services. Why not?
How is quality of services important for those who are aging and those
with disabilities? How will you balance the demands of cost efficiency
and quality of services?
Answer 4. Establishing quality standards and ensuring our programs
meet them is absolutely critical. Many of ACL's programs already have
outcome measures related to service quality. This must of course be
woven into the fabric of everything we do.
Question 5. During your opening statement at the hearing on August
1 you mentioned four goals you would work to achieve if you were
confirmed as Assistant Secretary for Aging and Administrator of
Community Living. These included (a) access to treatment and service
information, (b) support for caregivers, (c) elder justice, and (d)
increasing the network's business acumen. How will you plan to ensure
everyone who wants to receive care in their homes and communities can
do so? Will you commit to reviewing these goals with the aging and
disability communities and amending the goals depending upon the needs
identified by the communities?
Answer 5. Since its creation, ACL has advocated for the expansion
and coordination of home- and community-based services and improvements
in quality so that older adults and people with disabilities have more
and better options about how and where to receive the long-term
services and supports they need. I am excited to continue this work as
the ACL administrator.
To do that most effectively and efficiently, we have to work
together across all levels of government, within the aging and
disability networks, and with all potential partners to establish
strategies for meeting these goals. Through my work at the State level
and as a leader within NASUAD, I have spent many years working in
partnership with my colleagues in other organizations to do exactly
that. I am looking forward to continuing to work with my colleagues in
the disability community to ensure we are doing the right things to
best serve the greatest number of people with the greatest needs.
Question 6. While a number of the goals you identify for ACL
address aging concerns, they do not specifically call out the needs for
individuals with disabilities and their families. There are many
barriers that people with disabilities face, including continued
prejudice and discrimination in services, employment, treatment and
supports. How will you ensure ACL prioritizes people with disabilities
as well as aging issues?
Answer 6. The strategy I shared in my testimony applies to both
older adults and people with disabilities. For both populations,
navigating the systems of services and support, identifying what is
available, and understanding how to access those services, can be
overwhelming. We have to streamline that process and ensure the needs
of the person are kept at the forefront of our focus.
Families and friends play a critical role in supporting older
adults and people with disabilities alike. Supporting this community is
essential to helping older adults and people with disabilities continue
living independently in the community. It is imperative that we ensure
the community-based organizations that form the aging and disability
networks are able to survive in the increasingly complex healthcare
environment. ACL has been investing in helping the networks develop the
business acumen necessary to integrate the services they provide into
the overall healthcare spectrum. I believe that work is absolutely
critical.
Question 7. Your experience with the disability community at a
national level is very limited. How will you go about engaging the
community and learning what issues are most important to the community?
Will you commit to personally have quarterly meetings with leaders of
the disability community for at least the first 18 months of your
tenure?
Answer 7. I look forward to getting to know my colleagues in the
disability field and I am committed to working closely with them to
ensure we are best meeting the needs of the people we serve. I expect
to establish an ongoing dialog, and we will meet as frequently as
necessary.
Question 8. This Administration has proposed cutting Medicaid
funding both through repealing the PPACA and through the budgeting
process. The latest budget bill coming out of the House of
Representatives calls for $1.4 trillion in cuts to Medicaid. Included
in ACL's mission is the statement that,
``All Americans--including people with disabilities and older
adults--should be able to live at home with the supports they
need, participating in communities that value their
contributions.''
After unpaid family supports, Medicaid is the largest funder of
home and community-based long-term services and supports. It makes it
possible for individuals to live in their own homes, independently move
about their communities, and obtain and retain jobs. How will you
advocate for protecting Medicaid funding and how will you ensure the
mission to have all Americans who are aging and/or have disabilities,
live at home in their communities?
Answer 8. ACL's work to help older adults and people with
disabilities live independently in their communities has never been
more important. There are 65 million people age 60 and older. All but a
tiny percentage of them live in non-institutional settings, as do
nearly 57 million people with disabilities. Both populations are
growing, and older Americans are one of the fastest-growing
demographics in the country; by 2020, there will be more than 77
million people over the age of 60.
I have been an advocate for older adults and people with
disabilities throughout my career. I look forward to continuing that
role at the Federal level to help ensure the long-term sustainability
of the critical programs that support older adults and people with
disabilities and help them live independently.
Question 9. ACL recently published three requests for comments in
the Federal Register, for both aging and disability datasets, regarding
the removal of data collection elements on Sexual Orientation and
Gender Identity (SOGI). Both Office of Management and Budget and
Healthy People 2020 recognize the need for collecting data on this
underrepresented group as a way to measure unmet need. Will you commit
to restoring the LGBTQ questions to these surveys?
Answer 9. I am committed to working with the aging and disability
networks to help them best serve older adults and people with
disabilities, particularly those with the greatest social and economic
needs. I am committed to better understanding these issues and ensuring
that ACL's programs serve all people, including LGBT older adults and
people with disabilities.
Question 10. Over the last several months, I have sent multiple
letters to HHS about the Administration's ongoing efforts to undermine
and sabotage the Affordable Care Act through executive action. HHS has
failed to provide responses to many of my letters. If HHS has
responded, the response letters have been wholly inadequate and have
not been responsive to my requests. If you are confirmed, do you commit
to respond in a timely manner to all congressional inquiries and
requests for information from all Members of Congress, including
requests from Members in the Minority?
Answer 10. Yes, I will appropriately respond to all Member
requests. I look forward to working with all Members of Congress to
address the needs and concerns of older adults and people with
disabilities.
senator franken
Question 1. Do you support the use of Medicaid home and community-
based services for both older adults and people with disabilities? What
will you do to make sure seniors and people with disabilities can stay
in their communities and remain independent as long as possible?
Answer 1. Since its creation, ACL has advocated for the expansion
and coordination of home- and community-based services and improvements
in quality so that older adults and people with disabilities have more
and better options about how and where to receive the long-term
services and supports they need. I am excited to continue this work.
Question 2. How will you work with Congress to shape the next Older
Americans Act legislation? What priorities do you think the legislation
should address?
Answer 2. We need to tackle one of the most critical issues facing
us today--the role of the aging services network and its capacity to
truly partner with the healthcare system in order to provide and
partner in an integrated service delivery model. I look forward to
working with the aging network and Congress to this end.
senator bennet
Question 1. Many chronic diseases are preventable or better managed
when caught early. When they are not, there is a large cost burden on
our society. The American Diabetes Association estimates that the
economic cost of diabetes was nearly $250 billion in 2012, a 41 percent
increase since 2007. In Medicare, 15 percent of the sickest enrollees
that often have multiple chronic conditions, account for 50 percent of
Medicare spending.
What is your strategy around prevention so that certain chronic
diseases are avoided or better managed in order for us to improve
outcomes and save Medicare dollars?
Answer 1. Under Title III-D of the Older Americans Act, ACL
supports a number of evidence-based programs that help older adults
maintain their health and wellness. This includes programs that help
older adults learn to effectively manage chronic diseases like
diabetes, programs that help prevent falls, and other such programs.
Centers for independent living and university centers of excellence on
developmental disabilities offer similar programs for people with
disabilities. Programs like these that use evidence-based models help
to avoid the far higher costs associated with advancing disease, and I
look forward to continuing to build on these efforts.
senator whitehouse
Question 1. President Trump's budget eliminates Senior Corps, a
program that engages a quarter of a million older adults who volunteer
almost 75 million hours of service each year to community programs that
serve seniors, children, veterans and others. Although the Assistant
Secretary for Aging does not oversee Senior Corps, the Administration
for Community Living has a memorandum of understanding with the
Corporation for National and Community Service to promote volunteerism
by older adults and people with disabilities.
Do you believe the elimination of Senior Corps will benefit
seniors?
Will you advocate within the administration for funding for
programs like Senior Corps that help keep seniors engaged in their
communities?
Answer 1. I believe strongly in the value that older adults provide
to their communities, and I believe we are stronger when we harness the
power of everyone's talents. ACL is different from many Federal
agencies in that advocacy is explicitly included in several of the
statutes that authorize its programs. I am looking forward to
continuing that role at the Federal level to help ensure the long-term
sustainability of the critical programs that support older adults and
people with disabilities and help them to fully participate in their
communities.
Question 2a. President Trump's budget cuts almost $80 million from
disability programs within the Administration on Community Living,
which is overseen by the Assistant Secretary for Aging. The President
himself has publicly mocked a disabled person.
Do you believe these budget cuts will lead to better outcomes for
people with disabilities?
Answer 2a. I support the idea of delivering services that help to
achieve independence, productivity, integration, self-determination and
inclusion in the community while eliminating silos that make it harder
for people to access the services they need. I look forward to working
with ACL team members, HHS leaders, and Congress to ensure these
programs are funded in the most responsible way.
Quesion 2b. Please list three things you will do if confirmed to
support disabled Americans and the Federal programs that serve them.
Answer 2b. I am looking forward to working with my colleagues at
ACL and throughout HHS to learn more about the programs and initiatives
already in place. The strategy I shared in my testimony applies to both
older adults and people with disabilities. For both populations,
navigating the systems of services and support, identifying what is
available, and understanding how to access those services, can be
overwhelming. We have to streamline that process and ensure the needs
of the person are kept at the forefront of our focus.
Families and friends play a critical role in supporting older
adults and people with disabilities alike. Supporting those people is
essential to helping older adults and people with disabilities continue
living independently in the community. It is imperative that we ensure
the community-based organizations that form the aging and disability
networks are able to survive in the increasingly complex health care
environment. ACL has been investing in helping the networks develop the
business acumen necessary to integrate the services they provide into
the overall health care spectrum. I believe that work is absolutely
critical.
senator baldwin
Question 1. In 2012, the Administration on Aging (AOA) issued new
guidance on the definition of the term ``greatest social need'' in the
Older Americans Act that included ``individuals isolated due to sexual
orientation or gender identity.''
Do you support AOA's guidance that States can classify LGBT older
adults as a greatest social needs population? Please explain your
answer.
Should ACL do more to ensure States are assessing and meeting the
needs of the LGBT older adult population?
What, if anything, did you do as the director of the Aging Services
Division in Oklahoma to both assess and meet the needs of LGBT older
adults under your tenure?
Answer 1. I am committed to working with the aging and disability
networks to help them best serve older adults and people with
disabilities, particularly those with the greatest social and economic
needs. I am committed to better understanding these issues and ensuring
that ACL's programs serve all people, including LGBT older adults and
people with disabilities.
Question 2a. I am concerned with ACL's proposals to eliminate data
on key demographic populations, including LGBT older adults as well as
transgender older adults, from this year's National Survey of Older
Americans Act Participants. This critical survey is used to evaluate
the effectiveness of the Older Americans Act programs funded through
HHS, including who is able to access the programs.
Answer 2a. Older LGBT and transgender individuals face many
challenges including financial insecurity, social isolation,
discrimination, and barriers to access for aging and accessibility
services. I believe that removing sexual orientation and gender
identity questions from these surveys will limit HHS's ability to
address these issues. In fact, NASUAD sent a statement to ACL
addressing their data collection efforts on LGBT individuals which
reads,
``. . . we believe that there is opportunity to improve the
data collection regarding the needs and prevalence of different
populations served by the aging network [and] recommend that
ACL continue to refine this data collection in order to provide
meaningful analysis rather than eliminate the questions.''
While, I am encouraged that HHS has decided to retain the sexual
orientation question, I remain very troubled by the proposed
elimination of the gender identity question. Further, I am concerned
that these actions reveal a troubling pattern by HHS to rollback
efforts to improve community care and address health disparities for
these vulnerable populations.
Question 2b. Do you believe HHS and ACL should do more to improve
data collection on LGBT individuals? Will you commit to enhancing ACL's
efforts to collect data on LGBT older adults and people with
disabilities?
Answer 2b. I am committed to working with the aging and disability
networks to help them best serve older adults and people with
disabilities, particularly those with the greatest social and economic
needs. I am committed to better understanding these issues and ensuring
that ACL's programs serve all people, including LGBT older adults and
people with disabilities.
Question 3. Former HHS Secretary Kathleen Sebelius played a leading
role in establishing ACL and stated that, ``. . . we now recognize that
LGBT older adults also represent a community with unique needs that
must be addressed''. Do you agree with this statement?
Answer 3. I am committed to working with the aging and disability
networks to help them best serve older adults and people with
disabilities, particularly those with the greatest social and economic
needs.
senator murphy
Question 1. As you may know, State Health Insurance Assistance
Programs (SHIPs) play an essential role in helping Medicare
beneficiaries, who are often low-income or have complex health
conditions, navigate make informed decisions about their Medicare
coverage.
Answer 1. In Connecticut, the SHIP program, known as CHOICES,
helped 34,200 seniors, people with disabilities, and family caregivers
last year find the health care program that works for them and their
families. Connecticut received over $676,000 in Federal funding last
year through the SHIP program. There are five regional offices that
administer the program.
SHIP counselors provide personalized, one-on-one assistance to
seniors and their families that cannot be replicated by 1-800-MEDICARE
or other broad outreach activities, because it is often the Medicare
beneficiaries with the most complex cases and fewest resources who seek
their help. SHIP counseling assistance can save individual Medicare
beneficiaries hundreds, or even thousands, of dollars every year, and,
as a result, can save some seniors from having to choose between paying
for their health care and essentials such as their rent or groceries.
Unfortunately, Federal funding for SHIPs has been targeted for
elimination or reduced funding over the years.
As Assistant Secretary of Aging, will you advocate for adequate
Federal funding for the State Health Insurance Assistance Program
(SHIP) in light of the need for critical SHIP services for seniors--
particularly low-income seniors navigating an increasingly complicated
Medicare system?
For older adults, people with disabilities, and their families,
navigating the systems of services and support, identifying what is
available, and understanding how to access those services can be
overwhelming. Similarly, determining the best Medicare elections for
individual situations can be challenging, and many people who are
eligible for Medicare need assistance understanding the various
options. I look forward to working with all parties to ensure that
older adults, people with disabilities, and their families understand
the choices and services available to them and how to access them.
Question 2. A recent report by the National Academies of Sciences,
Engineering and Medicine found that close to 18 million Americans of
working age help disabled or older family members or friends with
activities of daily living on an ongoing basis. In Connecticut, 1 in 6
residents are providing care for a relative, and 70 percent believe
they will at some point. The report forecast that the numbers of family
caregivers will continue to rise, not taking into account any potential
cuts to Medicaid that would likely exacerbate our country's caregiving
crisis.
As you may know, family caregiving obligations have a substantial
economic impact, as workers in this situation often have to take time
off from jobs, cut back on working hours, or leave the paid workforce
altogether. Unfortunately, this lowers their future Social Security
benefit, threatening their own retirement. Studies indicate that on
average, total wage, private pension, and Social Security losses due to
caregiving add up to more than $300,000. In Connecticut, an estimated
459,000 caregivers in 2013 spent 427 million hours providing nearly $6
billion in unpaid caregiving.
I believe that family caregivers deserve our gratitude, not
punishment for taking time off to care for a loved one. That's why,
after hearing concerns from family caregivers around Connecticut, I
introduced the Social Security Caregiver Credit Act, which would add a
credit to caregivers' lifetime earnings to determine how much they
should receive in Social Security benefits. By creating a Social
Security Caregiver credit, caregivers who had to leave the workforce
entirely, or continue to work with significantly reduced hours, would
receive modest retirement compensation.
What specific initiatives will you, as Assistant Secretary on Aging
and Administrator of the Administration for Community Living, undertake
to facilitate family caregiving?
Answer 2. As I shared in my testimony, my vision includes a
strategic focus on supporting caregivers. Informal caregivers of
individuals with disabilities and older adults and the services and
supports they provide them are the epicenter of the long-term services
and supports system. Under my leadership we will continue to promote
evidence-based solutions, and build support systems that work. We will
continue to seek ways to meet caregivers where they are and equip them
with the tools they need to be successful in this important role.
senator warren
Medicaid
According to the Centers for Medicare and Medicaid Services (CMS),
8.3 million low-income seniors and people with disabilities receive
health care coverage through both Medicare and Medicaid, making them
``dually eligible.'' People who are dually eligible receive financial
assistance to help pay their premiums, out-of-pocket costs, nursing
facility care, eyeglasses, and hearing aids.\1\ Medicaid also provides
the backbone for coverage of long-term services and supports (LTSS),
including home and community-based services (HCBS) that help seniors
and people with disabilities live independently.\2\ Two-thirds of
Americans living in nursing homes rely on Medicaid.\3\
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\1\ Centers for Medicare and Medicaid Services, ``Seniors &
Medicare and Medicaid Enrollees'' (online at: https://www.medicaid.gov/
medicaid/eligibility/medicaid-enrollees/index.html). Accessed August 1,
2017.
\2\ Erica L. Reaves, MaryBeth Musumeci, ``Medicaid and Long-Term
Services and Supports: A Primer,'' Kaiser Family Foundation (December
15, 2015) (online at: http://www.kff.org/medicaid/report/medicaid-and-
long-term-services-and-supports-a-primer/).
\3\ Ina Jaffe, ``Nursing Homes Worry Proposed Medicaid Cuts Will
Force Cuts, Closures,'' NPR (June 28, 2017) (online at: http://
www.npr.org/sections/health-shots/2017/06/28/534764940/proposed-
medicaid-cuts-likely-to-put-pressure-on-nursing-homes).
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President Trump has supported legislation that would cut Medicaid
by more than $700 billion, converting it to a per capita cap or block
grant system.\4\ His budget proposal for fiscal year 2018 (FY18) also
proposed an additional cut to Medicaid of over $600 billion.\5\
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\4\ Philip Bump, ``By 2026, Annual Medicaid Cuts under the Senate
Health-Care Replacement Plan are Steeper than Under Repeal,''
Washington Post (July 19, 2017) (online at: https://
www.washingtonpost.com/news/politics/wp/2017/07/19/by-2026-annual-
medicaid-cuts-under-the-senate-health-care-replacement-plan-are-
steeper-than-under-repeal/?utm_term=.27c6f093a793); Danielle Kurzleben,
``GOP Health Plan Would Leave 23 Million More Uninsured, Budget Office
Says,'' NPR (May 24, 2017) (online at: http://www.npr.org/2017/05/24/
529902300/cbo-republicans-ahca-would-leave-23-million-more-uninsured).
\5\ Iris J. Lav, Michael Leachman, ``The Trump Budget's Massive
Cuts to State and Local Services and Programs,'' Center on Budget and
Policy Priorities (June 13, 2017) (online at: https://www.cbpp.org/
research/state-budget-and-tax/the-trump-budgets-massive-cuts-to-state-
and-local-services-and).
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As Assistant Secretary for Aging, as well as the Administrator for
Community Living (ACL), you will be responsible for addressing the
concerns and advancing the interests of America's seniors and people
with disabilities.
Question 1. Do you agree that Medicaid plays an essential role in
ensuring that seniors and people with disabilities can get access to
affordable high-quality services that allow them to live independently
at home and in their communities?
Answer 1. Medicaid plays an essential role along with other public
and private resources at the Federal, State and local level and support
provided by family members and other caregivers to assist individuals
to live independently and participate fully in society.
Question 2. Do you agree that hundreds of billions of dollars in
cuts to Medicaid would have a negative impact on the ability of seniors
and people with disabilities to access health care?
Answer 2. Medicaid plays an essential role along with other public
and private resources at the Federal, State and local level and support
provided by family members and other caregivers to assist individuals
to live independently and participate fully in society.
Long-term services and supports
The Assistant Secretary for Aging oversees the Administration on
Aging (AOA), which includes the Office of Elder Justice and Adult
Protective Services and the Office of Long-Term Care Ombudsman
Programs. These two offices work together to advocate for the rights
and protection of the elderly and adults with disabilities from
``abuse, neglect, self-neglect, or financial exploitation.''\6\ The
Long-Term Care Ombudsman Program works to resolve problems and promote
policies that protect patients in LTSS settings, including assisted
living facilities. This program is required to identify and investigate
complaints of residents in LTSS settings, provide administrative and
legal services for residents, and ``analyze, comment on, and recommend
changes in laws and regulations pertaining to the health, safety,
welfare, and rights of residents.''\7\
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\6\ Administration for Community Living, ``Supporting Adult
Protective Services'' (online at: https://www.acl.gov/programs/elder-
justice/supporting-adult-protective-services). Accessed August 1, 2017.
\7\ Administration for Community Living, ``Long-Term Care Ombudsman
Program'' (online at: https://www.acl.gov/node/68). Accessed August 1,
2017.
Question 3. Do you agree that America's seniors, people with
disabilities, and their families deserve to know that when they or
their loved ones are in a nursing home or assisted living facility, it
is a safe, high-quality care facility?
Answer 3. All people have the right to live their lives with
dignity and respect, free from abuse of any kind, regardless of the
setting.
Question 4. Nursing homes are regulated at the State level and via
CMS, and CMS has established the Nursing Home Compare Web site to
provide information to help seniors and families choose the facility
that best suits their needs. How does the AOA work with CMS to ensure
that seniors have access to this and other information that they need?
What other actions does the AOA take to improve the quality of
nursing home care?
If confirmed, what additional steps will you take to improve the
quality of nursing home care?
Answer 4. CMS and ACL work closely together on several nursing home
initiatives to support quality care, including initiatives to reduce
the misuse of antipsychotic medications, reduce inappropriate discharge
and evictions, and to foster person-centered care practices.
ACL has also worked with its National Ombudsmen Resource Center to
develop consumer education materials for individuals and their families
regarding residents' rights and other provisions related to the revised
nursing home regulations in order to inform consumers and to support
quality, individualized care.
Question 5. The Federal Government pays for care in assisted living
facilities via Medicaid waiver programs that allow payments for such
care. However, there is limited or no Federal oversight of these
facilities. What actions does the AOA currently take to improve the
quality of care in assisted living facilities and to ensure that
seniors have access to the information they need to choose the best
facility for their needs?
Answer 5. State Long-Term Care Ombudsman programs offer complaint
resolution services, information and assistance, and training to both
consumers and staff of assisted living facilities. In assisted living,
board and care, and other residential care communities, Ombudsman
programs most frequently work on complaints such as, medication errors,
food concerns, improper eviction or inadequate discharge, lack of
dignity or respect for residents, poor staff attitudes and building or
equipment hazards or need for repair. Through the National Ombudsman
Resource Center technical assistance and training related to assisted
living facility settings is provided through Web materials and through
webinars and other training.
Question 6. What additional steps do you believe that AOA can take
to ensure that the care provided to seniors at Assisted Living
Facilities is both high quality and cost-effective?
Answer 6. Key steps include further promoting person-centered care
practices and educating and training facility staff on the indicators
of and how to report abuse, neglect and exploitation.
Question 7. Will you commit to advocating on behalf of seniors and
people with disabilities living in nursing homes or assisted living
facilities, including advocating for robust funding and policies that
ensure consumer protections?
Answer 7. ACL is different from many Federal agencies in that
advocacy is explicitly included in several of the statutes that
authorize its programs. The Long-Term Care Ombudsman in every State
works with residents of long-term care facilities, including nursing
homes, to protect their rights and resolve disputes. Further, State
Long-Term Care Ombudsmen also serve as advocates for people living in
facilities, providing input on State and local legislation and policy
that affects facilities.
Question 8. What specific steps will you take to ensure that
seniors and people with disabilities, as well as their families, know
about the Long-Term Care Ombudsman Program and the services it
provides?
Answer 8. ACL will continue to promote the Long-Term Care Ombudsman
Program and its services and supports in partnership with national,
State and local grantees and stakeholders. This includes ensuring
information and referral through phone, internet, and in-person contact
with individuals with disabilities, older adults, and their families
and caregivers. Social media is an area where a new and additional form
of outreach is occurring.
Question 9. Between 2010 and 2014, more than 100 cases of abuse,
medical malpractice, or wrongful death related to skilled nursing
facilities were forced into arbitration.\8\ Forced arbitration
clauses--often buried in confusing paperwork signed under duress--bar
residents from taking these facilities to court. Last fall, the Centers
for Medicare and Medicaid Services (CMS) banned skilled nursing
facilities from compelling new residents to enter into such agreements,
but a new CMS proposal rescinds that ban, allowing SNFs to take
advantage of our Nation's most vulnerable citizens through this
predatory and opaque practice.\9\ Do you agree that arbitration should
be transparent and agreed to voluntarily, without threat of being
turned down or kicked out from residence of a skilled nursing facility
where a patient would like to receive services?
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\8\ Jessica Silver-Greenberg, Michael Corkery, ``In arbitration, a
`privatization of the justice system' '' The New York Times (November
1, 2015) (online at: http://www.nytimes.com/2015/11/02/business/
dealbook/in-arbitration-a-privatization-of-the-justice-system.html).
\9\ Virgil Dickson, ``CMS Lifts Ban on Nursing Home Arbitration
Agreement,'' Modern Healthcare (June 5, 2017) (online at: http://
www.modernhealthcare.com/article/20170605/NEWS/170609949).
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Answer 9. All people have the right to live their lives with
dignity and respect, free from abuse of any kind, regardless of the
setting.
State Health Insurance Assistance Program (SHIP)
The Administration on Aging oversees the State Health Insurance
Assistance Program (SHIP), which ``provides Medicare beneficiaries with
information, counseling, and enrollment assistance.''\10\
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\10\ Administration for Community Living, ``State Health Insurance
Assistance Program (SHIP)'' (online at: https://www.acl.gov/node/162).
Accessed August 1, 2017.
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Medicare provides quality health care coverage to millions of
American seniors and Americans with disabilities. State Health
Insurance Programs help direct individuals to the right care options by
providing support and information for beneficiaries. SHIPs help
beneficiaries enroll in the Medicare plans that are right for them,
resolve billing issues, report fraud, and otherwise help beneficiaries
navigate the Medicare system.
These programs operate in all 50 States. In recent years, 7 million
individuals were provided assistance with Medicare through SHIPs.\11\
However, President Trump's budget proposal for fiscal year 2018
proposed gutting the program.\12\
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\11\ ``NCOA Issue Brief: FY 2018 Medicare SHIP Funding,'' National
Council on Aging (July 2017) (online at: https://www.ncoa.org/
resources/ncoa-issue-brief-fy18-medicare-ship-funding/).
\12\ ``President's FY 2018 Budget Eliminates Key Federal Programs
Supporting Older Adults and Caregivers,'' Area Agency on Aging (May 24,
2017) (online at: http://info4seniors.org/presidents-fy-2018-budget-
eliminates-key-Federal-programs-supporting-older-adults-caregivers/).
Question 10. Do you agree that SHIP is an important program for
seniors and individuals with disabilities?
Answer 10. For older adults, people with disabilities, and their
families, navigating the systems of services and support, identifying
what is available, and understanding how to access those services can
be overwhelming. Similarly, determining the best Medicare elections for
individual situations can be challenging, and many people who are
eligible for Medicare need assistance understanding the various
options. I look forward to working with all parties to ensure that
older adults, people with disabilities, and their families understand
the choices and services available to them and know how to access them.
Question 11. Will you advocate for these individuals by supporting
the continued funding of SHIPs?
Answer 11. For older adults, people with disabilities, and their
families, navigating the systems of services and support, identifying
what is available, and understanding how to access those services, can
be overwhelming. Similarly, determining the best Medicare elections for
individual situations can be challenging, and many people who are
eligible for Medicare need assistance understanding the various
options. I look forward to working with all parties to ensure that
older adults, people with disabilities, and their families understand
the choices and services available to them and how to access them.
senator hassan
Question 1. As you know, President Trump's budget proposal include
steep cuts to a number of important programs that make meaningful
community inclusion possible for individuals who experience
disabilities. These cuts include billions of dollars from Medicaid and
significant reductions to programs across the government that assist
individuals who experience disabilities, including cuts to the
Administration for Community Living, such as the elimination of funding
for State Councils on Developmental Disabilities. Will you stand up
against the President to protect funding for vital programs that
support individuals who experience disabilities?
Answer 1. I have been an advocate for older adults and people with
disabilities throughout my career. I look forward to continuing that
role at the Federal level to help ensure the long-term sustainability
of the critical programs that support older adults and people with
disabilities and help them live independently.
In addition, I believe that the use of innovation and evidence-
based practices will be critical to keeping these programs vital and to
meeting the evolving needs of older Americans and those with
disabilities.
Question 2. In our one-on-one meeting, you and I discussed that a
marked difference between individuals who are aging and those with a
disability is fully integrated employment. Individuals with
disabilities have a labor participation rate of around 20 percent,
which is less than a third of the labor participation rate of
individuals without a disability. What do you think the Administration
for Community Living can do to help ensure more individuals who
experience disabilities become gainfully employed?
Answer 2. ACL strives to assure that older adults and people with
disabilities do not face barriers to employment. Ensuring that everyone
who wants to work has opportunities to do so is a critical element of
helping people to live their lives fully integrated into their
communities. Increasing access and eliminating barriers to employment
has been part of ACL's mission since its creation, and I look forward
to continuing that important work.
Question 3. While Governor of New Hampshire, I signed a law which
made New Hampshire the first State to eliminate the payment of sub
minimum wage for individuals who experience disabilities. Do you
support the closure of sheltered workshops and ending the practice of
paying a sub minimum wage to individuals who experience disabilities?
Answer 3. Ensuring that everyone who wants to work has full
opportunities to do so is a critical element of helping people to live
their lives fully integrated into their communities. Increasing access
and eliminating barriers to employment has been part of ACL's mission
since its creation, and I look forward to continuing that important
work.
Response by Brett Giroir, M.D., to Questions of Senator Murray, Senator
Sanders, Senator Franken, Senator Bennet, Senator Whitehouse, Senator
Baldwin and Senator Warren
senator murray
Question 1. The Office of the Assistant Secretary for Health (OASH)
has a key role to play with regards to our Nation's response to both
HIV and hepatitis. What is your vision and plans to continue our
Nation's response to these public health issues? Will you continue to
implement the National HIV/AIDS Strategy and the National Viral
Hepatitis Action Plan? Will you commit to focusing efforts on areas
where we know more needs to be done while sustaining and building on
programs and activities that have been proven effective?
Answer 1. If confirmed, it is my intent that OASH will continue its
strong leadership role in implementing and extending both the National
HIV/AIDS Strategy and the National Viral Hepatitis Action Plan. There
is much work to be done to reduce the number of new infections with
increased prevention, diagnosis, and treatment. While we have made
enormous progress, we should strive to do more.
Question 2. Secretary Price has indicated that combating childhood
obesity is among his top three clinical priorities, and yet we've seen
little action from the Administration on this issue. In fact, Secretary
Price praised FDA's recent delay in implementing key menu labeling
requirements. Under his watch, we've also seen a delay in important
deadlines for updating the nutrition facts panel on packaged food. What
role does access to accurate and comprehensive nutrition information
play in supporting families' healthy eating efforts? What role does
such information play in combating childhood obesity? What would your
priorities be with regards to addressing childhood obesity?
Answer 2. As a pediatrician--and exercise enthusiast--with
programmatic experience in obesity and diabetes, I fully support the
Secretary's prioritization of childhood obesity as one of his top
objectives. If confirmed, I plan to work alongside the Secretary in
developing, coordinating, and implementing effective initiatives to
reduce childhood obesity through the programs that the Office of the
Assistant Secretary for Health administers.
In terms of food labeling, I certainly agree that it is important
to provide parents and children with meaningful, easily understood
information.
Question 3. Recent outbreaks have underscored the dangers of
delaying or avoiding recommended vaccines. If confirmed, you would
oversee the National Vaccine Program Office (NVPO). What do you view as
the key priorities for NVPO? Can you describe specific strategies NVPO
can take to improve vaccine usage? What can NVPO do to increase
adolescent and adult vaccination rates? HPV vaccination rates remain
much lower than other adolescent vaccines, even though the vaccine
prevents infections that can lead to cancer. What can be done,
including by NVPO, to improve adolescent HPV vaccination rates
specifically?
Answer 3. Vaccines save lives. They are the most important health
innovation of modern times. If confirmed, I will be a passionate
advocate for vaccines while working to continue our effective and
transparent monitoring systems to provide American families assurance
that vaccines remain safe. While no public health intervention,
including vaccinations is 100 percent risk-free, vaccines are the gold
standard of disease prevention. It's our job to provide parents high-
quality, scientifically accurate information so that they can feel
confident in the safety of the vaccines we recommend for American
children.
Question 4. Will you provide continued support for the current
revision of our Physical Activity Guidelines and similarly, would you
find ways under the current fiscal environment to optimize
communication and release of those guidelines?
Answer 4. As a fitness enthusiast, I understand the importance of
physical fitness for healthy living. If confirmed, I will work
collaboratively with the relevant agencies, including the CDC and NIH,
to ensure that Americans have scientifically sound information about
physical fitness and will support efforts to continue developing
research initiatives to improve our evidence base.
Question 5. The National Public Health Commissioned Corps is key to
the defense of public health in our country and played an important
role in Katrina, Ebola, and many other national and global crises. How
will you work to elevate the National Public Health Commissioned Corps
and their expertise in a modern way to assist in the response during
the next public health emergency? What do you view as the greatest
assets of the Corps?
Answer 5. I am proud of the honorable and hard-working members of
the Commissioned Corps. They are certainly an impressive and dedicated
group of professionals. I look forward to working with them more to
advance the President's and the Secretary's public health agenda and to
protect the health of all Americans.
Question 6. Title X is the only Federal grant program dedicated
solely to providing individuals with comprehensive family planning and
related preventive health services. It is designed to prioritize the
needs of low income families or uninsured people, including those who
are not eligible for Medicaid. These individuals may not otherwise have
access to these health care services. It promotes positive birth
outcomes and healthy families by enabling individuals to decide the
number and spacing of their children. Secretary Price has warned
current multi-year title X grant recipients that their funding ends
after this year, mid-way through the grant period, and they must
compete again for funding that they have already been awarded. As
Assistant Secretary for Health, you would oversee multiple grant making
programs. Can you assure future grant recipients that if they receive
grants for a certain term of years, the agency will not act to
prematurely terminate those grants, which the recipients rely on to
serve the highest need populations? Can grant recipients trust that
they can rely on the funding they have been awarded by you?
Answer 6. If confirmed, I commit to implementing the laws passed by
Congress and signed by the President effectively and faithfully, and
following the grant making rules and procedures of the Department.
Question 7. HHS regional offices are incredibly important to the
work the Department does in States and communities. How do you view the
role of regional offices in supporting the priorities of the
Department?
Answer 7. It is certainly true that the majority of the Nation's
wisdom does not reside inside the borders of Washington, DC. I will
definitely seek counsel and intelligence from the field, including from
Departmental offices as well as, and perhaps especially, from State and
local public health agencies and officials who are doing the bread-and-
butter public health work protecting Americans every day.
senator sanders
Question. As you know, one in five Americans between the ages of 19
and 64 years, cannot afford the medicines that their doctors prescribe
to them. Additionally, more than 7 in 10 Americans support the idea of
being able to purchase prescription drugs that are imported from
Canada. In detail, please share your position on drug importation from
Canada? Are you familiar with the recent CBO analysis that has shown
that importation would save the government $6.5 billion over 10 years?
What would it mean for the health outcomes of the 35 million Americans
who currently are unable to afford their medicines?
Answer. The President and the Secretary have made reducing the
financial pain at the pharmacy counter a major priority. As we carry
out that initiative, the safety and quality of medicines that Americans
take, as well as their affordability, will be our guide.
senator franken
Question 1. The President's proposed budget and actions taken so
far have sought to undermine the very programs that you will be charged
with supporting. What will you do to ensure that public health and
effective prevention measures remain a top priority at the Department
of Health and Human Services?
Answer 1. Preventable diseases and chronic diseases account for a
majority of American health disparities and healthcare expenditures.
Protecting the public's health will of course involve a strong
commitment to prevention, and the President's budget recognizes this
reality. If confirmed, I will work to keep prevention at OASH a top
priority.
senator bennet
Question 1. I was recently in Otero County, CO where drug overdoses
have been increasing. The entire community was engaging to address the
rise in opioid abuse. This included coordinating hospitals, the courts,
schools and foster care services. Even when we see a decrease in
prescription overdoses, it is usually countered with an increase in
heroin overdoses. In the 1960s, more than 80 percent of heroin users
started with heroin. In contrast, currently, about 80 percent of heroin
users first started using prescription opioids.
What are practical steps you plan to take to address the opioid
crisis?
How can we ensure that Americans are not becoming addicted in the
first place while making it easier for people who currently have an
addiction to obtain access to treatment?
Answer 1. The Secretary has laid out a robust five-point plan for
combating the opioid epidemic, grounded in expanding access to
treatment, prevention and recovery services, promoting the use of
overdose-reversing drugs, better and more real-time data, innovative
research to develop new products in addiction prevention and treatment,
and better provider practices when it comes to pain management. I am
fully committed to helping him implement his plan--it is the right one
and we must step up the fight to protect American communities from the
terrible scourge of opioid addiction and overdose.
Question 2. As you know, ``super bugs,'' or bacteria that are
resistant to multiple antibiotics, are increasingly becoming a public
health threat. Antibiotic innovation is failing to keep up with patient
needs. This has left many patients struggling with severe and life-
threatening infections without effective treatment options. At the same
time, economic challenges have caused most pharmaceutical companies to
stop investing in research and development for antibiotics. Last year,
I worked with Senator Hatch to pass the PATH Act in 21st Century Cures.
The bill created a new drug approval pathway to streamline access and
encourage innovation for lifesaving antibiotics.
What else can we do to encourage the research and development of
antibiotics that treat life-threatening infections?
Overuse of antibiotics is a main driver of antibiotic resistance.
As the Assistant Secretary for Health, how would you help reduce
inappropriate or excessive antibiotic use?
Answer 2. You are absolutely right about the threat represented by
antimicrobial resistance. If confirmed, I intend to engage in a
personal way to support the Presidential Advisory Council on Combating
Antibiotic-Resistant Bacteria (PACCARB), which is overseen by OASH, as
well as the important work on this issue being done by CDC, FDA, ASPR,
and other Federal partners.
Question 3. Many chronic diseases are preventable or better managed
when caught early. When they are not, there is a large cost burden on
our society. The American Diabetes Association estimates that the
economic cost of diabetes was nearly $250 billion in 2012, a 41 percent
increase since 2007. In Medicare, 15 percent of the sickest enrollees
that often have multiple chronic conditions, account for 50 percent of
Medicare spending. What is your strategy around prevention so that
certain chronic diseases are avoided or better managed in order for us
to improve outcomes and save Medicare dollars?
Answer 3. Preventable diseases and chronic diseases account for a
majority of American health disparities and healthcare expenditures.
There is clearly room for additional focus on preventive care to
improve health and competitiveness, while being fiscally responsible
and preserving our safety net and entitlement programs for future
generations. If confirmed, I will work to keep prevention at OASH a top
priority.
senator whitehouse
Question 1. The Centers for Disease Control and Prevention
estimates that two million people develop antibiotic-resistant
infections in the United States every year, resulting in at least
23,000 deaths. The Assistant Secretary for Health oversees the
Presidential Advisory Council on combating Antibiotic-Resistant
Bacteria, which will expire on September 30 unless it is extended by
Executive order of the President.
Do you believe the Presidential Advisory Council on combating
Antibiotic-Resistant Bacteria has done effective work? If not, why not?
Will you encourage the President to continue this important council
and its work to combat antibiotic resistance?
Answer 1. If confirmed, I intend to engage in a personal way to
support the Presidential Advisory Council on Combating Antibiotic-
Resistant Bacteria (PACCARB), which is overseen by OASH, as well as the
important work on this issue being done by CDC, FDA, ASPR, and other
Federal partners.
Question 2. As the Assistant Secretary for Health, you would
oversee the National Vaccine Program Office. You've been vocal about
your support for childhood vaccinations, and their safety and
importance to public health. President Trump, however, has repeated
disproven claims about the dangers of vaccines--a position that seems
at odds with your informed professional judgment. Will you work to
ensure that only scientifically accurate information about vaccines is
communicated to the public and to others in the Administration?
Answer 2. Vaccines save lives. They are the most important health
innovation of modern times. If confirmed, I will be a passionate
advocate for vaccines while working to continue our effective and
transparent monitoring systems to provide American families assurance
that vaccines remain safe. While no public health intervention,
including vaccinations is 100 percent risk-free, vaccines are the gold
standard of disease prevention. It's our job to provide parents high-
quality, scientifically accurate information so that they can feel
confident in the safety of the vaccines we recommend for American
children.
Question 3. The Assistant Secretary for Health oversees the Office
of Population Affairs, which administers the title X family planning
program and provides guidance on a range of reproductive health topics.
President Trump's pick to lead this office is someone who has called
contraceptives ``medically irresponsible,'' despite the fact that she
has no medical training. She has also said that the birth control pill
doesn't work, despite overwhelming evidence to the contrary.
In your professional opinion, are the statements above about
contraception true?
Do you believe statements like these should be used to inform
policies of the Department of Health and Human Services?
What will you do as Assistant Secretary for Health to ensure the
Department's policies on women's health are guided by science rather
than ideology?
Answer 3. I look forward to working with HHS staff if I am
confirmed. I am committed to promoting the public's health and applying
evidence and common sense to our policymaking process.
senator baldwin
Question. There has been incredible progress in the fight against
HIV/AIDS over the last 30 years. Through investments in HIV prevention,
hundreds of thousands of new infections have been prevented, savings
billions of dollars in treatment costs. While HIV prevention efforts
are working, there are still an estimated 37,600 new infections each
year. Similarly, hepatitis C (HCV) kills nearly 20,000 people in the
United States each year and complications, and HCV-associated deaths
now exceed the number of deaths from 60 other nationally notifiable
diseases. Rates of new cases of HCV have increased nearly threefold
from 2010, particularly as the opioid epidemic proliferates.
Can you please discuss how you would continue our Nation's response
to these public health issues?
Will you continue to implement the National HIV/AIDS Strategy and
the National Viral Hepatitis Action Plan?
Answer. If confirmed, it is my intent that OASH will continue its
strong leadership role in implementing both the National HIV/AIDS
Strategy and the National Viral Hepatitis Action Plan. There is much
work to be done to improve over the status quo and reduce the number of
new infections with increased prevention, diagnosis, and treatment.
While we have made enormous progress, we should strive to do more.
senator warren
Evidence-Based Reproductive Health
The Assistant Secretary for Health oversees multiple offices within
the Department of Health and Human Services that promote the
reproductive health of women, men, and teens across the Nation,
including the Office of Women's Health, the Office of HIV/AIDS and
Infectious Disease Policy, the Office of Population Affairs, and the
Office of Adolescent Health.
National reproductive health experts agree that evidence-based,
scientifically accurate sexual education is critical to the control of
sexually transmitted infections (STIs), including HIV/AIDS, as well as
to the reduction in teen pregnancy rates: according to the Guttmacher
Institute, ``comprehensive sex education programs . . . have been shown
to delay sexual debut, reduce frequency of sex and number of partners,
increase condom or contraceptive use, or reduce sexual risk-taking.''
\1\ To the contrary, ``abstinence-only'' sex education programs have
proven to be ineffective, if not detrimental, to efforts to reduce teen
pregnancy and STI rates.\2\
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\1\ Heather D. Boonstra, ``What Is Behind the Declines in Teen
Pregnancy Rates?'' Guttmacher Institute (September 3, 2014) (online at
https://www.guttmacher.org/gpr/2014/09/what-behind-declines-teen-
pregnancy-rates).
\2\ Sexuality Information and Education Council of the United
States, ``What the Research Says . . . Abstinence--OnlyUntil--Marriage
Programs'' (online at http://www.siecus.org/index
.cfm?fuseaction=Page.ViewPage&PageID=1195).
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As the Assistant Secretary for Health, it is essential that you
understand--and act upon--the plethora of evidence showing that
abstinence-only education does not promote the Department's mission to
``enhance and protect the health and well-being of all Americans.'' \3\
---------------------------------------------------------------------------
\3\ U.S. Department of Health and Human Services, ``About HHS''
(online at https://www.hhs.gov/about/index.html).
Question 1. Do you agree that policies demonstrated to increase the
number of unintended pregnancies and STIs among teenagers should not be
supported by HHS?
Answer 1. If confirmed, I intend to develop and implement evidence-
based policies and programs to, among other things, decrease unintended
pregnancies, and STDs among all Americans, especially among teenagers.
Question 2. As HHS Assistant Secretary for Health, would you commit
to implementing and expanding evidence-based programs that improve
teenagers' reproductive health?
Answer 2. See above.
Question 3. Please provide a detailed description of steps you
would take as HHS Assistant Secretary for Health to improve teenagers'
access to evidence-based reproductive health education and services.
Answer 3. See above.
Teen Pregnancy Prevention Program
Though teen pregnancy has reached historic lows, around 25 percent
of teen girls in the United States will become pregnant by age 20.\4\
To combat teen pregnancy rates, the Office of Adolescent Health
administers the Teen Pregnancy Prevention (TPP) Program, an ``evidence-
based program that funds diverse organizations that are working to
prevent teen pregnancy across the United States.''\4\ Since the
program's implementation in 2010, teen childbearing has declined by 35
percent nationwide, suggesting that the program is ``highly
effective.'' \5\
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\4\ The National Campaign to Prevent Teen and Unplanned Pregnancy,
``Fast Facts: Teen Pregnancy in the United States'' (April 2016)
(online at https://thenationalcampaign.org/sites/
default/files/resource-primarydownload/
fast_facts_teen_pregnancy_in_the_united_states
.pdf).
\5\ U.S. Department of Health and Human Services, Office of
Adolescent Health, ``Teen Pregnancy Prevention Program (TPP)'' (online
at https://www.hhs.gov/ash/oah/grant-programs/teen-pregnancy-
prevention-programtpp/index.html).
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Despite the effectiveness of the TPP Program, the Office of
Adolescent Health announced on July 5, 2017, that it would cut short
all 81 TPP grants and defund TPP grantees on June 30, 2018.\6\ OAH
provided no rational for this decision. On July 21, I joined my Senate
colleagues in sending a letter to Secretary Price, requesting detailed
information on the justification behind OAH's decision.\7\
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\6\ Christine Dehlendorf, ``Successful teen pregnancy prevention
program threatened by funding cuts,'' STAT News (April 20, 2017)
(online at https://www.statnews.com/2017/04/20/successful-teen-
pregnancy-prevention-programthreatened-funding-cuts/).
\7\ Christine Dehlendorf, ``Successful teen pregnancy prevention
program threatened by funding cuts,'' STAT News (April 20, 2017)
(online at https://www.statnews.com/2017/04/20/successful-teen-
pregnancy-prevention-programthreatened-funding-cuts/).
Question 4. As Assistant Secretary for Health, would you commit to
re-implementing the TPP grants that OAH cut short without explanation
on July 5th?
Answer 4. If confirmed, I commit to implementing the laws passed by
Congress and signed by the President effectively and faithfully, and
following the grant making rules and procedures of the Department. I
also believe that the reasoning for decisions be transparent to
Congress and the American people.
Question 5. Will you commit to ensuring that Secretary Price,
through the Office of Adolescent Health, provides a detailed response
to the July 21st letter requesting OAH's justification for shortening
TPP Program grant agreements?
Answer 5. See above.
Title X Family Planning Program
The Assistant Secretary for Health oversees the Office of
Population Affairs, which runs the Title X Family Planning Program
(Title X). The title X program funds basic reproductive health
services--including cancer screenings, STI testing, and birth control--
to over 4 million low-income Americans every year.\8\
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\8\ U.S. Senate Committee on Health, Education, Labor, & Pensions,
``Murray, Senate Dems Challenge Trump Administration Over Move to Slash
Teen Pregnancy Prevention; Dems Say Action `Short-Sighted,' Will Make
it Harder to Prevent Unintended Pregnancies'' (July 21, 2017) (online
at https://www.help.senate.gov/ranking/newsroom/press/murray-senate-
dems-challenge-trump-administration-overmove-to-slash-teen-pregnancy-
prevention-dems-say-action-short-sighted-will-make-it-harder-to-
preventunintended-pregnancies-).
---------------------------------------------------------------------------
In recent years, some States have attempted to exclude reproductive
health centers that also provide abortion services from receiving title
X funds. In December 2016, the Obama administration issued a rule
clarifying that title X recipients cannot be barred from receiving
funds ``on bases unrelated to their ability to provide title X services
effectively.'' \9\ In spite of the critical services that title X
provides, a Republican Congress--after calling in Vice President Pence
for a tie-breaking vote--nullified this rulemaking through the
Congressional Review Act.\10\
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\9\ Planned Parenthood Action Fund, ``Title X: America's Family
Planning Program'' (online at https://www.plannedparenthoodaction.org/
issues/health-care-equity/title-x).
\10\ Health and Human Services Department, Compliance With Title X
Requirements by Project Recipients in Selecting Subrecipients (December
19, 2016) (online at https://www.federal
register.gov/documents/2016/12/19/2016-30276/compliance-with-title-x-
requirements-byproject-recipients-in-selecting-subrecipients).
---------------------------------------------------------------------------
Teresa Manning, Deputy Assistant Secretary for Population Affairs,
has stated that ``contraception doesn't work'' and that ``its efficacy
is very low.'' \11\ She has also--incorrectly--stated that a ``dominant
. . . mechanism of the morning-after pill is the destruction of a human
life already conceived.''\12\
---------------------------------------------------------------------------
\11\ Colin Dwyer, ``Trump Signs Law Giving States Option to Deny
Funding for Planned Parenthood,'' NPR (April 13, 2017) (online at
http://www.npr.org/sections/thetwo-way/2017/04/13/523795052/trump-
signs-law-giving-states-option-to-deny-funding-for-planned-parenthood).
\12\ Juliet Eilperin, ``Trump picks antiabortion activist to head
HHS family planning section,'' Washington Post (May 2, 2017) (online at
https://www.washingtonpost.com/news/powerpost/wp/2017/05/01/trump-
picks-antiabortionactivist-to-head-hhs-family-planning-program/?utm_
term=.292889b81423).
---------------------------------------------------------------------------
If confirmed as Assistant Secretary for Health, it will be your
responsibility to ensure that the Office of Population Affairs makes
policy decisions regarding title X based on scientific evidence--not
falsehoods.
Question 6. Do you believe that ``contraception doesn't work'' and
that ``its efficacy is very low''?
Answer 6. I look forward to working with HHS staff if I am
confirmed. I am committed to promoting the public's health and applying
evidence and common sense to our policymaking process.
Question 7. Do you believe that emergency contraception is akin to
``the destruction of human life already conceived''?
Answer 7. See above.
Question 8. As Assistant Secretary for Health, would you push back
against attempts in the Office of Population Affairs to implement
policies based on inaccurate, scientifically disproven assumptions
about contraception, regardless of efforts by others in the
administration to implement policies based on falsehoods?
Answer 8. See above.
Question 9. As Assistant Secretary for Health, would you advocate
for adequate funding for the title X program?
Answer 9. See above.
Question 10. As Assistant Secretary for Health, would you advocate
for increased funding for the title X program?
Answer 10. See above.
Question 11. As Assistant Secretary for Health, would you revive
efforts within the Department to ensure that States do not deny title X
funding to health providers for reasons other than their ability to
provide reproductive health services?
Answer 11. See above.
Contraception and the Affordable Care Act
Section 2713 of the Affordable Care Act (ACA) requires qualified
health plans to cover ``preventive services'' for women (considered an
``essential health benefit'') without imposing cost-sharing.\13\
``Preventive health services,'' for women, include FDA-approved
contraceptive methods, with some limited exceptions for religious
organizations.\14\
---------------------------------------------------------------------------
\13\ Juliet Eilperin, ``Trump picks antiabortion activist to head
HHS family planning section,'' Washington Post (May 2, 2017) (online at
https://www.washingtonpost.com/news/powerpost/wp/2017/05/01/trump-
picks-antiabortionactivist-to-head-hhs-family-planning-program/?utm_
term=.292889b81423); Planned Parenthood, ``The Difference Between the
Morning-After Pill and the Abortion Pill'' (online at https://
www.plannedparenthood.org/files/3914/6012/8466/
Difference_Between_the_MorningAfter_Pill_and_the_Abortion_Pill.pdf).
\14\ Kaiser Family Foundation, ``Preventive Services for Women
Covered by Private Health Plans under the Affordable Care Act''
(December 20, 2016) (online at http://files.kff.org
/attachment/Fact-Sheet-Preventive-Servicesfor-Women-Covered-by-Private-
Health-Plans-under-the-Affordable-Care-Act).
---------------------------------------------------------------------------
Prior to the full implementation of the ACA, one in five women
reported that they ``put off or postponed preventive services''--
including contraception--due to cost.\15\ As a result of the ACA, over
55 million women with private health insurance have guaranteed coverage
of these preventive services with no co-pays.\16\ And since the ACA was
implemented, women have saved $1.4 billion in out-of-pocket cost
spending for oral contraceptives. Yet in May 2017, a leaked rule from
the Department suggests that HHS may be planning to overhaul the
limited exceptions to the ACA's contraceptive mandate, creating a
``very, very broad exception for everybody'' that would ``allow[] any
employer to seek a moral or religious exemption from the requirement.''
\17\
---------------------------------------------------------------------------
\15\ HealthCare.gov, ``Preventive care benefits for women'' (online
at https://www.health
care.gov/preventive-carewomen/).
\16\ Kaiser Family Foundation, ``Preventive Services for Women
Covered by Private Health Plans under the Affordable Care Act''
(December 20, 2016) (online at http://files.kff.org/attachment/Fact-
Sheet-Preventive-Services-for-Women-Covered-by-Private-Health-Plans-
under-the-Affordable-Care-Act).
\17\ Adelle Simmons, Jessammy Taylor, Kenneth Finegold, Robin
Yabroff, Emily Gee, and Andrew Chappel, ``The Affordable Care Act:
Promoting Better Health for Women,'' ASPE Issue Brief (June 14, 2016)
(online at https://aspe.hhs.gov/sites/default/files/pdf/205066/ACA
WomenHealthIssueBrief.pdf).
---------------------------------------------------------------------------
As the Assistant Secretary for Health, you would oversee the Office
on Women's Health, which ``coordinates women's health efforts across
HHS and addresses critical women's health issues.'' \18\
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\18\ Dylan Scott and Sarah Kliff, ``Leaked regulation: Trump plans
to roll back Obamacare birth control mandate,'' Vox (May 31, 2017)
(online at https://www.vox.com/policy-and-politics/2017/5/31/15716778/
trump-birth-controlregulation).
Question 12. As Assistant Secretary for Health, would you work with
the Office on Women's Health and other Department partners to oppose
policies that would reduce women's access to contraceptive services?
Answer 12. I am fully supportive of women's access to healthcare
services. The system we ought to have in place is one that equips women
and men to obtain the healthcare and preventive services that they need
at an affordable price.
Question 13. As Assistant Secretary for Health, what initiatives
would you prioritize to ensure that women's access to preventive health
services, including contraception, breast and cervical cancer
screenings, and STI screening, is maintained and expanded?
Answer 13. See above.
HIV/AIDS Programs
The Assistant Secretary for Health oversees the Office of HIV/AIDS
and Infectious Disease Policy. Along with the Office of HIV/AIDS and
Infectious Disease Policy, the Office of the Assistant Secretary for
Health provides ``management and support services'' for the President's
Advisory Council on HIV/AIDS (PACHA).\19\ Yet in June 2017, six members
of PACHA resigned, stating that the ``Trump Administration has no
strategy to address the on-going HIV/AIDS epidemic, seeks zero input
from experts to formulate HIV policy, and--most concerning--pushes
legislation that will harm people living with HIV and halt or reverse
important gains made in the fight against this disease.'' \20\
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\19\ U.S. Department of Health and Human Services, Office on
Women's Health, ``Who we are'' (online at https://www.womenshealth.gov/
about-us/who-we-are).
\20\ HIV.gov, ``What is PACHA?'' (online at https://www.hiv.gov/
Federal-response/pacha/about-pacha).
Question 14. As Assistant Secretary for Health, would you
prioritize HIV/AIDS initiatives and provide support to PACHA?
Answer 14. Access to care for HIV/AIDS and related conditions is
vital for the health of such patients. If confirmed, I commit to
working within the capabilities of OASH to improve access to care for
HIV/AIDS patients, as well as for all those in need of prevention or
treatment services.
Question 15. As Assistant Secretary for Health, will you commit to
ensuring that all Americans maintain access to existing levels of care
for HIV/AIDS and related conditions?\21\
---------------------------------------------------------------------------
\21\ Scott Schoette, ``Trump Doesn't Care About HIV. We're Outta
Here,'' Newsweek (June 16, 2017) (online at http://www.newsweek.com/
trump-doesnt-care-about-hiv-were-outta-here-626285).
---------------------------------------------------------------------------
Answer 15. See above.
Question 16. Will you commit to expanding access to care for HIV/
AIDS patients?
Answer 16. See above.
Question 17. As Assistant Secretary for Health, will you commit to
maintaining existing levels of funding for HHS programs within your
purview that combat HIV/AIDS?
Answer 17. See above.
Inclusion of Women and Underrepresented Minorities in Clinical Trials
The Assistant Secretary for Health aims to ``optimize the Nation's
investment in health and science to advance health equity and improve
the health of all people'' and oversees the Office of Women's Health
(OWH) and the Office of Minority Health (OMH).\22\ These two offices
are responsible for promoting the health of women and racial and ethnic
minorities and helping coordinate efforts across HHS and other Federal
agencies to support policies and programs that reduce health
disparities.
---------------------------------------------------------------------------
\22\ Office of the Assistant Secretary for Health, ``Office of the
Assistant Secretary for Health (OASH)'' (online at: https://
www.hhs.gov/ash/index.html).
---------------------------------------------------------------------------
Disparities in biomedical research are one factor exacerbating
existing health disparities. Clinical trials are an essential component
of drug innovation and development, and data from clinical trial
research is used to shaping health care decisions, including coverage
decisions. In July 2016, the OMH awarded a grant to ``develop and begin
implementing an education program on clinical trials that educates and
recruits minorities and/or disadvantaged populations, particularly
groups underrepresented in clinical research.''\23\
---------------------------------------------------------------------------
\23\ Department of Health and Human Services Office of Minority
Health, ``HHS Office of Minority Health Awards $2M to Help Reduce Lupus
Related Health Disparities'' (July 5, 2016) (online at: https://
minorityhealth.hhs.gov/omh/content.aspx?ID=10338). Accessed August 1,
2017.
Question 18. Do you agree that the inclusion of women and
minorities in clinical trials is important to developing new drugs and
therapeutics, improving medical treatments, and addressing health
disparities?
Answer 18. As a physician and scientist, I have spent my career
focusing on this area and believe it is vital that we strike the right
balance between inclusiveness of potentially affected populations in
clinical trials with the need to speed cures to patients. We have to
work harder to achieve both goals. It is important for all Americans to
know if they are eligible for clinical trials, and to particularly
focus on rare diseases and minority populations. If confirmed, I commit
to seek a broad diversity of opinions and include them in the public
health decisionmaking process, consistent with my role.
Question 19. As Assistant Secretary of Health, what specific steps
will you take to educate women and minorities about clinical trials?
What specific steps will you take to help recruit them for the trials?
Answer 19. See above.
Question 20. Do you agree that women and minority health concerns
should be tightly integrated within all aspects of the Federal
Government's approach to health care and health research, including in
the development of policy and programs?
Answer 20. See above.
Question 21. As Assistant Secretary of Health, what specific steps
will you take to ensure that women and minorities are included in
public health decisionmaking processes?
Answer 21. See above.
Combating Antibiotic Resistance
The 2014 National Strategy for Combating Antibiotic-Resistant
Bacteria brought together the Secretaries of Health and Human Services,
Agriculture, and Defense to declare that, ``the misuse and over-use of
antibiotics in health care and food production continue to hasten the
development of bacterial drug resistance, leading to the loss of
efficacy of existing antibiotics.'' \24\ Through this initiative, we've
made some significant progress establishing policies that better
protect lifesaving antibiotics.
---------------------------------------------------------------------------
\24\ ``National Strategy for Combating Antibiotic-Resistant
Bacteria,'' The White House (September 2014) (online at: https://
www.whitehouse.gov/sites/default/files/docs/carb_national
_strategy.pdf), p.4.
---------------------------------------------------------------------------
There is strong and growing evidence that antibiotic use in food
animals can lead to antibiotic resistance in humans, yet the use of
medically important drugs in food animals continues to grow. According
to the FDA, ``Domestic sales and distribution of medically important
antimicrobials approved for use in food producing animals increased by
26 percent from 2009 through 2015, and increased by 2 percent from 2014
through 2015.'' \25\
---------------------------------------------------------------------------
\25\ Food and Drug Administration, ``2015 Summary Report on
Antimicrobials Sold or Distributed for Use in Food-Producing Animals''
(December 2016) (online at: http://www.fda.gov/downloads/ForIndustry/
UserFees/AnimalDrugUserFeeActADUFA/UCM534243.pdf).
Question 22. Do you agree that curbing the misuse and over-use of
antibiotics in health care and food production should be a public
health priority?
Answer 22. If confirmed, I intend to engage in a personal way to
support the Presidential Advisory Council on Combating Antibiotic-
Resistant Bacteria (PACCARB), which is overseen by OASH, as well as the
important work on this issue being done by CDC, FDA, ASPR, and other
Federal partners.
Question 23. As Assistant Secretary for Health, what specific steps
will your office take to prevent the development of bacterial drug
resistance?
Answer 23. See above.
Response by Robert Kadlec, M.D., to Questions of Senator Murray,
Senator Sanders, Senator Casey, Senator Franken, Senator Whitehouse,
Senator Baldwin, Senator Murphy and Senator Warren
senator murray
Question 1. During the last reauthorization of the Pandemic and
All-Hazards Preparedness Act (PAHPA), this committee included key
provisions to ensure the unique needs and considerations of ``at-risk
individuals'' are incorporated into preparedness and response
activities and planning. Do you think these needs have been
sufficiently incorporated into ASPR's activities? What more could be
done to ensure the needs of at-risk individuals are met? What
populations do you view as being at especially high risk in the event
of a public health emergency?
Answer 1. The reauthorization of PAHPA in 2013 provided additional
authorities to address the needs of at-risk individuals. ASPR continues
to work with its Federal, State, local, and community partners to
better integrate the needs of at-risk populations, particularly those
with access and functional needs, into its planning and its
preparedness and response activities. ASPR does this by providing
guidance and ensuring State and local public health grants include
preparedness and response strategies to address at-risk population
needs; ensuring the Strategic National Stockpile considers the needs of
at-risk populations; overseeing the progress of, and considering the
recommendations of, the Advisory Committee on At-Risk Individuals and
Public Health Emergencies and many other work groups; and by developing
training and best practices for preparing for, and responding to, the
needs of at-risk individuals prior to, during and after a public health
emergency.
ASPR also created the Nation's first interactive map that
integrates big data on healthcare, real-time weather data, and
Geographic information system (GIS) to help communities prepare for the
needs of over 2.5 million people who rely on electricity-dependent
medical equipment and other critical medical devices in every zip code.
At-risk populations are those that could experience more severe
effects from a disaster or attack. Easily identified are the very young
and old or individuals with pre-existing disorders or chronic
conditions, which place them at greater risk for detrimental health
effects in a disaster or public health emergency. Regardless of the
underlying factor, as President John F. Kennedy noted, society will
judge how well we address at-risk and vulnerable populations and afford
them the appropriate care whatever the circumstance.
I plan to fully assess ASPR's current activities, and determine
what ASPR is doing well, and what should be improved. Assisting at-risk
populations will be incorporated into any improvements made to the work
ASPR performs.
Question 2. The more rapidly we can detect an emerging infectious
disease threat, the more effectively we can protect the public from the
spread of disease. This requires well-resourced tools, including a
highly skilled public health workforce, state-of-the-art surveillance
and diagnostic techniques, and research to deliver effective medical
countermeasures. What gaps do you believe exist in our outbreak
preparedness and response capabilities, and how should they be
addressed?
Answer 2. Since its creation, ASPR has helped coordinate the public
health emergency, public health preparedness and response activities
across HHS. The Hospital Preparedness Program (HPP) helps prepare our
local medical workforce to prepare for public health threats as well as
provide situational awareness in the event of an emergency. We must
continue to buildupon the foundation at ASPR in these areas. Part of
the evolution at ASPR in this area should be the creation of a
``national contingency health care'' system. There is an urgent need to
better organize, train and equip our State and local healthcare
systems, facilities and providers to ensure that they cannot only
better respond to routine emergencies, but also to extraordinary events
that are likely to occur. Here we have an opportunity to better
integrate Emergency Medical Services, the ``tip of the spear'' of our
national medical response into these efforts, and to increase effective
coordination across HHS and the Federal departments, such as the
Department of Defense and the Department of Veterans Affairs, to
support State and local responders.
To achieve this, we need to support the sustainment of robust and
reliable public health security capabilities that include an improved
ability to detect and diagnose infectious diseases and other threats,
as well as the capacity to rapidly characterize and attribute them.
Question 3a. One of the issues we have seen time and again is that
the response to major crises, like the Ebola outbreak, Zika outbreak,
and Flint water contamination, crosses agency lines.
As you are well familiar, ASPR is intended to be the health lead
during major disasters. How do you envision the coordinating role of
ASPR?
Answer 3a. The Assistant Secretary for Preparedness and Response
serves as the Secretary's principal advisor on all matters related to
Federal medical preparedness, response, and recovery for public health
emergencies, as well as activities throughout HHS including human
services. The Secretary has expressed a passionate commitment to public
health security and resiliency and has high expectations for ASPR and
its role in emergencies and disasters that affect HHS's health, public
health, and human services mission.
In this position, I will be the leader for preparing for and
responding to emergencies and disasters, including public health
emergencies, which implicate HHS's mission. I intend to maintain
visibility and accessibility in order to direct coordination, within
HHS and across other Federal agencies, to prevent duplication or
uncoordinated efforts. The challenges we face today demand more
effective Federal coordination to assist State and local health
authorities and fully mobilize the private sector in response to such
disasters and emergencies, especially public health emergencies. It
will be my priority to integrate and support the capabilities of the
Centers for Disease Control and Prevention, the National Institutes of
Health, the Food and Drug Administration, the Public Health Service
Commissioned Corps, and other agencies as well as increase coordination
with external partners such as the Departments of Defense, Homeland
Security, Veterans Affairs, and State and local responders, among
others.
Question 3b. How would you work with the directors of the Centers
for Disease Control and Prevention (CDC) and other relevant agencies
both within and outside of the Department of Health and Human Services
(HHS) to ensure appropriate management of a disaster response?
Answer 3b. Appropriate management of response and recovery
activities is contingent on both strong leadership and the fostering of
effective routine, pre-crisis working relationships with the CDC
Director and other senior leaders inside and outside of HHS. These
relationships need to be framed by clear and documented expectations of
ASPR's and others' roles and responsibilities, and a governance
approach that can be effective in fully utilizing the equities and
capabilities of each individual agency to elicit a more effective
response effort. Additionally, I believe practice makes perfect. That
is why I plan to increase the number of public health emergency
exercises ASPR coordinates to ensure we are ready across HHS and other
departments to respond when called upon.
ASPR coordinates and collaborates across HHS through the Disaster
Leadership Group (DLG). The DLG brings together senior leaders from
across HHS, including the Director of CDC (or her representative(s)),
to make decisions on policy issues that affect medical and public
health systems during disasters which includes coordination on issues
that impact national health security.
Question 3c. How will your office work with the White House--which
has not prioritized public health preparedness--to ensure coordination
and avoid duplication of efforts?
Answer 3c. ASPR has an impressive cadre of medical, public health,
and other professionals, with both technical and policy expertise, who
work closely with the National Security Council (NSC) staff through
Policy Coordination Committees in preparedness matters and during
responses. This ensures that ASPR provides the public health
preparedness and response expertise that NSC needs to align these
efforts with overarching administration policies. ASPR has worked
closely with NSC to develop a series of frameworks for responding to
emerging infectious diseases and chemical, biological, radiological,
and nuclear (CBRN) threats that delineate the roles and
responsibilities of the NSC and the Federal departments and agencies.
Question 4. In light of the growing threat of antibiotic
resistance, how can the United States play a leadership role in
combating this threat to national and international security? In what
ways do you think the Combating Antibiotic Resistant Bacteria
Biopharmaceutical Accelerator (CARB-X) has helped or will help to
combat the spread of antimicrobial resistance (AMR)?
Answer 4. I believe antibacterial drugs underpin every facet of
modern medicine and public health emergency preparedness and response.
Antibiotics would be relied upon in the event of an attack with a
bacterial threat agent like anthrax or pneumonic plague, but also in
events where prolonged hospitalization was required or a patient's
immune system was impaired (e.g., exposure to immune-compromising
agents, burn injury, radiation exposure). ASPR's Biomedical Advanced
Research Development Authority (BARDA) has advanced six antibiotic
candidates into Phase III clinical development. The U.S. Food and Drug
Administration (FDA) review of one will be complete by the end of
August and may represent the first BARDA supported antibiotic to enter
the market.
CARB-X in its first year has supported 18 different companies
developing 17 candidate therapies and one point of care diagnostic that
is capable of determining if an individual has viral or bacterial
pneumonia. The 17 candidates are quite novel in their approach. There
are 8 novel classes, 10 novel bacterial targets, and 5 nonantibiotic-
based approaches that are capable of treating the infection.
Collectively, the purpose of CARB-X is to build and maintain a robust
preclinical pipeline of novel antibacterial therapies that will mature
into promising candidates for advanced development support and eventual
FDA approval.
Question 5. As I'm sure you know, last week Texas officials
reported the first local case of mosquito-transmitted Zika since last
fall. If confirmed, this would be the first case of nontravel-related
Zika within the continental United States this year. The Zika virus
presents a number of discrete challenges to any public-health
response--for example, only about one-fifth of people infected with the
virus experience symptoms. It is additionally the first mosquito-
transmitted virus in history with the ability to cause birth defects,
including microcephaly. Do you believe a robust family planning support
network is necessary to your ability to address the Zika pandemic? If
so, how do you respond to agency attempts to reduce access to family
planning services? If not, why not?
Answer 5. The challenge from the Zika virus remains an active
ongoing concern for HHS. The risk it poses to pregnant females demands
our best efforts to understand the risks to the unborn. We have to
pursue a firm understanding of the etiology of all forms of the disease
and a better understanding of the spectrum of complications that occurs
in exposed babies. Until we have a vaccine that FDA has licensed as
safe and effective, our best efforts must be focused on protecting
expectant mothers from being exposed. Family planning support is only
one arm of that effort. Aggressive environmental surveillance for Zika-
infected mosquitos, eliminating their breeding grounds, and reducing
the risk of pregnant women being exposed is our best course of action
until we have a vaccine.
senator sanders
Question 1. Climate change is a serious threat to human health.
Climate change can harm our health by threatening the quality and
safety of our water supply and by increasing the risk and spread of
vector-borne disease, extreme weather events and air pollution.
Vulnerable populations--including low-income communities, communities
of color, the elderly, young children, and those with chronic
illnesses--bear the greatest burden of injury, disease and death
related to climate change. President Trump has stated that ``nobody
really knows'' whether climate change is real, yet the overwhelming
scientific evidence shows that not only are climate change and its
associated negative health impacts occurring, it also points to human
activity as the primary cause of global warming over the past 50 years.
How would you characterize the health threats posed by climate
change and what will you do to address these threats? What can the
Federal Government do to make sure State and local health departments
have the tools and resources they need to protect the public from the
immediate and long-term health threats associated with climate change?
Answer 1. ASPR identifies, analyzes, prepares for, and responds to
changing or emergent threat landscapes across an array of risk areas
including natural and human-caused disasters and public health
emergencies. This includes provision of technical assistance and
guidance to key partners such as State and local public health agencies
as well as participation in interagency efforts to ensure that public
health concerns are appropriately integrated into overall planning and
preparedness. Specific weather and climate-related public health
concerns may include changing the severity or frequency of health
problems that are already affected by climate or weather factors and
unanticipated health threats in places where they have not previously
occurred.
senator casey
Question 1. Many existing medical countermeasures (MCMs), including
both vaccines and therapeutics, are only approved for use in adults,
and lack pediatric formulations, dosing information or safety
information. This poses serious challenges to our ability to protect
children in the event of a disaster or disease outbreak. What steps can
you take, if confirmed, to collaborate with industry, academia, Federal
agencies and other BARDA partners to ensure that all MCMs available
include appropriate pediatric formulations or doses, as appropriate?
Answer 1. ASPR's Biomedical Advanced Research and Development
Authority (BARDA) continues to pursue and support expanding the
indications of medical countermeasures (MCMs) to address ``at-risk''
individuals, including children, as mandated under the Pandemic and
All-Hazards Preparedness Act. Many of the products that have been
developed under Project BioShield (PBS) or for pandemic preparedness
can be administered to pediatric populations or have ongoing or planned
pediatric trials to expand their label indications. In addition, the
Strategic National Stockpile has numerous products that can be
administered to pediatric patients. Some of the products may have to be
administered under an Investigational New Drug (IND) or through the
issuance of an Emergency Use Authorization (EUA) by the FDA. ASPR also
participates in the National Advisory Committee on Children and
Disasters. Protecting children will be a priority issue during my
tenure as ASPR.
Question 2. During our meeting, we talked about the role of the
ASPR in our public health preparedness efforts, and you shared some
suggestions for steps you might take to improve coordination among
Federal agencies, such as supporting a staff member at CDC to liaise
between the CDC Director and yourself. What other steps would you take
to ensure maximum coordination between Federal agencies and State and
local partners, both vertically and horizontally? How would you ensure
that all of HHS's agencies working on preparedness and response are
learning from previous emergency responses?
Answer 2. What I learned about creating more effective coordinated
responses comes from my time in U.S. special operations at a particular
formative period after the failure at DESERT ONE. One of the findings
of the Holloway Commission was that the stove piping and the lack of
integration in planning and operations contributed to the failure. I
personally saw and experienced this in the mid-1980s. Creating greater
transparency by exchanging personnel, jointly working on planning for
emergencies, and committing to regular joint exercises goes a long way
to overcoming parochialism and uncoordinated efforts and to better
integrated operations. In special operations, commanders must commit to
this. It starts at the top. Having not been at the Department, I do not
mean to suggest that the same kind of problems exist at the Department,
or between ASPR and CDC, but these lessons would guide my efforts to
ensure maximum coordination between agencies.
Question 3. There is a saying in health care, ``children are not
small adults.'' This holds true when we are talking about public health
preparedness and biodefense. The Hospital Preparedness Program (HPP) is
administered by the Assistant Secretary for Preparedness and Response
and provides funding to every State and territory to support health
system preparedness, whether the system is responding to a pandemic, a
terrorist attack or a natural disaster. HPP is the primary Federal
funding program for hospital emergency preparedness and has provided
critical resources to improve health care surge capacity. Can you
describe how you plan to use the existing Federal funding mechanisms
through the Hospital Preparedness Program (HPP) to ensure that the
States and cities receiving HPP funding are prepared to meet the needs
of children?
Answer 3. In 2016, the Hospital Preparedness Program (HPP) began an
intensive effort to revise its core guidance, namely the 2017-22 Health
Care Preparedness and Response Capabilities. Throughout the revision
process, ASPR engaged the American Academy of Pediatrics and the
Children's Hospital Association to ensure that the needs of children
are optimally integrated into HPP's planning guidance. In addition, in
HPP's fiscal year 2017 funding opportunity announcement, awardees were
required to submit a joint letter of support with their jurisdiction's
Emergency Medical Services for Children (EMSC) program, detailing how
the two programs will work together during this budget period to meet
the needs of children during emergencies. HPP and EMSC also have a
joint performance measure to evaluate awardees' capabilities to respond
to pediatric emergencies. The specific program measure is the percent
of hospitals with an emergency department recognized through a
statewide, territorial, or regional standardized system that are able
to stabilize and/or manage pediatric medical emergencies. I will
continue ASPR's work with the HPP to ensure that it will meet the needs
of pediatric patients in public health emergencies and disasters.
Question 4. Over the last several months, I have sent multiple
letters to HHS about the Administration's ongoing efforts to undermine
and sabotage the Affordable Care Act through executive action. HHS has
failed to provide responses to many of my letters. If HHS has
responded, the response letters have been wholly inadequate and have
not been responsive to my requests. If you are confirmed, do you commit
to respond in a timely manner to all congressional inquiries and
requests for information from all Members of Congress, including
requests from Members in the Minority?
Answer 4. I intend to respond appropriately to all Member requests.
senator franken
Question 1. You have called for increased attention to public
health and for funding for preparedness efforts. The President's budget
proposed an emergency fund for infectious disease response but it drew
its funding from transfers from existing programs. Would that emergency
fund be sufficient for preparedness efforts? Based on your experience
are additional funds needed? If so, what funding level would be ideal
for such a fund?
Answer 1. The fiscal year 2018 President's Budget requests the
authorization of the ``Federal Emergency Response Fund,'' to support
the following priorities for domestic preparedness and global health:
1. To prevent, prepare for, or respond to a chemical, biological,
radiological, or nuclear threat, and,
2. To prevent, prepare for, or respond to an emerging infectious
disease.
The Fund may be used for a public health threat or emergency that
the Secretary of HHS determines has significant potential to occur. As
such, the Fund may be used for preparedness efforts and to prevent a
public health emergency. The Fund provides flexibility to the Secretary
of HHS to address potential threats at earlier stages, thereby reducing
the likelihood of a more severe impact on the health and security of
American citizens.
Public health and medical emergencies are unpredictable in nature,
specifically with regard to the scope and magnitude of potential
disease, injury, or death. Consequently, emergency supplemental
appropriations, such as those used to respond to the Ebola and Zika
outbreaks, could still be needed. However, the fund provides the
Secretary of HHS the capability to respond quickly and nimbly, while
the needs and resources of an emergency supplemental are determined.
As the new Assistant Secretary for Preparedness and Response, it
will be one of my top priorities to ensure our public health, health
system, and scientific research infrastructures are strong. This will
be critical to mitigating the impact of potential public health
emergencies, as well as to improve the overall health and well-being of
U.S. citizens. To this end, I will actively identify where additional
investments are needed and work with my HHS and Administration
colleagues to communicate those needs to Congress.
senator whitehouse
Question 1a. Preparedness for a naturally occurring global disease
outbreak presents distinctly different challenges than preparedness for
an intentional bioweapon attack.
What are the key differences in being adequately prepared for a
pandemic disease outbreak versus a bioweapon attack?
Answer 1a. The basic capabilities required to prepare and respond
to naturally occurring pandemics and bioweapon attacks are generally
similar. For example, both require strong public health systems that
are able to detect an event and respond with appropriate medical and
non-medical interventions. Each also has unique differences. The scale,
scope, and speed needed for a response to a bio-attack differ
significantly from a naturally occurring pandemic. In addition, the
national security consequences of a bio-attack are of greater
consequence. Pandemic disease outbreaks generally affect populations
across geographic and healthcare delivery system boundaries. In
contrast, bioweapon attacks may be more localized, but can also
immobilize entire healthcare delivery systems. A major difference,
however, is that an adversary using a biological weapon is intent on
affecting our national will, our economy and confidence in our
government. In doing so, they would likely try to achieve maximum
psychological and physical effects and use other attack modalities such
as cyber and/or conventional weapons as well. As a result, pandemic
disease outbreaks and bioweapon attacks differ in requirements for
support and operational coordination.
From an operation's standpoint, ASPR's preparedness for both an
emerging infections disease and bioweapon attack must be multifaceted.
ASPR requires clinical, pharmaceutical, and non-pharmaceutical tools to
build capacity at the State, local, healthcare sector, and private
sector levels. ASPR must have the capacity to develop (with its
governmental and industry partners) the medical countermeasures
necessary to respond to biological threats, to build the tools to
support the immediate consequences of a biological threat, and to
support States and communities in recovering from and mitigating the
risk of future biological threats.
Question 1b. What immediate steps will you take to improve our
preparedness for both types of emergencies?
Answer 1b. I will immediately work with government partners to
assess our current capabilities for responding to global disease
outbreaks and intentional bioweapon attacks that pose a threat to our
homeland. Global disease outbreaks are different for an intentional
bioweapon attack, primarily in timing. Global disease outbreaks occur
in waves that potentially provide some time to prepare, unlike an
intentional bioweapon attack that would be an acute event with numerous
individuals exposed in a very short timeframe requiring an immediate
response. However, both types of emergencies require preparedness
efforts to ensure an appropriate response.
For global outbreaks such as pandemic influenza, ASPR's Biomedical
Advanced Research and Development Authority (BARDA) maintains
stockpiles of pre-pandemic influenza vaccine, bulk product, and
adjuvant that may be quickly manufactured into vaccines and antiviral
drugs. To prepare for a bioweapon attack, ASPR works with its
government partners to develop and stockpile medical countermeasures to
address the negative health impacts of exposure to various threat
agents. These include vaccines, therapeutics, and diagnostics. For
example, ASPR/BARDA is supporting the development of early, in-home
diagnostic technologies to be able to rapidly identify an outbreak, as
well as platform-based production systems that will enable a more rapid
medical countermeasure response to a known or unknown threat.
One area that will receive my initial serious evaluation is our
ability to rapidly distribute the medical countermeasures we have in
our stockpile.
Additionally, ASPR is working with its U.S. Government stakeholders
to develop the first-ever National Biodefense Strategy, a comprehensive
plan for how the United States will work across the executive branch to
prepare for, prevent, detect, respond to, and recover from biological
events, regardless of their source. I am committed to both the
development of the Strategy, as well as to working within the
Department to ensure that both ASPR and the Department take the
necessary steps to implement the Strategy.
Question 1c. How would you describe this administration's current
level of preparedness for a pandemic and for a bioweapon attack?
Answer 1c. I intend to conduct a rapid assessment of the State of
biodefense preparedness upon my entry on duty as the ASPR.
Question 2a. BARDA uses its ``TechWatch'' program to work with
smaller companies on the development of medical countermeasures, but I
have heard from companies in my State that BARDA and other divisions of
HHS could do more to support small companies in this space.
How would you instruct BARDA to improve its engagement with small,
innovator companies?
Answer 2a. Capitalizing on the rapidly advancing biotechnology and
life science is an essential element of a strategy to not just keep
even with, but get ahead of the threats confronting the Nation. I will
ensure that BARDA continues to invest in innovative technologies to
address some of the most serious threats faced by our Nation. The
TechWatch program has been successful in providing, to companies of all
sizes, the opportunity to meet face-to-face with BARDA. BARDA's mission
is to support advanced research and development. In case technologies
are not mature enough for consideration for BARDA, other PHEMCE
partners such as the National Institutes of Health and the Department
of Defense are invited to the meetings to provide additional avenues
for potential partnerships. ASPR continues to exceed its small business
goals and will invest in companies that have promising technologies,
regardless of their size. BARDA subject matter experts work closely
with all companies to support development of candidate products,
especially those companies that may not have much experience in
developing products.
Question 2b. In addition to the TechWatch program, ASPR holds a
yearly BARDA Industry Day which provides everyone the opportunity to
interact with BARDA and ASPR's Office of Acquisitions, Management,
Contracting, and Grants. This venue provides opportunities for
companies to ask questions regarding how to work with the Federal
Government.
The 21st Century Cures Act contains a provision called the
Strategic Investor Initiative that offers new opportunities for ASPR
and BARDA to invest in promising new technologies. I will ensure that
we implement this provision and that the initiative receives the
appropriate priority and resourcing to be successful.
How will you ensure BARDA's development and procurement activities
don't overlook small innovator companies that have less experience
working with Federal partners?
Answer 2b. Please see (a) above.
Question 3. You have long advocated for a strong Federal role in,
in your words, ``confronting the risk from deliberate biological
threats.'' Although many programs overseen by the ASPR were spared from
proposed cuts in the President's fiscal year 2018 budget, in my view
the Trump administration has done little else to demonstrate its
commitment to biodefense. Will you advocate for robust funding for and
the prioritization of biodefense work within HHS and with other members
of the administration?
Answer 3. ASPR plays a critical role in preparing the Nation to
face biological threats. My previous experience as Deputy Staff
Director of the Senate Intelligence Committee and numerous other roles,
have made clear the need for strong national biodefense capabilities.
The threats we face are real, and the Department of Homeland Security
has identified, through the material threat assessment, those of
greatest concern. To prepare for these threats, we must continuously
invest in the development of new medical countermeasures and ensure we
are sustaining the production of countermeasures already developed. The
Trump administration recently announced its intention to draft an
updated national biodefense strategy. I look forward to being a part of
that policy discussion and ensuring a comprehensive strategy with an
accompanying implementation and resource plan is produced.
Question 4a. Antibiotic resistance is a growing threat to our
health security. The Centers for Disease Control and Prevention
estimates that two million people develop antibiotic-resistant
infections in the United States every year, resulting in at least
23,000 deaths.
Do you believe combating antibiotic resistance is a matter of
national preparedness?
Answer 4a. Antibiotics underpin nearly every facet of modern
medicine, and their continued effectiveness would be heavily relied
upon in a mass public health emergency. Antibiotic resistance is a
matter of national public health and a national security concern.
Antibiotics would be relied upon in the event of an attack with a
bacterial threat agent-like anthrax or pneumonic plague, but also in
events where prolonged hospitalization was required or a patient's
immune system was impaired (e.g., exposure to immune-compromising
agents, burn injury, radiation exposure).
The development of new antibiotics will remain a priority for me.
ASPR will continue to make progress in mitigating the threat posed by
drug resistant infections through a number of mechanisms, including
ASPR's Biomedical Advanced Development Authority's (BARDA) clinical
stage program, which has progressed six candidate antibiotics into
Phase III clinical development, and CARB-X's novel public-private
partnership aimed at building an innovative preclinical stage pipeline
of antibacterial therapies, diagnostics, and vaccines,. There are a
number of ways the Federal Government can spur innovation in antibiotic
research and development. Currently, the Federal Government provides
push incentives that lower the research and development costs for new
antibiotics. While push incentives are helpful, in order to adequately
address the market challenges that BARDA's industry partners face
developing and marketing new antibiotics, completely new business
models are needed. These models need to create a strong pull incentive
that provides a known return on investment for the development of an
antibiotic that addresses unmet medical need(s). If companies can rely
on a certain level of return on their investment, it will drive
additional private sector investment in research and development for
this critical area. Under my leadership, ASPR will work to develop and
implement such business models.
Question 4b. As ASPR, will you prioritize the development of new
antibiotics?
Answer 4b. Please see (a) above.
Question 4c. How can the Federal Government best encourage
investments in antibiotic research?
Answer 4c. Please see (a) above.
senator baldwin
Question 1. Our country has recently seen some of the most extreme
public health outbreaks--from Ebola to Zika--and we know that the next
outbreak could be right around the corner or just a plane ride away. I
am particularly concerned about our country's preparedness efforts for
pandemic influenza. In 2004, we saw a dangerous shortage of influenza
vaccine in the United States due, in part, to disruptions in vaccine
production overseas, and we saw a deadly pandemic of H1N1 in 2009.
Dr. Kadlec, what lessons did we learn from these experiences and
how will you strengthen and maintain our stockpile of vaccines before
we face the next influenza pandemic?
Answer 1. The H1N1 influenza pandemic of 2009 and the more recent
public health emergencies for Ebola and Zika have shown that pandemic
influenza and emerging infectious diseases are serious and
unpredictable. The disease can spread rapidly and, in most cases,
funding to rapidly ramp-up response is dependent upon supplemental
funding that often takes months to approve. This is why a Public Health
Emergency Fund is essential for a quick response. Although the amounts
in such a Fund may not be sufficient to complete the job, such funds
would allow for efforts to begin immediately. The most effective
mitigation requires deployment and vaccination before the peak of virus
spread. The faster we can initiate product development and
manufacturing activities, the quicker a vaccine will be available.
ASPR's Biomedical Advanced Research and Development Authority
(BARDA) has supported new cell- and recombinant-based technologies for
pandemic influenza vaccines that have received U.S. Food and Drug
Administration (FDA) approval. ASPR/BARDA-supported development of
adjuvanted pandemic influenza vaccine technologies serve to increase
the number of vaccine doses that will be available by reducing the
amount of antigen that is necessary to generate a protective immune
response. ASPR/BARDA and its Federal partners are funding and
conducting clinical trials to evaluate the safety and immunological
response of pre-pandemic influenza vaccine stockpiles to make sure they
remain safe and effective after long-term storage. This element of the
strategy is particularly important. By working closely with our CDC and
NIAID partners who identify potential pandemic influenza strains
emerging globally, BARDA can commission the initial production of a
pre-pandemic stockpile that (1) demonstrates the ability to produce an
effective vaccine against that potential strain, and (2) creates an
emergency stockpile that permits an immediate response should that
strain emerge as a pandemic.
ASPR/BARDA is also developing novel antiviral drugs and novel
influenza therapeutics to mitigate the emergence of antiviral drug
resistance often observed in influenza. The most important lesson
learned is that an immediate response is necessary to mitigate the
spread of disease.
senator murphy
Question 1. In the event of a pandemic, it is critical for the
public health to be able to respond quickly and in a way that does not
adversely impact the rest of the health care delivery system. To that
end, we must ensure there are an appropriate number of drug delivery
devices available to deploy therapies to patients in real time. The
Biomedical Advanced Research and Development Authority (BARDA) has the
ability to manage this with existing contracts, but without regular
task orders to maintain a viable level of product at-the-ready, I'm
concerned we won't be prepared.
How will you ensure BARDA not only has contracts in place to
provide a sufficient amount of drug delivery devices, but that BARDA
also issues task orders against those contracts so that an adequate
level of product is always on hand?
Answer 1. ASPR's Biomedical Advanced Research Development Authority
(BARDA) maintains indefinite deliverable/indefinite quantity (IDIQ)
contracts with producers of ancillary supplies for vaccine delivery.
Periodically, ASPR/BARDA issues task orders to procure additional
ancillary delivery supplies to refresh outdated inventory that is
maintained for rapid response for pandemic preparedness. I plan to
continue this approach to ensure these materials will be available when
needed for a pandemic response.
senator warren
Pandemic Flu
The Department of Health and Human Services (HHS) would lead the
Federal Government response to a pandemic flu. Before leaving the
Centers for Disease Control and Prevention (CDC) in January 2017, the
former Director, Dr. Thomas Frieden, stated his concerns about such a
pandemic, noting that the greatest public health threat we face is
``always for an influenza pandemic,'' and that ``[I]f the resistant
organisms emerge in one part of the world, they will inevitably come to
other parts of the world.''\1\
---------------------------------------------------------------------------
\1\ Lena H. Sun, ``Outgoing CDC Chief Talks about Agency's
Successes--and His Greatest Fear,'' Washington Post (January 16, 2017)
(online at: https://www.washingtonpost.com/news/to-your-health/wp/2017/
01/16/outgoing-cdc-chief-talks-about-the-agencys-successes-and-his-
greatest-fear/?tid=a inl&utm_term=.8ca1cf116944).
---------------------------------------------------------------------------
President Trump's fiscal year 2018 budget proposal included $1.3
billion in cuts for the CDC and substantial cuts for key public health
programs including $107 million in cuts for the CDC's Public Health
Emergency Preparedness Cooperative Agreements, $2 billion in State
Department global health assistance.\2\ President Trump's budget--and
legislation attempting to repeal the Patient Protection and Affordable
Care Act (ACA) would eliminate the Prevention and Public Health Fund
and impose substantial cuts to the Medicaid program.
---------------------------------------------------------------------------
\2\ Facher, Lev, ``HIV programs, mental health: 8 ways Trump's new
budget might affect public health,'' STAT (May 24, 2017) (online at:
https://www.statnews.com/2017/05/24/trump-public-health/).
Question 1. Do you agree with Dr. Frieden about the risks of a
pandemic flu outbreak?
Answer 1. I have the greatest respect for Dr. Frieden, as I have
known him since he was New York City's Public Health Commissioner. I
would note that influenza is not the only pandemic threat. As we have
witnessed, SARS and MERS (alpha coronaviruses) also represent potential
pandemic threats. I would also add that a deliberate re-introduction of
smallpox, either from retained cultures or synthetically produced,
would present an equal or potentially greater risk.
Question 2. What impact could substantial budget cuts have on
pandemic flu preparedness?
Answer 2. ASPR has invested significantly to establish domestic
preparedness and response capacity and capabilities for an influenza
pandemic. Substantial budget cuts could have an immediate impact on the
Nation's preparedness posture and, in the very near term, risk
investments made in the past decade on infrastructure and medical
countermeasure development and stockpiling.
State and local jurisdictions and the U.S. healthcare system rely
on ASPR's Hospital Preparedness Program (HPP) funding to prepare for
all hazards, including pandemic influenza. Substantial budget cuts to
HPP could lead to a diminished capability to enhance preparedness
across the public health and medical continuum. Without the proper
funding, there may be limited ability to validate plans, processes or
procedures through exercises and to evaluate and identify strengths,
gaps and shortfalls which could enhance preparedness.
Question 3. What specific HHS programs under the purview of the
Office of the Assistant Secretary for Preparedness and Response receive
funding that is used for pandemic flu preparedness?
Answer 3. ASPR's Biomedical Advanced Research and Development
Authority (BARDA) uses HHS funds to develop and procure medical
countermeasures for pandemic influenza preparedness, including
vaccines, adjuvants, antiviral drugs, diagnostics, respiratory
protection devices, and ventilators.
ASPR's Hospital Preparedness Program (HPP) receives funding to
prepare the Nation's healthcare system for all hazards, including
pandemic influenza. HPP enables healthcare systems to save lives during
emergencies that exceed day-to-day capacity of health and emergency
response systems. HPP promotes a sustained national focus to improve
patient outcomes, minimize the need for supplemental State and Federal
resources during emergencies, and enable rapid recovery.
Last, the international division within ASPR's Office of Policy and
Planning receives pandemic influenza funding which supports
preparedness and response to pandemic influenza and other emerging
infectious diseases with simultaneous domestic and international health
security impacts.
Question 4. How are these funds used in each program?
Answer 4. See (3) above and the following: HPP grants enable
recipients to prepare their healthcare systems to save lives through
the development and sustainment of regional healthcare coalitions
(HCCs) that incentivize diverse and often competing healthcare
organizations with differing priorities and objectives to work
together. Events that cause a surge in patients require healthcare
facilities, including those that are not part of the same corporate
network, to work together as part of a coalition to ensure that
patients receive optimal and timely care. HPP grants enable HCCs to
enhance surge capacity within hospitals, alternate care systems, and
outpatient clinics to increase the number of patients that can be cared
for during an emergency. ASPR's international division also utilizes
pandemic influenza funding.
Question 5. What impact will the President's budget have on funding
in each of these program areas?
Answer 5. As I have not been inside the Department, I have not been
involved in budget discussions. In the role of the ASPR, I plan to
ensure that we efficiently execute the Department's core preparedness
program missions.
Question 6. How will you address the impact of these proposed cuts?
Answer 6. Budget and funding reductions, across government, are a
reality during times of fiscal restraint. I intend to approach this
challenge as an opportunity to creatively find new efficiencies in our
operations and collaborate with partners to achieve the highest levels
of readiness. This effort requires coordination within ASPR, HHS, and
across the government to pinpoint areas where we can maximize the
effective use of preparedness funding to get ``more bang for the
buck''.
ASPR will remain committed to preparing States, local
jurisdictions, and healthcare systems for emergencies by providing
substantive preparedness and response technical assistance to them, and
by connecting them with resources and subject matter experts through
ASPR's Technical Resources Assistance Center and Information Exchange
(TRACIE). TRACIE provides evidence-based applications, technology, and
proven best practices to help States and communities build enhanced
capacity and improve their knowledge and effectiveness.
In addition to TRACIE, HHS's emPOWER map provides de-identified
data on populations reliant on lifesaving electricity-dependent medical
equipment and healthcare services to inform disaster response. We will
use these resources and others to support both Federal partners and
partners at the State, local, tribal, and territorial levels in
preparing for, mitigating, and responding to emergencies and disasters.
Question 7. Specifically, what would be the impact of elimination
of the Prevention and Public Health Fund on pandemic flu preparedness?
Answer 7. It is important that we prepare for all threats,
including pandemic flu. I am not aware of the extent to which current
preparedness efforts are funded by the Prevention and Public Health
Fund. I plan to be a strong advocate for ensuring that the agency has
the resources it needs to address all threats.
Question 8. How would you address these potential cuts if they are
imposed on the Agency by the White House and Congress?
Answer 8. Budget and funding reductions, across government, are
unpleasant but necessary during times of fiscal restraint. I intend to
approach this challenge as an opportunity to creatively find new
efficiencies in our operations and reduce duplicative and unnecessary
spending. This effort requires coordination to pinpoint areas within
ASPR, HHS, and across the government where we can consolidate funding
and responsibilities and more effectively and efficiently use our
resources.
Question 9. What do you believe are the most important steps needed
to insure that the Nation is prepared for a potential pandemic flu
outbreak?
Answer 9. All aspects of pandemic influenza preparedness, response,
mitigation, and recovery strategies are essential to our national
preparedness. I believe the important steps to ensure our Nation is
prepared for a pandemic flu outbreak include maintaining and improving
our surveillance systems; improving processes for delivery, dispensing,
and administration of medical countermeasures; advancing healthcare
system surge capacity through greater coordination of inpatient and
community-based healthcare service delivery; and having a dedicated
workforce, trained and ready to operate when needed.
Pandemic Flu and Hiring Freeze
In January 2017, President Trump issued a Federal hiring freeze,
resulting in 700 vacancies at the CDC. While the hiring freeze has
since been lifted, Secretary Price has left the hiring freeze in place
at the Department of Health and Human Services, of which the CDC is a
part.\3\ What will be the long- and short-term impacts on pandemic flu
preparedness of President Trump's hiring freeze?
---------------------------------------------------------------------------
\3\ Ranking Members Pallone and Engel letter to President Trump on
the hiring freeze and impacts on preparedness (July 26, 2017) (online
at: https://democrats-foreignaffairs.house.gov/sites/
democrats.foreignaffairs house.gov/files/Pallone-
Engel%20CDC%20%staffing%20letter%200
72617.pdf).
Question 10. Does this Executive order apply to the Assistant
Secretary for Preparedness and Response (ASPR)?
Answer 10. I am aware of the hiring freeze issued by the President
that was administered across the government. The Executive order, and
the guidance issued by the Office of Management and Budget (OMB) and
the Office of Personnel Management (OPM) on the Executive order,
included exemptions to the hiring freeze for positions relating to
public health/safety and national security. My understanding is that
HHS created and implemented a process to exempt such positions from the
hiring freeze. I also understand that the hiring freeze, to the extent
applicable, has now been lifted.
Question 11. Has the Executive order prevented ASPR from hiring any
employees since it was put in place in January 2017?
Answer 11. I have not been privy to ASPR's hiring decisions during
my confirmation process.
Question 12. Will this Executive order cause ASPR to reduce the
projected number of staff employed by the agency to address pandemic
flu preparedness and other emergencies?
Answer 12. The Executive order, and the guidance issued by the
Office of Management and Budget (OMB) and the Office of Personnel
Management (OPM) on the Executive order, included exemptions to the
hiring freeze for positions relating to public health/safety and
national security. My understanding is that HHS created and implemented
a process to exempt such positions from the hiring freeze. I also
understand that the hiring freeze, to the extent applicable, has been
lifted.
Question 13a. Has the OMB provided clear guidance and a clear
timeline on implementation of the exemption process?
In the event of a pandemic flu outbreak, will you exempt any
positions at ASPR from the hiring freeze because they are necessary
``to meet national security or public safety responsibilities''?
Answer 13a. The Executive order, and the guidance issued by the
Office of Management and Budget (OMB) and the Office of Personnel
Management (OPM) on the Executive order, included exemptions to the
hiring freeze for positions relating to public health/safety and
national security. My understanding is that HHS created and implemented
a process to exempt such positions from the hiring freeze. I also
understanding that the hiring freeze, to the extent applicable, has
been lifted.
Question 13b. How many positions will be exempted in this manner?
Please provide a detailed list of these positions.
Answer 13b. The Executive order, and the guidance issued by the
Office of Management and Budget (OMB) and the Office of Personnel
Management (OPM) on the Executive order, included exemptions to the
hiring freeze for positions relating to public health/safety and
national security. My understanding is that HHS created and implemented
a process to exempt such positions from the hiring freeze. I also
understand that, as of June 2017, to the extent applicable, the hiring
freeze was lifted and ASPR has been able to resume hiring for all
requested positions.
Question 13c. Does the exemption apply to prevention personnel
engaged in preparedness activities, or does it only apply to an
emergency once a pandemic has begun?
Answer 13c. The Executive order, and the guidance issued by the
Office of Management and Budget (OMB) and the Office of Personnel
Management (OPM) on the Executive order, included exemptions to the
hiring freeze for positions relating to public health/safety and
national security. My understanding is that HHS created and implemented
a process to exempt such positions from the hiring freeze. My
understanding is that the exemption process applied to both
preparedness and emergency response personnel.
Pandemic Flu and Regulatory Freeze
On January 20, 2017, President Trump imposed an Executive order
freezing all regulations in progress,\4\ and on January 30, 2017, he
issued a second Executive order, imposing a new requirement that
``whenever an executive department or agency publicly proposes . . . a
new regulation, it shall identify at least two existing regulations to
be repealed.'' \5\ OMB guidance on this order allows exemptions ``for
emergency situations or other urgent circumstances relating to health,
safety, financial, or national security matters, or otherwise.'' \6\ It
is not clear how those exemptions will apply to regulation or guidance
from CDC or other HHS agencies and programs, whether they apply to
prevention efforts, or how they will be implemented in the event of a
pandemic flu outbreak.
---------------------------------------------------------------------------
\4\ Reince Priebus, ``Memorandum for the Heads of Executive
Departments and Agencies,'' White House Office of the Press Secretary
(January 20, 2017) (online at: https://www.whitehouse.gov/the-press-
office/2017/01/20/memorandum-heads-executive-departments-and-agencies).
\5\ ``Presidential Executive Order on Reducing Regulation and
Controlling Regulatory Costs,'' White House Office of the Press
Secretary (January 30, 2017) (online at: https://www.whitehouse
.gov/the-press-office/2017/01/30/presidential-executive-order-reducing-
regulation-and-controlling).
\6\ Mark Sandy, then-Acting Director of the Office of Management
and Budget, ``Memorandum: Implementation of Regulatory Freeze,'' White
House Office of the Press Secretary (January 24, 2017) (online at:
https://www.whitehouse.gov/the-press-office/2017/01/24/implementation-
regulatory-freeze).
Question 14. In previous outbreaks, has the ASPR needed to impose
any new regulations--either to address short-term concerns, to respond
to ``lessons learned'' during the outbreak, or to prevent future
outbreaks?
Answer 14. It is my understanding that ASPR compiles lessons
learned following every emergency. With those lessons in hand, we can
work to inform decisionmakers about what is needed to help us better
prepare for the next response. My intent is to ensure these lessons
learned can be collected quickly and be evaluated and shared across
Federal agencies and with State and local authorities.
Question 15. Would the Executive orders imposing a regulatory
freeze and requiring the repeal of two existing regulations for every
new regulation put in place potentially prevent ASPR from imposing
similar regulations in a future pandemic flu outbreak?
Answer 15. HHS already has the powers and authorities necessary to
address a pandemic influenza outbreak, or other public health
emergency, under the Public Health Service Act. However, each emergency
is different. If confirmed, you have my commitment that we will conduct
a thorough review following every emergency to pinpoint areas for
improvement, including any obstacles that need to be addressed.
Question 16. Has OMB provided clear guidance and a clear timeline
on implementation of the Executive order's exemption process ``for
emergency situations or other urgent circumstances relating to health,
safety, financial, or national security matters, or otherwise?'' \7\ In
the event of a pandemic flu outbreak, will these exemptions be
necessary for ASPR to impose new regulations?
---------------------------------------------------------------------------
\7\ Mark Sandy, then-Acting Director of the Office of Management
and Budget, ``Memorandum: Implementation of Regulatory Freeze,'' White
House Office of the Press Secretary (January 24, 2017) (online at:
https://www.whitehouse.gov/the-press-office/2017/01/24/implementation-
regulatory-freeze).
---------------------------------------------------------------------------
Answer 16. Under the Public Health Service Act, ASPR has the powers
and authorities necessary to fulfill its mission during a public health
emergency like pandemic influenza. With that in mind, I will welcome
any opportunities for improvement and efficiencies provided by the
Administration or Congress.
Vaccines
Question 17. President Trump has linked vaccines to autism and has
embraced vaccine ``skeptics.''
Do you believe that there is any scientific or medical validity to
President Trump's concerns about vaccine safety? If so, please indicate
which sources lend scientific or medical validity to his concerns.
Answer 17. There is abundant evidence that vaccines are safe. They
remain a cornerstone of public health and biodefense strategies.
Question 18. Are you concerned that President Trump's statements
may dissuade members of the public from receiving flu or other
vaccines?
Answer 18. Vaccinations are a critical component of our national
health resiliency and national security. With that in mind, I am very
confident in the U.S. Food and Drug Administration's work to uphold
vaccine safety and efficacy. ASPR works with its industry partners and
FDA to ensure that all vaccines manufactured under the Biomedical
Advanced Research Development Authority (BARDA) are safe and effective
to protect the American people. While BARDA does issue contracts to
stockpile some items prior to FDA approval, data on patient safety of
the therapies or vaccines are reviewed prior to stockpiling.
Coordination in Response to Public Health Emergencies
The Assistant Secretary for Preparedness and Response (ASPR)
focuses on preparedness and public health emergency response.\8\ The
President's hiring freeze and fiscal year 2018 budget request would
impact the U.S.'s ability to properly respond to a public health
emergency or disaster, such as pandemic flu, Ebola, or a bioterrorist
attack.\9\
---------------------------------------------------------------------------
\8\ U.S. Public Health Emergency Web page, ``Office of the
Assistant Secretary for Preparedness and Response (ASPR)'' (online at:
https://www.phe.gov/about/aspr/pages/default.aspx).
\9\ Emily Baumgaertner, ``Trump's Proposed Budget Cuts Trouble
Bioterrorism Experts,'' New York Times (May 28, 2017) (online at:
https://www.nytimes.com/2017/05/28/us/politics/biosecurity-trump-
budget-defense.html); Blue Ribbon Study Panel on Biodefense Strategy
statement on proposed closure of biodefense laboratory (July 12, 2017
(online at: http://www.biodefense
study.org/news-item/blue-ribbon-study-panel-on-biodefense-statement-on-
proposed-closure-of-biodefense-laboratory); Jeff Schlegelmilch, ``5
Ways the President's Budget Blueprint Could Change the Way We Respond
to Disasters,'' The Hill (May 3, 2017) (online at: http://thehill.com/
blogs/pundits-blog/homeland-security/331818-5-ways-the-presidents-
budget-blueprint-could-change-the).
Question 19. What would substantial budget cuts mean for the
Administration's ability to coordinate across departments and agencies
in the event of a public health emergency, such as pandemic flu, Ebola,
or a bioterrorism attack?
Answer 19. Without the proper funding, there may be limited ability
to validate plans, processes or procedures through exercises and to
evaluate and identify strengths, gaps and shortfalls which could
enhance preparedness.
Question 20. What would a hiring freeze mean for the
Administration's ability to coordinate across departments and agencies
in the event of a public health emergency?
Answer 20. Currently, there is no Administration hiring freeze.
Should a hiring freeze be implemented in the future, it is likely that
there would be exemptions for public health/safety and national
security personnel. I would expect HHS to implement such exemptions.
ASPR needs a trained, qualified and credentialed team to effectively
and efficiently manage response and recovery operations. I will work
with partners throughout HHS to ensure ASPR has the workforce it needs
to prepare and respond to public health emergencies.
Question 21. The ASPR plays an important role in coordinating
agencies and departments involved in the response to a public health
emergency. Does the ASPRs coordinating role change depending on whether
the emergency event originates domestically or internationally?
Answer 21. ASPR is the Secretary's principal advisor on all matters
related to manmade and naturally occurring public health emergencies.
This includes medical preparedness, response, recovery, as well as
activities throughout HHS including human services. ASPR, on behalf of
the Secretary, is also the Emergency Support Function--8 (ESF-8)
Coordinator under the National Response Framework. The ASPR's role in
protecting the health security of our Nation is the same whether the
threat starts within or outside our borders.
Gene Editing and Synthetic Biology
Researchers in Canada recently reported that they reconstructed the
currently extinct horsepox virus, an evolutionary relative of the
smallpox virus, using commercially available genetic material.\10\ The
researchers are partnering with New York-based Tonix Pharmaceuticals to
develop a safer human smallpox vaccine, and potentially new cancer
therapeutics, highlighting the dual-use potential of this and related
research and development.\11\
---------------------------------------------------------------------------
\10\ Kai Kupferschmidt, ``How Canadian Researchers Reconstituted an
Extinct Poxvirus for $100,000 Using Mail-Order DNA,'' ScienceInsider
(July 6, 2017) (online at: http://www.sciencemag.org/news/2017/07/how-
canadian-researchers-reconstituted-extinct-poxvirus-100000-using-mail-
order-dna).
\11\ Jeff Bessen, ``GMOs Lead the Fight Against Zika, Ebola and the
Next Unknown Pandemic,'' AP (July 27, 2016) (online at: https://
apnews.com/a86a1ba205154be4b175a1c11406332e/gmos-lead-fight-against-
zika-ebola-and-next-unknown).
---------------------------------------------------------------------------
The advent of easy-to-use and relatively cheap biotechnological
tools, such as rapid DNA sequencing and gene editors, underlines the
importance of developing a national biodefense strategy, including a
plan for emergency preparedness and development of medical
countermeasures. Last month, the White House announced it is developing
such a comprehensive biodefense strategy,\12\ as required by the fiscal
year 2017 (FY 2017) National Defense Authorization Act (NDAA).\13\ The
bill charges the Secretaries of Defense, Health and Human Services
(HHS), Homeland Security, and Agriculture to develop a strategy and
implementation plan to address our Nation's biodefense, including
``prevention, deterrence, preparedness, detection, response,
attribution, recovery, and mitigation.''
---------------------------------------------------------------------------
\12\ Jonathan Landay, ``White House Developing Comprehensive
Biosecurity Strategy: Official,'' Reuters (July 20, 2017) (online at:
http://www.reuters.com/article/us-usa-security-biodefense-
idUSKBN1A52HZ).
\13\ S. 2943, National Defense Authorization Act for Fiscal Year
2017, Section 1086 (online at: https://www.congress.gov/bill/114th-
congress/senate-bill/2943/text).
Question 22. Do you agree that research, such as that using gene
editing and synthetic biology technologies, is essential to advancing
the development of medical countermeasures?
Answer 22. As the ASPR, I will consider the implications and
potential advancements that would result from all of the latest
technologies. Like any new technologies, their potential and
implications need to be evaluated. It will be a subject that I will
carefully monitor going forward.
Question 23. What steps will you take to work across agencies and
departments and with other stakeholders to ensure that dual-use
research, such as that using gene editing and synthetic biology
technologies, is conducted in a responsible and ethical manner, while
also promoting and supporting such research?
Answer 23. ASPR has been a leader in the effort to determine how to
manage and balance the need for scientific research and discovery with
respect to potential bioterror and pandemic agents, and the potential
risks posed by this type of research.
HHS policies provide a mechanism for ongoing oversight and review
of high risk research to help ensure that important research can
proceed, while minimizing safety and security risks. I look forward in
my role to participating and contributing to this important task.
Response by Elinore F. McCance-Katz, M.D., to Questions of Senator
Murray, Senator Sanders, Senator Casey, Senator Franken, Senator
Bennet, Senator Whitehouse, Senator Baldwin, Senator Murphy and Senator
Warren
senator murray
Question 1. Access to mental health and substance use disorder
screening and assessment, and to the full spectrum of evidence-based
therapeutic services, is necessary to recognize and appropriately
address mental health and substance use disorder needs for all
individuals. Untreated mental health disorders lead to higher rates of
family dysfunction, poor school performance, juvenile incarceration,
substance use disorder, unemployment, and suicide. For example, in
2012, more than 5,000 children and youth aged 10 to 24 died by suicide,
making it the second-leading cause of death in this age range.
Behavioral health needs are often identified and addressed in different
settings, not just primary or behavioral health care settings. For
example, social workers often identify behavioral health needs in
schools. How do you plan to support and strengthen these activities,
especially outside primary or behavioral health care settings?
Answer 1. Given my previous work at SAMHSA, I am aware of the
agency's long-tenured investment in treating children in their
communities and in natural settings. Concurrently, SAMHSA has invested
in prevention and treatment programs for young people that have a
strong evidence base. Moving these programs and practices to settings
beyond primary and behavioral health care settings is critical. The
21st Century Cures Act also provides instruction and funding to address
issues related to behavioral health in children and families outside of
healthcare settings. I will work with Federal partners and national
stakeholder groups such as the National Alliance on Mental Illness
(NAMI) and Mental Health America, both of which are grassroots,
community-based organizations that can help with outreach in community
settings and dissemination of education about issues related to
behavioral health in communities. I will also be looking to States and
Congress as partners in helping SAMHSA consider how best to serve our
families.
Question 2. You have mentioned the importance of incorporating
psychosocial variables when engaging the mentally ill. There is concern
that taking too rigid a view of evidence-based practices will overlook
critical aspects of everyday life, such as stable housing, education,
obtaining and maintaining an occupation. If confirmed as the Assistant
Secretary for Mental Health and Substance Use, how will you ensure
psychosocial variables are included in the dissemination of research
findings and evidence-based practices to service providers? In
addition, how will the new National Mental Health and Substance Use
Policy Laboratory (NMHSUPL) promote evidence-based practices and
service delivery models that address psychosocial variables?
Answer 2. There is a research base for assertive community
treatment programs that include assisting with psychosocial needs
including housing, education and employment and even more basic needs,
such as how to shop for food and other necessities which are associated
with positive outcomes. My goal is to see psychiatric medical care and
psychosocial service providers work together to assure that Americans
receive the spectrum of services necessary for recovery.
The National Mental Health and Substance Use Policy Laboratory
(NMHSUPL) was newly stood up as a result of the 21st Century Cures Act
to promote evidence-based practices and service delivery models,
including those that address psychosocial variables. I look forward to
working with my colleagues at SAMHSA in establishing processes for
coordinating across SAMHSA programs and the Center for Behavioral
Health Statistics and Quality, and engaging a wide range of
stakeholders including Federal partners, providers, patients, research
institutions and others to ensure that SAMHSA policy is guided by the
best evidence and information about the state of the behavioral health
field.
Question 3. For over 40 years the Minority Fellowship Program (MFP)
at the Substance Abuse and Mental Health Services Administration
(SAMHSA) has been leading efforts to reduce health disparities and
improve behavioral health care outcomes for racial and ethnic
populations. The program was recently authorized in the 21st Century
Cures Act, which we passed last year. Can you elaborate on how you will
ensure the program continues as authorized and on the importance of
having a behavioral health workforce in reducing health disparities?
Answer 3. The behavioral health workforce continues to have major
shortages of professionals and care providers that serve minority
communities. It is vital that we continue to build the behavioral
health workforce pipeline. I look forward to supporting programs that
increase the behavioral health workforce and improve behavioral health
care outcomes for racial and ethnic populations.
senator sanders
Question. The President's budget includes extremely drastic cuts to
the Substance Abuse and Mental Health block grants during a time when
other behavioral health programs also are being considered for funding
cuts. This has the potential to dismantle our country's mental health
and substance abuse system, and to walk back the progress we have made
around mental health and substance abuse care in the last decade.
If confirmed, and as the first Assistant Secretary for Mental
Health and Substance Abuse, what are you planning to do to strengthen
the service system and improve access to critically needed substance
abuse, mental and behavioral health services?
Answer. I plan to review current programs and determine those that
are producing positive results for individuals with substance use
disorders and serious mental illness. I will be a strong advocate for
the programs that are working.
senator casey
Question 1. Substance use disorder, including the opioid epidemic,
continues to be one of the most pressing public health problems facing
our country. Given what we know about the impact of exposure to
traumatic events in childhood, including an increased vulnerability to
substance use disorders, what ongoing initiatives or new efforts might
SAMHSA support to address this critical issue in a comprehensive and
coordinated way?
Answer 1. There is evidence showing a strong correlation between
opioid addiction and traumatic experiences, particularly early
childhood adversity.
There are multiple strategies that SAMHSA can implement to address
addiction in a comprehensive and coordinated way, building on existing
mechanisms. For example, SAMHSA convenes, in partnership with the
Department of Labor, an Interagency Trauma Workgroup, consisting of
multiple departments and agencies. This workgroup coordinates
collaborative interdepartmental efforts focusing on prevention and
treatment of mental and substance use disorders that may be associated
with trauma and is expanding their work to address the connection
between early adversity, trauma and opioid use and misuse. In taking on
this leadership role in SAMHSA, I will continue to work with the
national stakeholder groups representing providers, people living with
mental and substance use disorders, and families that can provide input
to SAMHSA regarding whether there are other actions that could be taken
to better address issues related to childhood adversity, challenges,
and trauma. We can review State models that have had success in
addressing these issues and disseminate that information nationally, as
well as explore what actions in this area other agencies, such as the
Departments of Labor, Education, and Housing and Urban Development, may
have pursued.
Question 2. The Administration has proposed massive cuts to
Medicaid through its budget proposal and through efforts to repeal the
ACA. The House's budget bill proposes cutting $1.4 trillion from
Medicaid. As you know, Medicaid is the primary funder for public mental
health treatment and the availability of mental health services is
sorely lacking. Do you support these proposed cuts to Medicaid and how
will you advocate for more mental health services in an environment
that is proposing to cut massive amount of funding for the services?
Answer 2. I support the goal of ensuring that all Americans have
access to affordable coverage that best meets their needs and those of
their families, including mental health services. I am committed to
advocating on behalf of those needing these services. I would see a
significant part of my role as Assistant Secretary for Mental Health
and Substance Use as working closely with the States and others to
improve efficiencies in these programs and to focus the use of funds on
evidence-based practices to maximize their reach and impact.
Question 3. Dr. McCance-Katz, the President's budget included
drastic cuts to both the Substance Abuse and Mental Health block grants
at a time when other behavioral health programs are also being
considered for funding cuts. This has the potential to dismantle our
country's mental health and substance abuse system. As Assistant
Secretary, and more specifically as the first Assistant Secretary for
Mental Health and Substance Use, what are you planning to do to
strengthen the service system and improve access to critically needed
behavioral health services?
Answer 3. One of my goals as the Assistant Secretary for Mental
Health and Substance Use will be to address the integration of care,
specifically behavioral health and primary care. I look forward to
meeting with stakeholders across the Department and governmentwide,
such as the Centers for Medicare & Medicaid Services, to explore
opportunities to develop strategies for better alignment and
integration of behavioral health and primary care. One of my primary
goals will be to reach out to Federal agencies and to providers about
the need to both integrate and co-locate these services.
Question 4. What is your view of the role and importance of
behavioral treatment approaches and peer support versus psychotropic
medication in the treatment of mental health and substance use
disorders?
Answer 4. I don't see behavioral treatment approaches/peer support
and psychotropic medication treatment as mutually exclusive. My goals
include focusing on both psychiatric treatment, which is essential to
restoring one's mental capacity and psychosocial services, which are
essential to assisting a person in recovery. In leading SAMHSA, I am
committed to reinforce the understanding that psychiatric care and the
use of medications along with behavioral treatment is critical to
patient care.
Question 5. How do you plan to incorporate and learn from the wide
range of stakeholders in the mental health and substance use field--
including providers, consumers, and researchers--to help inform your
vision for the agency during your tenure in this Administration?
Answer 5. I think it is of paramount importance to engage a wide
range of stakeholders to help inform SAMHSA's efforts. I plan to listen
and learn from stakeholders in a variety of ways including one-on-one
conversations, addressing major conferences and allowing time for
questions and answers, reaching out to key coalitions such as the
Mental Health Liaison Group and the Parity Implementation Coalition,
and visiting prevention, treatment and recovery support organizations.
I have been a practicing psychiatrist and a funded researcher and have
worked in State government both in California and Rhode Island. I have
sought out stakeholders to inform my approach to psychiatry and
addiction psychiatry and will continue to seek stakeholder input. I see
these groups representing providers, consumers, and families as
essential to my success and to helping to assure that SAMHSA is doing
the best it can to meet the needs of Americans with mental and
substance use disorders. As a clinical researcher, I will continue to
keep up to date on research progress and findings and to use SAMHSA to
help to disseminate these findings so that States/communities can make
use of evidence-based practices in their programs.
Question 6. Will you commit to responding to monitoring and
oversight questions from all committee members and be responsive to our
requests for information?
Answer 6. I am fully committed to responding appropriately to
congressional oversight inquiries and to work cooperatively with
committee Members and staff to provide accurate and timely responses.
Question 7. During the questioning at the August 1 hearing you
mentioned that health insurance plan benefits is a reason why many
individuals do not receive adequate mental health treatment. What will
you do to ensure mental health coverage parity and to expand access to
mental health and substance abuse treatment for those who need it?
Answer 7. My understanding is that SAMHSA has already begun efforts
to provide States support through technical assistance, access to
national experts, individualized coaching, and product development. I
am encouraged that SAMHSA led these efforts in collaboration with DOL
and CMS (CMCS/CCIIO) and, with the opportunities afforded by the 21st
Century Cures Act and the momentum of the Parity Policy Academies, I
look forward to continuing to lead efforts in assisting States in
advancing parity implementation.
Question 8. Over the last several months, I have sent multiple
letters to HHS about the Administration's ongoing efforts to undermine
and sabotage the Affordable Care Act through executive action. HHS has
failed to provide responses to many of my letters. If HHS has
responded, the response letters have been wholly inadequate and have
not been responsive to my requests. If you are confirmed, do you commit
to respond in a timely manner to all congressional inquiries and
requests for information from all Members of Congress, including
requests from Members in the Minority?
Answer 8. I am fully committed to responding appropriately to
congressional oversight inquiries and to work cooperatively with
committee Members and staff to provide accurate and timely responses.
senator franken
Question 1. Can you highlight some of the benefits and successes
that have stemmed from mental health block grant funds? President
Trump's budget recommends cuts to the mental health block grant. How
would these reductions affect access to services for people with mental
illness and substance use disorders, especially at a time when the
country is facing an opioid epidemic?
Answer 1. The mental health block grant funds have enabled States
to provide evidence-based services to those with mental illness and
substance use disorders. I believe that people with mental illness and
substance use disorders need access to services, and I will be a
champion for ensuring that they are able to receive these services.
Question 2. Can you describe which patients, from your perspective,
may be able to benefit most from peer support services? Based on your
review of the evidence, at which stage of treatment are these peer
support services appropriate for different population groups?
Answer 2. I believe that peer professionals will, over the coming
years, become a standard resource available to people struggling with
mental and/or substance use disorders. Those who participate in
training programs gain skills in how to work as part of a care team and
support all aspects of a person's treatment plan including psychiatric
care. This psychiatric care often includes psychotropic medications
that are, in my view as a psychiatrist, very valuable. While the
evidence base is nascent, there are studies that show the benefit of
peer involvement in a person's care. A person available within the
community to assist a person in accessing the recommended treatments
and resources and serving as a source of support is valuable.
senator bennet
Question 1a. I was recently in Otero County, CO where drug
overdoses have been increasing. The entire community was engaging to
address the rise in opioid abuse. This included coordinating hospitals,
the courts, schools and foster care services. Even when we see a
decrease in prescription overdoses, it is usually countered with an
increase in heroin overdoses. In the 1960s, more than 80 percent of
heroin users started with heroin. In contrast, currently, about 80
percent of heroin users first started using prescription opioids.
What are practical steps you plan to take to address the opioid
crisis?
Answer 1a. I am committed to helping Secretary Price advance his
five-point plan to address the opioid epidemic. As a leader in the
field of addiction psychiatry, I plan to engage in each strategy:
strengthening public health surveillance, advancing the practice of
pain management, improving access to treatment and recovery services,
including medication-assisted treatment, targeting availability and
distribution of overdose-reversing drugs, and supporting cutting-edge
research. I am also aware that both the 21st Century Cures Act and the
Comprehensive Addiction and Recovery Act provided specific actions that
SAMHSA and other HHS and Federal agencies can undertake to address the
crisis, and I will be working across the government to implement these.
In addition, I plan to prioritize prevention initiatives in the form of
education of the American people and continue to advocate for training
of healthcare practitioners so that they can receive the DATA waiver
and prescribe buprenorphine/naloxone for opioid use disorder.
Question 1b. How can we ensure that Americans are not becoming
addicted in the first place while making it easier for people who
currently have an addiction to obtain access to treatment?
Answer 1b. Prevention and treatment are both key components to
addressing the opioid crisis. I know the Department has issued the
Opioid State Targeted Response grants that will help States address
treatment for those struggling with addiction. An important part of
prevention is the education of providers and the American people--
people need to know about the dangers presented by such activities.
senator whitehouse
Question 1. The President has proposed deep cuts to SAMHSA
programs. Do you believe cutting funding for SAMHSA will benefit people
with mental health and substance use disorders?
Answer 1. I believe that we should ensure that resources spent are
truly benefiting Americans with mental health and substance use
disorders. I commit to being an advocate for programs that are proven
to work and provide help to those in need.
Question 2. As you know, the opioid epidemic is currently one of
the biggest public health challenges facing Rhode Island and the States
of many of my colleagues. Last Congress, we passed The Comprehensive
Addiction and Recovery Act (CARA), a law I co-authored. CARA authorizes
several important SAMHSA programs, including programs to treat pregnant
and post-partum women struggling with addiction, medication-assisted
treatment programs, naloxone training programs, and peer-to-peer
recovery programs. I was pleased that these programs received funding
as part of the fiscal year 2017 appropriations bill, and hope they will
continue to receive funding in the coming years. Do you support the
full funding of the programs authorized by CARA, and will you work
within the Administration and with Congress to ensure funding these
programs is a priority?
Answer 2. CARA is an important law that will help SAMHSA to address
the opioid epidemic head-on. I look forward to implementing these
programs and will work to ensure that they are implemented consistent
with the CARA.
Question 3. You have previously written that SAMHSA spends too much
time on peer support and recovery services.
Do you support SAMHSA's current programs related to peer support
and recovery services?
As Assistant Secretary for Mental Health and Substance Use, will
you prioritize SAMHSA's peer support and recovery work?
Answer 3. I believe that peer professionals will, over the coming
years, become a standard resource available to people struggling with
mental and/or substance use disorders. Those who participate in
training programs gain skills in how to work as part of a care team and
support all aspects of a person's treatment plan including psychiatric
care. This psychiatric care often includes important psychotropic
medications. While the evidence base is nascent, there are studies that
show the benefit of peer involvement in a person's care. A person
available within the community to assist a person in accessing the
recommended treatments and resources and serving as a source of support
can be valuable.
Evidence-based medical treatment of serious mental illness must be
a major focus for SAMHSA. I will prioritize the full spectrum of
evidence-based services to assist those with serious mental illness and
substance use disorders. This will include openly embracing evidence-
based medical treatment of these disorders as well as psychosocial
supports, which include peers.
Question 4. You have written favorably about the Affordable Care
Act's expansion of mental health and substance use disorder coverage.
In the aftermath of last week's votes, I hope that the Senate can begin
working in a bipartisan way to improve our health care system, without
jeopardizing the coverage gains we've made under the ACA. As the Senate
continues its work to reform our health care system, maintaining health
insurance coverage for mental health and substance use disorders will
be a priority of mine. If asked for your expertise on this issue, will
you advocate for policies that help expand access to mental health and
substance use services?
Answer 4. I will be a strong advocate for people with mental health
and substance use disorders and will advocate for policies that promote
access to coverage and the critical services on which these patients
rely.
Question 5. As Assistant Secretary for Mental Health and Substance
Use, how will you approach the prevention of and screening for mental
illness and behavioral disorders in children?
Answer 5. Mental illness, emotional and behavioral disorders tend
to have their onset in adolescent and young adult developmental periods
and increasingly we are realizing that early signs of these disorders
appear even earlier in childhood, but often go unrecognized by
practitioners.
There is burgeoning research documenting the capacity to link
results of early childhood screening with later problematic behaviors,
including mental disorders, substance use disorders, problematic school
behavior and subsequent involvement with the juvenile justice system.
Child, family, societal human and fiscal costs have been documented.
As Assistant Secretary, it is clear that we will need to look at
behavioral health as a two-generational issue and that screening for
these issues in children and families needs to be the standard of care.
Question 6a. As you know, key members of the behavioral health
community--psychologists, community mental health centers, and
psychiatric hospitals, among others--are not eligible to receive
incentive payments for adopting certified electronic health record
(EHR) technology under the Medicare and Medicaid EHR Incentive Programs
(Meaningful Use). Last year's SAMHSA ``Leading Change'' report included
health information technology as one of six ``Strategic Initiatives.''
Will you continue to make the dissemination and effective use of
health IT among behavioral health providers a priority within SAMSHA?
Answer 6a. I plan to continue to make dissemination and effective
use of Health IT among behavioral health providers a priority within
SAMHSA especially in rural and extremely rural areas across the Nation.
Question 6b. As Assistant Secretary, in what ways will you promote
the use of health IT among behavioral health providers?
Answer 6b. As Assistant Secretary, I plan to coordinate on
Department-wide initiatives focused on IT integration and will assist
with outreach to the behavioral health provider community.
Question 7. The Mental Health Parity and Addiction Equity Act
(MHPAEA) was passed in 2008, and although it has been fully
implemented, enforcement continues to be a problem. What steps will you
take to improve Federal enforcement of mental health parity?
Answer 7. I will continue to ensure that SAMHSA supports efforts at
mental health parity implementation. SAMHSA's leadership and
partnership with States, providers, and consumers positions the agency
uniquely to provide guidance and support in the advancement of MHPAEA.
Question 8a. In Rhode Island, you created the Centers of Excellence
program, which brings together doctors, nurses, counselors, peer
professionals, and others to provide patient-centered care to
individuals receiving medication-assisted treatment. As you know, the
medication is just one part of medication-assisted treatment, and
additional services are often needed to support recovery.
As Assistant Secretary for Mental Health and Substance Use, how
would you evaluate promising treatment models being used at the State
level?
Answer 8a. In developing the model for the Centers of Excellence
(COE) for Rhode Island, we also determined outcomes that would help to
inform whether these programs were providing the impact and benefit we
hoped for. These variables include: number of people referred into COE
treatment, number of people who complete admission/induction
(engagement), number of people receiving medication-assisted treatment
(MAT), number of successful discharges to community office-based opioid
use disorder providers, number of negative toxicology screens (opioid),
number of opioid toxicology screens obtained, number of negative
toxicology screens (all other illicit substances), number of toxicology
screens obtained (all other illicit substances), number of patients
admitted to the emergency department, number of hospitalizations over
course of treatment, and number of patients remaining in COE until
referral to another provider (retention). These types of variables can
be generalized to substance use disorder treatment programs to assess
effectiveness. SAMHSA can explore with States how to develop systems to
collect such data.
Question 8b. How would you share those models with other States or
communities that could benefit from them?
Answer 8b. A major and important function of SAMHSA is to be a
repository of epidemiological data, evidence-based practices, and
promising models. SAMHSA has information reported to it by the States
and can facilitate dissemination in a number of ways such as:
informational webinars and dissemination through other information
technology tracks, written documents, and use of SAMHSA national
programs that provide training and peer support including provider
clinical support systems and addiction technology transfer centers as
examples.
senator baldwin
Question 1. As HHS implements the 21st Century Cures Act, I hope
that, if confirmed, you would pay close attention to the mental illness
with the highest mortality rate--eating disorders. The eating disorder
provisions included in the law, derived from the bipartisan Anna Westin
Act of 2015 (H.R. 2515/S. 1865), were designed to improve eating
disorder early detection by our health professionals, increase access
to quality and affordable treatment for eating disorders under mental
health parity, and provide the public with resources to help prevent
and identify the disorder. Taking swift action to implement these
provisions is critical to ensuring meaningful access to treatment for
men and women with an eating disorder, specifically by incorporating
the eating disorders parity rulemaking into existing mental health
parity regulations.
Will you commit to swiftly advancing the rulemaking process to
implement the eating disorders mental health parity provisions?
Answer 1. I recognize the importance of provisions enacted by
Congress and reflected in the 21st Century Cures Act emphasizing that
Mental Health Parity and Addiction Equity Act (MHPAEA) requirements
should fully apply to eating disorders. My understanding is that in
June 2017, HHS published a guidance/frequently asked questions document
that notes the applicability of parity provisions to eating disorders,
citing the 21st Century Cures Act and requesting public comment
regarding ``whether any additional clarification is needed regarding
how the requirements of MHPAEA apply to treatment for eating
disorders.'' I will ensure SAMHSA will work with CMS and DOL to review
comments and to develop further guidance on these issues as necessary.
Question 2. As a physician, can you discuss the importance of
intermediate level of care benefits for the treatment of severe eating
disorders?
Answer 2. People with eating disorders require high-quality health
care. Several levels of specialty care may be best for people with
eating disorders. The goal is to help the person get to a normal weight
and normal eating. The best treatment option depends on the severity of
the disorder and the person's past response to treatment. An
intermediate level of care, such as day treatment or partial
hospitalization, can address medical conditions and provide
psychological support. This can be done as a transition from inpatient
to outpatient care. It can also be an alternative to inpatient care.
senator murphy
Question 1. As you know from your past experiences in Connecticut,
my State has a proud history of the recovery movement. As I mentioned
in our meeting, some groups have been critical of your nomination based
on some of your past writings regarding the recovery model.
Can you discuss the balance that needs to be struck between
medication and recovery supports? Also, can you explain the role that
you believe peers should play?
Answer 1. I believe that for those with serious mental illnesses,
such as schizophrenia and bipolar disorder, who experience
hallucinations and delusions--which are prominent symptoms in these
disorders and which can be associated with behaviors that can cause
serious harm to the people affected and/or others--medical treatment
including psychotropic medication and psychiatric care must be
available. There is a large evidence base supporting medication
treatment, and it is the standard of care for those with these types of
symptoms associated with serious mental illness. However, I also
strongly support psychosocial interventions including peer support to
provide encouragement, assistance in getting services needed, and to
provide a model for recovery instilling hope (all of this is predicated
on the idea that the peers are supportive of medical care recommended
for the individual). I do not believe that either medical interventions
or peer support alone provide for all of the needs of persons affected
by serious mental illness. Therefore, I will continue to encourage
partnerships between medical services and recovery-support services--
indeed, I see medical services as a recovery support.
Question 2. I was fortunate to work with Chairman Alexander,
Ranking Member Murray and Senator Cassidy on the mental health bill
that eventually was passed in the 21st Century Cures Act. One of my top
priorities in that bill was SAMHSA's integration program because
studies have shown that despite overall gains in life expectancy,
individuals with serious illnesses is attributable to acute and chronic
co-morbid physical conditions, such as heart disease.
I know the Mathematica interim evaluation of this program recently
showed substantial improvements in physical health outcomes among
clients who have chronic physical health conditions at enrollment and
positive trends in functional improvement and substance use. I am
hopeful that the changes that we made in the Cures Act will also
improve the outcomes for grantees and lead to States breaking down
barriers that can discourage integration.
Unfortunately, the administration has proposed eliminating funding
for the program in its budget request. Can you talk about the
importance of integrating mental health and physical health care and
why the administration would zero out this funding?
Answer 2. I consider the integration of physical and behavioral
health services to be very important to improving health outcomes. I
have not been privy to discussions about the budget prior to my
confirmation, so I cannot speak to the budget request. I have worked in
integrated-care systems in my clinical practice, and I have supported
and encouraged establishment of integrated healthcare systems in my
government work. I will continue to do so. I also believe that we must
integrate the treatment of mental and substance use disorders given the
high rates of co-occurring disorders and look forward to reviewing the
data on Certified Community Behavioral Health Centers (CCBHCs), which
SAMHSA has worked to establish with the States.
Question 3. As you know, Congress has put a focus on the needs of
individuals with early serious mental illness. As SAMHSA noted in its
fiscal year 2018 budget justification,
``The majority of individuals with serious mental illness
experience their first symptoms during adolescence or early
adulthood, and there are often long delays between the initial
onset of symptoms and receiving treatment. The consequences of
delayed treatment can include loss of family and social
supports, reduced educational achievement, incarceration,
disruption of employment, substance abuse, increased
hospitalizations, and reduced prospects for long-term
recovery.''
Most recently, Congress increased this setaside from 5 percent of
the Mental Health Block Grant to 10 percent. There are promising models
targeted to this population, including Yale's Specialized Treatment for
Early Psychosis (STEP) program. STEP patients are hospitalized nearly
50 percent less than other patients and when they do need a
hospitalization, the length of stay averages 6 fewer days than standard
treatment. Additionally, approximately one-third more STEP patients
were engaged in vocational training and these individuals were more
involved in outpatient mental health treatment.
Can you describe the importance of programs like STEP and what
Congress and SAMHSA should be doing to scale their reach?
Answer 3. There are now a number of evidence-based approaches that
can successfully provide services and supports to individuals
experiencing a First Episode Psychosis (FEP). These approaches, based
on the evidence-based Coordinated Specialty Care (CSC) model, have a
number of common elements including an interdisciplinary team approach
that focuses on the comprehensive needs of the patients served by
providing rapid access to high-quality treatment and offering support
in areas such as employment and education. SAMHSA can help to scale the
reach of these programs through dissemination of information about this
approach and findings related to use of these approaches from research
studies and from States' experiences. SAMHSA has a long track record of
making such information available and will continue this important
function going forward. Similarly, SAMHSA leadership, given
opportunities, can speak to the benefit of these programs as another
means of information dissemination.
Question 4. Will you prioritize the treatment of emerging serious
mental illnesses, such as schizophrenia and bipolar disorder, and
substance use disorders in transitional age youth? If so, how?
Answer 4. There has been an increasing amount of clinical research,
such as the North American Prodrome Longitudinal Study, examining the
prodromal phase in order to understand and develop interventions to
mitigate psychosis. Transitional-age youth and young adults who present
with prodromal symptoms are at increased risk for developing clinical
psychosis, which can be one of the most chronic, debilitating features
of serious mental illness. Early detection and intervention in people
at risk for developing psychosis can be successful in delay of the
first episode and reducing the severity of illness. I believe this is
an important area for continued research and focus. SAMHSA, working
collaboratively with NIMH, can assist with dissemination of the
evidence base for prodrome and approaches/interventions designed to
ameliorate these symptoms and improve the quality of life for young
people at high clinical risk for psychosis.
Question 5. Mass violence events, like the tragedy that occurred in
my State at Sandy Hook Elementary School, have lasting effects on our
children, families, and the community at-large. Federal programs like
the SAMHSA-administered National Child Traumatic Stress Initiative have
played an important role in supporting the acute and long-term mental
health needs of our community as we continue to recover from this
terrible tragedy.
How will you guide SAMHSA's efforts to strengthen our national
capacity to prevent and respond to traumatic events like this?
Answer 5. SAMHSA's strength comes from its collaboration,
coordination, and communication with community, State, regional, and
Federal partners in all phases of response and recovery. SAMHSA further
works to ensure behavioral health is meaningfully addressed in local,
regional, State, and Federal response plans and provides tools and
guidance to ease its inclusion.
I will ensure that SAMHSA continues to update and disseminate tools
describing best practices, informational materials, and fact sheets
addressing aspects of response and recovery. I will explore and
evaluate grant programs that address needs which cannot be met in other
ways and make sure that lessons from those programs guide our best
practices and inform disseminated materials as well. I will also
support evidence-based early intervention programs that SAMHSA has
overseen in the States. I will support ongoing technical assistance to
States as they seek the best and most appropriate interventions for
their communities including education about serious mental illness,
recognition of potential illness, and how to access resources. I will
continue to encourage healthcare-practitioner education and explore
mechanisms for increasing the number of psychiatrists, physicians, and
allied providers who are trained to provide mental health services in
communities. I will openly and actively endorse recovery supports
including psychiatric medical care for those struggling with serious
mental illness.
Question 6. Recent research has shown that there is a link between
childhood exposure to trauma and subsequent substance use problems.
In what ways can you ensure that issues related to child and adult
trauma are part of substance use disorder and opioid programs that you
will oversee in your role as the Assistant Secretary for Mental Health
and Substance Use?
Answer 6. SAMHSA has provided significant leadership in the area of
child and adult trauma. Screening tools, interventions, and
informational materials, and a framework for addressing trauma and
implementing a trauma-informed approach in multiple health and human
service systems has been well-articulated with increasing uptake in
different sectors. This framework and associated interventions can more
intentionally and systematically be implemented in our substance use
disorder and opioid specific programs. Further, substance use disorder
treatment programs must include evaluation of both substance use and
mental disorders (as well as assessment of physical illnesses) given
the high rates of co-occurring mental disorders in those with primary
substance use disorders (approximately 40 percent). Assessment for
mental disorders should include assessment for trauma and trauma-
associated mental disorders. SAMHSA can use its existing training
programs, such as the Providers Clinical Support Systems and the
Addiction Technology Transfer Centers, to disseminate best practices in
these areas. Further, SAMHSA can prepare and disseminate special topic
trainings in this area. SAMHSA has a strong record of high-quality
presentations with national experts that are well attended by
practitioners and the public.
Question 7. Mental Health America's recent launch of a national
certification program for peer support specialists shows that creating
a workforce of peers will be a key ingredient in the future of mental
health and substance use care delivery.
Do you support an effort to add peer workers to the care workforce
and, if so, how would you support this effort?
Answer 7. I believe that for those with serious mental illnesses,
such as schizophrenia and bipolar disorder, who experience
hallucinations and delusions--which are prominent symptoms in these
disorders and which can be associated with behaviors that can cause
serious harm to the people affected and/or others--medical treatment
including psychotropic medication and psychiatric care must be
available. There is a large evidence base supporting medication
treatment, and it is the standard of care for those with these types of
symptoms associated with serious mental illness. However, I also
strongly support psychosocial interventions including peer support to
provide encouragement, assistance in getting services needed, and to
provide a model for recovery instilling hope (all of this is predicated
on the idea that the peers are supportive of medical care recommended
for the individual). I do not believe that either medical interventions
or peer support alone provide for all of the needs of persons affected
by serious mental illness. Therefore, I will continue to encourage
partnerships between medical services and recovery-support services--
indeed, I see medical services as a recovery support.
senator warren
Medicaid
As the Nation's first Assistant Secretary for Mental Health and
Substance Use Disorders, you will play a central role in efforts to
guarantee and expand access to behavioral health services. In
combination with the Mental Health Parity and Addiction Equity Act of
2008 (MHPAEA), the Affordable Care Act (ACA) and Medicaid expansion
have provided critical guarantees of access to behavioral health
services. Medicaid covers a disproportionate share of individuals with
individuals with mental illness--22 percent of adults with mental
illness and 26 percent of adults with serious mental illness received
Medicaid coverage in 2015.
President Trump has supported legislation that would cut Medicaid
by more than $700 billion, converting it to a per capita cap or block
grant system. His budget proposal for fiscal year 2018 (FY 18) also
proposed an additional cut to Medicaid of over $600 billion.
You have previously emphasized the role of the ACA and Medicaid
expansion in reducing barriers to addiction treatment.
Question 1. Do you agree that Medicaid plays an essential role in
ensuring that individuals with mental health and addiction disorders
can access medically necessary treatment?
Answer 1. Yes, Medicaid provides access for eligible people with
mental health and addiction disorders to receive medically necessary
treatment.
Question 2. Do you agree that hundreds of billions of dollars in
cuts to Medicaid would have a negative impact on the ability of
individuals with mental health and addiction disorders to access health
care?
Answer 2. I support the goal of ensuring that all Americans have
access to affordable coverage that best meets the needs of themselves
and their families, including mental health services. I see a
significant part of my role as Assistant Secretary for Mental Health
and Substance Use as being an advocate for those with mental and
substance use disorders and to address their treatment and recovery
service needs.
Opioid Epidemic
At the core of the opioid epidemic has been the over-prescribing
and misuse of addictive and dangerous prescription painkillers. CMS
reported that generic Vicodin was prescribed to more Medicare
beneficiaries than any other drug in 2013--more than blood pressure
medication, more than cholesterol medication, more than acid reflux
medication. The National Institute on Drug Abuse has estimated that
over 70 percent of adults who misuse prescription opioids get the
medication from friends or relative, so efforts to reduce the amount of
unused medications in the home is a powerful new tool to tackle
prescription drug abuse. The Comprehensive Addiction and Recovery Act,
passed in July 2016, includes a bipartisan provision that I worked on
with Senator Capito which empowers patients to talk to their physicians
and pharmacists about partially filling their prescription medications
in order to reduce the amount of unused opioids in circulation.
In Massachusetts, more 2,000 individuals died from opioid overdoses
in 2016. The illicit distribution, sale, and increased use of fentanyl,
a dangerous synthetic opioid that is more potent than heroin, has
further contributed to this public health crisis--particularly in New
England States like Massachusetts. A November 2016 study by the
Massachusetts Department of Public Health found that of the opioid-
related fatalities in the State in which toxicology screens were
available, 74 percent of individuals tested positive for fentanyl.
Question 3. Do you believe that reducing the number of unused
medications in the home is an important tool in tackling the misuse of
prescription medications?
Answer 3. Yes. Providing education to both prescribers and patients
is important to reduce the number of unused medications in the home and
the risks of misuse that come with it, especially with regard to opioid
medication.
Question 4. What will you do to work with other agencies and the
physician community to address the overprescribing and misuse of
addictive prescription medications, while still ensuring that patients
who need pain medication can receive it?
Answer 4. Secretary Price has made the opioid epidemic one of the
Department's top clinical priorities. I look forward to working across
agencies to ensure that physicians are educated on the clinical
guidelines for the prescribing of opioids. I have worked for a number
of years at the interface of pain management and addiction. I was the
former medical director of SAMHSA's national training and mentoring
program, Providers' Clinical Support System for Opioids (PCSS-O). I
have worked with patients and their families on reducing unsafe opioid
use in the context of ongoing pain.
I believe SAMHSA has a major role to play in educating providers
and the public. I would welcome the opportunity to work with Congress
on this important issue.
Question 5. How will you work with States, physicians, pharmacists,
and patient groups to increase awareness about partial-fill policies?
Answer 5. I look forward to coordinating across agencies to ensure
that States, physicians, pharmacists, and patient groups are aware of
partial-fill policies.
Question 6. You have advocated for Medication-Assisted Treatment
(MAT) as an important evidence-based addiction treatment. How will you
work to ensure that other influential health officials in the
Administration understand the value of this treatment?
Answer 6. I know that HHS is committed to bringing everything the
Federal Government has to bear to address the health crisis opioids
pose. The first pillar of the HHS opioid strategy is to improve access
to treatment and recovery services, including medication-assisted
treatment (MAT), and all health officials in the Administration
understand the value of this treatment. I look forward to working with
both my Federal colleagues as well as members of the HELP Committee to
continue to advance MAT as a component of evidence-based addiction
treatment. While MAT alone is not enough, MAT addresses tolerance and
withdrawal and gives many people the ability to participate in
counseling, psychotherapy, and other necessary recovery supports that
form the basis of a comprehensive recovery program.
Question 7. As Assistant Secretary, what specific steps will you
take to build on HHS's efforts to support communities that are dealing
with the impact of fentanyl use on the rise in fatal overdose rates?
Answer 7. I will help coordinate HHS' efforts to assist States and
communities to identify synthetic opioid-related overdose deaths
including potential clusters and respond with prevention and treatment
strategies.
Syringe Exchange Programs and Supervised Injection Facilities
Syringe exchange programs are locations where individuals can go to
get sterile needles and syringes and safely disposed of used items, as
well as get education on safer practices and even treatment for other
medical, social, or mental health needs. The CDC, the Institute of
Medicine, among other scientific organizations, report that needle
exchanges are ``highly effective in preventing the spread of HIV/
AIDS.''
Question 8. As Assistant Secretary for Mental Health and Substance
Abuse, would you advocate for the use of Federal funds to support
syringe exchange programs?
Answer 8. People who inject drugs are at increased risk of
acquiring and transmitting HIV, viral hepatitis, and other blood-borne
infections. The opioid epidemic has focused attention on the dangers of
sharing needles, as evidenced by the HIV outbreak in rural Indiana in
2015. Under current law, in some jurisdictions, people who inject drugs
can access sterile needles and syringes through syringe services
programs (SSPs) and through pharmacies without a prescription. In
addition, current law gives States and local communities, under limited
circumstances, the opportunity to use Federal funds to support certain
components of SSPs. I look forward to working with Congress on this
issue and other avenues to address the health crisis opioids pose and
to improve the health of intravenous drug users.
Question 9. Research has also shown the benefits of Supervised
Injection Facilities (SIFs), where people can use their own drugs,
under medical supervision. Research indicates that SIFs help reduce HIV
and hepatitis transmission risks, prevent overdose deaths, and increase
the number of people seeking out addiction treatment. Would you commit
to advocate for studying safe injection facilities as a tool in the
fight against the opioid epidemic?
Answer 9. I am aware that the American Medical Association (AMA)
approved a resolution calling for the development of pilot SIFs, and
that there are sites proposed in Seattle, San Francisco, and New York,
to name a few. There is much we don't yet know about the effectiveness
of SIFs in saving lives and/or in encouraging people who use
intravenous drugs to seek treatment, and what little research data is
available does not, at least at this time, appear promising in the role
of these programs to assist people to treatment.
Peer Support
You have said before that ``SAMHSA has supported programs that
provide little help to those in greatest need,'' giving the example of
SAMHSA putting ``a major emphasis on developing a `peer workforce,'
through which individuals with mental disorders offer support to those
experiencing an acute episode of mental illness.'' \1\ However,
literature reviews have shown the effectiveness of peer support
programs for individuals with mental health and addiction disorders.\2\
---------------------------------------------------------------------------
\1\ McCance-Katz, Elinore, ``New Hope for the Mentally Ill,''
National Review (November 22, 2016) (online at: http://
www.nationalreview.com/article/442382/donald-trump-mental-illness-
needs-more-aggressive-treatment).
\2\ ``Peer Support: Why it Works,'' National Coalition for Mental
Health Recovery (April 2014) (online at: https://www.ncmhr.org/
downloads/References-on-why-peer-support-works-4.16.2014
.pdf).
Question 10. Why do you believe that peer support is not helpful in
treating mental illness?
Answer 10. I believe that peer professionals will, over the coming
years, become a standard resource available to individuals struggling
with mental and/or substance use disorders. I think they have a role in
the continuum of care. However, as a practicing psychiatrist for 30
years who has run the Rhode Island State hospital system for the last 2
years, I can say with great certainty that those with serious and
persistent mental illness--a population that receives little attention
yet suffers greatly and, untreated, can be at substantial risk to
themselves and sometimes others--need evidence-based psychiatric
interventions to assist them in their recoveries. Peers are a part of
the recovery process, but peers cannot impact psychosis,
hallucinations, and/or delusions. I am committed to embracing the
spectrum of recovery services including medical treatment for those in
need along with the use of peers as appropriate.
Question 11. Do you believe that peer support is helpful in any
context?
Answer 11. I believe that peer support is an important component of
recovery. As a physician, I can provide medical care onsite which lasts
for a very brief period. Peers can be far more available as part of a
treatment team and as supporters in the community. They can help
patients to obtain the medical, psychotherapy interventions, and other
recovery resources recommended. They provide emotional support and,
through their own recoveries, can provide hope. The value of such
services cannot be underestimated.
Question 12. You have been supportive of other community-based
programs in treating behavioral health disorders at SAMHSA.\3\ Which
community-based programs do you believe are useful?
---------------------------------------------------------------------------
\3\ McCance-Katz, Elinore, ``What is SAMHSA's Role in Today's
Healthcare System?'' SAMHSA (May 29, 2014) (online at: https://
blog.samhsa.gov/2014/05/29/what-is-samhsas-role-in-todays-healthcare-
system/#.WYHieoTytGo).
---------------------------------------------------------------------------
Answer 12. I support the integration of behavioral health and
primary care and the integration of treatment for mental disorders and
substance use disorders. I support programs that provide case
management and wrap-around services including assistance with
vocational/educational needs, housing, and assistance with legal issues
as needed. I support opioid treatment programs that expand to provide
primary care and mental health services. I support recovery housing and
programs for pregnant and post-partum women with opioid use disorder. I
support crisis intervention programs designed to avoid emergency
department visits and hospitalizations. All of these programs could
involve peer specialists.
Question 13. Would you commit to further studying and considering
the usefulness of peer support programs?
Answer 13. There is accumulating data on the value of peer support
programs and, yes, I would commit to further controlled research
studies aimed at determining the usefulness of peer support programs--
for who and under what conditions.
Response by Jerome Adams, M.D., to Questions of Senator Murray, Senator
Sanders, Senator Casey, Senator Franken, Senator Bennet, Senator
Whitehouse and Senator Warren
senator murray
Question 1. Earlier this year, a woman in Nevada died from an
infection that was resistant to all 26 antibiotics that are available
in the United States. The Centers for Disease Control and Prevention
(CDC) have estimated that antibiotic resistant infections infect over
two million and kill 23,000 Americans each year. A recent report found
that if we don't take action, drug-resistant infections will kill more
people worldwide than diabetes and cancer combined by 2050. Do you
agree that antibiotic resistance is a significant threat to human
health, and if so, how will you work to reduce this threat as Surgeon
General?
What role does the Surgeon General's office play in ensuring
antibiotics are used effectively and appropriately?
Answer 1. The issue of antibiotic resistance poses a serious threat
to public health and clinical care. HHS has been a leader across the
government in implementing a range of interventions. I am prepared to
work to address antibiotic-resistant bacteria with my colleagues across
the Administration to continue to advance these efforts. In particular,
I believe the Surgeon General is well-positioned to engage with the
medical community to encourage antibiotic stewardship and appropriate
antibiotic prescribing, and to help patients and the public understand
how to appropriately use antibiotics.
Question 2. In December, the Surgeon General issued a report that
concluded use of e-cigarettes by youth and young adults is a public
health concern. It found that use of e-cigarettes by youth is now more
common than use of regular cigarettes and that e-cigarettes come in a
wide array of fruit and candy flavors and are marketed in ways that
appeal to youth. Yet, last week, the Food and Drug Administration (FDA)
announced they would delay current deadlines for review of these
products.
Do you share the view that e-cigarette use by young people is a
public health concern that requires action at the Federal, State, and
local levels? Do you agree that FDA has an important role to play to
reduce youth use of e-cigarettes? What can CDC and other Federal
agencies do to address this public health concern? What role should the
Surgeon General play in raising awareness of this problem and spurring
the adoption of policies and programs that will reduce youth use of e-
cigarettes and all tobacco products?
Answer 2. Protecting and improving public health is at the core of
the Department's mission. While serving as the Indiana State Health
Commissioner, I have overseen Indiana's tobacco cessation efforts. I
look forward to working with the FDA, CDC, and other Federal agencies
to protect our children and significantly reduce tobacco-related
disease and death.
Question 3. Do you plan to continue the efforts of the National
Prevention Council and implementation of the National Prevention Plan?
Answer 3. As Surgeon General, my commitment is to prevention. I
believe it is the best way to improve the health of Americans and
decrease the burden on our health system. Once in the office, I will
work with stakeholders and Department leaders to evaluate the National
Prevention Council and National Prevention Strategy to ensure goal
alignment with the Department to better serve the American people.
Question 4. How will you support CDC's Office for Smoking and
Health and ensure they have the capacity to continue with and optimize
their prevention and cessation efforts, particularly their extremely
successful Tips from a Former Smoker campaign?
Answer 4. Recognizing the important role of CDC's Office on Smoking
and Health, I will work with the CDC Director, Dr. Brenda Fitzgerald,
to collaborate and communicate the available scientific information on
tobacco use and related diseases to the public, consistent with my role
as Surgeon General.
Question 5a. For the first time in two decades, life expectancy in
the United States has declined. Death rates among middle-aged
Caucasians in the South are increasing, largely due to drug overdoses,
liver disease, and suicide. Deaths due to chronic conditions such as
diabetes and heart disease have also stopped falling after years of
improvement. These conditions are all fully preventable.
How will your office work with the CDC and others within the
Department of Health and Human Services (HHS) to address these
preventable conditions?
Answer 5a. I believe it is critically important for all of the
agencies within the Department to work together in a coordinated
fashion to address preventable conditions. I look forward to serving as
Surgeon General and working to bridge the efforts of the various
agencies to improve the health of Americans, consistent with my role
and responsibilities.
Question 5b. How will this work be challenged by the current budget
environment, considering the proposed deep cuts in the President's
budget to the CDC and the repeated threats to the Prevention and Public
Health Fund?
Answer 5b. It is important that the Office of the Surgeon General
support efforts to prevent disease and encourage individuals to make
informed choices about their health. I am committed to working hard in
my role to advocate for prevention at HHS.
Question 6. Many health conditions and significant racial and
ethnic disparities are heavily influenced by various social and
environmental factors that typically exist outside of the health care
context. For example, sub-standard housing that promotes mold,
moisture, and pest infestations can trigger asthma. As Surgeon General,
how would you help make sure HHS is a leader in actively bridging the
divide between clinical care and community conditions?
Answer 6. Tackling disparities such as these is always a challenge,
especially when taking into account social and environmental factors
that exist outside of the health care context. As I said in my opening
statement, we need to get out into our communities and learn about
their obstacles and successes, share best practices, and help empower
them to implement local solutions. I am committed to working with
partners at the Federal, State, and local level to end disparities.
Question 7. Surgeons General have often depended on the Dietary
Guidelines for Americans (DGA) to promote healthy eating for families
across the country. Do you support development of the evidence-based
DGAs? As you know, the DGAs are currently under review and the review
process might be subsequently changed. Do you support the current
process in place to review the evidence that is the underpinning for
the DGAs? How would you optimize communication of the DGAs to the
American public? What do you feel the appropriate role for industry and
other stakeholders is in the process of developing the DGAs?
Answer 7. The Dietary Guidelines are science-based recommendations
that give Americans advice on building healthy eating patterns that can
help prevent chronic diseases and promote and advance their health and
well-being. The focus of the Dietary Guidelines is on preventing diet-
related health conditions, such as obesity, diabetes, and heart disease
rather than treating these and other diseases.
The Dietary Guidelines should be grounded in the strongest
available scientific evidence and represent our current understanding
of the connections between food and health. The development process
includes input from an independent group of nutrition and medical
experts and practitioners to inform each edition of the Dietary
Guidelines, public comment, and exhaustive systematic review of the
literature and current science.
Question 8. At your confirmation hearing you stated that ``guns and
gun owners aren't inherently a public health problem, but the violence
that results absolutely is.'' What public health interventions do you
think are needed to address gun violence and, as Surgeon General, how
would you work to promote such interventions?
Answer 8. When addressing the challenge of violence in our
communities, we must look at the underlying issues--such as untreated
mental illness--and address them. As I reiterated in my opening
statement, I share the Secretary's urgency of addressing untreated
mental illness, especially serious mental illness. I will work to
ensure that we are identifying indicators of violent behavior so as to
promote appropriate interventions, consistent with my role as Surgeon
General.
Question 9. Infant mortality is often an indicator for the health
of a society and the efficacy of its policies. According to the CDC,
the infant mortality rate in the United States in 2014 was 6.1. This
means that 6 out of 1,000 infants born will not live to see their first
birthday. The rate is the higher than 25 other developed countries.
This is an unsettling statistic. You have been very involved in efforts
to reduce the number of infant deaths in Indiana, which had one of the
highest infant mortality rates for individual States. How would you
translate these efforts to the Federal level? Maternal mortality rates
in the United States, while improving overall, have also fallen behind
those of other countries. If confirmed as Surgeon General, how would
you work to improve the maternal mortality rate in the United States?
Answer 9. As Surgeon General, I would draw upon my experience in
Indiana to build relationships across HHS, the States, and local
communities to identify strategies that are working to improve infant
and maternal mortality. Many States, much like Indiana, are facing a
multitude of health challenges that are reflected in these rates. I am
committed to working with all levels of government and impacted
communities to better address these two important health concerns.
Question 10. The African-American infant mortality rate is twice
the white infant mortality rate. In 2013, the Secretary's Advisory
Committee on Infant Mortality included in the National Prevention
Strategy a recommendation on this topic. What recommendations would you
offer clinicians to address this health inequity in the African-
American community?
Answer 10. This issue is of great concern to me as a physician and
a parent. I feel one important step to improving infant mortality in
any community, but especially the African American community, is
collaboration and engagement across the community. By leveraging
interagency, public-private, and multi-disciplinary collaboration and
partnerships, we can work together to identify targeted strategies to
reduce infant mortality in the African American community. This is a
multifaceted problem. Clinicians cannot fully address this problem
without the help of other partners. To achieve any level of success, it
will require clinicians working together and with other stakeholders
across all disciplines to identify models and best practices
appropriate for the communities we serve.
Question 11. There unfortunately has been a history of reproductive
coercion in this country, particularly among Black and Latina women.
The Surgeon General's office frequently makes recommendations on ways
that Americans can improve their health outcomes. Do you have any
recommendations to make sure that all women have the ability to choose
the birth control--and provider--of their choice?
Answer 11. As Surgeon General, I would look forward to ensuring
that women and men can obtain the health care that they need at an
affordable price.
Question 12. When you committed to me that you would stand up for
vaccines, you told me that you will stand up for science where the
science is settled. You also said there are topics on which people
think the science is settled but it is not. Can you please elaborate on
what those topics are and what the outstanding questions are?
Answer 12. As Surgeon General, science will always guide and be
reflected in my efforts. I will also convene and work with partners to
make sure that, where there remains scientific debate, we can talk to
each other, and come up with a direction that is best for, and accepted
by, the American people. The Department has a responsibility to ensure
that the American people are receiving the most up-to-date, science-
based information, and also to make sure we listen to and work with all
citizens--not just the ones we happen to agree with.
Question 13. For decades, the Surgeon General has been an outspoken
voice on the health risks posed by smoking, particularly among children
and teens. As noted above, the Surgeon General has recently spoken out
about the risks posed by e-cigarettes. In Indiana, you have led several
public campaigns to warn of the dangers of tobacco, stating ``quitting
smoking is the single best thing you can do for your health.'' Yet,
according to your Public Financial Disclosure Report (OGE Form 278e),
prior to your nomination you were invested in some of the largest
manufacturers of tobacco products, including e-cigarettes: Altria Group
Inc., British American Tobacco PLC, Philip Morris International Inc.,
and Reynolds American Inc. with holdings totaling between $5,005 and
$75,000. Please explain how you reconcile the past work from the Office
of the Surgeon General--and your own work--about the public health
risks posed by tobacco with your decision to hold stock in some of the
world's largest tobacco companies?
Answer 13. The majority of my investments are held in managed
accounts with the investment decisions made by the account managers. I
hold several smaller investment accounts where I control the
investments with the advice of my financial advisor. My advisor and
account managers make decisions that they deem best for my portfolio,
and which are unknown to me. Following my confirmation, all of my
accounts will be moved to accounts under my full control. As you
mention, my commitment to tobacco prevention and cessation is well-
documented.
Question 14. You have spoken extensively about your experience with
the opioid epidemic and the resultant HIV outbreak in Indiana. You
testified before Congress that ``[t]argeted marketing by the
pharmaceutical industry encouraged providers to use opioids more
aggressively to treat chronic, non-terminal pain'' and you called on
the pharmaceutical industry to be held accountable for its role in
expanding access to opioids. Yet, according to your Public Financial
Disclosure Report (OGE Form 278e), prior to your nomination you were
invested in companies that are some of the largest manufacturers of
opioids in the country, including Allergan, Pfizer, and Novartis. In
fact, the State of Ohio recently brought a lawsuit against Allergan,
among others, for their role in the opioid epidemic. Please explain how
you can reconcile your work speaking out about the dangers of the
opioid epidemic, specifically your calls to hold the pharmaceutical
industry accountable, with your decision to hold stock in some of the
Nation's largest opioid manufacturers?
Answer 14. The majority of my investments are held in managed
accounts with the investment decisions made by the account managers. I
hold several smaller investment accounts where I control the
investments with the advice of my financial advisor. My advisor and
account managers make decisions that they deem best for my portfolio,
and which are unknown to me. Following my confirmation, all of my
accounts will be moved to accounts under my full control. As you
mention, my commitment to combating the opioid epidemic is well-
documented.
senator sanders
Question 1. As you know, this Nation has been and remains plagued
by health disparities. These disparities not only are well-documented
as it pertains to health status and health outcomes, but also in the
stark differences that exist between different populations in access to
reliable, affordable health care. These disparities not only carry a
significant human health toll, but a financial one, as well. As Surgeon
General, please share in detail how do you plan on leveraging the
influence of the office to help make significant strides in ongoing
efforts to reduce and even eliminate some of our most pressing health
disparities? Also, please share how you plan to work to reduce health
disparities while President Trump is seeking to cut or eliminate the
very programs that are vital to this effort.
Answer 1. As Indiana Health Commissioner, one of my main areas of
focus was on health disparities impacting health outcomes, such as
infant mortality disparities by race and geography. As Surgeon General,
I would ensure health disparities continues to be an area of focus
through my communication and convening platforms. I would spotlight
community and employer engagement on evidence-based programs and
policies that are reducing health disparities across our Nation in
order to increase their reach.
Question 2. There are dire and often immediate public health
challenges that can be direct results of the lack of access to
screening, treatment and care for substance abuse, HIV and other STI
testing, and needle exchange programs. These are issues, as you know,
that hit rural communities extremely hard, and were highlighted when
Scott County, in your own State of Indiana, experienced an HIV outbreak
that has since been linked to opioid misuse and needle sharing. As you
know, when this HIV outbreak occurred, then-Governor Pence refused to
support needle exchange programs. Additionally, more than 60 percent of
rural counties--including Scott County--did not have enough physicians
qualified to prescribe buprenorphine--an FDA-approved medication to
treat opioid use disorder. In detail, please share your perspective
about the importance of the Federal Government's support for programs
like needle exchange and HIV screening, as well as the Federal
Government's role in assisting States and local communities to expand
access to treatment for substance use disorders in rural, underserved
areas, like Scott County? Additionally, in detail, please share your
thoughts about the impact that defunding Planned Parenthood--which
provides not only HIV and STI screening and testing, but also mental
health and substance abuse counseling and treatment to millions of
vulnerable Americans--will have on efforts to prevent what happened in
Scott County from happening in other rural communities across the
country.
Answer 2. Our Nation is in the midst of an unprecedented opioid
epidemic. I share Secretary Price's tremendous sense of urgency to
combat this public health threat. As Secretary Price outlined in April
2017, HHS is implementing a comprehensive strategy to reduce opioid
abuse, addiction, and overdose, including the provision of
comprehensive services such as substance abuse treatment, testing for
HIV and hepatitis C, and, where appropriate and effective, access to
sterile syringes, consistent with Federal, State, and local laws, for
people who inject opioids and other drugs. Building on my first-hand
experiences addressing these complex issues in Indiana, I look forward
to advancing these efforts and helping communities to implement local
solutions to their toughest problems. I also look forward to working
with partners across HHS to leverage community health centers in this
effort. This critical resource plays a vital role in health care
delivery, especially in rural communities.
senator casey
Question 1. In your opening testimony at the August 1 hearing you
stated the importance of prevention activities to address many of the
public health problems in our country. As you know, the Affordable Care
Act has a significant prevention fund that has been targeted for
defunding by the Administration. How will you advocate for continuation
of this program and funding within the Administration?
Answer 1. A primary focus of the Surgeon General is prevention. I
look forward to getting into my position and evaluating programs that
are already in place. As you mentioned, I am eager to ensure that
prevention is a key focus.
Question 2. Over the last several months, I have sent multiple
letters to HHS about the Administration's ongoing efforts to undermine
and sabotage the Affordable Care Act through executive action. HHS has
failed to provide responses to many of my letters. If HHS has
responded, the response letters have been wholly inadequate and have
not been responsive to my requests. If you are confirmed, do you commit
to respond in a timely manner to all congressional inquiries and
requests for information from all Members of Congress, including
requests from Members in the Minority?
Answer 2. As Surgeon General, I look forward to working with you
and Members of Congress on both sides of the aisle. I am eager to
maintain an ongoing dialog with Congress as we work to improve the
health of all Americans.
senator franken
Question 1. Can you explain why it is essential and in the best
interest of the Nation's public health to have an independent Surgeon
General whose sole focus is promoting and advancing evidence-based
public health practices rather than the political agenda of the
administration in which the Surgeon General serves?
Answer 1. It is important for a Surgeon General to be an
independent and unbiased authority.
Question 2. The Surgeon General's office has produced landmark
reports over the years that have been tremendously influential,
including last year's report on addiction. What would your priority
issues be and how do you intend to utilize previous work of the office
to advance your goals?
Answer 2. As detailed in my submitted confirmation testimony, my
priorities will be (1) addressing the opioid epidemic, (2) promoting
wellness and prevention, and (3) engaging the business community to
improve health. All of the previous reports of the Surgeons General
will have relevance to and overlap with my priorities--particularly
previous reports on addiction and smoking. My intent is to buildupon
the work of previous holders of this position, to make America
healthier.
Question 3. As Surgeon General, you will help lead the Public
Health Commission Corps. What plans do you have to utilize this group
to fight the opioid epidemic and other public health crises?
Answer 3. The USPHS Commissioned Corps is comprised of
approximately 6,500 licensed, public health and safety professionals
(doctors, nurses, mental health providers, etc.) trained to respond
individually or as part of a larger Federal disaster response. As
Surgeon General, I look forward to working with the Commissioned Corps
to advance the President's and Secretary's public health agenda and to
protect the health of all Americans.
Question 4. The President, while on his campaign echoed the
concerns raised by anti-vaccine organizations. What will you do to
educate the President, his administration, and the public about the
importance of vaccines?
Answer 4. There is no doubt that vaccines have played a significant
role in improving public health in our country. I will work to ensure
that patients have confidence in the immunizations recommended by the
Department.
senator bennet
Question 1a. I was recently in Otero County, CO where drug
overdoses have been increasing. The entire community was engaging to
address the rise in opioid abuse. This included coordinating hospitals,
the courts, schools and foster care services. Even when we see a
decrease in prescription overdoses, it is usually countered with an
increase in heroin overdoses. In the 1960s, more than 80 percent of
heroin users started with heroin. In contrast, currently, about 80
percent of heroin users first started using prescription opioids.
What are practical steps you plan to take to address the opioid
crisis?
Answer 1a. The opioid epidemic is one of the greatest health
threats in recent history. To be successful in ending this crisis, we
must focus on a comprehensive strategy that addresses the underlying
drivers of the epidemic and brings together public health, public
safety, community members, faith-based organizations, and many other
elements of society. As Surgeon General, I would build on my experience
in Indiana, to partner with the medical community to increase the use
of evidence-based addiction treatment, including medication-assisted
treatment, and support individuals in recovery. A key aspect of this
work is communication and convening, and the Surgeon General is well-
positioned to bring stakeholders together on this pressing issue. I
look forward to carrying out these efforts.
Question 1b. How can we ensure that Americans are not becoming
addicted in the first place while making it easier for people who
currently have an addiction to obtain access to treatment?
Answer 1b. Prevention is a key part of the strategy to combat the
opioid epidemic. As Surgeon General, I would build on efforts already
underway at HHS to support community-based prevention programs, and
work with the medical community to improve opioid prescribing--too
often a starting point of addiction for many Americans. At the same
time, the data are clear that most people who have opioid addiction do
not receive treatment for it. Thus, to turn the tide on the epidemic, I
would advance efforts to expand access to treatment, including the full
spectrum of medication-assisted treatment.
Question 2. Many chronic diseases are preventable or better managed
when caught early. When they are not, there is a large cost burden on
our society. The American Diabetes Association estimates that the
economic cost of diabetes was nearly $250 billion in 2012, a 41 percent
increase since 2007. In Medicare, 15 percent of the sickest enrollees
that often have multiple chronic conditions, account for 50 percent of
Medicare spending.
What is your strategy around prevention so that certain chronic
diseases are avoided or better managed in order for us to improve
outcomes and save Medicare dollars?
Answer 1. The Office of the Surgeon General's primary function is
to translate science to ensure the American public is aware of the most
practical and evidence-based information to prevent disease. For
example, the Surgeon General's Call to Action on Walking and
Walkability focuses on increasing physical activity. The Office also
highlights active living and healthy eating as standards to improve
chronic diseases. The Healthy Aging in Action report (HAIA) developed
by the National Prevention Council addresses best practices for
longevity and improving health costs for seniors. I plan to carefully
review recommendations such as these and determine the best way during
my tenure as Surgeon General to promote prevention of chronic disease.
senator whitehouse
Question 1a. You are well aware of the toll the opioid epidemic has
taken on families across the country. Evidence shows that medication-
assisted treatment can reduce cravings and withdrawal symptoms among
people suffering from opioid addiction, and help them stop using
opioids and get back to living productive lives. Despite this evidence,
Secretary Price has claimed that medication-assisted treatment is
ineffective, just substituting one opioid for another.
Do you agree with Secretary Price's statements about medication-
assisted treatment?
Answer 1a. There are many years of rigorous research documenting
the effectiveness of medication-assisted treatment. Like Dr. Price, I
am committed to ensuring that people struggling with opioid addiction
have access to evidence-based care, including the full spectrum of
medication-assisted treatment.
Question 1b. What do you see as the role of medication-assisted
treatment in combating the opioid epidemic?
Answer 1b. To turn the tide on the epidemic, we must have a
comprehensive strategy. A critical component of that is to expand
access to treatment, in particular all forms of medication-assisted
treatment. I am prepared to use the role of Surgeon General to help
educate providers, patients, and the public about opioid addiction,
what treatments are available, and how people can access treatment.
Question 2. You have referred to antibiotic resistance as ``one of
the biggest health threats we face'' and have encouraged the
responsible prescribing of antibiotics. The Centers for Disease Control
and Prevention estimates that two million people develop antibiotic-
resistant infections in the United States every year, resulting in at
least 23,000 deaths. As Surgeon General, will you prioritize combating
antibiotic resistance, preventing healthcare-acquired infections, and
raising awareness about this public health threat?
Answer 2. HHS has been a leader across the government in
implementing a broad range of activities to curb antibiotic resistance.
As Surgeon General, I will work with my colleagues across the
Administration to continue to advance these efforts. In particular, I
believe the Surgeon General is well-positioned to engage with the
medical community to encourage antibiotic stewardship and appropriate
antibiotic prescribing and to help patients and the public understand
the appropriate role antibiotics play in our health and health care
system. I look forward to helping raise the visibility of this
important issue.
senator warren
Reproductive Health
The U.S. Surgeon General, the Nation's top doctor, is responsible
for offering Americans ``the best scientific information available on
how to improve their health and reduce the risk of illness and
injury.'' Reproductive and sexual health are critical components of
overall wellness.
Currently, a key priority of the Surgeon General is the ``National
Prevention Strategy,'' which aims to enhance ``health and well-being''
by ``integrating recommendations and actions across multiple settings
to improve health and save lives.'' The National Prevention Strategy
includes recommendations for reproductive and sexual health and
prioritizes support for ``effective sexual health education, especially
for adolescents,'' the ``early detection of HIV, viral hepatitis, and
other STIs,'' and the ``increased use of preconception and prenatal
care.''
Reproductive health centers--including Planned Parenthood clinics--
are critical to these efforts. Each year, Planned Parenthood's 600
health centers serve nearly five million people, providing 295,000 Pap
tests, 320,000 breast exams, and 4.2 million STI tests. In addition,
Planned Parenthood offers evidence-based, medically accurate sex
education to 1.5 million teens annually.
Republicans often claim that federally qualified health centers
(FQHCs) could fill the gaps in reproductive health care access that
would result from a defunding of Planned Parenthood. Recent analysis by
the Guttmacher Institute, however, demonstrates that this claim is
patently false. The analysis points out FQHC sites providing
contraceptive care would need to dramatically increase their
contraceptive client caseloads, taking on an additional two million
patients nationwide, in order to fill the gap should the Republican
Congress choose to cut Planned Parenthood health centers out of the
family planning safety net.
Question 1. As Surgeon General, would you continue to promote the
National Prevention Strategy, including its recommendations on
reproductive and sexual health?
Answer 1. Reports and strategies often need to be updated to best
reflect changing evidence. I plan to carefully review all of the
recommendations of the NPS and determine the best way during my tenure
as Surgeon General to promote reproductive and sexual health.
Question 2. Do you agree that policies demonstrated to increase the
number of unintended pregnancies and STIs among teenagers should not be
supported by HHS?
Answer 2. As Surgeon General, I commit to working to decrease
unintended pregnancies and STIs among all citizens.
Question 3. As Surgeon General, would you commit to promoting
evidence-based programs that improve teenagers' reproductive health?
Answer 3. Yes.
Question 4. Do you agree that Planned Parenthood health clinics are
essential to Federal efforts to promote effective sexual health
education, increase STI detection, and improve reproductive health
care?
Answer 4. Women's health is very important to me. As Surgeon
General, I would strive to ensure that both women and men have access
to the quality health care they need.
Question 5. Do you agree that FQHCs cannot fill the gaps left if
Planned Parenthood health clinics no longer received Federal funding?
Answer 5. As Surgeon General, I will work to ensure all women have
access to affordable, high quality health services, consistent with my
role as Surgeon General.
Zika Response
The Surgeon General is also responsible for offering the public
``facts on emerging public health threats'' and ``list[ing] steps
individuals can take to protect themselves and their families.'' The
Zika virus is one such ``emerging public health threat'': infection
during pregnancy can result in microcephaly, a severe brain defect, as
well as miscarriage and stillbirth. According to the Centers for
Disease Control and Prevention (CDC), ``[o]ffering family planning
services, including information and access to the full range of
contraceptive methods, is a primary strategy to reduce the number of
unintended pregnancies affected by Zika virus infection.''
Question 6. As Surgeon General, would you commit to providing the
American people with evidence-based, scientifically and medically
accurate information about Zika prevention--including information on
``the full range of contraceptive methods--regardless of any partisan
efforts to restrict information on and access to contraceptive
services?
Answer 6. As Surgeon General, I will communicate the full range of
evidence-based, scientifically and medically accurate information on
all public health topics, including Zika prevention, to help patients
make informed decisions about their health.
Question 7. As Surgeon General, would you oppose efforts by the
Trump administration to reduce access to contraception, including
efforts to defund Planned Parenthood health clinics?
Answer 7. As Surgeon General, my role is to communicate evidence-
based health information to the public. I would work with my public
health and clinical partners to raise awareness about evidence-based
prevention, including efforts to reduce preventable causes of morbidity
and mortality, including infant mortality and teenage pregnancy.
Opioid Epidemic
The opioid epidemic is a public health crisis. In Massachusetts
alone, an estimated 2,000 people died from opioid overdoses in 2016.
Addressing addiction and substance use is one of the Surgeon General's
top priorities. In 2016, the Surgeon General worked to promote a
national campaign that urged health care professionals and prescribers
to talk with one another about best prescribing practices. In the same
year, the Surgeon General presented a report, ``Facing Addiction in
America: The Surgeon General's Report on Alcohol, Drugs, and Health,''
which included a series of recommendations on preventing and treating
addiction. This report also provided a look into the country's current
``treatment gap,'' which has helped inform policymakers as they work to
find solutions and slow the rise in fatal overdose rates.
At the core of the opioid crisis has been the over-prescribing of
addictive prescription painkillers. CMS reported that generic Vicodin
was prescribed to more Medicare beneficiaries than any other drug in
2013--more than blood pressure medication, more than cholesterol
medication, more than acid reflux medication. The National Institute on
Drug Abuse has estimated that over 70 percent of adults who misuse
prescription opioids get the medication from friends or relative, so
efforts to reduce the amount of unused medications in the home is a
powerful new tool to tackle the prescription drug epidemic. The
Comprehensive Addiction and Recovery Act, passed in July 2016, included
a bipartisan provision that I worked on with Senator Capito that
empowers patients to talk to their physicians and pharmacists about
partially filling their prescription medications in order to reduce the
amount of unused opioids in circulation.
In addition to the impact that prescription drug use has had on the
opioid epidemic, the illicit distribution and sale of fentanyl, a
dangerous synthetic opioid that is more potent than heroin, has
contributed to this public health crisis--particularly in New England
States like Massachusetts. A November 2016 study by the Massachusetts
Department of Public Health found that of the opioid-related fatalities
in the State in which toxicology screens were available, 74 percent of
individuals tested positive for fentanyl.
Question 8. What will you do to work with other agencies and the
physician community to address the over prescribing and misuse of
prescription medications, while still ensuring that patients who need
pain medication can receive it?
Answer 8. I firmly believe that most physicians want to do what is
best for their patients and to relieve suffering without putting their
patients and families in harm's way. Ensuring that patients with pain
receive high-quality, evidenced-based pain care must be an essential
component of the response to the opioid epidemic. As Surgeon General, I
would engage with the medical community, government partners, and State
and local stakeholders to ensure that policies and programs aimed at
reducing opioid abuse, addiction, and overdose do not penalize patients
with legitimate medical needs.
Question 9. You have been supportive of Indiana's recent partial
fill legislation. In the role of Surgeon General, would you work with
States, physicians, pharmacists, and patient groups to increase
awareness about Federal partial fill policies?
Answer 9. Yes.
Question 10. Will you support the findings of the report, ``Facing
Addiction in America,'' and will you continue to inform the
Administration and Congress about the need to fight the opioid
epidemic?
Answer 10. It is clear to me that the Administration and Secretary
Price have taken an early and aggressive approach to combating the
opioid epidemic. I look forward to working with partners across the
Administration and external stakeholders to build on the progress that
has been made in recent years. The Surgeon General's Report on Alcohol,
Drugs, and Health can serve as a science-based resource to help advance
evidence-based policies and programs to reduce the burden of opioid
addiction.
Question 11. What do you believe are the next steps in tackling
this opioid crisis?
Answer 11. At all levels of government and in communities across
America, health care professionals, parents, people in recovery, first
responders, and many others are taking action to reduce the harms
associated with opioid abuse, addiction, and overdose. I look forward
to leveraging the Office of the Surgeon General to build on these
efforts. In particular, I believe the Surgeon General is well-
positioned to engage with the medical community to encourage the
appropriate use of opioids and to advance evidence-based pain care, and
to help raise awareness of addiction and spur efforts to reduce stigma
around addiction among patients, providers, and the public.
Question 12. You have advocated for Medication-Assisted Treatment
(MAT) as an important evidence-based addiction treatment. How would you
work to ensure that other influential health officials understand the
value of this treatment?
Answer 12. There are many years of rigorous research documenting
the effectiveness of medication-assisted treatment. Yet, despite the
evidence base, the vast majority of people with an opioid addiction do
not receive treatment for it. Expanding access to medication-assisted
treatment is a key part of the response to the opioid epidemic. I am
prepared to use the role of Surgeon General to help educate providers,
patients, and the public about opioid addiction, what treatments are
available, and how people can access treatment.
Question 13. What do you plan to do to build on HHS's efforts to
address a specific component of the opioid epidemic, the illicit sale
and use of fentanyl?
Answer 13. The emergence of illicitly made fentanyl and fentanyl
analogs, largely coming from China, has accelerated the ongoing opioid
epidemic in the United States. As Surgeon General, building on my
experiences in combating the opioid crisis in Indiana, I will work
collaboratively with experts across HHS and with our partners in law
enforcement to raise awareness about the dangers of illicit fentanyl
and fentanyl analogs in our communities, encourage the broader use of
naloxone to reverse overdoses, and use the platform of the Surgeon
General to reduce stigma around opioid addiction--a key barrier to
getting people into treatment and stopping their drug use. In addition,
I will work with the medical community to curb the inappropriate
prescribing of opioid pain medications, which was the starting point
for many Americans now addicted to heroin and illicitly made fentanyl.
Tobacco
Tobacco, the leading cause of preventable death in the United
States, is traditionally one of the Surgeon General's top priorities.
The Surgeon General's 2016 report, ``E-Cigarette Use Among Youth and
Adults,'' concluded that the use of e-cigarettes among youth and young
adults was a public health concern, and suggested a number of policies
to impose stricter regulation of e-cigarettes.
However, in July 2017, the FDA announced that it would further
delay deadlines for e-cigarettes, cigars, and other previously
unregulated tobacco products to come into compliance with the 2016 FDA
deeming rule that imposed stricter oversight of these products.
Question 14. As Surgeon General, would you continue to promote the
recommendations of the Surgeon General's 2016 report on e-cigarette
use?
Answer 14. Reports and strategies often need to be updated to best
reflect changing evidence. While the aforementioned report is only a
year old, at the time of its release there was controversy in the
public health community about the evidence on e-cigarettes. Since the
Report's release, a large volume of research that further expands our
understanding of e-cigarettes has been published. I plan to carefully
review all of the recommendations of the 2016 report and this new
research to determine the best way during my tenure as Surgeon General
both to promote harm reduction for current smokers and to prevent
smoking initiation, especially among youth.
Question 15. Do you agree that stricter FDA oversight of e-
cigarettes, cigars, and other previously unregulated tobacco products
could improve public health outcomes?
Answer 15. Protecting and improving public health is at the core of
the Department's mission. While serving as the Indiana State Health
Commissioner, I have overseen Indiana's tobacco cessation efforts. I
look forward to working with the FDA, CDC, and other Federal agencies
to protect our children and significantly reduce tobacco-related
disease and death.
Combating Antibiotic Resistance
The 2014 National Strategy for Combating Antibiotic-Resistant
Bacteria brought together the Secretaries of Health and Human Services,
Agriculture, and Defense to declare that,
``the misuse and over-use of antibiotics in health care and
food production continue to hasten the development of bacterial
drug resistance, leading to the loss of efficacy of existing
antibiotics.''
Through this initiative, we've made some significant progress
establishing policies that better protect lifesaving antibiotics.
There is strong and growing evidence that antibiotic use in food
animals can lead to antibiotic resistance in humans, yet the use of
medically important drugs in food animals continues to grow. According
to the FDA,
``Domestic sales and distribution of medically important
antimicrobials approved for use in food producing animals
increased by 26 percent from 2009 through 2015, and increased
by 2 percent from 2014 through 2015.''
Question 16. Do you agree that curbing the misuse and over-use of
antibiotics in health care and food production should be a public
health priority?
Answer 16. Yes.
Question 17. As Surgeon General, what specific steps will your
office take to prevent the development of bacterial drug resistance?
Answer 17. HHS has been a leader across the government in
implementing a broad range of activities to curb antibiotic resistance.
As Surgeon General, I will work with my colleagues across the
Administration to continue to advance these efforts. In particular, I
believe the Surgeon General is well-positioned to engage with the
medical community to encourage antibiotic stewardship and appropriate
antibiotic prescribing and to help patients and the public understand
the appropriate role antibiotics play in our health and health care
system. I look forward to helping raise the visibility of this
important issue.
[Whereupon, at 4:45 p.m., the hearing was adjourned.]
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