5 Takeaways From HHS Nominee Becerra's First Senate Confirmation Hearing

Healthcare executives should ignore the political theater commonly associated with confirmation proceedings and instead focus on Becerra's forward-looking health policy statements.

After a lengthy delay, Xavier Becerra, the Attorney General of California and President Joe Biden's nominee for Secretary of Health and Human Services (HHS), had his first Senate confirmation hearing Tuesday morning.

Becerra spoke in front of the Senate Health, Education, Labor and Pensions (HELP) Committee. This is the first of two confirmation hearings; Becerra will also speak in front of the Senate Finance Committee Wednesday afternoon.

Related: Stakeholders Discuss Biden Healthcare Agenda Ahead of Inauguration Day

Ahead of the confirmation hearing, the Association for Community Affiliated Plans (ACAP) wrote an open letter to leaders on both the HELP and Finance Committees in support of Becerra's nomination.

"We encourage a swift confirmation of Mr. Becerra, so that he can quickly get to work addressing the multitude of health care issues that have befallen the American public—from the COVID-19 pandemic, to all-too-frequent churn within the Medicaid program, to the loosening of ACA rules that protect consumers from inadequate, junk insurance plans," the letter read. "Throughout his career Mr. Becerra has been a stalwart supporter of policies to improve the lives of lower-income and vulnerable populations; we look forward to working with him and Congress to further improve the lives of Americans nationwide."

Below are five key takeaways from his more than two-and-a-half-hour testimony:

1. ACA and coverage solutions in the crosshairs
   
   The future of the Affordable Care Act (ACA) and how the Biden administration will seek to bolster the landmark healthcare law was top of mind during the questioning of Becerra during the hearing.
   
   As California Attorney General, Becerra led a coalition of more than 20 states in defending the ACA in California v. Texas, an ongoing case that could decide the fate of the legislation.
   
   Responding to a question from Sen. Tammy Baldwin, D-Wisc., Becerra committed to defending the ACA and supporting policies that will build upon the legislation to expand coverage for vulnerable Americans.
   
   Becerra pointed to the Biden administration's three-month ACA special enrollment period as one approach to expanding coverage and also mentioned the importance of addressing the 'coverage cliff' faced by middle-class Americans. 
   
   Sen. Mitt Romney, R-Utah, asked how Becerra could expand Medicare when the program is facing solvency challenges within the next decade, to which Becerra stated that the Biden administration would aim to implement a public option and support it through the general fund rather than the trust fund. 
    
2. GOP skepticism and policy pushback
   
   Ahead of Tuesday's hearing, Senate Minority Leader Mitch McConnell, R-Ky., issued a statement opposing Becerra's nomination.
   
   "Mr. Becerra has no particular experience or expertise in health," McConnell said. "His chief passion project in California seemed to be using the force of government to attack Americans’ religious liberty and freedom of conscience."
   
   Several Republican senators on the HELP Committee also expressed skepticism with Becerra's healthcare record and previous experience as a congressman and California Attorney General.
   
   Ranking Member Sen. Richard Burr, R-N.C., said that the need for "extensive healthcare experience" at HHS is "never more important than today," raising questions about the lack of medical experience in Becerra's background.
   
   In his opening statement, Burr said he had concerns about Becerra's qualifications for the position and respect for the private sector's role in healthcare, noting that he's "not sold."
   
   Sen. Bill Cassidy, R-La., probed about how Becerra would approach the much-maligned 340B Drug Pricing Program and asked if there needs to be a statutory definition for contract pharmacy and patient. Sen. Jerry Moran, R-Kan., pressed for a follow-up, to which Becerra promised to build on the Trump administration's reforms to the program while also protecting patients.
   
   Cassidy also asked if Becerra supported the proposal to pass 100% of prescription drug rebates on to consumers, to which he said that there needs to be reform but did not explicitly support that specific policy.
   
   Sen. Mike Braun, R-Ind., expressed concerns with Becerra's public record, pointing to the lawsuit filed against the Little Sisters of the Poor receiving a religious exemption from the HHS contraception mandate.
   
   Braun pressed Becerra on his plans for increased healthcare transparency, to which Becerra committed to "robust enforcement" of price transparency for consumers.
    
3. COVID-19 response and public health plans
   
   Following the Biden administration's approach to the pandemic, Becerra said that "science must come first" and committed to more consistency and transparency in the federal response to COVID-19.
   
   Becerra said he remains confident in the Biden administration's goal for 100 million shots in the first 100 days but did not indicate support for the idea that herd immunity can be achieved by April or May.
   
   In response to a question from Sen. Susan Collins, R-Maine, Becerra said that he would support including funding for long-term care facilities through the Provider Relief Fund in a pending $1.9 trillion COVID-19 stimulus package. 
   
   Related: Opinion: Confirm Xavier Becerra as Health and Human Services Secretary Now
   
   Sen. Bob Casey, D-Penn., asked Becerra about his thoughts on the social determinants of health (SDOH) and how health disparities have been exposed by the pandemic. 
   
   Becerra said he was encouraged by the bipartisan acknowledgment of SDOH and recognizing the impact on patients. He added later that his team at HHS will "live and breathe" health equity.
   
   Becerra stated that the decision to extend or end the public health emergency related to the COVID-19 pandemic would be driven by data and involve the insights of healthcare stakeholders.
    
4. Committed to rural health support, focused on provider consolidation
   
   Sen. Lisa Murkowski, R-Alaska, questioned how Becerra would address rural health issues, to which he said it's important to meet the "unique needs" of rural populations, specifically referencing the need for bolstering broadband capabilities and continuing to support the expansion of telehealth and virtual care services.
   
   When asked by Sen. Chris Stewart, D-Conn., about how the federal marketplace can have a functional marketplace between providers and payers, Becerra referenced the $575 million settlement he secured from Sutter Health over allegations that the provider organization violated state antitrust laws by wielding its massive market power in Northern California to drive up prices.
   
   "If consumers knew what they were paying, they'd push to have the price go down," Becerra said. "That's why our effort was supported up and down the state of California when we went after [Sutter,] because people had an instinctive feeling that the prices they were paying were way too high."
   
   Becerra said it's important to "go behind the curtain" to see how large healthcare companies are operating.
   
   In response to a question about implementing surprise medical billing legislation from Sen. Maggie Hassan, D-N.H., Becerra said that the Biden administration will review the arbitration provision and enact consumer protections.
   
   Sen. Roger Marshall, R-Kan., an OB-GYN by training and former chairman of the board of Great Bend Regional Hospital, asked Becerra for his thoughts on value-based care and Stark Law.
   
   "If we truly [value-based care] the right way, we'll reduce the number of visits, the number of incidents, and provide quality of care instead of quantity of care," Becerra said.
    
5. Will prescription drug pricing remain a priority?
   
   Lowering prescription drug pricing was a cornerstone of the Trump administration's healthcare agenda and while there was bipartisan support for some initiatives, the Biden administration's approach to this issue remains unclear.
   
   In response to a question about prescription drug prices from Sen. Bernie Sanders, I-VT, Becerra did not lay out specifics about lowering costs for consumers but did commit to supporting federally qualified health centers and expanding the National Health Service Corps.
   
   Sen. Tommy Tuberville, R-Ala., asked how HHS can reduce the price of insulin, to which Becerra said drugmakers must be properly compensated but noted that consumers must come first.
   
   In a follow-up question, Tuberville asked about pharmacy benefit managers (PBM), to which Becerra said these companies have a role but "can't be middlemen" or gouging prices, which echoed the rhetoric of former HHS Secretary Alex Azar.
   
   Sen. Braun noted in his questioning that while Becerra's nomination is supported by the American Hospital Association, American Medical Association, and America's Health Insurance Plans, PhRMA has not, and "I think we know why."
    

Contentious confirmation

As was clear from Tuesday's confirmation hearing, Becerra's nomination has stirred a bitterly partisan divide. 

Former HHS Secretaries Donna Shalala and Kathleen Sebelius, who served under Presidents Clinton and Obama, respectively, have supported Becerra's nomination while also criticizing the delay in holding his confirmation hearings.

Norris Cochran, HHS Deputy Assistant Secretary of Budget, has served as acting HHS Secretary while Becerra has awaited his confirmation hearings.

Related: With Becerra as HHS Pick, California Plots More Progressive Health Care Agenda

Meanwhile, Heritage Action for America and Susan B. Anthony List, two conservative advocacy groups, launched advertising campaigns against Becerra's nomination late last week.

Additionally, Sen. Tom Cotton, R-Ark., penned an op-ed for Fox News in late January about why the Senate should reject Becerra as a "culture warrior."

Focus on issues, not theatrics

Heather Meade, a principal at Washington Council Ernst & Young, told HealthLeaders prior to the hearing that healthcare executives should ignore the political theater commonly associated with confirmation proceedings and instead focus on Becerra's forward-looking health policy statements.

"As a healthcare leader, I will be listening for questions that are focused not so much on what he supported in the past, but in any messaging that he expresses about where he wants to focus as [HHS] Secretary," Meade said. "I think that's much more helpful and telling; will he take his expertise on the ACA and focus on rolling back some of the prior administration's efforts to constrain the ACA? Is he going to focus his time on drug pricing, or will we see him focus on market consolidation? These are all issues that he's focused on in the past and I think listening for what he tells us about where he wants to spend his time and how he'll be supporting the agenda of President Biden is probably more useful than focusing on some of the more political issues."

Meade added that as a presidential candidate, Biden included hospital consolidation on his list of campaign priorities going into the general election and was a topic that Vice President Kamala Harris pursued when she served as a senator.

"All of those [approaches to hospital consolidation] were done through the judiciary; [Becerra] was using his role as attorney general to pursue legal actions in the context of hospital consolidation," she said. "The FTC has a lot of authority from the federal level but [Becerra] won't have oversight of those particular levers of the government, so we may see him think about market power consolidation through other tools that he has at HHS."