Senators Seek Answers From HHS Chief on ACA Reforms, Title X Funds

Organ allocation, unaccompanied minors also discussed at appropriations hearing.

This article was first published on Thursday, April 4, 2019 on MedPage Today.

By Joyce Frieden, News Editor, MedPage Today

WASHINGTON -- Overturning the Affordable Care Act, maintaining women's access to birth control, and taking better care of unaccompanied minors entering the country without papers were just a few of the issues Health and Human Services Secretary Alex Azar addressed during a Senate Appropriations committee budget hearing on Thursday.

"The fact is the administration is doing everything it can to sabotage healthcare, and this budget appears to be just more of the same," said Sen. Patty Murray (D-Wash.), ranking member of the Senate Appropriations Subcommittee on the Departments of Labor, Health and Human Services, and Education, and Related Agencies, which was holding the hearing. "Your budget calls for repealing and replacing the ACA with the failed Trumpcare bill, which was rejected by the last Congress, and ... last week President Trump sided with the [district court] ruling that all of the ACA should be struck down -- all of it."

"According to reports, you initially opposed President Trump on that and issued a statement of support," she continued. "Did you initially object to the president's decision to side with the Texas court because you know the impact this would have; it would be devastating for so many families?"

'Reasonable Minds Can Differ'

Azar did not answer the question directly. "The advice of a Cabinet member to the President of the United States is highly confidential and it wouldn't be appropriate for me to comment on that," he replied. "The position the administration took in the ACA litigation is an appropriate position; it's supporting a district court's decision ... Reasonable minds can differ on this question of legal issues. This is not our policy position; that is a legal conclusion about the ACA ... We want to protect preexisting conditions; if the litigation ends up in that position we want to work with you to secure better care for people and make sure all the issues you raised are taken care of."

Sen. John Kennedy (R-La.) was a little more friendly to the secretary. "I remember when Congress passed [the ACA], we were promised ... that it would make health insurance more affordable. Has it done that?" he asked.

"No it has not," Azar said. "We were promised health insurance would cost half what it cost at the time; in fact, during President Obama's tenure, it doubled in cost for people having to buy insurance."

"Congress also promised us it would make health insurance more accessible," Kennedy said. "Has it done that?"

"No it has not; in fact it has restricted choices for individuals now, with a large percentage of states having only one carrier in the individual market," said Azar. Kennedy then asked whether the president supported repealing the ACA without a replacement. "The president has always supported replacing the Affordable Care Act with something else that is better," Azar said.

Changing the Rating Bands

Sen. Joe Manchin (D-W.Va.) asked how -- given that the ACA is already integrated into a sixth of the U.S. economy -- the Trump administration would fix the program. Azar said he would lift the 3-to-1 age band restriction that requires insurers to charge their oldest enrollees no more than three times what they charge their youngest ones; that restriction "has made insurance for [those who are] healthy and young unaffordable, and [so] they walk away from the market," he said.

Manchin said that such a change -- which would allow insurers to charge older patients much more than they do now -- might make insurance unaffordable for older patients. Azar responded that one fix for that was providing insurers with reinsurance for high-cost patients. Several Senate bills have attempted to address the reinsurance issue but have gotten bogged down by various issues, including provisions related to abortion.

The secretary was also asked questions from both Republican and Democratic committee members related to how the agency treated unaccompanied children seeking asylum in the U.S. "I was especially appalled by the great lengths former ORR [Office of Refugee Resettlement] director Scott Lloyd went to [in order] to prevent minors in ORR custody from accessing reproductive care, including cases where pregnancies were the result of sexual assault," said Murray.

"Despite the fact that a federal judge issued an injunction in March of 2018 barring ORR from obstructing access to abortion, a recently released spreadsheet shows ORR continued to track minors' private reproductive health information [such as their menstrual periods] through June 2018 ... Does ORR still keep [such] a spreadsheet?"

"I'm not aware of any centralized spreadsheet," Azar said. "I believe the intention [was to collect] the last menstrual period date ... which is vital to prenatal care just to know the age of the child ... I believe we're fully compliant with the court's order and injunction."

Concerns Over Title X

Murray also asked Azar about his department's recent announcement of grants that were issued under HHS's Title X program, which funds birth control and other women's reproductive health services for low-income patients. She noted that one grant went to "an ideologically driven organization that doesn't even offer FDA-approved birth control ... Is birth control an evidence-based family planning option?" she asked.

"We support the full range of family planning; that's why we kept the Title X program at flat funding even as we cut other parts of the budget," said Azar. "We do support access to contraception and birth control and the full range of family planning options."

Sen. Jerry Moran (R-Kan.) wanted to discuss the controversy over the allocation of donated organs, specifically livers. "Let me first ask if you believe enough is being done to help individuals with end-stage liver disease who are not yet on a waitlist; is enough being done to advance their well-being?" he asked.

"The number one thing we can all be doing is working to increase the supply of livers we have for transplantation," said Azar. Moran asked whether Azar would commit to public disclosure of the process being used to allocate livers. Azar responded that organ allocation was a challenging topic for his office because "Congress took that out of my hands to make it a nonpolitical issue ... but I'm happy to work with you and your staff on any vehicle to ensure [a public process]."

Moran appeared unsatisfied with that response; he noted that the HHS secretary appoints the director of the Health Resources and Services Administration, who oversees the transplant allocation process. "It was only after a lawsuit was filed, as I understand it, that this allocation process was then considered for change," he said. "This process has been flawed. You're right -- the issue is more organ donation and the policy being developed is contradictory to what you said was the goal."